Claudine Litman: Designing Better Healthcare Solutions

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We’re excited to welcome Claudine Litman today, but first, we always like to check in on hot topics or what’s going on in health and healthcare. So Harlan, why don’t you kick us off?

Harlan Krumholz: Yeah, I thought it might be fun, Howie. We’re still in January, and lots of people still looking back on 2023 and digesting, curating, evaluating some of that data and as we tend to do when we start a new year. One of the things that caught my eye was a blog that came up that had seven charts that sum up U.S. healthcare in 2023. And we’ll post the link to this. I thought it was really interesting. I thought I would just roll them off and see what you think of them and whether you would agree that these were sort of—

Howard Forman: Yeah.

Harlan Krumholz: So the number one was one that you’ve talked about at length, this great Medicaid unwinding that led to at least 13 million people losing coverage. And the chart that this person, Halle Tecco, chose was one that showed actually the states. And so I think you’ve said this a bunch, but the number one state with Medicaid disenrollment?

Howard Forman: Texas.

Harlan Krumholz: Texas, 62%. Over 1.5 million people disenrolled for Medicaid, followed by Florida, then California, New York, and Ohio. Of course, our highest-populous states had the largest numbers of people, but Texas really leading by a fair amount. Let’s go. Number two was about, again, another topic that we’ve talked about on this show, but again, when you see it in a figure, it’s so striking, that for the first time, more than half of Medicare beneficiaries enrolled in Medicare Advantage, that we’re really drastically shifting. The balance between this fee for service traditional Medicare system that has existed since the inception and this managed-care Medicare Advantage system that everyone’s seeing advertised out the gazoo on TV during the enrollment period. But what struck me was something I’d forgotten, which was that in 2007, less than 20% of people in Medicare were in these Medicare Advantage plans. In 2023, we went to 51% for the first time, and this is really a dramatic change. What do you think?

Howard Forman: Well, not only is it a dramatic change, but in 2010, I typically have one or two Republican speakers in my colloquium coming to my classes, so it’s a good way for me to gauge how they’re thinking about things. Every single one of them told me that Obamacare destroyed Medicare Advantage, and we’re going to pay the price for it. And I just think it’s funny, in retrospect, there have rarely been things so, so wrong. Medicare Advantage has thrived since Obamacare passed. It’s over 50%. It’s heading higher still, and we still do not know whether it’s actually more cost-effective than fee-for-service Medicare.

Harlan Krumholz: But the third one is interesting too, employees paid more for employer-sponsored health premiums than ever before. And again, take a look at this for the figures showing us in 2013, $16,000 and by the time we got to 2023 up to $23,000 at $23,900, actually just about $24,000. So the annual premium for these things rose 7% year over year, higher than inflation, hitting that $24,000 mark. I think people are feeling that pain. What do you think, Howie?

Howard Forman: Yeah, this ties in with a paper that just came out I think even in the last week by Zeke Emanuel and others that points out something that I’ve tried to point out in class for over 20 years, and that is this enormous expense means that lower-income workers that are fortunate enough to have employer-sponsored health insurance are taking home lower income. Effectively it really forces down the take-home income of lower wage workers because healthcare is this fixed, very high, expensive cost. And so every time I see this going higher, I think to myself, “If you’re somebody that’s earning $10 or $15 an hour, let’s imagine $15 an hour, you’re earning less than $30,000 a year in income. If you are getting an employer-sponsored plan, let’s say you’re at Yale, half of your compensation may be coming in the form of healthcare, and it holds down your income.”

Harlan Krumholz: Wow, that’s amazing. Number four, and I’ll get through these rest of these pretty quick. Another topic we’ve talked about, the GLP-1 medications, the anti-obesity medications like Ozempic, the title of this one became a household name. It’s a figure that shows the dramatic increase in the use of these medications. But I’ll tell you a thing that caught my eye, Howie, is even though they have increased dramatically, it looks like fewer than a million people were on them in 2023. And when we’ve got what, 30% to 40% of Americans facing obesity, it still represents only the tip of the iceberg of what we probably will see in the future. What do you think?

Howard Forman: The only thing that I keep thinking about is that we are doing all of this so quickly, and we don’t know enough about long-term effects on it. And while in general the evidence seems strong and we do have about 10 years of data on diabetes patients on these types of drugs, I hope people go slow, and I hope people don’t just assume that because they’re becoming more popular that everybody should be on them. I think we should be at least a little cautious.

Harlan Krumholz: Okay, three more, quickly. Healthcare providers warmed up to AI tools. Not only have they come out and are being shown to be more and more accurate, healthcare providers, physicians are saying, yeah, they think they might have a place in clinical practice. You think we’re going to see more of that?

Howard Forman: No question. We’re using it in small ways in big places. It’s just going to grow.

Harlan Krumholz: The last two aren’t going to surprise you either. In the first full year since Supreme Court overturned constitution rights to abortion, more Americans lost safe abortion access, but here’s the kicker to it. Actually, we haven’t decreased abortions in the country either. It’s just that we’ve lost access to safer abortions. What do you think?

Howard Forman: It is such a shame, and you talk about health equity issues, there’s no greater health equity issue than reproductive rights right now because if you’re rich, you can travel the hundreds of miles you need to go from Texas to get an abortion. If you’re poor, you cannot.

Harlan Krumholz: Last one, something we’ve talked about a little bit, but investor appetite in digital health cooled that in fact, we’re in this sort of a venture capital winter for digital health. And as you know, the valuations of stocks that went IPO and went public during that period have dropped dramatically, by the way. Anyway, I don’t even need to name them for you, but thoughts about this for the future?

Howard Forman: It’s fascinating, but it’s predictable. When the cost of money goes up, investors become more cautious. That’s it.

Harlan Krumholz: But also the S&P went up dramatically. Health tech declined.

Howard Forman: Yeah, because health tech right now has no return, so people are betting on the future, whereas the S&P, you’re actually investing in existing earnings. It may not be the wisest move, but it’s definitely the short-term logical move.

Harlan Krumholz: So that’s great. That’s a quick rundown on those seven. Hey Howie, let’s get to our guest, Claudine Litman.

Howard Forman: Claudine Litman is the executive director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation, also known as CORE, working and collaborating with our own Dr. Krumholz, the founder and director. CORE is a leading national outcomes research center dedicated to transforming healthcare for the betterment of people and society by leveraging data analytics and technology. Prior to working for Yale New Haven Hospital, Claudine founded Gendron Design and Innovation, which focuses on using data and human-centered design to elevate healthcare business processes, products, culture, and experiences. A designer by training, Claudine spent over a decade at VSA as a partner and design practice lead, leading multidisciplinary teams and working on design and strategy initiatives for clients as diverse as IBM, Bloomberg and Nike. Claudine holds two degrees in design from Cégep de Sherbrooke in Québec and the School of Visual Arts in New York. She holds an MBA from the Yale School of Management, which is when I first met her.

And Claudine, you and I have talked about this briefly, but I just want to get you to tell the arc, the narrative, the story, because our executive MBA program does have this healthcare track. You came in through the healthcare track, and as I understand it, you were design first and then because of personal experiences in your family, you started to become much more interested in healthcare and you applied design to healthcare, and then you decided to do our MBA program at Yale. And I’m curious to hear about how you got to that point and what the program did for you in helping to move your career to pivot, as I like to describe it, to where you are right now.

Claudine Litman: Absolutely. Well, as a designer, you’re trying to basically solve business problems, a variety of business problems—and that may be an experience; that may that be a strategy, a go-to-market strategy. So as a designer, we were touching different types of industries, and as you said, my son got sick when he was about three. And as a parent, it was just a very difficult thing to navigate and to understand how to make informed decisions and how to move forward with feeling confident in the decisions that we were making as parents. So as a designer, that’s actually when I decided that at some point in my career, I would take my design skills and apply them in the healthcare industry. And in order to do that well, you actually have to understand an industry deeply and in areas like operations, economics, even just understand the flows and how decisions actually happen within that industry.

And so you have the instincts of how to do that as a designer and you may become an expert in a specific industry, but I was really eager to learn more about healthcare in order for me to understand the right tenets and philosophy so I could be effective as a designer in the healthcare space. So it was a passion. And to have the right tools and learn the right best practices, I learned about the healthcare program at Yale through this AIGA program that’s called Business Perspectives for Creative Leaders. So this is how I learned about the MBA program, how I get to meet some of the teachers—you in particular, Howie and others—through that program. And I just knew that that was the way that I could gain that business acumen specific to the healthcare system for me to be an effective and inspiring designer in that space.

Howard Forman: Can you speak to the moment that you realized that you would leave pure design with an emphasis on healthcare and decide to get more immersed in healthcare with an emphasis on design, let’s say?

Claudine Litman: So through my personal experience in navigating the healthcare system as a patient, as a human being, I was seeing more needs than in other industries, perhaps. It felt to me like if it come from the experience itself, the products, the interactions, I just saw a tremendous amount of need for better design solutions, and I’ll interchange design and business solution, in whatever needed to happen to have an impact on people’s lives in these different interactions. And again, that I think for me was a challenge. I really saw for me there a passion and a desire to really have impact on people’s lives. And I was able to do that in different industries in my career, but I really wanted to move towards that specific area as I felt like it was a more direct interaction and impact on people. And I was just at a point in my career where I really wanted to make sure that everything I did on an everyday basis had an impact on society, which is also what inspired me for the choice of the school and the choice of CORE eventually.

Harlan Krumholz: One of the things we’ve talked about is the lack of design within healthcare itself in the sense that it’s grown organically, it’s optimizing for features that may not have been the same features you would choose if you said, “I want to design this system so that it produces the best results for patients in society.” And that’s in some ways what we talk about on the show a lot around the incentives that are embedded and the way in which our systems are configured, the way that patients interact with it, the way that staff, physicians, clinicians, everyone, all healthcare professionals interact. And so the result that we’re getting from the current system is a stagnation or even reversal of health outcomes, a burnout among people who are participating in staff, a dissatisfaction of the experience of it by patients. Is this a clarion call for someone with design skills to come in and help?

Claudine Litman: I do believe so, it certainly is an element. And I do believe that being able to integrate design capabilities, may that be in a hospital, in a group that is specialist into looking at these different types of solutions for healthcare settings, I do believe it brings a different layer of if you’re able to really focus on the human-centered aspect of these experiences and products. And we also have grown as consumers to really consume information in a very intuitive way, right? Products are designed in such a way, experiences are designed in such a way—it just hasn’t gotten at that level in some of the healthcare settings. And therefore I do believe that there would be great benefits gained for both providers and patients if more focus on these design solutions could be integrated.

Harlan Krumholz: So just one follow up to that is you spent a lot of time talking to people in health systems, especially as you were doing your EMBA and trying to decide what your next steps would be. What do you think needs to happen? ’Cause from my perspective, it’s needed, but the demand on the health system side and on the medical care side isn’t really there because it’s an externality for most of them. It doesn’t interfere with their business that their waiting rooms are full, their revenues are coming in. There’s not the same kind of need that you may have experienced when you were working with businesses who had to continue to delight customers in order to maintain their standing in their field. And for many healthcare systems, they’re just trying to figure out how to handle the demand of patient care, and they’re not under any pressure to evolve that way. What do you think needs to happen to get them to pay attention?

Claudine Litman: Well, I think when you have needs and you don’t have demand, part of this is to be able to, if you’re unable to show the potential ROI, maybe it is about showing what may be the waste that you would save almost or that you wouldn’t experience by changing your approach. So I think through my experience, a lot of these conversations are all about being able to identify the potential benefits of integrating design philosophies and processes inside healthcare. It’s not always easy, but sometimes it is just about making sure that the right observations are being done. It is about the negative space of what a patient may go through and what is not being told and not being captured in some of the more basic data that one would expect from that experience.

So it’s a challenge, but again, anywhere where you have needs and non-demand, I think it’s the ability to articulate the potential benefits. And I think a lot of that is through really good data visualization and being able to explain the ROI and when ROI is not tangible is what you can actually save and not waste. Easier said than done, but I think that’s doable.

Howard Forman: My one experience with this field, probably not my one experience, but the one that stays in my mind the most is when we renovated the emergency room about 10 years ago or a little more than that. And around that time right after it had been done, or maybe it was being done, Jonathan Feinstein, who is a professor in the School of Management, was teaching a design class. Even though I think he comes from a finance accounting background, he was teaching a design class because I think the students wanted it, and one of the modules was healthcare. They came over to look at the ER, and even though I’d been involved in the renovation and watching it happen, I had not understood how many design features were put in place for that emergency room renovation. A complete renovation by the way, gutted and started from scratch, basically. There are several features of it that continue to make eminent sense and they’re beautiful.

The fact that the ambulance bay lines up with the major trauma rooms and that those rooms line up with my department, radiology, is a beautiful design feature that you like having, but some of the things are disappointing to me in that we’ve never fulfilled the promise of them. Things like being able to chip stretchers and patients and equipment so that we can track them easily and always know where people are. To this day, we lose patients. And there are ways through all the doors to be able to track where people moved without completely encroaching on their privacy, but we lose patients. Patients walk off for an hour or two hours, it’s amazing. I’m wondering, are we doing enough to fulfill the promise of our design once we’ve put it in place? Or are we failing because we’re putting physicians and managers in charge at that point and not maintaining the involvement of designs?

Claudine Litman: I think that’s probably right to say. I do believe that a constant design eye and the iteration based on the observations being made is important over time. I think what’s especially challenging with physical spaces is the aspect of prototyping. It is very difficult to put in place a prototype of a new space being redesigned and tested. There’s so much infrastructure and dollars that go into it, it’s a really hard thing to test. Now, you would imagine, and not knowing how the design process went about the importance then to being able to really, really articulate and document and analyze what are the main constraints that are going to be inevitable in redesigning the space? Where are the priorities? And who are the stakeholders that have the greatest needs? Because at the end of the day, I don’t believe any design is perfect, but you will have constraints and needs that will override others.

And to be able to use those as your design guidance almost, the things that you will make sure regardless of the material, the space you have or the interactions to happen, that those are the ones serviced first. That’s, again, much easier said than done, but there is a way to go about it to make sure that there are certain features of a space that get addressed as priority versus others that may not be as important and impactful on that experience. But prototyping space is probably the most challenging.

Howard Forman: When you say “prototyping,” what do you mean by that?

Claudine Litman: If you design a digital product, it’s somewhat easy to be able to design the platform, making sure that the digital interactions, you can put a mobile app right in the hands of a user and see how they’re tracking. Are they’re understanding what to click, how to click, how to go about interacting with that tool versus a space that’s 3D and physical. And again, if you think of a hospital setting even more, it’s very difficult to be able to prototype those. Now, certain institutions were able to do that in the past, and they were really testing their ER or testing the patient exam rooms. So there’s a degree of that being done, but that story is not unique, Howie, I’ve have heard that many, many times about reconfigurations and redesigns of spaces in the healthcare space.

Harlan Krumholz: Howie, I first met Claudine through the EMBA program and immediately I thought, “Gosh, this person is amazing, off the charts, amazing and was able to get her involved in CORE.” Actually with Erica Spatz, we taught a course to undergraduates about how to design solutions in healthcare. She came into CORE and helped us think about how we were organized and she worked in that way as a consultant. We had someone who’d been an executive director for many years, Jennifer Mattera, who’d been a wonderful partner for me since we started CORE but was thinking about retiring. And I was able to entice Claudine to join us in a leadership role as executive director at CORE, but Claudine, here’s what I want to ask you, what was it that drew you to CORE? Also a very different direction for you, and what are your hopes for it in the future?

Claudine Litman: Two things I think I would prioritize about what attracted me at CORE. The mission, which is very important to me and I believe very important to the community that’s at CORE today, and that will be at CORE tomorrow. And again, that has always been a criteria for me, what does the organization believe in? So that was very important. Secondly, people. Again, companies have capabilities, they have different business strategies, but if you have the people who are visionary, motivated, they’re experts in their field and are willing to change and transform what they wake up for every day, that matters a lot. That to me is really the most attractive feature of CORE.

Harlan Krumholz: And maybe just for a second you could just explain to people what CORE is again, just so that we’re clear for folks listening.

Claudine Litman: Absolutely. CORE is a group of experts, clinicians, analysts, researchers that really come together to solve a lot of business problems in the healthcare space. That would be my language, but we do a lot of work for CMS and our groups are for a community within CORE, specialists into quality measurement. And we’ve done this work for decades now.

Harlan Krumholz: CMS being the government group that is in charge of Medicare and Medicaid?

Claudine Litman: Correct, Centers for Medicare and Medicaid. So that group in particular really focuses on quality measurement where other groups are top-notch experts in different areas of science, and they’re doing research on these particular areas. And all together we’re really working towards advancing impact in the healthcare community and for patients and providers as well. So I think that it’s been a bit of a challenge not being all together physically over the last few years, but I do believe that the connective tissue that brings people at CORE and that keep people at CORE is this idea that we are truly informing policies and quality in healthcare.

Harlan Krumholz: Why do you describe it as “a business problem”? This is, I think, by the way, the great thing, you’re bringing a different perspective in on it. And I do think at its root it’s a business problem. Howie probably thinks that because of the perspective he brings, but why do you call it business problems?

Claudine Litman: I do believe that the intersection between the business and the design aspect of what we do is the power of what we do. And I do believe that the way in which our experts go about doing the work that they do, they go beyond just delivering on that work. They actually take into account the stakeholders. They do take into account the long-term impact. They do take into account a lot of the aspects that are not perhaps inner scope, but that together actually go beyond and making sure that the solutions that we deliver go even further in impacting healthcare as an industry. And for me if I take it back to my role within CORE, even in how we think about organizing our teams, what are going to be the types of capabilities that we want to put forward?

All those go again beyond just the substance of what we do, and it really goes into how we go about helping our partners and the people that we do work for and with to really deliver solutions that are, again, beyond just the scope of what we do and that actually have a tremendous impact on the industries at large.

Harlan Krumholz: What’s your hope for the next five years? So you’re in CORE, what do you hope happens as a result of bringing this design perspective, the business sensibility into this academic think tank that’s trying to drive solutions within healthcare?

Claudine Litman: My hope is that internally to be able to integrate more design principles in what we do every day, and I’ll expand on that a little bit. If as planners, because there are plans in everything that we do, we’re technically designing every day and in our design process if we’re able to implement design principles in how we go about designing solutions, those design principles should be helping all of us inside of CORE to design solutions that are more efficient, implementable and user-centered design. I think that the processes, there’s so many design processes out there, design thinking, agile and whatnot, and they’re all very important and viable. But if we’re able to really dissect and being able to implement what are the actual tenets that inform these design process? So that as we do our planning and our work in the scope of what we do every day, we are able to put solutions there that are more long-term efficient and implementable and user-centered design.

I really do think that that’s where the impact will continue to evolve and grow, and that’s my hope. That is my hope that moving forward in the future patients and providers have the opportunity to go through journeys and experiences, interact with products and dashboards and information that is designed for them to consume and use and put to good use in their day-to-day journey. So that is my hope. And while it’s not necessarily easy to see the direct connection, I think you and I, Harlan, see it. I think that’s what you and I saw in common in one another as well, the ability to bring science and design together to create a better healthcare. And I do believe that at CORE we have the expert and the passion to do that.

Howard Forman: Thank you very much for joining us. Thank you for joining Yale. It’s almost exactly seven years since you first stepped foot on this campus for that group interview session, and we’re so thankful for that and so thankful that you continue to work with Harlan.

Claudine Litman: Same here. Thank you so much to the two of you, who’ve had a great influence in my career, and I couldn’t be more grateful for that, Howie and Harlan. So thank you very much.

Harlan Krumholz: Thanks so much for joining us, Claudine. It’s such a pleasure.

Claudine Litman: Thank you.

Harlan Krumholz: Hey, that was a terrific interview, Howie. I am so glad that we had her on and got to hear her perspectives, especially the importance of design in healthcare, but let’s get to your segment now. What’s on your mind?

Howard Forman: Yes, this is just interesting. Maybe it’s a little too wonkish, but the FDA issued a sort of reprimand letter to Novartis this week regarding what they saw as misleading advertisement for a drug called KISQALI. This is a drug that is used to treat a particular form of breast cancer. The FDA explained that in the TV ad, which aired in 2022 by the way, that it had overstated the benefits of this drug in terms of patient’s quality of life. This is a six-page letter dated January 18th, for our listeners, but they made clear that Novartis violated the principles of direct-to-consumer advertising as laid out in the original legislation and regulation. And I want to point out this dates back, this is in the legislation from 1962. It’s been revised over time, and you should also, for our listeners, know that we, along with New Zealand, are the only countries in the world, to the best of my knowledge, that allow for direct-to-consumer advertising of drugs. It’s free speech, but it’s regulated.

The FDA has a fairly spotty record of holding firms accountable for their ads and promotional materials. In the last seven years, the most number of letters they’ve issued was seven. Although in 1998, 156 letters were issued. Last year it was just four. And as I mentioned, we have one letter so far this year and the TV admonishments are rarer still. And it may be the case that maybe the earlier large number of letters has led to better practice and better compliance with the law, but it does turn out that the FDA has limited reach in these regards. By the time the FDA gets around to reviewing and responding to ads, they can already be off the airways and the FDA does not require that they get to review ads before they are aired. There are a lot of requirements around direct-to-consumer advertising. You have to make sure that if the drug name is mentioned, for instance, you have to be able to talk specifically about all the risks and contraindications.

But suffice it to say that the companies do know how to comply. And in this instance, Novartis does appear to have gone beyond the actual data and evidence in making a statement of improved quality of life for these patients when the data just wasn’t quite there. So Novartis has an opportunity to respond to this letter, but more importantly, I hope, and I think that the reason why the FDA is so committed to sending out a letter like this is to just try to get companies to remember they have this obligation to the public to be honest about both the benefits and the risks and contraindications.

Harlan Krumholz: It does seem to me like we could do a lot better in these ads, the communications. They drive you crazy when they come on. They’re flashy. The side effects go by so fast, you can’t really grasp them, and they’re not really presenting information to inform people. They’ve got people dancing or showing this is what a happy patient looks like who’s on this med. I bet a lot of people watching them don’t even know what the med’s for, some people who do. I think it’s a predicament that we’re in. It’s like, these should be informative. Maybe they do need some more regulation. I think we need more study of them, but the companies must believe they’re driving sales or they wouldn’t be doing it.

Howard Forman: The evidence is really.... Yeah, the marketing evidence is—

Harlan Krumholz: Is it strong?

Howard Forman: Yeah, the marketing evidence is strong. Direct-to-consumer advertising pays for itself.

Harlan Krumholz: Wow, that’s interesting.

Howard Forman: Yep.

Harlan Krumholz: Well, thanks for bringing that up today, Howie. Yeah, it’s something we should keep our eye on.

Howard Forman: Thanks.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, we hope you can now find this on Threads.

Harlan Krumholz: Yeah, we’re going to try Threads. I’m @H-A-R-L-A-N-K-R-U-M. That’s @HarlanKrum. I should have come up with something better. I don’t know why.

Howard Forman: You can still change it, I think.

Harlan Krumholz: All right. Okay. Maybe I will.

Howard Forman: And I’m @the4man, that’s @—

Harlan Krumholz: Which is much better. That’s much better.

Howard Forman: Well, that was something that my father and I created many years ago, but @the4man, that’s @4-M-A-N, T-H-E-4-M-A-N. You can also continue to email us at health.veritas@yale.edu. And in addition to Threads, we’re still on Twitter, but we’re still here and we’d love to interact with you on LinkedIn if you’re on that platform. In addition to all that, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email or reach out to our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. Extraordinary people that we have the privilege of working with week in, week out.

Howard Forman: For sure.

Harlan Krumholz: Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.