Dr. Rebekah Gee: Can We Bring Family Healthcare to the Home?

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

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we will be speaking with Dr. Rebekah Gee. But first, we’d like to check in on current health news.

Harlan Krumholz: Yeah. Howie, you know I like to usually try news you can use, what’s going on in the ecosystem. And it’s been a busy week but again, I’m drawn back to talking about COVID. I just can’t help it. A couple of high-quality articles that came out this week. And one was in PNAS, one of the strongest scientific journals, came out about transmission. And while—people have talked a lot about, how long does COVID stay in the air and how long does it stay transmissible? And they’ve studied this thing in depth. And what they said was that actually, there’s an initial rapid decline in infectivity, within a few seconds to minutes of the aerosol generation. And I guess that’s consistent with how we’ve been thinking about this. It’s not that it lingers in the air or that it stays around for a long time. But it is true if you get into an elevator, a bunch of people were just in it, the breathing aerosolizes the transmission, the virus, the medium. It’s the medium for the transmission. And according to them, it can be seconds to minutes.

And it also depends on the relative humidity. The more relative humidity there is, apparently, then the better it is for the virus with regard to transmissibility. And then you see an article like this where they do all sorts of things to try to understand, and then they say something that you think, “Did you really have to study this to make this conclusion?” They concluded that transmission is greatest the closer you are to the source of the transmission. Okay. Thank you very much, I think we knew that. But one of the other things that they commented on was how much variability there is from people who are generating infections.

So that’s one thing. I thought that was interesting, just in terms of how it stays suspended, but: not that long. And that seemed to make sense. Another thing that came out this week was that a panel of FDA advisors have recommended us to think about COVID-19 vaccines for the fall, and that whether we should be taking vaccines that then take into account Omicron. And I think this is interesting because it seems like our regulatory and vaccine speed is moving with all due slowness because we’re actually marching forward with new variants all the time.

So we’re actually debating whether or not we should be using Omicron only, or whether Omicron ought to be folded in with the original vaccine, and how much should be done. But meanwhile, this new variant, the BA.5, represents 37% of COVID cases in the United States. And the BA.4/5, which is these two new variants’ combo, has now overtaken that one that was most recently here, BA.2.12.1. And all of these are still within the Omicron family, but the spike protein continues to mutate in ways that are evading our own defense and are likely to make even the early Omicron vaccines, I believe, to be less and less effective as time passes.

And it’s likely over the course of the summer that we will see continued evolution. And by the way, people, remember when we talked about Delta? Anyone remember Delta? Zero percent, according to the CDC. Zero percent of the COVID in the U.S. now is Delta. And if you look at the early Omicron variants, they really represent 5% or less of what you’re seeing. And like I said, these new ones within the Omicron label, the WHO label of “Omicron,” meaning that it’s still that general family. We went from Delta to Omicron.

But this is the point. When people are seeing so many people coming down with the virus, it’s because despite the fact it’s still Omicron, like I said, the spike continues to mutate and to cause problems.

So anyway, that’s the update. I think still yet to be told [is] what’s going to happen with boosters in the fall. What should we be doing? The new variants, again, spreading quickly throughout the population. Some consequence, of course, but...

Howard Forman: We’re talking about specific Omicron boosters three to four months later than we initially anticipated as well. If you think back to November, December, when this first happened, everybody said we could get boosters out by March. And now here we are at the end of June. So we’ve got to learn to somehow catch up to the speed of this virus.

Harlan Krumholz: Right, and we’re going to catch—we will have given it in the fall for something, the variant that existed a year prior. So let’s get onto Rebekah Gee. I can’t wait.

Howard Forman: I’m delighted to introduce Dr. Rebekah Gee. Dr. Gee is trained as an obstetrician gynecologist and is a tenured professor at the LSU Schools of Public Health and Medicine. She served as the secretary of the Louisiana Department of Health from 2016 to 2020. And prior to that, was chief medical officer for Louisiana Medicaid. During her term, Dr. Gee oversaw the expansion of Medicaid to over 500,000 Louisianans. She is an advocate for health equity and created the South’s first Office of Health Equity in a state department.

She’s an elected member of the National Academy of Medicine and an amazing mentor to many current physicians, medical students, and undergraduates and others. She’s an advocate and national leader in tackling pharmaceutical pricing.

She graduated from Columbia University, where she received a BA in American History and an MPH in Health Policy and Management. Cornell University, where she got her MD degree. Trained at the Brigham and Women’s Hospital at Harvard during her OB-GYN residency and completed the Robert Wood Johnson Clinical Scholars program at the University of Pennsylvania, where she received yet another master’s degree. She’s got four Ivy league schools in her background.

Harlan Krumholz: You know how one of my darkest days was when she decided to go to Penn instead of come to Yale for that—

Howard Forman: And she has told me that in the past as well. But today, we’re going to start off learning about her new venture at Nest Health, where she is the founder and CEO, which is... Nest is dedicated to improving care delivery and health for young children through a commitment to the children and their parents in the home. So, first of all, welcome to the podcast, Rebekah. You continue to inspire me. I’m so excited to learn more about Nest.

Rebekah Gee: Thank you, Howie and Harlan. The two of you are extraordinary. Having such impressive scientists and academicians and intellects.

Harlan Krumholz: Oh, come on. Oh, go on.

Rebekah Gee: But also, a real commitment to the community.

Howard Forman: Keep going!

Rebekah Gee: Both of you guys.

Harlan Krumholz: Thank you.

Rebekah Gee: No. You guys are—

Harlan Krumholz: Let’s hear about Nest. Come on. We want to hear about the company.

Rebekah Gee: As you mentioned, Howie, I’m former Secretary of Health for the state of Louisiana, where I led, was responsible for half the state budget, led disaster ops, led disability services, Medicaid, the Medicaid expansion, which now in a post-COVID era has over 600,000 people. And it was tremendous. And also as an OB, my career has really focused on both issues of health equity and women and children’s health. And I’ve led, for many years, efforts to improve healthcare quality for our state.

We really focus mostly on hospitals. We know that Black women die four to five times the rate of White women in pregnancy, and that we did a lot of great things in partnership with many great people to improve outcomes. And we were able to reduce morbidity by 60% in two years in Louisiana hospitals. But what we really haven’t done a good job in is redesigning the care delivery system, which is what Nest does.

What you did mention, Howie, is I’m a mother of five kids. I have two sets of twins and a middle child. They all are brilliant. They all have behavioral health diagnoses. They’re very challenging and brilliant. And as a working mother, it’s been really hard for me to manage this. And I have resources, and I’m a woman of privilege. Think about women who are low-income in this country. And this became so clear during COVID that we do so little for caregivers. We leave them so little options. We give them so few resources, not affordable childcare. There’s not a guarantee to paid family leave. We don’t have adequate transportation, public transportation in this country as we do in other nations.

And so it’s just that the degree of difficulty that we place on low-income working mothers, many and in fact most of whom are single mothers, is just extraordinary if not impossible to access care. And so that’s what Nest does, is we take care to them. Think of it as concierge care or care at home for lower-income folks. And we meet people where they are. So come to the home, take care of the entire family, thinking about combining appointments. If you have three kids, not different appointments, different days for different well-baby exams, and then yourself, different time for vaccine. But instead, one appointment, everyone at once.

Meeting those needs holistically. I’m thinking about nutrition in a holistic fashion, thinking about child development, parenting supports and what we’re calling the fourth trimester, that period after a woman delivers where in this country, we really... many women, including myself after I had my twins, felt alone, feel alone, not a lot of support. Changing that paradigm, making sure that we have home visiting and a parent advocate there to help make sure that things are happening in a healthy way.

So we’re bringing whole-person family care home. We’re really excited about what this might do to our models. We have, for example, right now, and we’ll get into talking about the Roe decision later, but 40% of women don’t go to a postpartum visit. So talking about the data that informs the creation of this company. Forty percent of women. We know that 50% of pregnancies are unintended. That postpartum visit is where women get contraception. What we know is that women will prioritize their child, their newborn, over their own health. But what’s happening, as a result, is women aren’t getting the ongoing contraceptive and reproductive healthcare that they need. And so that is part of what Nest aims to address, starting in the American South, which of course is the place in this nation now that needs this the most.

And what I didn’t mention. Our care team, really thinking about nursing leaders, nurse practitioners, MAs go into the home. We’re training as community health workers. We’re going to bring in a pediatrician, a PCP, a primary care document. And then behavioral health and nutrition because our minds and bodies are connected, and our current health system really doesn’t appreciate that. And so bringing all this into one model where you have a coherent sense of that family as they develop, and a consistent resource for that family, we think will really move the needle.

Harlan Krumholz: So one of the challenges is that the healthcare system is built around bound money, honestly. And Bob Galvin, who now works for Blackstone, we all know, who has famously taught the clinical scholars at Yale and has famously said, “Follow the money. Follow the money.” So that issue of money driving healthcare has led to the fact that those people who need the most help get the least. So when you’re developing a company that’s going to focus on those with the greatest need, how are you going to make this work from a business point of view? What’s the business model here that’s going to enable you to be sustainable and thrive by serving those who actually have the greatest need?

Rebekah Gee: And so, Harlan, there’s a reason why people... we are the only business that we know of in this country right now that’s a startup or a smaller company trying to improve the lives of moderately, moderate- to low-risk kids and their families. There’s a reason that people aren’t flocking to it. And it’s because if you were following the money, you wouldn’t even try. Because as a nation, we have decided that low-income children are not our priority, and low-income moms are not our priority. And we have crappy outcomes as a result.

And so what some of this involves... I’m an entrepreneur now. I have venture funding, was fortunate to get the opportunity to build this company through 8VC [Eight Partners VC], which is a venture fund. And Joe Lonsdale, who I developed a relationship with, believed in this idea of supporting families and has given me the resources to do this. I thought it was important to make this company work for profit. Why? I was formerly a CMO of Medicaid, CMO of Title V, I ran equality initiatives, and I’m sick of seeing everything that works being grant-funded and HRSA-funded. And it’s not scaling.

In New Orleans we have 6,000 moms who... and only 100 of them have a nurse-family partnership nurse visiting. So we’re going to figure this out, is the answer to it. And where the money is, is also in kids because you deal with volume.

So if you think about not a per-child payment, but a per-lots-of-kids payment. You have in Louisiana over 50% of kids on Medicaid. You have, as a nation, lots of employers. Think about Amazon, Walmart, lots of, hospitality industry. What do they care about? They actually care about their employees showing up to work. So there’s a value in making sure that people are well, they don’t have to miss work to go to a visit.

Part of what this business is, is testing out all these assumptions. Looking at, “Okay. Can we get a case rate for that family?” You’ve got a mom, a dad, maybe grandma, and three kids. Instead of having it be where Landmark can make it work, because it’s an elderly individual who has Medicare Advantage, we can make as much money if we go see four people. So that’s what assumption we’re testing. But to be honest, I have never been... I’ve been laughing a little bit about this, is I try to do hard things that are impossible, like taking on pharma. I didn’t want to spend this part of my life just doing something incremental, I wanted to revolutionize healthcare. And so it is challenging.

It would have been a lot easier to start Nest and wear an app or a widget. Let’s go after employers, let’s go after, as an employee benefit so we’re kind of cute. Not that these things don’t work, but they... I did not want to go after the Lululemon mom, like me. I wanted to think about changing society, how we structure the support. So it’s a journey, but I have got a lot of help. I’ve recruited the COO of Landmark and Babylon to—companies that are worth over a billion dollars. She’s incredibly adept.

There are lots of different funding streams that we can access. So we don’t have blinders on to the profit. We have to make money to make this work, but first we’re getting this model right, and then billing. We can bill for these things, and we can at least break even on that. And then we’re going to do a lot better by making sure that we optimize our value-based care model.

Howard Forman: How much of your business model is built around the existing payment models from presumably Medicaid managed care in Louisiana and maybe other locales, versus you negotiating with the state or the payer around creating alternative payment models, as you’ve suggested? Payment models that might be built around the family as opposed to around the service.

Rebekah Gee: Yeah. So right now we’re dual-track. We’re going to go in with all-payer to start. So there’s no wrong door for providers who want to shift to us. So if you’re on Blue Cross, the Nest will take care of you. If you’re on Medicaid, the Nest will take care of you. Our customer acquisition plan is to go after lower-income families and families that have not engaged effectively or have been able to engage the healthcare system. So that’s to start with fee-for-service, but we’re not building a fee-for-service business.

So we’ll start with that, collect the data... In parallel, we’re meeting almost every day with the managed care plan to talk about that model, what value-based contracts could work. We’re talking about a variety of different value-based frameworks. But as I mentioned earlier, there is also an argument for the Nest for a large employer, particularly for lower-income individuals who don’t have adequate supports. There’s an argument for Nest for the private sector. We know that there are many, many low-income families in Louisiana that are in the exchanges, or are employed, people that are...

For example, the MAs who... We’ve just hired one yesterday. She’s making $17 an hour and she has three kids. And so in New Orleans, that’s, she is lower-income. So she’s exactly one of the folks that we’d love to help, and she’s going to come on and help us learn how we help improve lives.

Howard Forman: So I want to pivot, in our final minutes, to just talk about—obviously, the biggest issue right now in this country over the last week is the loss of agency by so many women through the Dobbs ruling, overruling Roe v Wade. You and I have talked about this in the past. You have very strong feelings about this topic, and they have evolved over the course of your life. I would love for you to just give us your comments from the point of view of the Nest, from your personal point of view and your history. What are your thoughts on this?

Rebekah Gee: Sure. I grew up Mormon. I’m the great-great-granddaughter of a Mormon prophet, and I probably was pro-life/anti-choice-oriented. And in medical school, I spent most of my rotations at Lincoln Hospital in the Bronx because I really wanted to be with people who were more open to having med students, and I could be of more help. And there was both a sexual trauma unit, sexual abuse unit, as well as an HIV—at the time, crack baby ward. And there were just child after child crying in there with no one to hold them and just devastated. And the thought of having this life, what is that life going to be like? And so I changed. And there are lives that are just horrific, in terms of what happens. And the neglect and unintended pregnancy we know leads to a lot of consequences for that child.

And so I changed my opinion. I’ve spent a lot of time during my career advocating for reproductive rights. I sued Walmart when I was a resident and won, a lawsuit to get them to provide Plan B in their stores. It changed their national policy. It became a big issue of concern. When I came to Louisiana, I realized I was not going to have a career focused on reproductive health because of the climate, but it really focused on the inner conception and was able to get... even under Governor Jindal, we had all of these changes around contraception.

I, in partnership with Medicaid, got a state plan amendment for family planning. Louisiana on a report last year was number one in the nation for postpartum birth control and Medicaid, so did a lot. But on the abortion side I worked for a governor, by the way, who was the most extraordinary person I’ve ever worked for. Governor John Bel Edwards. Graduated from West Point, incredible man of honor and distinction. A brilliant guy. It was an amazing job because he deferred to me, let me do... He was not fearful of me taking on big battles. He just said, “Basically, Rebekah, stay out of politics. You do health, and I won’t tell you what to do. Just make people healthier and expand Medicaid.” So it was great.

But he is pro-life, he’s a devout Catholic. He truly believes in that. It’s not just baloney, he believes it and he signs bills, and it was very challenging for me to navigate. But on the one hand, at the time I worked for him, we were expanding access to care for hundreds of thousands of women. So I was able to sit right morally with myself, with my own moral compass. What became difficult at the end was my name then, because as secretary, I embodied the department in terms of the legal case.

There was a case, June Medical Services v Gee. There was no getting out of it, my name had to be on it, and it was going to the Supreme Court. It was about admitting privileges. If it had gone in the favor of Louisiana, it would really have been the undoing of Roe v Wade before this recent Dobbs case. So I decided I had to get my name off by March 2nd. I retired from the job March 2nd and got my name off that case. And now having seen the governor sign this bill criminalizing, putting potentially my colleagues in jail, I couldn’t... I’m glad I didn’t have to make that choice because I would have had to quit. So I’m really glad I got the chance to work with him, and that we got a chance to do these things together. I firmly believe there needs to be room in the Democratic Party for people with different views, including on this issue.

But it was a sad day. Frankly, I’m still sick about it. I have never, in my lifetime, seen my rights be taken away. And I feel a personal sense of responsibility. I have three daughters, and shame on my generation for letting this happen.

When my friends emailed me and they said, “Oh, well, I’m so shocked.” I said, “Well, where were you? When I was at the Capitol, where were you when these bills got passed? Because I know the pro-life people were there. What campaign have you donated to? When did you run for office? What have you personally done?” We took it for granted, and here we are. And it is devastating. People walked around New Orleans and even now, women, we feel this. And here the question now as an OB is, “Okay, you need one to save your life. Well, what matters? Does your heart matter? What about your kidney? What about your intestine? What of you needs to be alive for me to do this, even for a baby that’s not viable?”

That is just really, really, really difficult to stomach. So that’s what I think about it, I think it’s a sad day. And I know that most Americans, even those in Louisiana, are not for... They don’t understand what the consequences of this will be. And then sadly, they’re going to have to see them for this to change. But yeah, it’s a sad moment.

Harlan Krumholz: I appreciate that too. It’s something for all of us to reflect on. I told you, I wanted to just do one thing here at the end. You told me you’ve written a book recently. When I first met you, you told me... Many now years ago, you told me the story of your mother who had developed a terminal illness, recognized that her life was going to end prematurely and had written you letters for you to—I’m going to cry when I say this, because every time I think about it—letters for you to open on your birthday for many years after she was gone. I wonder if you could just tell people listening about that story and what you’ve done in writing a book about it.

Rebekah Gee: Yeah. So my mother died, she was a couple months younger than I am now. And she was an extraordinary woman. As I said, she—

Harlan Krumholz: How old were you?

Rebekah Gee: I was 16. Yeah. And I am now 46. So she was an ethicist, a professional ethicist. She was an incredible writer. And she, for much of her adult life, was the wife of a university president, which in the ’80s meant you did the duties. You did the party planning and the menus and the this and that. And she never got recognized for that contribution that she made, and she actually fought for that. She had breast cancer at a time when people didn’t talk about breast cancer. You didn’t have the pink parades and all of this. It was an embarrassing thing to have in that time.

And so she was just really courageous and left an indelible mark on me, not just with these letters but by her life. And as she was dying, wrote me these letters. So I got to open them every year. I would get a FedEx from my dad with a letter, a note saying, “Hey, Rebekah. I love you.” And I would be at Columbia or at Cornell or wherever I was studying at the time, opening these up, trying to reckon with what she wanted for me, which I was not able to have a conversation with her about and what I was doing.

And I disappointed her in that she desperately... as she got closer to dying, became more religious, then really wanted me to marry a Mormon man and follow the admonitions of the LDS church, which I didn’t believe in. I actually really struggled with that. I studied Mormon history in college and ended up going into the archives and really searching the truth, but decided to leave.

And so anyway, this year I’ve written a book called Letter Day Saint about these letters. And I’m now the age she was when... I wrote them, actually, when I was the exact same age she was while she was writing these, while she was dying. And I get to respond to her and tell her my story.

And then also, and as important, I think more important to me is her voice. I am not someone who sits down and writes for fun on weekends and whatnot. She was. She was an extraordinarily beautiful writer, so I really want, this is part of her legacy, so I’m trying to get this published. So if anyone knows a publisher, let me know.

Harlan Krumholz: That’s good.

Rebekah Gee: It’s on This American Life. So if you want to hear this story, it’s called “Parent Trap.” And they did a wonderful job interviewing me and my dad about how all this went down. And she was extraordinary. So she taught me to live life in fast-forward. She taught me that life is critical. And then I almost died a few years later. You knew me, Harlan, when I got hit by a... literally got hit by a truck and it killed my husband and nearly killed me.

So I guess the blessing of that, the flip side, is I’ve been reminded that life is precious. I’ve had that opportunity on multiple occasions, and I do try to take it... Howie follows me on Facebook, so he knows that I have a... I have a lot of fun too.

Howard Forman: You do.

Rebekah Gee: And I live in New Orleans, one of the greatest cities on Earth. And I have these five colorful children, so I take that seriously too, all of the other pieces. Not just the career.

Howard Forman: You’re an amazing public servant.

Harlan Krumholz: Thank you. And you’re a good friend and a colleague, and we so appreciate you taking the time with us.

Rebekah Gee: Oh, thank you. It’s an honor.

Howard Forman: We’re going to have you back, Rebekah, because I think there’s at least four more hours we can do.

Harlan Krumholz: Great. So, Howie, let’s turn to our last segment now. And we always like hearing what’s keeping you up at night or occupying your thoughts.

Howard Forman: Yeah. Following on what Dr. Gee talked about, in terms of the Dobbs ruling, this is going to be an ongoing topic. And it’s not something that I think is a simple topic to continue to talk about, but I think it’s important that we continue to raise the issues related to it. The most obvious impact is on the women who are or may become pregnant and their loss of agency over their own body in many locales. But this issue spreads far and wide within healthcare.

So abortions are healthcare. And when you make abortion illegal, you are impacting healthcare in numerous ways, many of which are not obvious. I am confident that the next several years will expose many more unintended consequences of this change in legal status. But I wanted to review some of what we already know and expect. So first, a few quick data points that our listeners may not be aware. The vast majority of abortions, 93% roughly, take place in the first trimester. And a slight majority of these occur through the use of mifepristone and misoprostol or medication abortion.

In fact, about half of all abortions are medication abortion, even at present. And that number’s been growing considerably over the two decades since that’s been approved. In areas where abortion is made illegal, obviously a higher percentage of abortions will then occur via medication abortion, even as the total number of abortions overall will be reduced due to lack of access.

So here’s three healthcare items that I’d ask you all to consider and think about. Nineteen states, as a start, will make remote prescription of abortion pills difficult, if not impossible. We may see the criminalization of prescribing of these pills leading to bounties and aggressive enforcement.

I would point our listeners to a very helpful summary of these concerns by Charles Silver in Health Affairs this week. He’s a law professor at the University of Texas at Austin. In his essay, he makes clear and cogent parallels between the war on drugs and the expected war on abortion and abortion pills.

Two, more than 40% of all OB-GYN residents by dint of the location of their training program will likely have to find new means to learn how to perform abortions, which is a necessary part of their training.

And three, medical record keeping, either by the patient or by the physician, will start to be more risky for people in some locales. Because when it comes to documenting whether it’s pregnancies, periods, miscarriages and so on, this information then becomes subject to potential discovery at some point and potential liability for the individual and criminalization.

When the Constitution was written, the founders did not contemplate the telephone, let alone telemedicine. They didn’t contemplate healthcare apps or the Metaverse. But here we are with laws that continue to be written around physical encounters when so much of what we do is happening virtually, and much harder to police by one state or another. Criminalization of the pregnant person receiving an abortion is very much a concern, even though lengths at the present time have been traveled to avoid this. Suffice it to say, the consequences of this ruling will be harmful to women and will likely lead to unnecessary deaths.

But we are just at the beginning of contemplating the vast impact that this has on our national healthcare delivery. Professor Silver, in his essay, ends with this quote: “A public health strategy that emphasizes education, female empowerment, and ready access to long-term contraceptives will outperform a punitive approach on every metric that matters, and will do so without converting the U.S. into a police state.” I hope that cooler heads prevail and that we can prevent further harm from this ruling.

Harlan Krumholz: Howie, we’re entering uncharted territory here, at least territory we haven’t seen for at least 50 years. And with different capabilities, with different issues, also all this stuff around surveillance. And if people even go to another state, following up people... There’s just so much at play here, so appreciate your words and insights on this. And it is indeed a situation that will continue to evolve. But it’s hard to imagine that this has occurred. And now that we live in a country where there are just such very different laws and expectations around rights for women, and that... I don’t know. The implications are profound. The implications are really profound. It is a public health issue now, and it definitely deserves all of our attention.

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, you can find us on Twitter.

Harlan Krumholz: I’m @hmkyale. That’s hmkyale.

Howard Forman: And I’m @thehowie. That’s at T-H-E-H-O-W-I-E. Aside from Twitter and our podcast, I am 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 for more information on our innovative programs, or you can check out our website at som.yale.edu/emba.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. Talk to you soon, Howie.

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