Transformative Changes for Pediatric Health Care

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Welcome, everyone. I'm Dr. John Whyte, the chief medical officer at WebMD. For anyone who is a parent, their child's growth and success is a top priority. As parents, we want to maximize their physical health, but also their mental health.

In recent years, many kids and families have been struggling. How do we fix this? My guest today is Paul King, the president and CEO of Stanford Medicine Children's Health, and he has some potential solutions. Paul, thanks for joining me today.

It's my pleasure. Nice to see you, John.

Paul, I want to start off with we're seeing many more cases, particularly in mental health challenges, for kids. Is it mostly because of the pandemic? Or are we more aware and more attuned to the mental health aspects of children?

I wouldn't say that it's due to the pandemic. The pandemic certainly didn't help. But when we think about mental health, particularly mental health for kids, I think if you look at any of the statistics that are reported through any number of different data sources, they'll share with you that most mental health disease is recognized, I think, more than half of it, by the time you're 14, and nearly 75% of it by the time you're 24.

So if we think about mental health as a childhood disease, clearly, the sooner we can recognize it and begin to treat it, the more successful we'll have in terms of helping kids have a brighter future. During the pandemic, when we were all sequestered and kids were left at home, not only with schooling, but also with just their life in general and being separated from their friends and classmates, I think that exacerbated what was already sort of an underlying condition of anxiety and depression. That is, I think some of the stigma also around mental health has been lowered. It's not, certainly, gone, but I think people are OK with actually talking about it now, whereas in the past that probably wasn't always the case.

So there's the one issue of the mental health. And I also talked about the aspects of physical health. And one of the things that we've seen in recent years is an increase in the rate of cancer in pediatric population. What do you think's going on here? And what are you doing to help address it?

A great question. I think as a physician, John, you know certainly better than I that we actually have a pretty good story to tell, particularly in childhood cancer. I think when you go back to the '50s and '60s, childhood cancer was, in those days, probably a fatal disease, whereas now, many of the cancers that children incur, particularly in the leukemias, they're cured.

And I think the increase that you're seeing in cancer cases across the country, across the world, actually, is an indication of probably better diagnosis and more case capture. We still, I think, have a pretty good story to tell in childhood cancer. I think some of the differences we see in childhood cancer that you don't see in adult cancers is the children's hospitals and children sort of collection of providers.

We probably do a little better job of sharing in terms of the children's oncology group, in terms of what works and what doesn't. And so those better practices are adopted and implemented more quickly in children's space than you would see similarly in adult cancers. And you also see a concentration of children cancer providers, primarily at the larger children's hospitals.

And so there's fewer people engaged in science-backed, science-proven treatments as opposed to a number of providers sort of dabbling in it. And so I think we have a better story to tell in terms of children's cancer treatments.

Paul, you talk a lot about innovations, but you also talk about transformation. So I want to push on that a little, because in the pediatric space, a lot of people have tried transformative interventions and failed. As you know, hospital care, health care is a very difficult beast, maybe, I will say.

So tell us about what you're doing that you believe is transformative, and why are you going to succeed? What's different, where others have equally tried and have failed?

I think there are a couple of ways to interpret your question there, John. I think, one, one way to talk about it is in terms of transformation in terms of actually care processes and how do we approach curing and preventing disease states. The other part of your question, I think, goes to the organization of health care, in terms of, how do we actually go about providing health care that's affordable, that's accessible, that's equitable, and all of those sorts of issues, I think are issues that are separate and distinct from how we go about treating disease.

For example, in our cancer program, we have some of our faculty, some of our physicians who are developing methods and technologies that allow a parent to have a stem cell transplant to their child, which then immunizes that kid, if you need it subsequently, then, to a solid organ transplant, for example. So now all of a sudden, these kids who were on a waiting list, waiting for an organ, a solid organ, now could have one of their parents do that, because their immune system has been sort of transformed to replicate that of their parents so they don't have to be on these long-term immunosuppressant drugs.

Other part of your question, as we think about, how do we reform health care? And to your point, there have been many people who've tried unsuccessfully. When we think about health care reform in general and health care reform in children's health, specifically, I think it's a very daunting task. And so I think our challenge, particularly in children's health, is to make sure that kids at least get a fair shake.

Now, when we think about the reimbursement that we get, if you're in the kids business, you're in the Medicaid business. On average, the average children's hospital has about 50% of their patients whose care is covered by Medicaid. Here at Stanford, that percentage for us is 43%.

I had the privilege of working with our colleagues down in Children's Los Angeles for many years. And in Los Angeles, that percentage was 70-- 7-0-- percent So an average is an average, but on average, nationally, it's about 50%. Also with your background, John, you're aware that Medicaid is a federal and a state program.

Every state has a different sort of flavoring of that program. And so here in California, we have a very rich sort of benefit package where our state Medicaid, which we call Medi-Cal here in California, covers a lot of services, but the level of reimbursement is quite meager. And as a result of that, providers choose not to participate in that program.

So even though a kid or a family may have a Medicaid card, they are still having trouble gaining access. Centers like ours here at Stanford, we take all comers. So we don't really care, quite frankly, what their insurance card is, whether it's Blue Cross, or any other of the commercials, or Medicaid. We'll take care of that kid.

Our faculty here at Stanford are all salaried, so there is no advantage or disadvantage, or they don't really have a reason to care what the insurance coverage is for the patients that we care for. But for those of us in leadership and administration, we have to work with our colleagues across the country to try to convince our elected officials to do something different and better for kids so that that Medicaid card actually provides not only coverage, but, actually, access.

Absolutely. So payment mechanisms play a role in incentives of how health care is delivered. But I also want to push a little more in terms of, you know, we talk about everyone wants to maximize a child's physical and mental health. But what are some of the biggest challenges?

So we know access plays a role. We know that resources play a role. But there are some other challenges. Even though here you sit at the head of a children's hospital, it's not all about coming into the hospital for care that impacts their health.

Some could argue it's what happens when you leave Stanford that really impacts your health as a child. So what are those one or two big challenges that are facing parents and their kids?

Yeah, that's a great, great question, John. As you know, the social determinants of health is what we collectively call them-- all of those things that impact the health and well-being of our population beyond the very small percentage of what we ended up doing with them when they actually come to our facilities. So food security, income security, the environment, transportation, housing security-- all of these things play a role in terms of a family and a child's ability to heal and to receive the benefit of the health care services that we provide.

So here at Stanford, as well as many other organizations across the country, we have leaned into, how do we provide sort of support for our families in terms of making sure that once they receive the excellent care at our institutions, can they, then, leave us and go back home to a healthier environment, whether that be where they live is maybe subject to more air pollution than other parts of town?

So how do you, as a health care system, do that?

What we do is we work in partnership with community organizations. As you also know, not-for-profit hospitals are required to do a triennial community needs assessment. And those community needs assessments are done collaboratively with all the providers in a given community, because you're serving the same community. It doesn't make sense for each institution to do their own.

But through that process, we're able to identify, what are the needs of our community? The most recent one we've had, wouldn't be surprising for you, is mental health access when we look at food security. Those are the things that sort of bubble up to the top.

And so food security, take that, for example-- we also have, with our electronic medical record, an ability to capture families' food security needs at the point of intake. Now, it's one thing to say, OK, this family needs help in the food security space, but now we have to connect an action step to that. And so we work with community food banks to make sure that if we identify a need in our patient family, that we can, then, connect them with a local food bank to actually provide that.

What do you say, Paul, to folks, though, that say-- just to interrupt that-- say, that's not the expertise of a children's hospital? You're there to treat serious health conditions, and there's other people that should be doing that. And as you and I know, many of your providers might say, they're not trained to do that.

They don't have time to do that. They're already overworked, overburdened. So I really appreciate what you're talking about, but not everyone shares that same perspective. So why should they adopt that perspective that you're doing?

That's a great pushback, John. I think the logic and the rationale of that is you want to make sure that you're addressing those other social determinants of health. Otherwise, the dollars you're investing in fixing and repairing health are wasted. So if we do all that we can here to bring a child back to a healthy state, and then they go back to the same environment that created that, it's just a cycle that just repeats itself.

So we can say that it's not our job, it's not our responsibility to do that, but as part of a community, and I think that's the magic here, we have to do that in partnership with others in the community.

Absolutely. Those are fair points. I think part of it is also, as we think more nowadays about the social determinants of health, on the clinical side, that's not typically something that doctors have been trained in and that are thinking about first and foremost. They're thinking about, how do I manage that condition in front of me?

And that's what they're hyper-focused on, whereas you're thinking more broadly about what we mean by "health" and "health care." Do you think that plays a role in what priorities are of a health care system?

I think it does, particularly in children's health. I think our physicians, because family-centered care and patient-focused care, is not a slogan for us, that's the way we actually have to do our business. Our patients can't advocate for themselves.

So they always have an advocate with them-- mom, dad, grandmother, trusted family friend, whomever that may be. And those caretakers are part of our care team as well. So we don't have the luxury of isolating just the disease. The other thing that happens, not only in our hospital, but even in adult hospitals, for that matter, is life doesn't stop at our front door.

All of those challenges that families are facing, all of those restrictive orders, all of those whatever family dynamics that comes in with the patient. And so particularly in a children's hospital, where we have to embrace that family because they're part of our care team, we have to go there in terms of, OK, what's going on with housing? What's going on with transportation?

And so our physicians, as opposed to saying, "I wasn't trained to do this" or "that's not my job," they actually have to embrace that as well. We have a number of our physicians who are advocates in this space, and, quite frankly, they push me as a CEO in terms of saying, we actually need to do more of that. As I mentioned before, we also have embedded in our electronic medical records capturing some of this information so that we can make sure to address it to ensure that the effort we're putting into healing that child isn't wasted by missing something that's contributing to that underlying condition.

What are you most excited about that you're currently working on at Stanford?

I think here at Stanford, we are blessed because we're here part of this crazy Silicon Valley world, and we have a board of directors who represent some flavoring of that in terms of venture capital, private equity. And so that idea of innovation, trying things, failing fast, checking, adjusting, and coming back and trying again, I think that spirit is infused in the work that we do as well.

So when we think about all of our employees, both physicians, nurses, therapists, administrators, God help us, all of these folks are called upon to bring their best to work every day. And if they have an idea, we have systems in place to take those ideas to, you know, hard test them and say, hey, is there something there or not? And I think that kind of environment just infuses energy into the space and allows us to do our best work.

And it also helps us to be here as part of a university, a research university, where some of those ideas can take hold and then actually end up helping populations well beyond Stanford, well beyond California. So that's always exciting. In children's health, we're in the future business.

So every one of our kids that we make better, that's an investment in the future. That kid's going to have a great life. Their family's going to be better because of that. Our community is going to be better because of that. So in the children's space, we're optimists by training.

By design. I love that approach-- investing in the future. Well, Paul, I want to thank you for all that you're doing to advance the future of kids and to share with us what you feel are some of those key priorities. So thank you.

Thank you, John. It's a pleasure.