Brian Kenny: When night falls in Las Vegas, Fremont Street lights up, awash in a canopy of 12.5 million LED lights and a 55,0000 watt sound system. But there was a time when the flashes that lit the sky over the Nevada desert were anything but benign. For four months, beginning in 1951, the United States military detonated atomic weapons 65 miles northwest of the Vegas strip. Assured that they were a safe distance away from any fallout, tourists clamored to Sin City for dawn bomb parties, downing atomic cocktails while waiting for the spectacle.
It was the sheep of Iron County, Utah, who first showed symptoms of radiation sickness. Before long, leukemia and other rare diseases were showing up in clusters in communities all over southern Utah. The “downwinders,” as they came to be known, were the unsuspecting victims of radioactive fallout. No one's sure of the full extent of the toll on human lives, but in 2000, the National Institutes of Health declared that 49,000 deaths could be directly linked to the testing.
And the effects linger on. Downwinders in Nevada, Idaho, and Utah, are still at greater risk for developing cancer. But now, there's someone looking out for them. Today we'll hear from professors Richard Hamermesh and Kathy Giusti about their case entitled, Intermountain Healthcare: Pursuing Precision Medicine. I'm your host Brian Kenny, and you're listening to Cold Call.
Richard Hamermesh is an expert on the business issues affecting health care policy and delivery. Kathy Giusti is a senior fellow at Harvard Business School, and the founder of the Multiple Myeloma Research Foundation. Together they co-chair the Kraft Precision Medicine Accelerator. Thank you both for joining me today.
Richard Hamermesh: Pleasure to be here.
Kathy Giusti: Thank you.
Brian Kenny: Really interesting case about Intermountain Healthcare. It's chock full of information, but also relevant, timely and compelling. Richard, start by telling us what led you to write this case.
Richard Hamermesh: As you mentioned, Kathy and I are co-chairs of the HBS Kraft Precision Medicine Accelerator, whose origin was a $20 million dollar endowment gift from the Kraft family, to quote unquote, advance progress, accelerate progress in precision medicine. Kathy and I have been at this for three-and-a-half years now. Part of what we do, in typical HBS fashion, is try to document best or leading practice. And in that regard we are at conferences all the time. We caught wind of Intermountain Precision Genomics and Lincoln Nadauld.
The light bulb immediately went off that this could be a great case, the challenges of delivering precision medicine. There are lots of challenges in developing precision drugs… There is a third author, [HBS professor] Rob Huckman, who's more a health care delivery person. Kathy and I are more on the biotech drug development side.
Brian Kenny: How does the case begin?
Richard Hamermesh: Well, the Intermountain Precision Genomics effort started three years prior to the case—the case is set in early 2017. Lincoln Nadauld, the director, is assessing the progress they've made, and how it's gone, which sets up the questions in class: How have they done? Why did they do this? Have they met their objectives? At the same time, they've been so successful in my mind, that some of their original initiatives have now taken on a life of their own. Dr. Nadauld is wondering what's the next thing to do? He's considering two alternatives. One, to try and figure out if there's some genomic test that would indicate for people who have depressive syndrome, which of the SSRIs would be most appropriate for them, and then he's also sitting on a tissue bank of 10 million samples, and he's wondering if they sequence those samples, could you glean some insight? It's both a big picture "what next" and then two specifics, very typical of a case.
Brian Kenny: Kathy, can you tell us about Intermountain Healthcare? What's their story? What's the big picture there?
Kathy Giusti: I think the beauty of this case is that Lincoln comes in. He cares deeply about precision medicine, and he led the way in precision medicine in oncology. Technically, that was a great place for Intermountain to start, to say, "We care about oncology, we care about sequencing the genomes of cancer patients, and I'm going to start where the highest unmet need is," which are Stage IV patients that desperately need to get their genomes sequenced. I think the fact that he was able to get Intermountain started around precision medicine, around oncology, made so much sense, because then you can move to other diseases in the precision medicine space.
Brian Kenny: Where is Intermountain located?
Kathy Giusti: In the Utah area. As you said, there is a high prevalence of cancer issues. The issue they were facing early on was that they were not the most well respected place in the community for cancer care. For Lincoln, moving that over to the precision medicine space was truly helpful. It helped to set Intermountain apart right from the beginning.
Brian Kenny: But Lincoln was coming from Stanford [University]. How did Intermountain Healthcare convince Lincoln to come from Palo Alto, California, to a pretty rural part of Utah?
Kathy Giusti: As you saw in the case iIt took him a year of discussions to actually get to that point, and they actually talked about having legal quagmires that went into that. But I think the beauty of it was they were allowing Lincoln to have a research space. When you come in from Stanford, from the academic space, you still want to believe that you are doing your research. You also tie that back to the culture of Intermountain, which was about excellence in clinical care. Yes, we want the research to be getting done, but we take great pride in making sure that the clinical outcomes are as strong as they possibly can be. What Lincoln is passionate about is sharing data in those community centers with a two-fold approach. One is: identify new targets where you can, but second is optimize the care pathways that every patient should be on. That is the best thing for a patient to hear.
Richard Hamermesh: Two things. Intermountain is known for developing patient care pathways that result in better outcomes and lower costs. The other thing is that there was a very personal story that Lincoln went through when he was at Stanford, a 39-year-old mother of two with advanced stomach cancer. He tried to get her targeted therapies, and of course, this was a number of years ago. And you would need to get compassionate use or off-label use. By the time they finished getting through all the regulatory hurdles at Stanford and the NCI and so on, the patient passed away the day before. I think that left Lincoln with, yes, he can do all this great research at Stanford, but he also wants to be at a place where he can have an impact on patients who are very sick, who he knows there's a drug that may work. And, Intermountain is so dedicated to patient care and pathways.
Kathy Giusti: But remember, too, I think it's interesting in tying it back to Kraft, that was the same story that you heard with Robert Kraft and why he started the precision medicine accelerator was the same thing happened. His wife gets diagnosed with ovarian cancer, they can't find a drug for her fast enough either, and I think the focus becomes two-fold. One is, should we be sequencing patients earlier so you're not frantically trying to find out what their genome is? The second is, how do you accelerate the drug development so that you identify the target and you get a multitude of new drugs to that space?
Brian Kenny: For people listening who don't know what precision medicine is, can you put a definition on it?
Kathy Giusti: We always define it as getting the right patient, the right drug, at the right time. And when you look at it in the field of oncology, it's so important for every patient to understand that just because you've been diagnosed with one form of cancer, like for myself multiple myeloma, it doesn't mean that my myeloma looks like everybody else's. There's ten different forms of myeloma that we know of. And each of those will end up being treated slightly differently. So, as a patient, you need to know your subtype, your specific genome as much as you possibly can, because it will affect your treatment, your care pathway, as Lincoln would say. Secondly, the more you share that data, the faster we can identify a target and attract pharmaceutical companies and biotechs to the field, to give us the new drugs we need to help cure you. That data piece becomes really important in precision medicine.
Brian Kenny: Let's go back to Intermountain for a second. They've got a history of innovation. You mentioned that HBS had written cases about them as much as 10, 15 years ago. This case outlines some of the real innovations that they've come up with, even those not directly related to precision medicine.
Richard Hamermesh: Dr. Brett James led this effort. It really is applying Toyota management, Edward Deming principles, to health care delivery. What does that mean? Reduced variation, and developing several paths everyone would follow. The results have been quite spectacular. Some of these are outlined for acute respiratory distress syndrome. By just standardizing the treatment—what order you give antibiotics, how many you give—their survival rates went from 9.5 percent, and this is a tough syndrome, to 44 percent. That’s a huge deal.
And just by having better and more specific criteria for preemies [around] who gets into an incubator or not, survival increased and costs were cut dramatically. The answer was, as often happens in medicine, that less is more. If you can get the right therapy, you don't need as much. One other note. That cost Intermountain money, because in our fee-for-service system, if you have a preemie on a respirator, you get reimbursed handsomely. Not nearly what you'd get if they're just getting I.V. antibiotics and not on the respirator, but for them, their mission is the best treatment at the lowest cost. But starting with the best treatment.
Brian Kenny: So, Kathy, clearly Dr. Nadauld is in a place that's open to innovation. They're willing to do things differently. Precision medicine has a set of obstacles that come along with it.
Kathy Giusti: The biggest obstacle is that in precision medicine, the joy was that genomic sequencing started to happen, started to become somewhat affordable. But the question becomes, who pays for it? That's obstacle number one. The patient doesn't know to ask for it, and then even if you do need to get it done, you're not sure who will be willing to pay for it. It was hard to get every patient sequenced at that time. The second piece is … trying to get an abundance of a critical mass of data becomes a problem. So, patient awareness, reimbursement of the testing, and then the ability to share datasets all are the great obstacles on the precision medicine side.
Brian Kenny: And are there things that you are looking at in the Kraft Precision Accelerator to address some of those things?
Kathy Giusti: Every which way. In the accelerator, what we do on the patient side is work with five cancers to say, "What is the awareness that all five cancers, breast, prostate, pancreatic, lung, myeloma, have on precision medicine? What's their understanding of genomic testing?” Surprisingly, less than half of patients knew about precision medicine, and only 20 percent fully understood what genomic testing was all about. With Kraft, we're educating everybody on the patient side, and we're doing it in a collaborative way. On the data side, we tell everybody where the oncology data is, who the machine learning companies are, and how we combine datasets. We're actually doing that kind of work.
Everything we do moves in a cycle at the Kraft Accelerator, starting with the patient, helping them to understand the role of their data, moving that data to the clinic, and then making sure the venture firms understand with the most innovative models, how you commercialize it faster, addressing exactly what Lincoln and Robert Kraft were looking for. We need to get these drugs in the hands of the patients as fast as we can.
And what I thought was interesting about Lincoln, too, he always talks about [HBS Professor] Clay Christensen all the time, he is sort of a mentor.
Kathy Giusti: When Lincoln was talking about this whole idea, he reachied out to the advisory group and Clay was on there. And in just studying the case, [Christensen] stood up and said, "This is innovation. Let's allow Lincoln to do this." When you have leadership like that within your organization, that helps you.
Richard Hamermesh: But just back to what Kathy mentioned on data. Intermountain has a great information system … but, as Kathy said, it's limited. Pparticularly on the less common cancers, no one has enough data. And this is a great example, and it's in the case, he realized that they were seeing cases that he didn't have a large enough data set to really be able to help the patient. What does he do? He starts something called the open network.
Brian Kenny: Tell me more about that.
Richard Hamermesh: He was able to get Stanford Medical System and Providence Health Systems to combine their datasets, so that when he would have a patient of a certain sort, a certain subtype, a certain age, a certain sex, and he says, "I need to see 12 patients like this." He may have only three. Well, 12 isn't great, but I'll tell you, it's a lot better than three. More and more with precision medicine, almost every cancer is becoming a small subset. Here's an example of someone who could rest on his laurels at Intermountain, but instead he's thinking bigger picture, how do we get even more data?
Brian Kenny: One of the things I was thinking about as I read the case was he's behaving like more than just a doctor here, he's thinking holistically about the whole process from beginning to end, which really gets into some serious management issues. We talk about information that's living in different places, and how do you pull that together, he's thinking about business models.
Kathy Giusti: He’s just an amazing man in terms of his leadership skills. When you get to know him I think it's the passion of the patient, as we saw. Because this patient really registered with him that had gastric cancer. But it's also the fact that he's business savvy, and it just comes naturally to him when you meet him. And third, is he has an amazing network. Somehow along the way, when you see he's reaching out to these other health systems … he's reaching out to people that know him and trust him, and know he's going to get things done. That's the leadership that allowed a lot of good people to come to Intermountain, and I think it's how he built the network around him. Even when you see Lincoln at a medical meeting and he's speaking, people go to his panels because he has something important to say. We tend to want to work with him because we know he will get things done.
Brian Kenny: What were some of the things they did to operationalize this at Intermountain?
Richard Hamermesh: There are three pieces of it. The first is, you get sequenced. Now, initially it was stage IV cancer patients, very sick people. They developed their own platform for this, and in typical Intermountain fashion, could turn it around very fast. Time is of the essence here, right?
Second, once you have the genomic information, what do you do with it? And like with a lot of things medical and in particular when you're that sick, there could be a difference of opinion on what to do. He formed what was called a molecular tumor board, both people in house and people—to Kathy's point about the network that he built—who would talk on the phone after hours. Let's all review this case. Here's what the sequencing says.
Third, a drug procurement team, who live night and day to deal with all the insurance companies and get off label use, get compassionate use, and as the case chronicles, of course at the beginning it was long and arduous. They've been doing this for three years, and 95% of the cases can sail through right away. Because they've been there, done that, a typical experience curve type of thing.
Brian Kenny: And they're gathering more data as they go.
Richard Hamermesh: Exactly.
Richard Hamermesh: The survival of these patients as a result of being on these targeted therapies, their survival increased just about two-fold. Now there was a downside, there is always the downside. The longer you live, the more cost you incur. It's sort of a red herring issue when you teach the case, because in the end this is whole purpose. Extend life and we'll figure out how to pay for these things. I'm not trying to minimize the…
Brian Kenny: No, I was going to say it's not a trivial question though, because we know we've got a health care payer system that's very complicate to navigate, that is very fickle about what they will and won't cover. So, how are they grappling with that issue?
Kathy Giusti: He's looking at late stage patients, who at that point they need to be sequenced if you're going to find last resort drugs for them. But the truth is, and this is a positive for the FDA, FDA doesn't get upset about this. You're also starting to get anecdotal information about what those targets are. And even though the drug might be a lung cancer drug, you may find new targets for other cancers. It's a very informative dataset that he's playing back to you. I think the joy of it is, once you start to get that anecdotal information, it gives the drug companies and the patients an understanding of where else these drugs might work, and then they can get additional indications on the label. And that can be incredibly powerful.
The business model for Intermountain was, yes you're getting the late stage patients, yes it's costly to take care of them, but you're establishing yourself as a very strong cancer center, and you're starting to bring in a lot of the other cancer patients that are going to be much earlier stage that you can have a greater impact on. The business model made a tremendous amount of sense, and it was incredibly thoughtful for all of the patients as well. The fact that he ended up also combining datasets with other health systems became really powerful. He understood that the larger I make this database, the better off we're all going to be over time. That helped everybody, too…
Richard Hamermesh: I don't think in health care that you can start with a financial motivation. I'm enough of a cheery-eyed person that I think if you do the right thing, it ends up paying off. And maybe not even in the real long run. Pretty soon.
Brian Kenny: Do you see Intermountain as something that could be replicated and scaled in other places?
Kathy Giusti: Absolutely. It takes the leadership of a Lincoln and the team he brought in to do it, but it’s absolutely scalable. You just need the right kind of health system. Everybody has big datasets. And the more they start to work on this, the better off we're all going to be. Most of cancer care is happening at the community level. 75 percent, they often say, is happening out of the community. So the more we can work with them, the better off we'll be. I think the joy of what an Intermountain does, especially is this closed system and a payer component to it, is they're always looking at the analytics.
Another part of what Intermountain does well is the education side… So, what he has often said is, if you come up looking at the data with the best care pathway, he still wants to make sure that that data, that medical education, is shared fully with every clinician at Intermountain. He likes to work with even patient advocacy groups to say, how do I communicate this and get the best myeloma doctor to talk about how this care pathway works? And then they can even watch to see if they execute the care pathway, what are the outcomes that they're changing. And so, because they have this amazing closed system everybody wants to work with them. I think they're setting the tone, but there's a number of health systems that can do this. It's a good thing for patients.
Brian Kenny: Do you get a sense from class discussions how people who are in the health care system will adapt to something like this? Are they going to eventually hit a wall where the system is not ready to accept it?
Richard Hamermesh: I think you've gotten the theme. I think great leaders, that's what they do. They figure out either how to bust through or go around. This started in a small part of Intermountain, a lot of innovation starts not in the center, but where you have more degrees of freedom. There are lots of leadership lessons. More and more, you are seeing a focus on developing care pathways. And he's a real pioneer.
Kathy Giusti: You look at first movers to second movers, and that's what Kraft does well. Within each of those work streams, we can definitely see who's a first mover that's doing the absolute best work in direct-to-patient, or data and analytics. Then you try to put them very close together with who could be the second or third mover. That way you start to move the system much faster. That’s a really good way to go because leaders want to work with other leaders.
Brian Kenny: Going back to Kraft for a second, how are you feeling about three years in about the progress you've made?
Kathy Giusti: I feel like we've made tremendous progress, I also think, Richard and I laugh about this, that we're solving a problem that nobody knows is out there. Over the years, I gave academic centers a hard time for not sharing their data, but the truth is, cancers don't talk to each other. And it's not that we're bad people, it's just that there's no easy vehicle by which to bring us together. So, one of the interesting things about the Kraft initiative is we literally are bringing all the cancers together to talk, to share best practices, to share their data, to share information that they would never have shared before. I think they're solving a lot of problems much faster than ever before. We feel much better that myeloma, pancreatic, glioblastoma, breast, prostate, are learning so much from each other, and speeding things along. We've made tremendous progress there.
The other thing we've identified is a lot of people don't know the real problems behind precision medicine. We've been doing it with them from the genomic standpoint, but in all honesty, this is not just an oncology issue. This is an Alzheimer's issue, it's a neurology issue. The more we keep disseminating our information we'll start bringing a lot of groups together, which will be really powerful.
Brian Kenny: Thank you both for joining me today.
Kathy Giusti: Thank you.
Richard Hamermesh: I appreciate it. Thank you, Brian.
Brian Kenny: If you enjoyed Cold Call, you should check out HBS Skydeck, a podcast series that features interviews with HBS alumni from across the world of business, sharing lessons they've learned and their own life experiences. Thanks again for listening. I'm your host Brian Kenny, and you've been listening to Cold Call, an official podcast of Harvard Business School.
Interview recorded on January 14, 2019. This transcript was edited for length and clarity.