Former CDC Director:
How to Fix Healthcare

A system designed to reward sickness

Michael Krigsman: He said to me, "We've studied it. The ROI for good diabetes care is positive, but it takes 7 years to turn positive, and our average beneficiary is only with us for 4 years, so I have a fiduciary responsibility not to provide good diabetes care." Dr. Tom Frieden ran the CDC under President Obama. He was health commissioner in New York City and is now CEO of Resolve to Save Lives, a global nonprofit.

His new book is The Formula for Better Health. Dr. Frieden, why is our health system set up to fail?

Dr. Tom Frieden: You get the system that has been designed, and our system gets the results that it was designed for, and those results are failing too many people. Now, the real question then is both why does that happen and how to fix it. And if it were easy, it would be done. But fundamentally, it's about incentives. Let me put it bluntly.

If you're a provider and you do a lot of great work and you prevent your patient's heart attack or stroke, you and your health system make a whole lot less money than if you don't do a great job and your patient has a heart attack and stroke. I don't think there is a single clinician in this country who wants their patients to have a heart attack or a stroke.

But I know that because our system is set up the way it is, we have a massive number of predictable heart attacks and strokes.

The weakness of primary healthcare

Michael Krigsman: Please elaborate on this. Explain to us how this disconnect takes place, the causes for it, and how it manifests.

Dr. Tom Frieden: We have an extraordinarily complicated healthcare system, but one of the things that I discuss in my book is the importance of keeping things simple, not simplistic, but simple. And if you keep it simple, one of the major flaws in our healthcare system is the weakness of primary healthcare.

Primary healthcare is where you get most of your healthcare, and that is true for every clinical encounter from a pregnant woman to a senior who is dealing with end-of-life care and everything in between. It goes so much better if you have someone who is your advocate and your translator in the healthcare system, and yet we underinvest in that. The number that you cited, hundred million, it's just stunning.

I mean, really keep a good sense of just how dysfunctional that is. In this country, we spend nearly a fifth of every dollar in our economy on healthcare. We spend about twice as much per capita as the next highest spending country, and nearly one in three people don't have the single most important thing that is needed in our healthcare system.

And if you look at the outcomes, something like blood pressure control, which should be really simple, that's done right less than half the time. So we're spending $4.5 trillion a year, and we're getting the most important question right less than half the time. It would be really hard to spend more and do worse. In fact, no country in the world does.

But I do really wanna make clear that this is not about healthcare facilities or the clinical services. I have no doubt also that if you've got a complicated medical problem and you're in the right place with the right team, you can get better care here than anywhere in the world. I'm not claiming that the US isn't doing a great job at many things in healthcare, but at preventing things, we're a laggard.

How Kaiser Permanente aligns incentives

Michael Krigsman: Can you talk about the economic relationships and economic incentives? You mentioned insurers, hospitals. We have primary care specialists. We have the government and so forth. What is the confluence of these groups that leads to the situation you've just described?

Dr. Tom Frieden: First off, our system developed over so many years in so many ways with so many different interest groups that it's really difficult to unpack the problems. Sometimes it's clarifying to look at the exceptions, and one of the things I discuss in the book is the Kaiser Permanente healthcare system.

When there are rigorous assessments of the quality of healthcare in the US, usually the top 5 systems in the country are Kaiser Permanente, and that's because it has different regions that operate quasi-independently. And they're not a little bit better than the rest of the healthcare system. They're a lot better, and there's a simple reason for that. Wonderful as Kaiser physicians are, it's not that their doctors are better. It's that their incentives are different.

If Kaiser prevents heart attacks and strokes, the system is more stable. It makes more money. It has more money it can invest in more things. If it allows patients to have preventable heart attacks and strokes, it ends up making less money. That's the exact opposite from most of our healthcare system, and that's the fundamental detail that we need to fix.

Michael Krigsman: That detail being the alignment of economic incentives?

Dr. Tom Frieden: Yes. And people talk a lot about value-based care. If you don't make more money by preventing a heart attack than by treating it, you're not in a value-based care system.

Michael Krigsman: Folks who are watching, you can ask your questions. Right now, there's a tweet chat taking place on Twitter, X. Use the hashtag CXOTalk. If you're watching on LinkedIn, just pop your question into the chat. Please, folks, take advantage of this opportunity. When else can you ask one of the most prominent healthcare advocates in the world pretty much whatever you want? So take advantage of this.

Dr. Frieden, you've been talking about the alignment of economic incentives. How does that work differently at Kaiser Permanente than the broader system that yields the results, the positive results you described?

The fiduciary case against good care

Dr. Tom Frieden: Kaiser Permanente has a capitation model. So you're paid by the number of people who you care for, and there's some adjustments, but basically you get a lump sum, and then there are a few things that will change that with incentives. And importantly, Kaiser's clientele are very stable. So the same people they're treating now are likely to be the people they treat in 20 years.

The payer and the provider are in the same organization. So in most of the healthcare system, you got the payer over here, and the providers are here, and the patients are there, and they're all fighting. The patient wants to get access and wants to be healthy. The provider, you know, doesn't wanna be hassled with insurance forms and wants to be able to provide good clinical care without the administrative burden.

And the payer is struggling to provide more, better services with increasing costs, while controlling costs and making profit. The Kaiser model flips that. All of the players are on the same side of the table working for the same goal, better care at lower cost with more independence, healthier people.

And it's just striking if you step back and say, "That's actually not the goal in most of our healthcare system." In fact, Michael, I'll tell you a painful story from the time when I was health commissioner in New York City. I met with the head of a large insurance company, and I was pushing for better care of people with diabetes, and the care of people with diabetes is really substandard in this country.

You know, everyone with diabetes should have their blood pressure controlled less than one thirty over eighty. They should have treatment with either a statin or another cholesterol-lowering drug if they're 40 years of age or older, and their glucose should be controlled ideally to an A1C of 7 or less or 6 and a half and less.

And really, those first 2 things are gonna provide them most of their health benefit, but it's very important to give comprehensive care, and there are other aspects as well. So I was going over this with the CEO, and he said to me, "We've studied it. The ROI for good diabetes care is positive, but it takes 7 years to turn positive, and our average beneficiary is only with us for 4 years.

So I have a fiduciary responsibility not to provide good diabetes care."

Michael Krigsman: I'm speechless. And this was from a healthcare CEO?

Dr. Tom Frieden: Yes.

Why vertical integration is not enough

Michael Krigsman: I can take this in and understand it rationally, but emotionally it's very hard to absorb this. Let me ask you about another type of healthcare provider that does have the pieces all under one roof or very closely aligned, and that is CVS. You described Kaiser Permanente, where the pieces are together and it yields these really great outcomes. But then we have CVS, which owns the pharmacy and owns the PBM and now owns clinics.

All these folks are together, working together to turn a profit. So how is that so different from Kaiser Permanente?

Dr. Tom Frieden: Doesn't have a hospital, doesn't have ongoing primary care. So yeah, you can go there for episodic care, but they don't know you, your family, your concerns. This gets back to primary healthcare. Primary healthcare is where you get most of your care when you need help, and this is what's so lacking in this country and around the world.

And I hope we'll get into more discussion of global health issues, but I believe that primary healthcare is the way we have to improve our health systems so that we can close this deadly gap between all these great treatments that we have and what actually happens in the real world.

Now, there are those who say, "Oh, primary care, that's so old school, you know, the family doctor, horse and buggy. We're past that. Specialists know everything." No. You know, when... If you've got a simple medical problem, fine, you can get that addressed one time. But for most people who have a chronic illness, there are many aspects of their care, and only a really good primary healthcare team can address those interests and help you manage it, not because they're gonna tell you what to do, but just the opposite.

They're going to make clear to you what are the options so that you can do what you wanna do for longer. But we don't do that. And you are seeing some measures. I thought you were going to go in a different direction. I thought you were going to ask about concierge medicine because this is a new direction in US healthcare system, and you can definitely understand it from the patient perspective and the provider perspective.

Concierge medicine is kind of, as it sounds like, it's kind of very high, high class. Some of it is not so expensive, some of it is super expensive, but it basically says, "We're gonna give you a team, we're gonna give you an individual, you're gonna know who your doctor is, and they're going to manage the system for you so you don't have

Michael Krigsman: To." And then we have a dividing of the healthcare system between people who can afford to pay for essentially being outside the initial aspect, having the outside the core system.

Dr. Tom Frieden: Concierge medicine is what Lewis Thomas used to call a halfway technology in that, you know, it does address the issue, but it doesn't address the problem, and the problem is a broken healthcare system. It's very expensive and doesn't deliver the kind of value that people need.

Michael Krigsman: We have a very interesting question from Arsalan Khan, who's a regular listener. He asks incisive questions, and he asks this. He says, "The for-profit nature of healthcare, a few key players in healthcare technology, and the resistance to change from various stakeholders are the issues. One entity can't fix this. Who can really fix all of these problems?"

Dr. Tom Frieden: One of the characteristics of these intractable problems that we face is that no one is clearly accountable. The system is complicated. That's why I think the approach has to be not so much to think about who can do it as what is the technical package, and I talk about this in the book. What is the approach that we need?

And then to think about what can be done by state governments, what can only be done by the federal government. Are there things that insurers can do? Are there things that providers or healthcare systems can do? Where are the positive outliers?

You know, even absent something like Kaiser Permanente, one of the things that we've analyzed is the different medical groups in the Minneapolis-Saint Paul area, and even though they are in different systems, they've coordinated in ways that improve patient care. So just 'cause we can't fix everything doesn't mean we shouldn't fix anything. We can, on the one hand, make incremental change wherever is possible.

On the other hand, we need to really try to make the bigger changes that will drive very rapid health progress.

See, believe, create

Michael Krigsman: Do you want to talk about your solution? You talk in your book about see, believe, create, and also as we have this discussion, if you would weave in examples from international health as you mentioned before, that would be great.

Dr. Tom Frieden: There is a formula that has already saved millions of lives. It can save millions more, including your own, and that formula is see, believe, create. See the invisible, believe that what may seem inevitable actually can be changed, and then work collaboratively, strategically to create a healthier future. Each of those 3 aspects is essential. That is the formula for better health.

So start with see the invisible. We need to see the threats. What are the microbes and toxins and also the trends that might be killing us? See also why we tend to ignore the biggest threats, and I discuss the Cassandra curse. Cassandra was a priestess in Greek mythology. She could see the future, so she knew which tragedies were gonna come, but she was cursed. Nobody would believe her, and so those tragedies that she foresaw came to pass. For all too long, we've been like Cassandra.

We can see the tragedies, but we walk right into them. I go through why that happens and how to counter it, and also using rigorous, scientific, fact-based evidence, see the pathway to progress, see how we can make progress. So that's the see the invisible part.

And in global health, we at Resolve to Save Lives, the organization I run, we partner with countries to see things like what's the trend in pandemic risk, and how can we bring that down? What's the trend in blood pressure control? Because high blood pressure is actually the world's most neglected condition. It kills more people than any other condition.

Eleven million a year, that's nearly one out of every five deaths in the world, and that's more than all infectious diseases combined. It's more than COVID at COVID's deadliest and at a younger age. So see the trends and see the pathway forward, what's called the technical package, what you need to do to make progress. That's seeing the invisible.

Then comes to believing the impossible, shattering an illusion of inevitability. We kind of assume the world is as it is, and it'll stay that way, but it's changed a lot, and it can change more. And I go through how to strengthen belief in the possibility of progress, and one of the ways is what we do at Resolve to Save Lives, to support countries to make phased progress because making phased progress shows that progress is possible and builds momentum.

And then the really hard part comes. After you can see the invisible and believe the impossible, you have to create a healthier future, and that means being very rigorously organized. It means simplifying, communicating well, and overcoming barriers because there are always going to be barriers to health progress.

One of the things that we've done at Resolve to Save Lives with more than fifty countries around the world is to support them to enact regulations or laws to ban artificial trans fat. Artificial trans fat is a toxic substance. It's added to food. It's now banned in the US and banned in more than 60 countries, 50 of which we supported to do that.

And in those countries, people don't have to worry about, "Oh, is there trans fat in my food?" You've changed the default value, so it can't be in the food, and that kind of policy change does require overcoming opposition, but having done it. Once done, it's going to be durable, it's gonna be sustained.

When we're done and we're called with the World Health Organization for the global elimination of trans fat, when that's over, no child will ever be exposed to trans fat again. Because if you think about it, programs that eradicate a disease are the ultimate in both equity and sustainability because they are for everyone and forever.

Measles and the misinformation crisis

Michael Krigsman: Can you describe how this see, believe, create approach could be applied, for example, to the current measles outbreak that we see in different parts of the US right now?

Dr. Tom Frieden: With measles, it's really important to see what the threat is. I began my career as a disease detective and epidemic intelligence service officer working on measles in New York City. We had many thousands of cases, hundreds of hospitalizations, tragically, children who died from measles. Measles is perhaps the most infectious of all infectious diseases.

You can see situations where one child with measles was in an emergency department and then left, and people coming in for the three, four, five hours after, if they were susceptible to measles, they got measles because it stayed in the air. So it's really effective at spreading, and the vaccine is highly effective and safe. So we need to see the pathway to progress.

We need to believe, hey, we got rid of measles. For the last 25 years, there hasn't been any measles in the US. All the cases have come from a traveler who went visiting and then came back and brought it or someone who was here and spread it.

We're going to lose that status in the next few days or few weeks, as a symptom that we've allowed measles to get a toehold again. But believe we've made progress, believe we can make more progress, 'cause we have, and then create a healthier future. So what does that mean? Simplifying. Simplify the vaccine recommendations, organize well, make sure that when there are outbreaks, we respond rapidly. Time is lives in an outbreak.

Even a couple of days can make a huge difference between a small outbreak and a large outbreak. And communicate well, and here is where we really do have a problem. Misinformation and disinformation are perhaps the most lethal health threats facing this country and the world. Why?

Because they undermine everything, every single step that people can take to live a longer, healthier life, whether that's what they do in their own lives or what medicines or vaccines they take or who they consult for information or what advice they follow, all of that is at risk because we are facing a fire hose of falsehoods driven by the monetization of misinformation. Fire hose of falsehoods driven by monetization of misinformation.

We need to address that by revealing it, also by communicating well, and that starts with listening. What are people hearing? What do they believe? And it turns out that, in fact, the vast majority of Americans understand that vaccines work and they're safe and they're effective.

I think there is a way to apply see, believe, create to the measles outbreaks in this country. It's also going to require real focus, and this is one of the insights I have from my career, that if you don't have an indicator of how well you're doing, it's very hard for government systems to function well. And we should be looking at things like vaccine rates by different states, by different groups, and then where there are problems, it's not about blaming. All right, let's work together and see how we can fix it.

Michael Krigsman: Let me just ask you to elaborate on a point you made. You said the monetization of misinformation is such a serious problem. Who is monetizing this misinformation or disinformation?

Dr. Tom Frieden: If anyone is selling you anything, don't believe anything they tell you about what may improve your health. What we're seeing from social media is enormous efforts to sell products, usually with very high profit margins, sometimes with some evidence of efficacy, but usually without. And this really preys on people's legitimate desire for objective information and a route to a healthier future. And I'm gonna go right back to this.

This is why having a primary care team is so important because you wanna have someone who has your best interest at heart, and ideally, in a good system, will actually do better economically if you're healthier, who is interpreting this information for you and answering your questions.

AI as a clinical partner

Michael Krigsman: Let me go to a question, again from Arsalan Khan, just because this is... Usually, I like to spread the questions out among folks, but this question from Arsalan is really, really great. He says, "Have we tried using the power of AI to quote-unquote, fix this multi-set of multi-level healthcare problems? Do we need a political push behind that?"

Dr. Tom Frieden: I'm a huge believer in the quality and potential of AI. I use it constantly in my life. I kind of think I'm partly becoming a cyborg. I'm part AI and part person in what I do. I've said before and I believe that it is now malpractice not to care for a patient with an AI as part of the team.

That's a pretty bold statement, but as a physician, I can tell you there are just a massive number of articles coming out, drug-drug interactions. Just in the last twenty-four hours, I was consulting on a treatment and a new article on a rare disease came out within the last twelve months that suggests that one treatment should definitely not be used. Now, I'm familiar with that rare disease.

I didn't know the article had come out. The doctor caring for the patient didn't know the article had come out. So this is just one type of example of the power of AI. What we have to always remember about AI is that it has really bad judgment. It has a great information bank, and some of the models hallucinate a lot less than others.

Some of them are tuned for medical work specifically, and that's important, and even those need to look really carefully at the different use cases within health and public health. So we're learning more. We need to try things and learn. I think it has enormous potential, but at this point, it's mostly just potential and documentation that it's improved outcomes, improved efficiency.

I'm optimistic that will come, but we don't have it yet, and we haven't figured out all the ways to make it work in a way that is safe and includes efficiency.

I was speaking with someone who is high up in one of the companies doing this, and I asked them about something I've been interested in for the work that we do in countries around the world, which is could you use it to help with triage? Triage is, you know, you've got a full waiting room, and what do people need and who should be seen first?

And I've thought from a naive standpoint, not knowing a whole lot about this, oh, that sounds like a great use of AI. And that individual was very reluctant.

They said, "Hey, you know, I understand the need, but that's really serious 'cause you get it wrong and something bad's gonna happen, and that's almost more like a medical device than just answering questions or being part of a team or transcribing or being an ambient listener." So I think, yes, AI has a lot of enormous potential, but we haven't yet figured out how to use it and use it safely, and that'll be, I think, the challenge of the coming weeks and months.

There's so much to keep in mind about AI. One of the things is that it's changing really fast, that some of these systems are getting better, you know, day to day, week to week. And 2 is that it's inconsistent. You can ask the same question in the same way on 2 different days and get different answers, and that's scary when you're thinking about medical advice.

Michael Krigsman: It's probabilistic rather than deterministic. I have to tell you, I had a medical thing, and I put all of the data into an LLM, and then I wanted to find a new physician, but I wanted the best person, and it was Claude I was using. I have the paid version of Claude, so you get some more depth there.

But Claude recommended, like, the right guy who's the chairman of the department, one of the big hospitals here in Boston, and then described why what he researches match what I have, and then I was going... Then I was able to research that person's papers, and lo and behold, I was able to get an appointment with, like, the top guy literally in a week. Well, with his PA, but I'm in his queue. It armed me.

It was amazing.

Dr. Tom Frieden: It armed you with information so that you could take more control of your life, and that's a great use of AI.

Structural change over moral appeals

Michael Krigsman: This is from Julia Goldberg Raifman, and she says she was struck by the story about diabetes care not being profitable. How might we encourage healthcare leaders to balance moral leadership with fiduciary leadership?

Dr. Tom Frieden: Diabetes care is very profitable. What's not profitable is prevention of complications for patients with diabetes, and that's a structural problem in our healthcare system. There are examples of parts of the healthcare system where that's not the case. Some of our community health centers work that way.

There are some demonstration programs under Medicare, such as the Accountable Care Organization program, working with doctor-operated Accountable Care Organizations, where when you prevent a heart attack or stroke, you actually save money and make money. So I think the most important changes are the structural ones. I don't think this is the result of a moral failing. I don't think that our system is lousy because people are greedy or selfish.

I think we have to, of course, look for the caring clinicians, look for the team that meets our needs. But we also have to try at the local level, at the facility level, the system level, the state level, the national level, we have to try, even if it's incrementally, to have our system change so that when people are healthier, the clinicians make more money. And that's a big change.

Michael Krigsman: You're making the assumption of healthcare practitioners and business leaders being morally responsible, but we need to align their goals more effectively, would that be the right way to say it, with positive patient outcomes and prevention?

Dr. Tom Frieden: Yes, absolutely. Basically, our healthcare system needs to reward health rather than reward volume or procedures. And again, in the book, "The Formula for Better Health," I talk about how to overcome barriers because there are big barriers to making progress here. There are, for example, hospitals and specialists that will make less money if we do this, and they're gonna oppose this.

If we say, "Oh, you know, let's pay primary care practitioners more, and let's incentivize team-based care where you have a whole team," 'cause that provides better care with nurses and pharmacists and outreach workers as well as the doctors. It provides better care at lower cost. Well, that money has to come from somewhere, and the places it comes from are going to oppose it.

All right. So what are the ways that we can analyze who wins and who loses? Who are the deciders and who are the influencers? Who are the advocates and who are the partners who can make a difference? What are the pragmatic compromises we can make, and what's the timing for those compromises? And with all of that, we can make incremental progress.

I talk in the book about Vinny DeMarco. He's an advocate in the state of Maryland. He spent over a decade advocating for really important healthcare improvements. He built a coalition, and because of that, Maryland has some of the best health policies in the country, and they can actually do things that allow them to pay for health. It gets a lot of opposition, but they've been able to make some progress, and it really shows how much difference an advocate can make.

What we generally see is that you need entities within the government, you need people who are reform-minded who want to make progress. You need advocates pushing them to do the right thing and supporting them when they do, and you need a rigorous monitoring system to track whether those changes are on track, keep everybody honest so that you can make more progress.

One of the real challenges about doing things in the public sector generally and in healthcare specifically is that we don't have the kind of feedback loops that you have in the private sector. In the private sector, if you're selling something and no one's buying it, you stop selling it. That doesn't happen in the government sector. In the healthcare sector, the people buying healthcare are generally companies buying it for your employees.

The employees or the patients getting healthcare are maybe paying co-payments or other things that really aren't correlated with the value of the care that they receive. So we have this very broken system, and to try to improve it so that patients get the care they need, the providers aren't being hassled with administrative requirements that take them away from patient care, and we end up providing more care that does more for more people.

The dismantling of public health infrastructure

Michael Krigsman: This is from Chetna Mehrotra Naima, and she says, Dr. Frieden, she's always been a fan of your work. Given how the CDC has been dismantled and has little say in public health messaging, including vaccine utilization, how can we build trust in what public health agencies, including local and state health departments, do and their communication?

Dr. Tom Frieden: It's been difficult for me as a former director of the CDC to see what's been happening to CDC. I don't know if that will get better in the coming months and years, but we shouldn't understate the damage that's been done.

Front and center has been the damage to our vaccine infrastructure, where highly respected independent experts who did not have conflicts of interest were all fired from the key entity that recommends vaccines and advises doctors on what works, the Advisory Committee on Immunization Practices. And that committee was then stacked with ideologues, many of whom have economic interests in the anti-vaccine movement.

So we really have a takeover, a hostile takeover of what was really a model program, and we're seeing other assaults on our vaccine infrastructure that will be very important to monitor.

One of them is a very little-known fund called the Vaccine Injury Compensation Fund or VICP, and what that does is says, "Okay, there are times when vaccines do cause problems." There's about a one in a million rate of serious adverse events for various reasons.

And rather than make all of those people go through our legal system, and some of them get big payouts, and many of them spend years and years and don't get anything, let's have a schedule. Say, if you have this from that vaccine, you get this much money. Now, that system isn't perfect. The number of judges or adjudicators hasn't changed in decades. The amounts provided haven't changed in decades.

So yeah, it needs to be modernized. But what Secretary Kennedy and his colleagues are trying to do is to put autism into that injury compensation fund because they're arguing that the measles vaccine causes autism, which has been studied repeatedly. There is no evidence to suggest that the measles vaccine causes autism.

But if you opened up for every child who has a diagnosis of autism, and virtually everyone's gotten the measles vaccine, so to sue that fund, you're gonna sink that fund. And then the parents who do have problems won't be able to get their response.

But the broader issue of CDC really is that it's an agency that has worked for 3/4 of a century keeping Americans safe. And there are still thousands and thousands of dedicated health professionals there who, I know, have turned down jobs where they could make more money in the private sector because they care about protecting Americans and keeping Americans safe from threats.

I hope what we'll see in the coming months is Congress insisting that the money they allocate for CDC and the programs they support for CDC actually get implemented because that didn't happen last year. Congress said, "Do this," and the administration didn't feel it had any need to do what Congress told it to do. So let's see if that happens this year 'cause a lot rides on that question.

Building trust starts with listening. So local health departments, state health departments need to understand what people are hearing, what they're seeing, and then to speak with the right messages and the right messengers in ways that people can understand. But this issue of where is there a beacon for valid health information, this is the most common question I get asked.

And right now you can look at medical societies, pediatrics, obstetricians and gynecologists, they have guidance out there, but if people are selling anything, don't believe what they say.

Michael Krigsman: Do you have any thoughts or explanations why the CDC is acting the way it is?

Dr. Tom Frieden: Well, I think the real question is why is the CDC so much in the crosshairs of this administration? And I don't know the answer to that. A lot of it does come back to the COVID pandemic and a belief, well-founded or not, that the CDC was behind mistakes that were made. I talk about this in the book at some length.

I do think there was a serious mistake made in 2020 where the CDC messed up a lab test. This was incomprehensible to me. During my time at CDC, a new flu strain came out, we came up with a new lab test, we distributed a million primer versions of it to more than a hundred countries, all the ones needed in the US without a glitch, within weeks. But this time there was a mistake.

Someone at CDC made a mistake or a team made a mistake, and they sent out a test that didn't work. It cost about 3 weeks of time early in the response, and that was a very costly 3 weeks 'cause it was just as COVID was coming in. So I think the hostility to the CDC is bound up in our frustration with what happened with COVID.

I do wanna emphasize that there are still thousands and thousands of dedicated health professionals at the CDC. They work hard, they're the experts in their area, and they're really dedicated to protecting people. New polling data just came out yesterday showing that Americans do trust the scientists at CDC a whole lot more than the politicians who sometimes are speaking for it.

Finding outbreaks faster with seven one seven

Michael Krigsman: Folks, ask your questions. We have a little bit of time left. If you are working in healthcare, what else will you have the chance to ask Dr. Tom Frieden pretty much whatever you want. So if you're on LinkedIn, pop your questions into the chat. If you're on Twitter, X, use the hashtag CXOTalk. And this would be an excellent time to subscribe to the CXOTalk newsletter so we can... We want you as part of our community.

You guys are great. Dr. Frieden, your book describes a system that you call seven one seven, where accountability is the goal. Can you talk about that?

Dr. Tom Frieden: We have been working for many years with countries around the world and realized that fundamentally, when it comes to infectious disease threats, our goal is to find problems faster and stop them sooner. And working with countries, we co-created this seven one seven approach.

Seven days to find every new threat, whether it's a suspected outbreak or a real outbreak, one day to report that threat to the relevant public health authority, and seven days to have all essential control measures in place. Seven one seven. When we began looking at this, only about two out of ten outbreaks met the seven one seven criteria.

We've been able to work with countries to look at that and to use every single outbreak as a way of improving outbreak preparedness. So whether it's a foodborne outbreak or measles or, in parts of the world where yellow fever is still present, yellow fever or cholera, dengue or other problems, to ask the question, not as a way of blaming people, but as a way of doing continuous quality improvement.

Did we find it quickly and stop it soon, or didn't we? And if we did or if we didn't, what were the things that went well? What were the enabling factors and how we strengthen those? And what were the bottlenecks, the things that didn't go well, and how do we address those and break those down? Currently, about fifty countries around the world are already using the seven one seven approach.

It's been adopted by many national and international organizations. It's a way of making visible what's usually invisible. When we stop an outbreak, nobody knows, right? Nobody woke up this morning and said, "Oh, thank goodness I didn't die from smallpox." But smallpox used to kill millions of people a year.

My organization, Resolve to Save Lives, publishes a periodic spotlight that's called Epidemics That Didn't Happen. And we identify a great team from somewhere around the world that found and stopped an outbreak before it spread so that we can begin to see the invisible, the outbreaks that didn't happen.

And what seven one seven, this approach to measurement does, is it allows us to see whether or not our systems are keeping us safe. And that 2 out of 10 is going up to 3, 4, 5, 6 out of 10 in many of the places where we're working. It's not perfect yet. We need investment in public health because that's investment in our safety, but this is one way of giving accountability and accelerating progress.

Michael Krigsman: Does this kind of approach work effectively in the United States as it has overseas?

Dr. Tom Frieden: We believe so, and there are 10 or 20 health departments around the US using it. They've generally found it to be very positive. It doesn't cost much to do. You just need a systematic way of tracking what happened with each outbreak and what was the timeliness, and then spend a couple of hours looking at, oh, well, what worked well, what didn't work well, and what can we do better next time?

In the public sector, generally, we need to have ways to track our performance so that we can improve because we don't have inbuilt tracking systems, and this is one that we think is quite relevant, not only globally, but also in the US.

Why other countries spend less and get more

Michael Krigsman: What is different about other countries than the US that causes our healthcare costs and results to be so far inferior to other countries?

Dr. Tom Frieden: There's certain things that are different in different countries. And when we look around the world, it is striking the degree to which each country's health system is different. It evolved in a different way. It has different ways of delivering services. And so the right answer for any one country, including the US, is going to have to include some understanding of where it's been, what's called path dependency.

So your next step is gonna be pretty dependent on where you are now. But what we see consistently in the countries with the highest performing health systems is a much bigger emphasis on primary care. As you said at the outset, less than 5% of our Medicare costs are spent on primary care. That's really pathetic.

There's one estimate that suggests that if it were done right, we could triple the amount we spend on primary care and reduce the overall amount we spend on Medicare. So we could triple our spending in this one area, give people doctors and teams to care for them, and then reduce our overall spending. I think primary care is really one of the essence of the challenge.

And of course, other countries take a different approach to saying, "Hey, everyone's got healthcare, and we're gonna reduce administrative burden." When I talk to people who've gotten injured or sick abroad, and they've gone somewhere in Europe or Scandinavia or Latin America with a good health system, they're really stunned. You know, the costs were so low, and there was no administrative complexity.

It's pretty pathetic how much time we spend on paperwork instead of caring for people.

Six things that matter most for your health

Michael Krigsman: How do we start to unravel this knotted ball of string in order to start addressing it?

Dr. Tom Frieden: I think we find the threads that are working well, and we extend them. And this goes back to the believe part of see, believe, create. Find the positive areas and make phased progress. This means health systems that have ways to make progress or states can take action. But really the federal government is on the hook here because it drives so much in our Medicare especially, but also Medicaid and other insurance systems.

And of course, you know, Michael, in the last chapter of "The Formula for Better Health: How to Save Millions of Lives, Including Your Own," I talk about the including your own, and I apply that see, believe, create formula to personal health because there's so much hype about personal health. It's tempting to kind of throw up your hands say, "Oh, we don't know what to do." You know, everyone's debating things.

But what I go through is that there are really six things that are the most important for everyone's health, and here they are. One, control your blood pressure. 2, control your cholesterol. 3, get enough sleep. 4, move, get regular physical activity, the closest thing we have to a wonder drug. 5, avoid toxins, including tobacco, alcohol, and the newer toxins. And also, you know, don't neglect nutrition.

Nutrition sounds complicated, but there are parts of it that are really quite simple. And for each of those 6 things, there's a fair amount of detail. Those are the big 6. They may sound obvious, but the details are pretty complicated.

So blood pressure should ideally be reduced or kept at less than one twenty over eighty. For cholesterol, you wanna look at your LDL-C and your ApoB, and you want them under 70. For sleep, you want 7 to 9 hours. For physical activity, you want at least 4 days a week, at least 30 minutes. For toxins, you really wanna stop smoking if you smoke, limit alcohol intake, and think about those newer toxins.

And for nutrition. You know, some of it is complicated, some of it is not so complicated. More fruit and vegetables, more fiber, more potassium, less free sugar, less processed meat, not that complicated. None of that has changed in decades. There are a lot of nuances. Dairy is a debate, what kind of fiber and how do you get it? There are lots of details, but the big picture, more fruit and vegetables, less added sugar, not that complicated.

What worked and what didn't in the ACA

Michael Krigsman: This is a question from Lisbeth Shaw, who says, "Part of the Affordable Care Act aimed at improving healthcare by shifting outcome incentives. Why didn't it work to improve health and healthcare?"

Dr. Tom Frieden: Part of it is having some promising results. I mentioned the Accountable Care Organization approach, and the analyses I've seen suggests that those ACOs, as they're called, that are operated by doctors, by physicians, have been a good example of delivering real value for less money. And some of them are reducing healthcare costs by hundreds of millions or billions of dollars by keeping people out of the hospital, and that's really important.

That's doing well by doing good. So I think there are aspects that have worked very well. Getting rid of the preexisting condition exclusion, extremely important.

There's no way that you can provide decent healthcare if you say, "Oh, but if you're sick, you can't have health insurance." And making sure that preventive care is free of charge to the patient is really important, and this is something we have seen in the work that we do at Resolve to Save Lives, we've focused on.

Patient co-payments are really good if you wanna reduce utilization, but if you want people to do more of something, you really have to make sure it's free and easy. So if we want to have fewer heart attacks and strokes, that means people need to take medicines to prevent heart attacks and strokes, and that means that should be easy for them. There should be 0 copay. 0, not $5, 0.

Big study done in Canada showed a five dollar copay for medicines significantly reduced use, and that will increase heart attacks and strokes and cost us more money later. So there are some things that are working, and there's more that we can do as well.

Michael Krigsman: Arsalan Khan comes back again. He's really on a roll. He says, "The real-time availability of shareable healthcare data is needed. Why hasn't anyone created a dashboard for doing this?"

Dr. Tom Frieden: There has been incremental progress, and there have been a series of failures. Failures first. There have been multiple attempts to build something that people, patients will use, that will have all of their information, and they can look at it and share it with others. That's been enormously difficult for a variety of reasons, trust and systems and others that I don't understand, but it hasn't worked.

Apple has tried, Google has tried, many other entities have tried, and it just hasn't hit its stride. There is increasing ability to share information among health systems and with different health packages, but some of this is the challenge of, you know, you have one electronic health record provider, and getting their information to another provider with another system is still something that's not easy. But this has gotten significantly better in recent years.

It's just not as good as we would wish.

A prescription for policymakers and leaders

Michael Krigsman: I think to finish up, I have to ask you for your advice, your prescription for policymakers at whatever level and/or corporate healthcare leaders. What advice... You're uniquely qualified among everybody on the planet, you're uniquely qualified to offer this advice, so please share your advice.

Dr. Tom Frieden: Progress is possible. That's the bottom line. Don't get discouraged by setbacks or the news of the day. We are healthier than we've ever been as a species. We have more potential to be even healthier than we've ever had as a species. And yes, there are terrible things happening and lots of problems that have to be addressed.

But if we take this approach of rigorously finding, seeing the invisible, seeing the threats, seeing the pathway to progress, seeing why we're blocked from that pathway all too often, seeing whether or not we're making progress, building belief in the possibility of progress, recognize past progress, make future progress, and cultivate optimism, which is enormously important, we can create a healthier future where we organize well, we simplify, we communicate and listen well, and we overcome the barriers to longer, healthier, more productive lives, communities, countries, and a society.

It's possible. Progress is possible.

Michael Krigsman: What should policymakers and the government do now?

Dr. Tom Frieden: I think we need to be really clear about what our goals are and then really transparent about what we're doing to achieve those goals. So if our goal is to get that 100 million people not having primary care doctors down to 50 million, what's the plan, and how are we gonna track it? Because unless we track it, unless we hold ourselves accountable, it's not gonna happen.

Michael Krigsman: Your advice to the very large healthcare organizations, whether it's CVS or UnitedHealthcare or any others, to the leaders running these large, large healthcare organizations, what thoughts do you have for them?

Dr. Tom Frieden: Think about the prevention that we're leaving on the table. Think about the preventive things that are not happening. Controlling blood pressure, reducing cholesterol, promoting, as a very simple intervention, at least for everyone with healthy kidney function, potassium-enriched low-sodium salt. Maybe the easiest healthcare hack. Change the brand of salt you use, and you can significantly reduce your chance of a heart attack, stroke, or early death.

So there are things that will make a really big difference. Think rigorously about which of them will make the most difference, come up with a plan, then monitor your implementation of that plan, and if you need to adjust it, adjust it.

Michael Krigsman: Okay, and with that, a huge thank you to Dr. Tom Frieden. He is now CEO of Resolve to Save Lives. Dr. Frieden, thank you so much for taking your time to be with us today. I'm very grateful to you.

Dr. Tom Frieden: Thank you, Michael. It's been a pleasure speaking with you and with your audience.

Michael Krigsman: And everybody who watched, you guys are great. Be sure to go to cxotalk.com and subscribe to our newsletter. We want you as part of our community. Thank you so much, everybody, and we'll see you again next time. Have a great day.