Livongo's Leslie Krigstein: COVID has had a positive impact on digital health

Krigstein will be a part of Vator's Healthcare in Politics salon on October 7

With the election right around the corner Vator and HP will be hosting their latest salon on October 7, called Healthcare in Politics (register for the event here!) where multiple panels of experts, policy makers and lawmakers who will be on hand to discuss topics related to healthcare policy and decision making. 

One of the panels will center specifically around the U.S. response to COVID, including how to balance saving lives with saving livelihood, and how we should think about the problem going forward. 

I spoke to one of our panelists, Leslie Krigstein, Vice President of Government Affairs at Livongo, about some of the iniatives the company is working on Capitol Hill, how the pandemic has reshaped telehealth, and how we need to transform our system so the next pandemic doesn't hit us as hard. 

VatorNews: Tell me a bit about yourself, your background and your work at Livongo.

Lesie Krigstein: I moved to DC a dozen years ago with big dreams of changing the world, like so many. And, unfortunately, or maybe fortunately, I was on Capitol Hill at a time when a lot of health policy decisions were made. So, one of the things that I will treasure, for better or worse, is that I was in the House chamber the night that the Affordable Care Act passed; it was something, like it or not, that I knew was going to likely change the trajectory of healthcare and the nation. I was happy to be there and to be a part of that.  

I've been working in digital health now for the last decade or so for a variety of health IT associations, including HIMSS and CHIME, so I have really watched as folks are actually realizing the interest and opportunity that exists in digital health. I jumped at the opportunity to join Livongo in January to initiate our government affairs effort and build on the great work that the team had already done, such as being able to provide benefits to government employees through our relationships with our employee benefit program. I wanted to see how we can translate our industry leadership into policy, because if there's anything that we've learned from COVID, and a number of the policy changes that Congress and this administration have facilitated, it’s that innovation hasn’t always been warmly welcomed. So, there's a great opportunity to modernize and to be in the driver's seat as Livongo is truly empowering individuals living with chronic conditions. 

This is something very personal for me: both of my parents have been living with type 2 diabetes for just about as long as I can remember. Now they are Livongo users, so I'm able to know that I will not get another phone call from my mother like I got earlier this year that said, “Leslie, I realized why I wasn't feeling well the last few weeks, my blood sugar was 480.” The fact that I know now that my parents have Livongo there to support them, that our coaches will be there to support them, in those kinds of instances, it just signifies that there is so much opportunity, there are so many users that are really experiencing a lot of this for the first time. Being at the forefront of digital health, and the opportunity this has presented, is something that I really appreciate.

VN: It’s rare to see a digital health company be active in Washington and actually have someone whose job it is to work with Capitol Hill. Can you share a bit about your priorities and why this is important for Livongo?

LK: There is a lot of education to be done. COVID has rapidly expedited and really shone the light on the potential for digital health. But I would say, first and foremost, there's a lot of opportunity just to socialize the concept. We're also looking at how we can infuse innovation. We've been advocating for access to telehealth and ease of access to digital health pre-COVID and we'll continue to do so. We have been looking at health disparities; we are experts in chronic condition management and empowering those individuals living with chronic conditions, but those government insurance programs that those millions of individuals that are living with chronic conditions may be using, they  probably don't facilitate the kind of access, in a costly fashion, to these kinds of technologies. So, we're really trying to level the playing field so that every American has access to the kind of resources that they feel can best allow them to live happier, healthier lives, and not have to worry minute after minute about their condition, but know that whether it is digital health, or whatever other tool they need, that it’s there for them. 

We've also been working on issues like data privacy and data security. At the end of the day, our AI engine is only as effective as our members’ willingness to share their data, and to really engage in the process. And so, the fact that they have the security in knowing that we're not going to sell their data, we're not going to share their data, that their care experience is personal to them, and that we're going to do our best to optimize their experience to allow for the best outcome for them, is something that we think should be replicated. We're very happy to be vocal about the real importance of recognizing the value of this data and the need to protect it and allow the individual to be in the driver's seat. That's everything from not monetizing the data, but also allowing our members, the individuals living with their chronic condition, to be able to share that data with their care provider, with their care team, and in a way that will fully enable the most support, the most engagement, the most empowerment, or best outcome.  

So, those are some just the taste of things that we've been working on. Whether it's bills for Medicare diabetes prevention programs and allowing virtual suppliers, whether it’s opportunities to improve access in terms of resources for providers. We were really excited to see a bill that was bipartisan and bicameral that would provide $50 million for investments in remote patient monitoring, particularly focused on rural and underserved communities. And then even things like the FCC COVID-19 program that was in the CARES Act, which gave $200 million for health care providers to invest in digital health, whether it be RPM or telehealth. So, there's definitely a lot of opportunity and COVID has certainly brought even more of a chance for us to really highlight the potential of digital health. I was saying to a colleague the other day that when Congress is in session it seems that there's at least a new digital health bill every day. So, there’s no shortage of excitement, no shortage of interest, and it is exciting to be in DC, to be one of the few digital health companies that’s made the investment and to be able to share the member experience that our 400,000 diabetes management members are living each and every day. So, there's a lot of work to be done in DC, I'll put it that way, and across the country, frankly.

VN: You mentioned telehealth a couple of times. Livongo recently merged with Teladoc, so what kind of insights can you give me into how COVID and the shutdown affected telemedicine and where you see that space going next?  

LK: I give a lot of credit to Congress and the administration for their swift action to bring telehealth as a resource forward, both for Medicare beneficiaries and all Americans, as well as for the providers. We saw the strain on the healthcare system and we watched the fact that the care experience, by necessity, was going to need to adapt on a seismic scale. Congress came in with the action that was necessary to facilitate that in a real way. And so, through the CARES Act, through the emergency declaration, and through the waivers that hinge on it, we did see this rapid, almost overnight, digitization of the health care system. For example, co-pays are now waived, you can receive telehealth at home. Even in the remote patient monitoring space, we saw that you no longer need an in-person referral to be able to initiate remote patient monitoring, and that remote patient monitoring can be used both for chronic and acute conditions. So, the commitment to telehealth, I would say, across the board among policymakers of both parties, Congress and the administration, there really and truly has been a doubling down on the potential of telehealth. As new opportunities have presented to further expand access or ease access, we've seen a willingness to do that. We've seen multiple executive orders that have referenced the value of telehealth, whether it be for our veteran population, for our rural population, for our minority population, this truly has been a transformative moment for our healthcare system, and a lot of credit goes to policymakers who really dove in with two feet, at least for the duration of the pandemic. 

Of course, a lot of those flexibilities will expire upon the expiration of the public health emergency, which we don't see happening anytime soon, but the reality is they are time delineated. So, even prior to the merger this was something that we were engaged in because it is in our members best interest to have access to telehealth and to be able to engage with their care, with their care providers and get the care that they need at home. That's fundamental to the transformation of healthcare, that's the Livongo model, and so that's something that we were pleased to advocate for long before the merger was a glimmer in anybody's eyes. I’m hopeful that we will see continued conversation on Capitol Hill because, of course, Congress will have to act to make many of these things permanent. I'm hopeful that we will be able to have a conversation about things like broadband. There was a JAMA article from a month or so ago that showed that access is inequitable, especially when you're thinking about Medicare, so working with policymakers on things like digital literacy and acknowledging that there's 26 or so percent of older Americans that don't have a smartphone or don't have broadband access in their home. So, this conversation is just taking off, the pandemic has really allowed that and a nationwide pilot program, and I hope that we will see permanent action, and we'll be able to leverage the experience to date. But give credit where credit is due: there really has been some tremendous and innovative work that we've seen come out of the administration and on Capitol Hill too.

VN: So, that’s something you obviously think we did well in our response to COVID. What else did we do well? What could we have done better? 

LK: We can really look at digital health as something that has gone well. I just about fell off of the couch the first night of the Republican National Convention when the nurse spoke to the benefits of telehealth. That's not something in my career that you've really seen spotlighted. That really speaks to the fact that it has played such a pivotal role in the response. So, definitely that is a highlight. The fact that we have allowed for innovation to occur, for there to be industry leadership, that's really positive.  

You know, clearly there's areas for improvement. None of us have ever gone through this. When we're looking at lessons learned, there will likely be many, but, speaking from the Livongo vantage point, and really from the digital health perspective, because that's really where my expertise lies if I'm being candid with you, we really have seen that seismic shift in recognition of needing to modernize our healthcare system, for better or worse. We wish it hadn't taken a pandemic to happen, but where there were weaknesses, where there were communities that were not being properly served by the current healthcare system, we've seen those gaps and now we know that we need to act on them. So, it hasn’t been an easy road, it's not going to be an easy road, there's still many lessons to be learned, but at least on the digital health side, I would absolutely put that as top of the list of success in terms of the national response.

VN: What do we have to do to make sure that we don’t have these same problems next time?  

LK: If you're thinking about the modernization of our healthcare system, we have done well to date with a fairly old and taxed infrastructure. So, going back to items like broadband and access, we need to really heed the fact that our healthcare systems, the healthcare providers, and ourselves as patients, we don't have the kind of infrastructure that we need to be able to really transform digitally moving forward. That's something that really is undeniable and future conversations will have to be about looking at our broadband infrastructure. We need to look at supporting technologies that providers will need, that patients will need and what exactly that should look like and what form that should take. 

We have learned that we need to do our best to serve those communities that may be underinsured, may be uninsured and may be minoritized. We need to make sure that the vaccine trials are equitable and reaching all communities, at how we're going to disseminate the vaccine in an equitable fashion and in a strategic way, that’s based in science. There’s also just a general recognition of how reliant we are on some things that, when taken away, are a problem, and also recognizing and beginning the conversation in earnest, about some of the mental health consequences from that. We have all had to come to terms with some of the emotional consequences, whether it be just being at home with your two year old for six months, like I've been, or folks who have unfortunately lost loved ones or who have had to say goodbye over the phone. This has really escalated the need to have a national conversation on mental and behavioral health, and what resources everyone needs, how many providers we may have, and how we're going to engage with those providers. That is something that is directly COVID related that, hopefully, putting up an action item, we can really engage in that conversation as a nation about what we can do to help, not just in a crisis scenario but do our best to serve folks from head to toe, taking that whole person approach, moving forward.

VN: Speaking of mental health, Livongo bought MyStrength last year, so I was going to ask you about that. How do we balance out keeping people safe from the virus and also keeping them economically safe but also mentally safe? Is it possible to do both at the same time? 

LK: I don't think there's a great answer to that. Even if you look at the blog post that our Chief Medical Officer did a few weeks back that looks at trending blood pressures to the different phases of the pandemic, there are causal relationships between what's going on with pandemic and then how you know folks are managing their conditions and living with their conditions. Without ubiquitous access to mental health services, or acknowledging that we've seen a lot of folks face that financial strain that was really unplanned prior to March, I don't think there is an easy answer and I don't think we're out of it yet. We're doing our best to manage that, and we're seeing good habits grow, while many are also fighting bad habits. For me personally, I've taken up running for the first time in a number of years and that's my outlet, but I know I'm fortunate and the weather will also change. So, how will that be impacted? So, that's the burden that we're watching firsthand as health policymakers are dealing with the consequences of COVID. Is it saving the national economy? Is it improving mental health by reducing some of the stay at home measures? Or is it completely locking down again and also looking back at what if we had completely shut down for those two weeks back in March? Would we be in a different place? So, it will be a good discussion during the panel because if anyone has the answer I'm really excited to hear it because I don't think there's a right answer to this. That's what made the finger pointing so common, there's just so much complexity to the environment that we find ourselves in today.

VN: Going back to what you were talking about with rural and underserved communities, I think it's harder for those communities to get through a shutdown than it for affluent communities. How do we address that?

LK: I mean, you hear the stories of folks driving to coffee shops or to fast food parking lots to get access to the internet so their kids can partake in school. Tribal communities have been ravaged by COVID because of a lack of resources, the lack of personal protective equipment and, frankly, the financial strains on communities. The typical definition of telehealth was to include audio and visual, and if you don't have high speed access, then that visual component of that experience doesn't exist. So, it's been important that we saw the administration adopt audio-only telehealth, and that those experiences can be augmented by remote patient monitoring. Livongo devices can operate on 2G and 3G, so, although you may not have that visual component, we're still able to generate real-time readings, and still allow for that real-time intervention from our coach if someone is registering a high or low reading, because they operate on lower frequencies. We've seen the need to be creative. Unfortunately, we've also seen the need to revert back to things like telephone-only or audio-only telephonic encounters, even in digital health. So, we have seen the disproportionate implications, we've seen the immense value that frontline workers have brought to all of us. But, yet, we've also seen the risks that are posed to them and then the likely inability to have the resources that they need to be able to manage themselves and their families through the pandemic.

Again, the fact that we've seen the FCC step up and offer additional money, whether it be for the COVID telehealth program or for looking at broadband and releasing spectrum. So, there is that recognition that we need to get into these rural and underserved communities, that there are also things like looking at those who are on high deductible health plans and making sure that they're not breaking the bank by doing a telehealth visit or other important, COVID-related treatments. It really has hit first certain communities harder than others, and the fact that we've at least seen a willingness on the policy side to think about what are some incentives, what are some resources, that we can be getting into these communities, is something positive. The focus on rural health care is definitely here to stay and it's something that we've seen the Trump administration really prioritize too, both pre-COVID and during the response. 

VN: Is there anything else I should know? 

LK: The takeaway for us is that we've watched digital health take center stage before our eyes, and the fact that Livongo was willing to make the investment to establish the government affairs team to be at the table. Everyone uses the phrase, “if you're not at the table, you're on the menu.” So, it means a lot for us to be engaged in these really pivotal conversations as we're watching our healthcare system transform. 

(Image source: livongo.com)