Alexandra Drane on Caregivers, the Unsung Angels of Healthcare

Melanie Marcus: Today’s episode is about what it means to “put your body there,” as our guest Alex Drane says.

It’s about what it means to put your whole being into the task at hand.

For Alex, putting her body there has meant learning what it means to be human in the world.

After she sold one of her businesses, she went to work at Walmart as a cashier and in customer service. It was, admittedly, an unusual choice for an entrepreneur like Alex, but Alex is not your usual entrepreneur.

Working a retail job, not only did she see how physical the work is for people in these roles, but she came to understand that the foundational element of humanity, as she puts it, is to care for others and to be cared for.

Now, this season, we’re talking about helping healthcare heal itself. On that note, something Alex said really stuck with me: “We have to expand the definition of health to include life, because when life goes wrong, health goes wrong.”

Today, on this episode, we find out how to put life into health.

A very warm welcome to the show, Alex, and as always, thanks to our audience for listening to “There’s a Better Way.”

It is so great to have you on the show, Alex. And I want to thank you for sharing your time with us today.

Alexandra Drane: It is a humongous honor and I'm overexcited, which is bad news for everybody.

Marcus: Oh, that's great. Now we're talking about archangels in this episode, but these aren't the type of archangels with wings. No, these are archangels who go by the name of caregivers. Millions of Americans are caregivers. They take care of their loved ones day in and day out. It could be a child with special needs, a spouse or partner with a debilitating injury, or an aging parent who needs time and attention.

We're also talking about what it takes to empower people as true consumers of healthcare, from caregivers at home to patients in the clinic. In a word or two, it's entrepreneurship and it's innovation. And Alex is going to take us through this step by step on today's episode, but we're going to start where we always start, which is at the very beginning.

Drane: Yeah, so my dad is actually a serial entrepreneur and I grew up as he was building a very successful company called Atex which really automated the newspaper publishing world. He was all about automation and technology, but always in a very human-oriented way.

And my mom is actually an activist. So she too, she's a CPA [certified public accountant] by training. Very, very good with numbers, as is my dad. But also, she's a Quaker and sort of somebody who really believes in putting your body there. So she's been a part of the development and creation of a lot of movements in her life.

So I think I get from both of them an insatiable hunger to be putting my body there in usually very data-driven, evidence-oriented ways.

Marcus: I love that. So how did you choose to study economics as your major at Tufts [University]?

Drane: I have to say I was such a slacker in high school. I love people. I love talking to people. I love their stories. I'm an outrageous flirt. I will flirt with a kitchen table. I will flirt with anybody, anywhere, ever. I love everybody that I get to meet.

And that was what I majored in really in high school. And I got into Tufts by the skin of my teeth. I'm the luckiest person ever. I would never have gotten in there now. And my first semester I did what I'd always done, which is just have a blast. And I got mono. As people sometimes do. And out of boredom, because no one would play with me, I started studying and I was taking an economics class.

And I've always been a huge believer in data. Economics is data that really explains in many ways why we do what we do. Sort of the fundamentals of why humans behave the way they do. And I fell madly in love with microeconomics in particular. And from then on, I became a super dork and studied day in and day out. Still took some time to party, of course.

But I ended up getting straight A's. So I really turned into an ultra geek, obsessed with data, obsessed with economics, obsessed with how we can tell stories with numbers.

Marcus: So, mono saved you.

Drane: Mono saved the day, yes!

Marcus: Mono saved the day.

I can understand your perspective here. I was a math minor and I loved just being able to say 1 plus 1 equals 2. Right?

You started many successful healthcare ventures, including the member engagement organization Eliza. Can you briefly describe some of the businesses you've cofounded and their areas of impact?

Drane: So when I got out of college, I actually was at a consulting company. I was an analyst, right? That very first day—we work a hundred hours a week—and I worked with a Bain spinout called CDI [Corporate Decision, Inc.] and it was genius. And CDI was very entrepreneurial. They would sometimes take equity instead of pure cash so that they could work with baby companies. So that they could work with more outrageous ideas.

And the first company I started, actually I left there with two of the partners and one of the managers. And that was the first of three companies that I was part of before ultimately starting Eliza. But what I will tell you about each of the three is each of them was doing something extraordinary and weird in a really cool, technologically enabled way.

And with each of them, there was something that we were doing that just did not work. None of them failed outright. But the learnings from going through with the first one, we tried to do consulting while also starting companies. And anyone who's been a consultant knows you can't do that, right? When you're a consultant, you sell your time. So trying to be a consultant while you're also starting baby companies does not work.

The second one was a company called NewMed [Corporation] and it had [created a] medical device that sat on top of a meter dose inhaler. It was like an early version of Propeller and we had unbelievable outcomes in impacting adherence, which is an area you know well at Surescripts.

And in the end, we rushed into CDS [clinical decision support] and actually started selling direct to consumer before the results from our national double-blind placebo-controlled trial came out that ultimately showed 30% positive impact on adherence. But we were impatient. And we didn't respect the system, right? There's a system. There's a way that the healthcare world likes to buy things. And providers have to be involved and studies need to be done and there needs to be a throughput. And we got arrogant and rushed in. And, you know, a mom would buy this meter dose inhaler for her kid’s asthma bronchodilator. And then bring the data from it to the physician and the physician had no idea what it was and would be irritated. So that company did not have the success it should have.

Another company was one where we automated dialysis clinics at Vivra. We were working actually with Kent Thiry way back when. And the big mistake we made there was we got on the floor in the dialysis clinic to design based on what was actually happening. And we listened too hard to the doctors. The doctors had a perspective about the process of care that happens in a dialysis clinic. Which, as you can immediately understand, has nothing to do with the process of care that actually happens. So that first attempt at that system was crap. And we had to go back to the drawing board.

And the second design, we only spoke to the people who were on the floor. So the techs, the nurses, the patients themselves, the unpaid caregivers sitting with those patients. And we designed an entirely human-centric, technologically enabled data-obsessed platform that did very, very well.

And then the next company that we did was a web-enabled injury tracking system for the U.S. ski team. That was very successful. The big mistake we made there was we didn't read the fine print of the contract. And when the gentleman we were working with at the Olympic committee came to us and said, “This is phenomenal. We're rolling this out everywhere.” And I was like, “Oh my God, I'm calling my mom.” And he said, “No, we just want to say thank you.” And I was like, “What are you talking about ‘thank you?’ Like we're rolling this out together, baby. We’re going.” And he said, “No, actually, in the contract it said we were paying you for services. Which means we own the code.”

So again, in each of those, that's a dumb error. Every entrepreneur out there, do not trust someone else to read your contracts. You read every single word of those contracts. Because in the end you are held to them. And that was a hard way to learn that lesson. And then the next company was Eliza.

Marcus: So you spent a year in Walmart. And I'm not knocking retail, but you did this after you'd already started some businesses. What inspired you to do this?

Drane: So, we had sold Eliza. Technically it was a very successful exit. But for me, it was hard because I loved what we were building. I believed in what we were building.

But I had what can only be considered a midlife crisis. And the work that we had done at Eliza had really highlighted, again, the same arc, the same string that in a very data-driven way we'd gotten around to the belief that we have to expand the definition of health to include life, because when life goes wrong, health goes wrong.

And that the biggest diseases in the US were actually caregiver stress, financial stress, relationship stress, and workplace stress. And I was doing a lot of speaking. I was being asked to be an expert on this topic that we were calling the unmentionables.

And I sort of had this realization. I'm not going to call myself a fraud. But I was like, “You live in a bubble, Alex, and you've never really experienced life. You have graduated from college, you've got this job, then this next job, you're doing these things, you live in a particular world. You need to get messy. You need to expose yourself to the elements.”

And so I decided that I wanted to be a cashier at Walmart. Um, for very specific reasons. Because we all know how many Walmarts there are. We know that Walmarts are visited by, it’s like 90% of the country goes through a Walmart in any year and you see everybody go through Walmart.

I wanted to be with everybody. I didn't want to just be with the people anymore that were in the bubble that I was lucky enough to be living in.

I was a cashier when I started. And then I got promoted to customer service. Cashiers, believe it or not, become very trusted parts of people's day to day lives. And because you're checking people out, you're seeing what they're buying, you're having conversations with them. You're watching their interaction with the people that they're with in line, but also the people who are behind them in line. So my job was technically as straightforward as, how quickly can you get somebody's products through the line?

Every single person who comes through, they are doing their best. And it doesn't matter what kind of education they got or who they are voting for or where they think their expertise is. People bring their best selves. They care for each other in the ways that they can, with the tools that they can, that they have, the stuff that's available and accessible to them. And they're kind. They're kind to each other. They're kind to strangers. They're kind to the cashier. And yes, you would see examples of someone having an absolute meltdown and you would usually know, because you could see enough of what was going on, that there was something really hard happening in their lives. They might be in pain, right? They might have a child with a disability. Back to your opening statement. And so you just end up realizing there is such a core to humans. And I think the most foundational element of humanity is to care for others and to be cared for ourselves. And that is universal.

Marcus: Wow. So do you have stories about serving customers in this role?

Drane: There was a guy who came through and it was the early morning shift. I used to love the early morning shift because you would see people getting off shifts like nurses and, you know, folks who worked in the frontline of healthcare would often come through or teachers would come in because they were heading into their classes.

But around seven, you'd see a lot of stuff go down. And there was a guy who came through and I said, “How you doing?” And I wasn't really paying attention to what he was buying. And he said something and I wasn't really listening. And then, you know how your brain retrospectively processes what somebody said? And I realized that he had said something like, “Well, my wife kicked me out last night.” And then I looked at what was on the checkout counter. And it was like toothpaste, toothbrush, underpants, T-shirt. And I was like, “Oh my gosh, this fellow slept in his car last night.” And we had this beautiful conversation about how hard it can be to have a hard stage in a relationship. And he felt like they just weren't communicating well. And I was like, “Well, have you tried?” He said, “She doesn't like talking. She gets mad.” I was like, “Have you tried writing to her? Like, what if you just write her a little note and tell her how you feel?”

You have these kind of conversations with folks where he's in a really vulnerable moment, you know? He's feeling stressed out. He shares this vulnerability. And as humans, that's a time to reach in if you can, right? Just to be there.

You would see that all the time. Yeah. People in their most beautiful, strongest, and most vulnerable moments would say extraordinarily powerful things. And to have a front line, to see that and to be able to be there was an amazing thing. You know, this is what anybody who's in the front line as a doctor, as a nurse, as a tech, as a cashier, as a postal worker, as a pharmacist. It is a great, great honor and a great responsibility.

Marcus: Well, amazing that you did that, and I just love the perspective that you have as a result.

So let's move to your organization, Archangels. And the name Archangels, which I love, implies caregivers function as chief angels for their loved ones. Can you describe what Archangels do on a day-to-day basis?

Drane: We chose the name Archangel because I think when people think about an unpaid caregiver, which is what we're working to support, they will think of me, right? A middle aged 53-year-old woman who's caring for an aging parent. And that's true. And I am.

But a huge percentage of folks in this role are not only middle-aged women. They're men of all ages. They're kids. There are elders caring for youngers. You name it. And what folks in this role—43% of adults right now are in this role—are doing, is whatever is asked of them.

So in some cases, you know, I met with the CEO of a massive health system the other day. And he was having the realization as we were going through the data that he also was an unpaid caregiver in a different kind of role. And he said, “My mom is 88. She's Irish Catholic. And every Sunday I am there and I am gardening because that is my job.” He's like, “And I just realized that's caregiving.”

So caregiving is the obvious things. Like, I'm picking up medication, I'm making sure you're taking it, I'm making sure you're eating, I'm turning you over at night, I'm making sure you're breathing, right? I'm changing your catheter. I'm doing whatever it is. From the very most basic of helping with your schoolwork. To the very intense clinically, medically complicated tasks that we're increasingly asking this population to do. But it's everything in between as well. It's anytime you are exhibiting and putting your body there with care for somebody in your orbit.

Marcus: Can you tell me what is the challenge facing them, and what needs to change?

Drane: So I think there's a couple of things. One, unpaid caregivers do not see themselves in this role. At least 50%. If you use the term caregiver, not only do they not understand it or are they confused by it, they actually don't like it. It might have a stigma associated with it. It might feel overly one way or the other to someone who sees themselves in a different way.

And so the number one challenge with this population is they do not realize that they're in this role. In fact, one of my favorite exercises—and I would encourage you to do this if you know someone in your life who's in this role—point out to them they're in this role and they'll be like, “I'm not in that role.” And they'll usually say, “I am just—" “Just” is a really beautiful word. Hold on to that word. They'll say, “I'm not a caregiver. I'm just a God-fearing person. I'm just a handyman. I'm just a good neighbor. I'm just a person who cares. I'm just a good son, a good daughter, a good wife, a good husband.” And the fact that they said “just” before they say these most beautiful words so epitomizes what this population is, because they're not self-focused. They're completely focused on service to others. And that's a beautiful aspect of them. But it's also very dangerous, because it means they're not caring for themselves. And a huge percentage of unpaid caregivers end up becoming sick themselves or having to leave their job or having some other injury happen as a result of this work.

And the other thing I think—so that's what's happening for the individual who's in this role—but I also think there's a missed opportunity on behalf of—whether it's a health system, a health plan, an employer, a community, a state, the federal government—to recognize this population and what they're doing, and to get them navigated over to resources that already exist and support them in this role so they can stay in their job. Because they want to stay in their jobs and they need to stay in their jobs and we need them to stay in their jobs. So both sides are the perspective that we hold.

Marcus: Right. So then how does your organization support caregivers? What is the model?

Drane: So, we get a lot of data. We understand—back to one of those hard learnings—that you need to have data. We've published multiple studies with the CDC [Centers for Disease Control and Prevention] with different journals, white papers, you name it. We understand that you need to have your data be buttoned up and respected and validated so it has authenticity and people will pay attention to it. We need CFOs to agree with us.

But the core of the platform is very, very, very simple. We run campaigns. Omnichannel campaigns or shameless hustlers will use any channel possible to find this population. And we do not use the word caregiver. We use the sassiest, most outrageous, most strength-based [word]—you know, and if it needs to be very warm, it's warm in a strength-oriented way.

So we run these campaigns to help somebody take a second and be like, “Wait, what's that? I'll be an archangel. What's that mean?” And then we get someone to get their score, which takes two minutes, and puts them in the green, yellow or red. And as a result of this very fast little process—it is not asking questions like, “How many hours a week are you doing these tasks?” That's actually not associated with intensity, which is the measure that we use, which is directly associated with mental health impact. Instead, it's looking at the impact this is having on your ability to get through a day as an example. Or to do your job, be productive, stay healthy.

So we get you in the green, yellow or red. And then we tell people that resources that exist, that are already paid for, that they have access to, that they don't know about—they don't know about them because they didn't realize they were in this role. They don't have time to think about themselves and even if they have realized they're in this role and they've had a moment where they're like, “I'm melting down because I don't know how to navigate a system,” they don't know how to go find the things that could exist to help them.

So we are the interstitial tissue that runs the campaigns, gets someone to have their score, which really validates for them “this is you.” And then instantaneously navigates them over to those resources that already exist, have already been paid for, and are specifically designed to support the things that are driving their intensity.

And then all of that kicks off a lot of impact and more data that we can use to wash, rinse and repeat.

Marcus: What do you see happening that holds the most promise for the future in healthcare using technology?

Drane: I have a favorite Walmart store manager. His name is Roma and he was one of the most extraordinary store managers that I ever got to work with. And I said to him once, “Roma, tell me, what is it that makes the most successful store manager?”

And I thought he was going to be like, “Well, you got to run the numbers such that you know how to merchandise and you look at this data point, that data point.” And he looked at me with the most beautifully profound face and said, “The very best store managers know absolutely everything that's going on in the lives of their associates,” which is Walmart's word for employees. Because you got to know if someone just got kicked out of their house. You got to know if someone just lost their car. You got to know if someone just went on food stamps. You got to know if somebody's got a child with a mental health challenge or just got diagnosed with cancer. Because the most important thing to running a store is that your employees show up and that they feel supported.

Walmart’s founder Sam Walton said, “You take care of the associates. The rest takes care of itself.” And that to me is such an example of what we've got to get back to in our world. We're just going to look at humans, realizing that they have this big, broad life that's beyond just what we're asking them to do.

And we have to support them in their life. When they leave every day, they take the way we interacted with them home. And if we treat them like crap, they go home and they have a hard time at home. And if their home life is hard and they leave in the morning and they come to work, they're going to bring all that pain with them. And we've got to start feeling responsible for the whole cycle of life. And really beautiful employers do that.

And the other example I was thinking about when you're talking about breaking down these silos is why I partially love hospital-at-home [programs] that everyone's so excited about right now. And I partially want to pinch it in the underbelly of its arms so badly, right? Because if you look at hospital-at-home within any silo, it sounds genius. “Oh, we're going to send you home early, right? You could have stayed here for seven days, but we're going to send you home in two.” And if you're the organization that's paying that hospital a lot of money, you get excited. You're like, “This is going to be cheaper because we're sending them home.”

Well, that's looking at it in the silo of the people who get the money from the hospital or who get the money for sending somebody home. But look at me. I have a job. I have children. I have a lot of responsibilities going on and I have a dad I love so much I could eat him with a spoon every second. And if somebody said to me, “Oh, we can send your dad home because he just had a cardiovascular procedure and so it'll be better for him if we send him home.” Unless that person sits down with me first, quietly, before they ask me in front of my dad. But quietly says to me, “I want to talk to you about what it could be if we send your dad home. This is the task that you're going to have to do. This is how much time it's going to take. Are you comfortable with that? Can you do that?” Do not ask me in front of my dad. They wouldn't ask me, they would ask my dad. “Hey dad, do you want to go home?” What's my dad going to say? “Yeah.” Am I going to be the daughter who's like, “He can't come home because I don't know how to handle this or I don't know how to change a catheter or I don't know how to do X, Y or Z.”

So we're putting humans in these very hard situations. Now the ripple effect of this is not only in my mental health as the unpaid caregiver. Because it looks good to everyone else, right? He's going home with her. But what about my employer? Because I'm definitely not coming to work the next four days. Definitely not. And actually, this might kick off a whole string of other things. I might not be able to come back to work at all. And maybe this stresses my kids out. We have to understand. Humans don't live in a freaking silo.

So when you come up with something genius like Hospital at Home, which under one interpretation done beautifully is elegant. But if you're not taking into consideration the ripple effect of that disruption in the universe of this happening, you might end up with someone who has to leave their job or has to quit, which is very bad for the employer, which ultimately could cause further downstream impact.

So I'm just obsessed with, “Break these silos down, chase these data, chase these dollars, chase the realities of this humanity oriented job we're doing called caregiving to the ground so we can measure it and support it.”

Marcus: I love that example. So, I'm going to turn to something not quite the same. Outside of work, outside of technology and entrepreneurship. We hear you like fast cars.

Drane: I do.

Marcus: What's it like to be behind the wheel on a track?

Drane: Everything I do, like when I was a cashier, there's a metric on how many things you can check out, how quickly. Like, I just want to go fast all the time, period. And I have always loved anything motorized. And the louder the better.

And the thing that's beautiful about race car driving, there's actually a really, really beautiful phrase about race car driving, which says, “if you're not afraid, you should be,” essentially. And one of the things about race car driving is you cannot be thinking about something else. And I'm always thinking about work. And you know, there are certain things in life that helped me not think about work. One is like, I pour myself a glass of prosecco, right? That's my self-medication of choice, or maybe another one, right? Well, that's not a very healthy self-medication.

When you’re behind a wheel of a car and you're winding your way around a racetrack, you'd best be laser focused on all the variables you're taking in at once to figure out the conditions of the track, who's coming at you, what else is going on, what's going to be around this next corner, the parameters of the vehicle that you're driving.

And so you get very Zen in a way because you are myopically focused on this one thing in front of you called “drive as fast as you can and don't die.” And I love that because I usually have way too many thoughts going on in my head. And I'm fiercely competitive and I like to win.

Marcus: Awesome. So, do you have any analogies from car racing that can apply to your work in business or healthcare?

Drane: One of the most important ones gets back to that notion of being afraid. I think back on one moment in Eliza's history when we almost lost the company. And it was because we got arrogant. We were doing really, really, really, really well. And then I got a phone call from our largest customer about a deal that had gone to bid, that we had not known had gone out to bid, on a new market dynamic-created opportunity that we did not see as a market opportunity. And we had lost it to a competitor that we didn't even know existed. And within 15 minutes, we had the entire company assembled to basically tell the story and say, “We got fat and happy guys. Like we thought we had all the answers. And in doing so we took our eyes off the wheel, right?”

In race car driving, if you are not paying incredible attention, don't sit there thinking you got it going on and race around the track feeling good about yourself. You have to be laser focused on all the mistakes you're about to make so you don't make them. Only the paranoid survive. For me, the analogy—if you're building something that matters, if you're building something that's new, if you're taking a risk, if you're trying, if you are an entrepreneur, if you're doing innovation, whatever innovation means—you're going to screw a lot of stuff up and that's OK. That's where the learning is. The risk is if you don't realize you're screwing it up. And so I'm just a huge believer in paying more attention to what's not working than to what is working.

Marcus: And only the paranoid survive. Wow. All right, this is kind of my favorite part of the discussion where I get to ask you about your diagnosis of healthcare and then prescription. So, healthcare is hurting. There's lots of things going on. We've talked about a few of them: invisible caregivers, there's high cost obviously, not as many professional caregivers as we need. What's your diagnosis for what's wrong?

Drane: I'm going to say it in two different ways. The humanitarian way to describe it would be, I think we're forgetting that core principle that you and I have discussed, which is at the end of the day, we are all way more alike than different. And the single most foundational element of humanity is to care for others and be cared for ourselves. And every interaction we have, whether it's through technology, it's face to face, it's written, it's with an employer, it's with a human, it's with a stranger, it's with a tree. Again, as a Quaker, the religious way of saying it, and I'm not super religious, but I just love this statement, “Answer to that of God in everyone.” And what it's trying to say is whoever you interact with, when you interact with them, have faith that they are a good soul. And to me, that's the secret sauce of healthcare, is whoever you're interacting with, have faith that they are doing their best and that they are very smart and that they want to do well by you and they want you to do well by them.

The other thing I would say sounds more “consultant-y”, so forgive me, but I think that one of the challenges we have right now is what I would call the value creation, value extraction disconnect. There are a lot of humans who are creating enormous value: unpaid caregivers. The amount of work that unpaid caregivers single-handedly are doing to keep our economy flowing is immeasurable. People try and put data on it. It's freaking huge. It's a dollar value. But these unpaid caregivers are not getting to extract that value. Other people, the system is extracting that value.

And humans are smart. And they figure it out. And I feel as though we're getting to a place in the arc of our own country where people are saying, “This is a bad deal and I'm not doing this bad deal anymore.” And that might manifest and they quit their job. It might manifest and they stop following directions. It might manifest in any number of ways that we can see and we can't see, but we have to solve this fundamental equation. We got to zero out this issue, right? Value creation has to match value extraction and it's OK that some people make more money than others. That's great. That's fine. But we can't keep getting so much off the back of people who are getting nothing. That is not going to scale.

Marcus: Right. And so what prescription would you write?

Drane: I think employers or anyone who's in a position of power—I'll give a very practical, tactical answer—pay attention to the humans in your universe, whether they're employees or plan members or customers, who are serving in this role of unpaid caregiver. Use the resources that you have to find them, to be deeply respectful of them, and to serve them. They are 43% of adults. The top- and bottom-line impact they can have for you for good, because you can market to them and sell more to them, you can help them keep their jobs, which is good for you and giving for everyone else, is enormous. And the impact that they can have for bad—if we don't do this, because they will quit their jobs, they will get sick, right? The top- and bottom-line [impact] is enormous.

So for me personally, when I keep boiling it down, you look at the arc of all the things I've worked on, I am now focused on the unpaid caregiver. Not because of a personal story. Although of course we all have one. Because I have been following the data. We have been following the data. And this population, unpaid caregivers, they are the epicenter of what our economy needs to do well or to not do well. And we can all play a role in finding them, supporting them. It's not a lot of money to find or support an unpaid caregiver. It's a lot of money if you don't.

Marcus: Well, amazing discussion. Truly. Like, this has just flown by. I've been honored to spend some time talking with you, and thanks for joining us.

Drane: I'm so glad that you guys are doing what you're doing. And I love your podcast. Thank you for letting me be a part of it. I really appreciate it.