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The US healthcare system makes it difficult, expensive, and often impossible for people with T1D to access the care, education, and support they need to live. Around the Circle: Living Well with T1D brings together voices from across the type 1 diabetes community to share real stories, expert insight, and practical support for living well with T1D.
Hosted by the team at Blue Circle Health, a U.S.-based program transforming type 1 care, this podcast helps people go from just surviving to truly living well with type 1 diabetes.
Learn more at BlueCircleHealth.org
I think you can agree our healthcare
system makes it expensive, difficult,
and sometimes even impossible for people
with T1D to get what they need to live.
But why is that?
we're going to talk about
that with Dr. Len D'Avolio.
He's the CEO and co-founder
of Blue Circle Health.
He spent over 20 years working
to improve healthcare and he's an
assistant professor at Harvard Medical
School and Mass General Brigham.
We're going to talk about why
our healthcare system makes
living with T1D so difficult.
And how Blue Circle Health
hopes to change that.
Len, welcome.
Thanks for talking with me today.
Your experience innovating
in healthcare spans decades.
If you had to, how would you distill
your experience into a few major
moments leading into what you're
building here at Blue Circle Health.
Sure.
two decades, right?
I feel old when you say decades.
, How would I distill my experience?
I got into healthcare because I was,
at the time, I was amazed with what
was going on in other industries.
And again, I'm dating myself a
bit, but I. We were watching as
information technology was making it
possible for companies like Google
and Facebook to come into existence.
And then even existing organizations
like FedEx and Walmart, like they
were all transforming their business
because of information technology.
But information technology is a tool,
and I started out as a software engineer.
What made me most interested in
that set of tools was it really
made it possible to learn at speeds
that were never before possible.
And so organizations like Amazon.
If they were selling books,
but that was a means to an end.
They were learning how to sell
things and they could learn
faster than anyone, and I thought.
If this new set of technologies, if its
superpower is learning, what if we applied
that into healthcare where we have so much
data and so many challenges to overcome?
And so I went ahead and pursued a PhD
in the application of data science to
healthcare specifically, and learned
things like natural language processing
and data science and machine learning,
and that I can remember quite distinctly.
Creating a software that was able
to predict what patients were most
likely to end up in a hospital.
And we validated it and
it worked very well.
And we brought this to the executives of
the hospital that we were affiliated with.
And we said, imagine what you could do.
You could predict which patients
are heading to the hospital
and then you could prevent it.
And I remember quite
clearly him, him saying.
And if we did that, we'd be out of a job.
and that was probably the most
eye-opening thing for me, having
just focused rather idealistically or
naively on what the tools could do.
I didn't until that
moment fully understand.
How important the incentive structure of
healthcare is for learning and improving.
And since that moment, that was near
the end of my PhD studies, but since
that moment, I was very intentional
in every project, job company, team
program, that I became a part of.
After that.
Was very much focused still on learning
and improving, helping, people get better.
But I was very intentional in identifying
projects where the economic incentive was
such that it actually paid to keep people
healthy, as opposed to how 95 plus percent
of healthcare is currently reimbursed.
It's called fee for service,
but in most of healthcare today.
those clinics and those hospitals, they
don't make money until you're sick.
And so my career path has
bounced in and out of for-profit,
non-profit, academic, public health.
But what every project had in common
was there was an opportunity to learn
and improve at incredible rates, and
there was economic incentive to improve.
And, Blue Circle is just a, the,
ultimate sort of culmination of
that, anytime you have a fixed
budget to keep people healthy.
You now have incentive to do things before
they're at the height of their illness.
and that's what we can really make
tremendous strides in healthcare.
When I think about trying to, wrap
your head around the economics of
healthcare, aside from all the cool
data stuff that you were doing, it.
It could take two decades to learn
just that model in it in and of itself.
How, was that experience for
you learning that side of it?
First, I think anyone going into
healthcare should take a minute to
understand, what are the economics
of this clinic or this health system,
or this company that I work for?
Because it really is the case in
healthcare that how the money is spent
dictates the outcomes that you get.
I won't go too deep in all of the
different contracts and types of
contracts, but the, I will say this,
right now in this country, we spend
more than any other nation by far.
Both, per capita, and also total
dollar amount and year after year when
international health organizations assess
who has the best and the worst outcomes.
The US is consistently at the
bottom of all developed nations.
People die sooner than they need to.
Infant mortality.
Maternal mortality, There, there's,
we continue to rank at or near the
bottom and, most of the major measures
of whether or not your, health system
is keeping your population healthy,
and it is not because we don't have.
The best doctors in the world.
People fly from across the world
to attend our universities.
It's not because we don't have
the best technologies or drugs.
So many of the drugs that have made
such a difference in millions of
lives come out of this country.
What it ultimately comes down to is
we pay for volume and complexity.
We don't pay to keep people healthy.
That's called fee for service.
So at the highest level, the one thing
you need to understand related to
healthcare economics is when 95% of
reimbursement in this country is based
on delivering more care and delivering
more complex care, you end up creating a
system that under invests in things like
prevention, education, ongoing support.
All of the things that you need to be
healthy in a condition like type one,
but really so many of the other chronic
complex conditions, whether you're talking
about heart failure or or CHF, and so on.
We do our worst.
As a country on diseases that benefit
from ongoing preventative care
and ongoing support because all of
the money is made in acute triage,
hospital-based, procedural based, big
money, drug-based, type conditions.
This is a, wonderful
country to be diagnosed.
To, need a knee replacement.
It's a, wonderful country to, we
do great actually with cancer.
and, and major surgeries because those are
acute, traumatic transactional, healthcare
and we fall down when it comes to things
like type one, or, type two or so many
of the other chronic complex conditions.
Let's talk a little bit more about
why type one diabetes feels so hard to
manage in the existing healthcare system.
I don't live with type one, but
an important part of my job is
understanding as best as I can, what
are the challenges, but also how do we
communicate those challenges because.
I, find that unless you live with or
have a loved one with this condition,
most people don't understand how
challenging this condition is.
And I think the best metaphor
I've heard to date comes from, a
young researcher, Dr. Alice Carr,
out of the University of Alberta.
And she, did a presentation.
And when I saw this slide, I
immediately sent her a note and we,
had a great conversation about it
'cause it really resonated with me.
And, her metaphor was, type one
is the plane that never lands.
and I thought, that's really powerful.
because in her analogy, basically
you walk onto an airplane and now
you learn that you're the pilot.
You, didn't ask for this
job, but now it's your job.
In order to keep that plane in the
air, you need to account for all of
these conditions that are thrown at
you as you're taking off and flying.
And that includes you need to
understand your current blood glucose
levels, the food you're going to
eat, the things you're going to
drink, the effects of exercise
and stress and sleep and hormones.
and, you need to understand all of this.
Plus manage life in general.
And your fuel is of course, insulin
and you, but you need to be able to
account for all of these conditions
in applying the right level of fuel.
And to help you do that, you have your
instrumentation, your CGMs, in some cases,
your automated insulin delivery systems.
Now, the consequences of not keeping.
The airplane in the air
are pretty dire, right?
So it does resonate in that you're
now responsible for keeping yourself
alive, and you're always making
adjustments in order to do that.
It's, I just thought it was a
really powerful metaphor because
you didn't ask for that job.
But now it's your job for
the rest of your life.
And you asked the question,
why is it so hard?
Beyond that, I, to me, that's
already so intimidating.
But we know that people can,
and it's possible to live a long
and healthy life with type one.
It's not easy, but it's possible.
If you have access to fuel the
insulin and the instrumentation, and
you've been trained to, to process
the mathematics of staying airborne.
But here's what I think is
just a terrible injustice that
most people don't understand.
Our healthcare system is designed to
make it more difficult, more expensive,
in some cases, impossible to gain access
to the fuel and, the instrumentation
and the training that you need, and.
I think that's the greatest
miss thus far in the design of
our current healthcare system.
When it comes to type is
it assumes that type one.
Can be successfully treated like many
other conditions where you go in,
you get what you need, you leave it's
triage, it's quick, it's 15 minutes.
But if you think of it in terms of the
plane that never lands and your job
is to keep it afloat, we would never.
Hold back fuel from a pilot
who needed to stay in the air.
We would never make it harder for them
to get access to instrumentation that can
tell them what's going on as they fly.
And we certainly wouldn't expect them
to fly the plane without training.
And yet that's what
we've done as a, society.
And there's the opportunity not
just for Blue Circle Health, but
for anyone that's paying attention
to what we're trying to do.
For anyone that believes that
care for T1D could be better,
the opportunity is to rethink.
what do, what are the real challenges here
and how do we deliver care holistically
care in a much more productive way
based on the fact that it really is
your job and the jobs of people with
T1D to keep the plane in the air.
It's our job as a healthcare system
to make that as easy as possible so
you can be successful in this lifelong
job that you never signed up for.
Yeah.
I don't know if that's helpful in
thinking about it, Scott, but that for me,
that was very helpful.
That's, a very good description
of what a type one diagnosis is,
so we know that there's this,
big problem in type one diabetes.
What can you share about.
What Blue Circle Health is and, how that
addresses those problems and, some of
the bits and pieces of conversations that
led you into building Blue Circle Health.
The problem is the misalignment
between all of the things that
people need to live a long and
healthy life with type one versus.
What they currently get
from our healthcare system.
And so Blue Circle Health was designed
in direct response to that it, it
is a free six month clinical care,
education and support program offered
to adults living with type one diabetes.
It is free, but not a free clinic in the
traditional sense because from day one
till the up to six months that people
stay, our goal is of course to equip
them with whatever they're missing.
If they need access to insulin insurance,
it's make sure they're connected to
a primary care physician or an endo.
So there is an aspect of triage,
equipping them, so they have the basics.
But the bigger goal here is we
have six months to prepare you for
this lifelong journey to educate,
to empower, to skills build.
And six months is enough time that
together both the team and participants
will experience some of the highs and lows
and be able to debrief on that and better
prepare them to continue on with what
is necessarily a self-managed disease.
so that, that's Blue Circle Health.
But if we can do this and do it
well, and at this point, we've now
helped over a thousand people in 17
states, plus the District of Columbia.
I think by the time this airs will
be in 20 states, our goal here is to
show not just the T1D community, but
the healthcare community that better
is possible, that we can achieve
much better outcomes potentially, and
we're still measuring this, but even
spending less money, but spending
it on the right things, education,
prevention, support, and Yes, our goal
is to care for as many as possible, but
we're also trying to become a beacon.
We're trying to shine a light on the
fact that better is possible, and we're
measuring very carefully whether or not we
can achieve much better outcomes by simply
designing the care based on what people
with this condition need to be successful.
While we let that sink in a little
bit, let's just take a quick break.
Hi, I am Erica.
I am part of the Blue Circle Health
team and I've lived with type
one diabetes myself for 25 years.
One of our favorite things is sharing
stories from people who've participated
in the program, and I have one here
from Candace who's been living with
Type one diabetes for 36 years.
I'm going to read it for you.
The challenges to living with diabetes
have been mostly the hurdles I jumped to
obtain the best health insurance possible.
That need has driven many of
the job choices I've made and
relationships I've endured.
The 15 minutes that my endocrinologist
is allowed to spend with me is
not enough to read and analyze the
data from my devices, let alone
inquire about my overall wellness.
That standard of care is
driven by profit alone.
It quickly burns out the providers
and patients come away dissatisfied
On the opposite end of the spectrum,
blue Circle Health has provided me
with excellent care by exceptionally
qualified endocrinologists and
stellar emotional support, none
of which is driven by profit.
The difference is night and day.
There is enough time
allotted for me to feel seen.
There are good answers available
to any and all of my questions.
And the level of kindness provided
is off the charts and it's free.
Thank you, Candace.
We really appreciate you sharing with us.
In each episode, I like to give a quick
shout out to one of the many amazing
organizations helping people with T1D.
Listen, there's no,
this is no sponsorship.
This is not an ad. In fact, they
don't even know I'm doing this.
It's just me showing some love.
And for this episode's, community
Partner Spotlight, I want to
talk about Diversity in Diabetes.
Diversity in Diabetes is a nonprofit
organization that knows a lot
about treatment options for people
of color living with diabetes.
In addition to several programs aimed at
creating a more equitable landscape in
diabetes management, their monthly insulin
inclusive virtual meetups are an easy
way to check them out and get involved.
Head over to diversityindiabetes.org
to learn more.
Len, welcome back.
Change in our healthcare system.
It feels so big that I don't
even know where to start and
I even wonder, is it possible?
How do you approach such an ambitious goal
using Blue Circle Health as the model?
What needs to happen here
to start moving the needle?
There's two things, right?
There's change at the macro level, which.
I won't say impossible
because it has happened.
there's been major periods of change in
the US healthcare system over the years.
It, was, during, the World War that
we attached insurance, to employment.
that was major, right?
We formed the CMS and they
issued, Medicare, and Medicaid.
there have been major periods of
change in the US healthcare system,
but they're precipitated by crises.
And in any policy, any opportunity
to bring a policy to life, there's
a thing that's been studied
called policy windows, right?
So you never let a crisis go to
waste is like a saying in politics.
What it would take to change things at
the macro level is, number one, a crisis.
The widespread recognition that healthcare
is broken or something needs to change.
And quite candidly, I, think we're
nearing that, we, if we continue at
this pace, healthcare expenditures
alone have the potential to bankrupt
this country and in the process of
spending more than any other nation.
We consistently deliver terrible results.
And with some of the recent
policy changes, we're now seeing
premiums jump through the roof.
So th this is becoming
more real for everyone.
And you can see healthcare
is now, once again, becoming
this major political issue.
Our job is to be prepared by showing
the world that healthcare can be better.
Now what we have control over is
one particular disease domain,
but if we can demonstrate.
That you can spend less money
and achieve much better results.
At a moment when the nation is looking
for examples of spending less money
and achieving much better results, I
think we'll be well positioned and,
this is exactly what we're aiming for.
Again, on the one hand, our job is
to care for as many as possible, but.
It's not lost on us that we're now
in 17, soon to be 20 states and DC
and we're talking to the health plan
executives in every state we go to, policy
makers in every state that we go to.
We work very closely with organizations
like the American Diabetes Association
to help them understand what we do and to
spread the word that better is possible.
So while we're working to deliver
direct care, we're also working
to show the world that care can
be better and different, and.
as, I said to, to David Panzi and the
folks that were funding this, look, I
can't change healthcare policy, but if
healthcare policy starts to change and
we are a already made plug and play
already there example of delivering
care better and at lower cost, or if.
In demonstrating what we're doing.
If we can demonstrate our results
and show that we're doing better,
if people adopt even parts of,
what we're doing, for example, we,
connect everyone to a community.
I think every clinic could prioritize
connecting people living with type one
to other people living with type one.
We don't require people to
see an endocrinologist before
they can see educators.
I think this is like a simple policy
change that would save money because most
everyone could benefit from education,
and we think there's dozens of examples
like that where with us doing common
sense things and sharing that as widely
as possible at a local level, some folks
might adopt it at a national level.
We, we might be positioned to become
plugged in to what comes next.
So that's the goal.
You talked a bit about working with the.
The different payers
and, healthcare systems.
How are the actual healthcare
professionals that, that we're talking
with, how are they taking this?
I think there's two stages
to the conversation.
If they've never heard of us, then
anything that's free in healthcare
sounds too good to be true.
There could also be the perception that
we're stealing patients from their panel.
Once they come to know us, the feedback
we're getting is you're doing the
things that I can't do because I have to
practice within the current structure,
within the current reimbursement
policies, within the current framework.
So the fact that.
We can see people between their
visits to their endocrinologist,
that's helpful to them.
they, all went into
medicine to help people.
So if we can be there to help
people in between, that's wonderful.
The fact that we can provide more
education than oftentimes they
can, connect the fact that we
have behavioral health supports
specific to type one diabetes.
So many of the providers we talk to
say, man, that's just not available.
It's wonderful that you're doing that.
I think our job is to, of course,
help, the participants in our program,
but to be successful in doing that.
We need to be helpful to the doctors and
nurses and educators that we partner with.
And, our number one source of
participants in the program today
is referrals from 120 plus clinics
across the states that we're in.
And we're proud of that because it
means that they recognize the value
we're adding in helping to make
the folks they care for healthier.
What opportunities within this
challenge of re-envisioning
type one diabetes care.
What opportunities do you see?
The first opportunity is to
communicate the challenges, right?
If people don't understand the
challenges that the type one diabetes
community faces, we won't get
enough attention in solving them.
And it's something like one half of 1% of
the population lives with this condition.
So it's easy for it to get
hidden under the larger bucket of
diabetes, or to be misunderstood.
so you know, I. Again, I think our
job is to both care for people, but
to raise attention to what could be.
And that requires drawing attention
to what is and why it's not working.
I just, some of the statistics that
shocked me that I share when I give talks
is over 70 county, 70% of counties in the
US don't have a single endocrinologist.
This is a disease that
must be self-managed.
Five to 7% of people with this
condition ever see an educator, right?
There's just this like long list
of, hey, the things we need are not
available and we need to do better.
When we talk about communicating, then
we talk about finding your community.
Then this is both.
An opportunity to advocate, but
also to improve your own health.
Coming from traditional healthcare,
I didn't fully understand how
important connecting people with
this particular condition to other
people with this condition is.
And the feedback we got first,
we were surprised by the number
of people we were caring for that
didn't have anyone in their life
that also live with this condition.
We began hosting events and you know
this, Scott, 'cause you host them
and you do a wonderful job, but.
we started by hosting our own events,
cooking classes and webinars and
just opportunities for people to get
together because we've recognized
the importance of connection.
And then we started to incorporate
it into our care model where we
said everyone should be prescribed
community from the start.
So this is another opportunity
where I'd love to see.
All of, diabetes clinics begin
to recognize the importance of
connecting people to community.
I think there's wonderful opportunities
in the advancements of the
technologies that people are wearing.
The, I think CGMs, automate insulin
delivery of, devices are only getting
better, and so we, we see a lot of
promise in that, and I'm just amazed.
How our rapidly evolving understanding
of biology is getting us closer e every
day to really what we need, which is
a potential cure to this condition.
So I think all of that and locally,
the impact that we're hearing from
the people we care for, like just
how these common sense things are
making a difference has me really,
I'm really optimistic that there's.
There's a lot of room to grow and there's
a lot of people working really hard
to, do what they can to help advance
the, this field and, improve the health
of people with type one diabetes.
Yeah, that's great and it's great to hear
that there, are so many opportunities.
Like I still feel like I have
a lot to be hopeful for in my
life with Type one diabetes.
Yeah, we have a lot of work to do.
Like, we, in some sense I'd say Blue
Circle Health shouldn't even exist, right?
We shouldn't, need a
philanthropically funded care
program to, to fill in the gaps.
Especially since we're paying as a nation
over $19,000 per person with type one.
So it's not that we're under, and
the average person with type one
then spends thousands out of pocket.
So it's, not It's not like we don't spend
enough money to dramatically improve.
Hundreds of thousands of lives right now.
It's that we spend it on the wrong things.
Yeah.
Is there anything that I haven't asked
about that you want to be sure to cover
in our conversation today as we think
about starting to wrap things up here?
No, I think I would say one
more thing, which is I've worked
across many, let's call them.
D disease domains, like I've helped in,
I've helped in all different types of
cancers and heart disease and, childbirth
and end of life care and, surgical
care at like dozens at this point.
And it's always interesting to
get to know the professional
and the patient communities
when you enter into a new space.
and I'm often the newcomer and I
will say that I've been blown away.
By how generous and supportive and
caring, both the professional, but
also the professional type one related
community, but also the people who live
with the condition, the way they've,
welcomed us in this new concept with
open arms, the way they've connected
us to other organizations that
have helped amplify our reach and.
Organizations like Beyond and Breakthrough
and, like I, I've just, and a DA
and there's, we now have organized
17 nonprofits to all come together
and to share a calendar and to share
messaging, and it's, I just haven't
seen that in other parts of healthcare.
so I think that one of.
The greatest assets that this
community has is the community.
And and I think if we're going to make
real progress in both drawing attention
to the fact that care can and should
be better and in lowering the price of
drugs and improving access via insurance
policies to devices, I think it's
going to be when this community comes
together and shares one voice and I've.
I've never come across a community as
capable of doing that, and I just think
for me, it's going to be really fun to
see how this community works together to
continue to drive progress and change.
Amazing.
then we've covered a lot today.
If you had to pick a few key
takeaways from our conversation,
what would those be?
Number one, fee for service.
Reimbursement for healthcare is the
number one cause of people being sicker
than they need to be in this country.
Number two.
There is a role for philanthropy to
fund into existence a single condition,
value-based care program that can prove
better results are possible at lower cost,
and, we're working on that number three.
This community is amazing, and I am
grateful to everything they've done to
pick us up and to connect us, and I'm
even more excited for what they're,
going to do next and to be a part of it.
And number four, Scott, thank you
for everything you do for Blue Circle
Health, but for the community, we met
you because you are already a pillar
in this community, and more than one
person said, you need to talk to Scott
if you're doing what you're doing.
And I, couldn't be more grateful,
that we've got you on the team.
Thank you.
Honored, to be here and, I
appreciate you building such
a place as Blue Circle Health.
It's it's very fulfilling for me to devote
my time and energy to this organization.
Len, thank you so much
for, talking with us today.
I really appreciate it and thank
you for all the work that you're
doing at Blue Circle Health.
It's, needed.
Yeah.
It's my pleasure.
Thanks Scott.
Appreciate it.
If you enjoyed this episode,
think about leaving us a review
and subscribing to the podcast.
You can also check out the video version
on the Blue Circle Health YouTube
channel, and be sure to tune in for
our next episode where we're going to
get some expert help in talking about
our type one diabetes with others.
I hope you'll join us.
Until then, keep living well with T1D.