247: Sutter Health's CCIO Dr. Richard Milani: Why RPM Billing Pays for the Wrong Thing, the 10-to-1 ROI of Chronic Disease Control, and Health Literacy as a Design Input, Starting With Measurement

Subscribe on: RSS | SPOTIFY | APPLE PODCAST | GOOGLE | BREAKER | ANCHOR

On this episode of The Digital Patient, Dr. Joshua Liu, Co-founder & CEO of SeamlessMD, and colleague, Alan Sardana, chat with Richard Milani, MD, Chief Clinical Innovation Officer at Sutter Health, about "Why RPM Billing Pays for the Wrong Thing, the 10-to-1 ROI of Chronic Disease Control, Health Literacy as a Design Input—Starting With Measurement, and more..."

Audio:

Guest(s):

• Richard Milani, MD, Chief Clinical Innovation Officer at Sutter Health
• Joshua Liu, MD (@joshuapliu), Co-founder & CEO at SeamlessMD

Episode 247 - Show Notes:

[00:05:36] Why chronic disease is "the elephant in the room" for health system design — Richard says preventive medicine, population health, and epidemiology shaped everything he has done since, and he went into cardiology because so much of prevention is cardiovascular in origin. Chronic disease consumes 70–80% of the healthcare budget and is the number one cause of disability, and the system fails at both prevention and management. Citing the National Academy of Medicine's conclusion that "trying harder will not work," he argues that systems of care built 120 years ago don't fit today's problems, and he has spent the last 15 years or so redesigning them.

[00:09:17] What stands in the way of prevention, and why societies can still overcome it — Richard is "pro prevention," but names an $80 billion a year food industry that targets children as young as two and three as a formidable barrier. Smoking cessation shows big societal changes are possible but take a long time; other examples include seat belts, speed limits, and Singapore's approach of charging locals to enter its casino and inflating car prices while building a strong transit system. The lesson: "You have to provide the alternative and make it really frictionless and easy." In the meantime, he says there is much to gain from better management.

[00:13:29] How small changes in convenience build healthy habits — most people will do whatever tastes good, is easy to get, and doesn't cost more, so a healthy option that takes two hours to prepare won't work. Richard describes keeping a bowl of fresh fruit in the kitchen for his children so the easiest choice was the healthy one. He also cites a study in American schools where free whole apples went largely uneaten until schools offered apple slices instead, one of the "minor little changes that make all the difference."

[00:20:54] Why SutterSync started with poor chronic disease control rates — Richard says the US control rate for high blood pressure is about 23%, and for diabetes about 43–44%, and those rates are dropping year over year. The 77% with uncontrolled hypertension are on a path toward strokes, heart attacks, kidney failure, and heart failure that is avoidable. Seeing a patient a few times a year can't fix this, because blood pressure changes week to week and care needs data directly from home.

[00:22:21] How SutterSync removes friction for patients and physicians — the goal is to make home monitoring "as easy as brushing your teeth." Sutter supplies its own blood pressure cuffs, glucose devices, and weight scales that go directly into Epic with no extra apps or setup. Because physician-level adherence to guidelines is generally under 50%, the work moves to a dedicated "focused factory" team: "We don't do brakes, we don't do windshields, we just do transmissions."

[00:24:05] The backbone behind SutterSync's results — patients receive bite-size education adjusted to their measured health literacy, delivered as one-minute "infomercials" instead of an hour-long booklet. A team reviews readings close to real time ("We're not an ICU") and makes iterative medication and dose adjustments. Richard reports that 90% of patients with long-uncontrolled hypertension reached control within six months, with ongoing monitoring, monthly reports, and phone calls to keep them there, since 20–30% of people in control at the population level fall out within a year. The program includes people in their 90s.

[00:26:11] Why multiple chronic conditions belong in one holistic program — more than half the US population has two or more chronic diseases, so a patient with diabetes and hypertension shouldn't be in two programs with two apps and two reports. SutterSync combines them into one program and one report showing what to do, what has been done, and progress made. Nationally, Richard says only 15% of people with both hypertension and diabetes have both controlled at the same time.

[00:27:43] Why patients stay in SutterSync indefinitely — with a continuous stream of data, the team can generally predict three to five weeks in advance that a patient is likely to fall out of control and intervene before it happens. Richard pushes back on the view of some insurers that "you're okay now, so you're done": "As long as you have the disease, you're not done."

[00:29:09] How the Essential Eight helps patients sustain adherence — Richard highlights the American Heart Association and American College of Cardiology tool that combines four measured factors, such as A1C, LDL, blood pressure, and weight, with four lifestyle behaviors, such as diet, sleep, and activity, into a 0–100 score. Patients see how each factor contributes and that more lifestyle change can mean less medication. He compares control to a seatbelt: it only benefits you as long as you're wearing it.

[00:32:13] Why health literacy determines whether a digital program succeeds — SutterSync was built at a fifth to sixth grade level and measures health literacy at the start. Richard says health literacy matters "overwhelmingly" for disease control across diabetes, hypertension, and COPD, and Sutter's own data shows adjusting for it helps, but not enough yet, so the team is building another education format for patients at the very lowest literacy level. Reports, phone calls, and communications tell patients what their results mean and what to do next, rather than leaving interpretation to them.

[00:34:29] What health systems miss by not measuring health literacy — "The first step is you have to measure it, and people don't even measure it." Richard says a 20-page, one-size-fits-all after-visit summary from a vendor is not adequate. Education should be delivered "in a way that fits you, not a way that makes it easy for us."

[00:35:45] How to decide between building and buying — Richard has no problem with vendors filling gaps, but health systems must know exactly what they want, because "the vendor doesn't" know the rules. That means defining the gap, how the tool must function, and how to prove it's working. Sutter built its own education and can track whether patients opened and read it, showing a direct correlation with control and reaching about 85% of patients so far.

[00:38:27] How Sutter plans to help other organizations replicate SutterSync — Richard agrees Sutter is "a little bit of an outlier." The team will publish its findings and ROI for both clinical and financial audiences, and eventually plans to make the whole system available for others to import, though he says there is still fine-tuning to do.

[00:39:37] Why payment models hold US health systems back — Sutter doesn't use CMS's remote patient monitoring (RPM) codes at all, because they pay on time spent rather than results; one patient may need five minutes and another two hours. Richard's argument to CMS: "Pay me for outcomes, which is what you seek." He says the new ACCESS model pays for outcomes but at such a trivial amount "it won't even pay for even an AI to do it." The opening is risk: with more than half of Medicare patients in Medicare Advantage, at-risk health systems see an ROI at one year and a bigger one at two.

[00:43:34] The hidden downstream costs behind a 10–20x ROI — Richard says this isn't "another money grab"; the goal is to cover costs. Because 70% of dialysis patients are there due to uncontrolled diabetes, hypertension, or both, he puts the return at "10, 20 to one." Most insurers think in short terms, but in the 65-plus population the financial returns appear within a year.

[00:45:38] How to make innovation self-sustaining with the right ROI measures — Richard compares innovation to raising children: an experiment that's going to live on has to support itself, or a CFO will eventually call it a "money pit." Teams should plan up front how to evaluate ROI, such as linking reduced physician turnover to recruiting and onboarding costs. With ambient listening, administrators may reflexively ask why a doctor isn't seeing more patients, but "maybe more patients isn't the right answer"; the value may be in reduced burnout, better quality work, and lower cognitive load, which has been shown to change outcomes like length of stay in the ER.

[00:48:50] Why niche innovations like NICU tools should measure every outcome — the approach is the same: decide up front which outcomes to expect, such as survival, length of stay, or cost, and "measure them all as much as you can." Almost everything that improves clinical outcomes reduces downstream costs, and Richard says taking the extra step to capture financial impact makes an innovation "pretty much bulletproof."

[00:50:44] What separates real innovation from incremental improvement — new software or an EMR upgrade is the day-to-day work of maintaining systems, not innovation. Real innovation asks where the unaddressed deficits are, such as circadian disruption in the ICU, which Richard says very few people are paying attention to and which, when favorably altered, reduces length of stay. "Think about the things that are not being routinely addressed that are big opportunities."

Fast 5 Lightning Round:

1. What is your favorite book, or the book you've gifted the most?

Big Bang by Simon Singh and Eat Your Ice Cream by Ezekiel Emanuel

2. If you could instantly master any skill, what would it be?

"Being multilingual"

3. Would you rather have super strength, super speed, or the ability to read people's minds?

"Mind reading"

4. What is something in healthcare you believe that others might find insane?

"The fee-for-service payment model: the worse I am, the more money I make"

5. What is the last movie or TV show you saw, and what did you think of it?

Project Hail Mary. "It's a fun movie. I would recommend it."

The Digital Patient has been recognized as Feedspot's #1 Patient Engagement Podcast of 2025. Thank you to our listeners for making this happen!