How Dr. Sanjeev Arora Helped Improve Care for 200 Million Patients

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Mark Masselli (00:04)
People around the world are living healthier, longer lives thanks to the work of our guest. He founded Project
ECHO, which provides training and mentoring that results in patients having access to the highest quality
healthcare.

Dr. Sanjeev Arora (00:18)
If we are willing to democratize our expertise and work together as interconnected set of providers, we can
rapidly improve the US healthcare system.

Margaret Flinter (00:32)
Dr. Sanjeev Arora recently retired from his role leading Project ECHO. But he has important lessons to share
with us about how we ensure that we're reaching every person with the best healthcare.

Dr. Arora (00:44)
And I know that your organization was actually playing a leading role, because what I found very unique in
your organization was this complete desire to be the most innovative community health center in the world.

Margaret (01:05)
This is Conversations on Healthcare.

Mark (01:18)
Well, Dr. Arora, welcome back to Conversations on Healthcare. It's so good to see you.

Dr. Arora (01:23)
Thank you. Thank you for, for this great honor, Mark and Margaret, and I've been a long admirer of your, of
your work and also of this, podcast.

Mark (01:35)
Oh, that's great. You know, it's been too long. Yeah. obviously, we've talked to you, in between the times that
you were here in 2011, but we know you so well. certainly, our community health center was the first of, the
federally qualified health centers to operate its own Project ECHO clinic. We couldn't have gotten there without
you, without your incredible leadership, and, you know, th- these ECHOs were really designed to meet the
needs of safety net primary care providers in their communities, not only in our communities, but all across the
globe. I'm wondering if you could just take our audience back to the original vision for Project ECHO. Where
did you get the idea?

Dr. Arora (02:16)
Yeah, you know, I'm a gastroenterologist by profession, and, what was happening was that I was, practicing in
the University of New Mexico, where I'm a professor, in 2001, I'm, I'm a professor there, and I s- I, I was an
expert in hepatitis C and I saw a patient, who was 43 years old and she had two children in the room, a 14-year-
old boy and a 9-year-old girl, and I asked her, "How can I help you?" And she said, "I have hepatitis C and I
want treatment." And I said, "Of course we'll do that. How long have you had it?" And she said, "I've had it for
eight years." So, I said, "Why did you not come earlier for treatment and being here?" And she said, "I've called
your nurse and there was an eight-month wait to see you, and I would have to drive 200 miles each way-" Hmm.
"... make 12 trips while I was getting these injections and pills, and with all these side effects, and I would, I
can't take so much time off work, because I'm, I'm a single, single mother." So, I said, "Okay, what made you
come today?" And she said, "I'm having pain here in the right upper side of my abdomen." Which hepatitis C
doesn't cause pain in itself. And I did an ultrasound and I found a cancer of her liver this big. And it was too
late, and she passed away and I was asking myself, "Why did she die of a disease that was potentially curable?
And, now we have these two children who are going to be missing their mother." And the challenge I was facing
was there were 28,000 hepatitis C patients in New Mexico that had been diagnosed and the state health
department had their names, but only 1,500 had been treated. And as I mentioned, I had an eight-month wait to
see me and I was working all the time, and I said, "This is an insoluble problem unless we change the way this
delivery system is working." And particularly difficult for underserved patients, because the people with full
insurance and lots of resources were able to somehow get access, but it was the lower income people who
couldn't. So, at, it's at that time I came up with the idea of Project ECHO. I was meditating- (laughs) ... in
December 2002 asking this question, "How can we, you know, what should I do to be of service?" And this idea

came to me. And the, the model was based on the idea of democratizing my expertise, and- Right. Wonderful. ...
that's how it was born. Yeah.

Margaret (05:03)
Well, that is a great story. we certainly remember our first Project ECHO, session here after we'd read about
you, gone to learn from you, Dr. Anderson came back and, and, and launched it. But I think the, the radical idea
in your democratizing of healthcare, from the healthcare system point of view might have been that you decided
that the answer was primary care. And that it was the primary care providers who would be the instruments of
this democratizing and bringing healthcare to people who need it. I wonder if you could, you know, before we
talk more about the future, just take us back to that for a moment and how you navigated the engagement of the
healthcare community in saying, "Primary care needs to step up and into this and we can support them." Tell us
a little bit of that part of the story.

Dr. Arora (05:49)
You know, for a long time I, I had this intuitive feeling that there was no solution to this healthcare system's
challenges of low quality, high cost, and poor access.... which I call three big, big problems. And there was no
easy solution to this problem unless we made primary care the center of this care delivery system. That means it
was not possible envision a system where a spec- a patient would from a specialist to specialist to specialist,
figuring out whom t- she needed, what specialist is the next one, and then who coordinates all the care
between ... It, it, there was just no other theoretical way. In my case, there was an additional problem. There was
a dire shortage of specialists, and that hasn't changed yet. Even today, 20 years, 22 years after I started ECHO,
for underserved patients in this country, access to care, specialty care, is very, very hard. It's like, you know, all
the airplanes, these are specialist appointments, are full with fully paid patients, and so it's very difficult for
underserved patients- ... to actually squeeze into those seats and it's really sad, to see what is happening. And so,
what, what I was seeing was, Margaret, was that there was a very large-scale problem in that knowledge was
increasing at an exponential pace and there was need for specialty expertise but there was no way there could be
just, we don't have ... It, we would need 10, 20 times the number of specialists and it wasn't ... Whereas in
primary care, there were a few very common diseases which they saw so much of. The Pareto principle was in
effect. That is 20% of the diseases accounted for about 80% of morbidity, mortality, deaths and if we were able
to democratize our expertise to empower them to t- take care, then only those patients that truly needed highly
specialized expertise would need to go to specialists. And care would be provided closer to home at a lower cost
by providers they knew and t- trusted.

Mark (08:34)
Well, this is kind of interesting, the democratizing of, of healthcare had a simple model behind it, a hub and
spoke structure, 'cause you've got a lot of people out in rural areas but you have the technology or the expertise
in one particular area- ... and I really find that hub being a force multiplier, right? It really just, strengthened,
wherever people were at the distance. Just talk a little bit, explain how that worked and why it really is, is
fundamental to the success that you've had.

Dr. Arora (09:04)
Yeah, no, I think, Mark, you absolutely, hit the nail on the head here. The reason why ECHO works is because
it's a force multiplier. For the more than eight billion people in the world, 85% of them don't have access to
specialty care. So, to even imagine a solution that will help them all, one would need force multiplication, and
the way I define that in healthcare is an exponential improvement in capacity to deliver best practice care ten
times. Not just doubling but going tenfold. And so, the way ECHO worked was it was based on four key ideas.
One was to use technology to leverage expertise and there was no Zoom at that time in 2003 when I started
with. hard to believe. (laughs) (laughs) Yeah. But we bought a used Polycom Bridge- Right. ... like paid $25,000
for it, put it in the basement and created something like Zoom for about 25 people could ... That's the max that
would come. The second key idea was to share best practices, so I went to primary care and I said, "Look, this is
how y- you treat hepatitis C." But they said, "No, no, this is, sort of a little bit of chemotherapy here. You can't
just give us lectures and we just do it." And it, it occurred to me that whenever there's a dynamically complex
problem like treating a patient with hepatitis C or complex diabetes, you need guided practice. That's how we
train doctors. So that brought me to the third principle of saying, "How did you become a specialist?" When I
was doing my fellowship I would see a patient, present to my professor, see another one, professor, and after
two years they said, "You're a gastroenterologist." (laughs) I said, "Aha!" (laughs) "I'm going to create new
hepaticologists in New Mexico." And I told them, "If you could just join me once a week for an hour or so and
present cases to each other and to me and my psychiatrist that we'll help you manage these patients. In a sense
hold your hands as you first crawl and then walk and then run." Learn one- And we did. ... do one, teach one,
right? Yes. Same way. Exactly. And so- (laughs) ... so as we did this week after week, in one year they became

experts and in 18 months the wait in my clinic actually fell to, from eight months to two weeks. And we knew
over the next many years we treated thousands and thousands of patients- Mm. ... that we had stumbled upon a
model that could be very helpful for people all over the world.

Margaret (11:55)
Well, you were 100% correct and-... as we think about that, we were so focused on hepatitis C at that moment
when we read about this work because we were dealing with it as everyone around the United States was, not
just in New Mexico. But was really transformative, to us was that moment in time also brought us the opioid,
epidemic- ... the challenge of how do we now manage chronic pain when the opioids are no longer? We clearly
know that it's unsafe to use them in most situations. We were still dealing with the HIV crisis. tell us a little bit
about how you took it then from a model that was highly effective with hepatitis C to make it a, kind of a
solution to all of the complex problems that we address in primary care if we can train new providers coming
into the practices to this model. Because, no surprise to anybody, people did not sign up for primary care
thinking they would necessarily be managing these. So, tell us a little bit about that transition from the hepatitis
C focus to all of the other conditions that you then began to lead teams in.

Dr. Arora (13:02)
Yeah. I mean, the first, important issue, observation was that a lot of people with hepatitis C had addiction as the
underlying issue. And not treating that, often addiction was associated with mental health disorders. So in the
very first ECHO clinics, we found that having a multidisciplinary team upskilling these general practice
providers would be necessary because primary care providers were not so interested in treating disease. They
were interested in managing patients. And to manage a patient, you have to provide a comprehensive solution.
So, we started that, but we had no money. And, but in 2004, I got a grant and we did a study, to prove that
primary care could do as good a job. We ultimately found they were better than specialists, when, because the
care was close to their home by doctors whom they knew and trusted, et cetera, as long as they were mentored
and supported. But then, um... And this paper was ultimately published in the New England Journal of Medicine
in 2011, showing that primary care could do as good a job, as specialty. That was a game changer for us. But in
the meantime, Robert Wood Johnson Foundation, had come up with a global competition called Disruptive
Innovations in Health Care that can change health care globally. This was around 2008, and it was sponsored by
the Ashoka Foundation and- ... Robert Wood Johnson Foundation. But the money for the competition was
coming from Robert Wood Johnson Foundation. And we were one of, three winners of this competition, and
ultimately, they gave us a $5 million grant to prove two things. One was, could it be applied to different diseases
which were still fitting within the Pareto's principle, that where they were the most common complex problems,
the 20% of the diseases that account for most of the problems that occur. And could we upskill primary care in
those setting, for those common problems? And the second was, could it be replicated to other states or was it
just a New Mexico-specific thing? And so, we got this grant and we started working on it. And we... The first
one we started was mental health disorders. Then we started a chronic pain one. Then we started diabetes. And I
know that your organization was actually playing a leading role, because what I found very unique in your
organization was this complete desire to be the most innovative community health center in the world. And, and
you were. That you immediately saw the potential for force multiplication, that one of your clinicians had
chronic pain expertise, if I recall. Another one had hepatitis C expertise. And you started upskilling. it was a
really wonderful example for me that this is not just a specialist-focused prob- thing. Primary care finds this
helpful. So, it wasn't just about disease outcome. 'Cause my wife is a primary care clinician, and they are in
embattled lot. There's a lot of pressure on them. And one of our goals was to produce joy of work for them. And
so- Right. ... in our initial studies, we published lots of papers. Now we have 700 peer-reviewed publications for
ECHO. But the earliest ones we showed that ECHO was producing joy of work for them, reducing their
isolation, increasing their satisfaction, and it was doing it by building communities of practice. So, that's how-

Mark (17:35)
Yeah. And those community of practice, certainly here and I know with Dr. Arora are groups who are
intellectually restless, and you found them all over the globe. I'm glad we found you, in that same spirit. But
Margaret, you were talking a little earlier about Zoom hadn't come around and Dr. Arora was saying things that
are game changers, and I'm just wondering if we look back at the COVID-19 pandemic, where the whole world
started to change in terms of healthcare and we had the means to communicate with so many- Right. ... so many
different people, that we hadn't... ... we never had exercised that muscle. I'm wondering if you could just share
again with our listeners how Project ECHO met the needs of patients who really at that point had limited access
to specialists?

Dr. Arora (18:21)
Yeah. What happened as the world shut down, we already had, had done something that I had met with Eric
Yuan, -who was the founder of Zoom- and told him, "Look, we wanna change the world." And he had given us
an unlimited Zoom license for the whole world, that I could give Zoom licenses to other universities and not-
for-profits, and we were giving thousands of them out. And what we found... And so that was one thing that was
in place. The second thing that was in place was ECHO was going on for diseases like diabetes and chronic pain
and mental health disorders and, and so on, for about 70 different disease conditions in 190 countries. Okay?
And as soon as the pandemic came, we put out a call basically that, "Look, temporarily you can shut down all
your ECHOs. Focus just... You already have primary care clinicians who have their time blocked on calendars,
right, once a week, once every two weeks. Let's do a switch and use COVID-19 as your subject. Let's try and
save lives." And I know you used it extensively, ECHO, for COVID-19. But so did, you know, more than 1,100
hubs at that time. Currently, we have more than 1,400 hubs, like Community Health Center, I think, all over the
world, the leading universities in, in co-, in more than 70 countries, actually. But the learners now are in more
than 200 countries, territories, areas, and millions of them. And has... ECHO has now impacted more than 200
million patients. But it would not have spread so quickly unless what Mark was talking about happened. COVID
came along, and entire governments didn't have the money for Zoom licenses. We provided the Zoom licenses
to them, and the ECHO training, for whole countries. Yeah. The entire COVID program for a country like India
ran on ECHO Zoom licenses. And so, I think it was, it just happened to be there, and then of course, as you
know, you participated in the nursing home project- Yep. ... with us, where what was happening was, too many
deaths were occurring in nursing homes in the US and ECHO was used very, very successfully, with a federal
grant to train nursing home personnel how to diagnose it, how to prevent it from spreading in the nursing home,
how to treat it, how to prevent hospitalization, how to... a- and so on. So, it, it was just... It's, it's been a blessing
to see how the model has been able to help many, many people. And, and of course very grateful to you for
being such early adopters.

Margaret (21:45)
Well, creating that platform let us all be very creative. And I think one of the, one of the most unanticipated
outcomes, Dr. Arora, that I have seen, and I, I referenced this really briefly but I, I want to shine a little bit of a
spotlight on it, is community health centers serve as such a vital function, in this country, and oversees
analogous systems. But 31 million people, or 35 I think now million people are cared for in a health center.
Workforce always an issue. to bring new physicians, new nurse practitioners, new PAs, new nurses into this
setting and say, "You have the opportunity to care for a amazingly wonderfully diverse group of patients, and by
the way, you will be caring for people whose health challenges include HIV or AIDS or substance use disorder,
chronic pain-" "... all the other, the diabetes, all these other things," to be able to offer this up as a platform that a
new provider, not the 20-year experienced person who just needs some additional work, but the new provider
can become expert through the case, based discussions, through being part of a team, has really been
transformative. And I, I wonder, if you have seen that as a lasting imprint on the landscape, certainly in New
Mexico but also around the world in your travels, that this is transformative for the workforce? Tell us a little bit
about that.

Dr. Arora (23:10)
I think your organization led the way in it. But ultimately, two things happened. One thing was we realized that
if you... ECHO is just a model. Our mission was to improve healthcare for underserved populations, so we had
to ask the question, who is providing healthcare for underserved populations? The vast majority in the United
States was community health centers and/or church-related, you know, other not-for-profits. And in, other,
Africa and India, et cetera, it was mostly governments. So, the learners in ECHO are predominantly in these two
categories. they're not private practice doctors who, typically... because our focus is on underserved- ... people.
But as you pointed out, and you innovated on this area-... that, it could be a very powerful recruitment retention
tool. Because primary care clinicians are seeing a patient one after the other after the other, and when an
organization tells them, "We are also very interested in your personal development-" "... and your growth of
your knowledge, and we will give you mentorship." So, in many, many parts of this country, the word got
around, and, and primary care would, oh, would tell community health centers that, "We would only work for
you if you gave us one hour a week or two hours a week to participate in ECHO." So- Uh-huh. ... what you
innovated on actually became a practice all over the United States in many places. Yeah. Because this was also a
break from them, from this continuous RVU juggernaut that is really hurting primary care.

Mark (25:07)
You know, beyond the United States, when I ... Dr. Arora mentions, being in 200 countries- Yeah. ... I think of
Dr. Venkat Swami- Sure. ... in India- Aravind. ... in Aravind. And really, the complexity I think our listeners
should understand for Dr. Arora to be in all those countries, where there's really no borders, in terms of trying to

meet the needs. It, it's a global, it's a global initiative. And, and we're so proud to know you to do that. I wanna
talk a little bit about, India because, maybe you could tell us about the outcomes you see from your mental
health training in India. But tell us a little bit about the work you've done, there as well.

Dr. Arora (25:49)
Yeah. So, you know, in India, there is a very, very large, mental health problem, of, in patients who don't have
any access to mental healthcare. They could be, in many states like Bihar and Northern India, and, uh-

Mark (26:07)
Poorest, poorest there.

Dr. Arora (26:09)
Yeah. And there is a ... There could be one psychiatrist for hundreds of thousands of patients. Suicide rates are
high amongst young farmers, for example- ... in India. Similarly, often people try and manage this depression or
anxiety with alcohol. And so, all of this gets mixed, and there's no access to specialty care. So, we partnered
with the government of India, and so ECHO became a part of the Mental Health National Plan. And we
partnered with the National Institute of Mental Health and Neurosciences in Bangalore, India, and then with
other academic centers all over India to democratize care for the, what I would say, the basic mental health
disorders, which would be depression, anxiety, early diagnosis suicidal tendencies- Mm. ... diagnosis of bipolar
disorder. You don't necessarily have to know how to treat it completely. But just these things account for such a
large number of patients, but what we saw in the, that as soon as we put these ECHOs in there, the number of
each, each clinician that we train ... So, in one, one outcome study where 22 clinicians were trained on mental
health disorders, in one year, they saw 22,000 mental health patients and treated them. It was the first
multiplication was so ex- amazing. And it wa- and this is not a one-year deal. Once we, they participate in a one
year of ECHO and get certification, which all their life they're treating more and more patients. So, it's, this was
this data collected for one year, so the impact, and then studies were done to show that these patients benefited
profoundly, because of this lack of access. And medicines which had never been used before got used in the
community, and it was, uh ... And so, in many, many disease areas, we have strong patient outcome studies like
hepatitis C, like diabetes, complex diabetes, prevention of cardiovascular illness, et cetera.

Margaret (28:50)
Well, Dr. Arora, we want to thank you for joining us today. We wanna thank you for your commitment, and
your service. We're honored really to call you a friend and a colleague. We look forward to potentially the
opportunity to continue to work with you. And if you would like to say any last words to our audience, to leave
them with about, your best advice to carrying this work forward, we'd love to give you an opportunity to do that.

Dr. Arora (29:17)
Well, thank you, Margaret. And first of all, thank you for this great privilege to be interviewed by the two of
you. I've been a long, longtime admirer of your work and your leadership in primary care, so my gratitude for
that. I think the one, the one key message is to never doubt that a small group of dedicated people in the world
can change the world. It's, indeed, it's the only thing that ever has. And so, I know there is, tends to be a lot of
negativity about the US healthcare system. But we have so much expertise here that we were just to think
differently. Instead of monopolizing knowledge for either money or fame or power or whatever other reason, if
we are willing to democratize our expertise and work together as interconnected set of providers, we can rapidly
improve the US healthcare system, improve rural healthcare, improve care for underserved populations. The
workforce is there, but if a primary care clinician doesn't know what to do, it creates a lot of inefficiency in the
system- ... unnecessary specialty visits, unnecessary cost, and so on and so forth. So, I'm hopeful that, with the
leadership of people like you, we will be able to get to a way where the role of a specialist is not to just see
patients, but to really step up and join this force to democratize expertise.

Mark (31:15)
Beautiful.

Dr. Arora (31:16)
Thank you.

Mark (31:17)
Thank you so much.

Margaret (31:18)
Thank you so much. Peace.

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Margaret (31:23)
This copyrighted program is produced by Conversations on Healthcare and cannot be reproduced or
retransmitted in whole or in part without the expressed written consent from Community Health Center Inc. The
views expressed by guests are their own, and they do not necessarily reflect the opinion of Conversations on
Healthcare or its affiliated entities.

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