WebMD Chief Medical Officer John Whyte, MD, MPH, speaks with Cheryl Pegus, MD, MPH, executive VP of health and wellness at Walmart, about the impact of the pandemic, providing care in underserved and vulnerable communities, and the integration of retail into healthcare.
This transcript has been edited for clarity.
John Whyte, MD, MPH: Welcome, everyone. I'm Dr John Whyte, chief medical officer at WebMD. If I asked you 5 years ago, "Would you get your healthcare at Walmart?" you might have looked at me as if I were crazy. But today if I ask you the same question, you might reply that you prefer to get your care there.
Walmart is opening health centers across the country. Sure, it includes the pharmacy but so much more. And it's all literally under one roof while you shop for food, clothes, and household items.
How is this changing the way that we deliver healthcare as well as how we define health? I had the opportunity to tour Walmart Health in Springdale, Arkansas, with Dr Cheryl Pegus, executive vice president of health and wellness at Walmart.
We talk about the impact of the pandemic, the importance of providing care in underserved and vulnerable communities, as well as the integration of retail into healthcare. She provides us with a glimpse of what she thinks healthcare will look like in just 2 years, as well as what keeps her up at night.
Cheryl, thanks for joining me today. It's great to see you again.
Cheryl Pegus, MD, MPH: Thank you so much for doing this with us. It's great to have you at Walmart. I'm excited to share with you what we're doing.
Whyte: You started your new position during the pandemic, a new role. How did that impact what you were trying to accomplish?
Pegus: Over the year, in 2020, we were all seeing the impacts of COVID on many communities. And what we all asked was, how do we educate the community? How do we make sure that everyone gets education? Not only those who have access to healthcare systems and physicians, but other communities. We've known each other for a long time and we're both really interested in health equity.
We were also looking at rolling out new vaccines. I started talking to Walmart early on in the pandemic about what they wanted to do for the communities that they serve. We have over 5100 stores, but 4000 of them are in medically underserved areas. And their commitment was to making sure that, in rural communities and underserved communities, when vaccines became available, there was a place to go get them. Because as you know, "medically underserved" means there aren't enough doctors' offices. It really resonated. And they wanted to partner and do everything that was necessary.
Whyte: As you pointed out, 80% of the immunizations that you did were in medically underserved areas. Why was that successful? You mentioned a couple of words. You mentioned "trust," you mentioned "partnerships." How did they play a role?
Pegus: Walmart has about 1.6 million associates in the United States — 1.6 million. And in these 5100 stores that I've mentioned, in each of those communities, our associates who work in those stores actually live in those communities.
And so the first thing that we spent a lot of time doing was letting our associates know the importance of COVID testing and COVID immunizations. Why did we do that?
We got to hear from them, whether they were in Alabama, Arkansas, or New Jersey. "Here are the questions I have." And if they had those questions, then their families would have those questions and people in those communities would have those questions.
Frankly, John, we began tailoring community by community, zip code by zip code, what those needs would be, what those partnerships would need to be successful. So if we needed to partner with the NBA in the Bronx, we did that. If we needed, in Alabama, to partner with NASCAR so that there were people they trusted, leaders they knew — or in South Side Chicago with aldermen — we did all of that.
As you know, it was an everyday job every week, understanding whom to partner with for trust — how do we build that? And then there was executing what for me has been an incredibly humbling experience: a logistical system of associates who wanted to do it right. That's how we've spent the year, but starting first with our associates and then moving outside to the community.
Whyte: Historically, as we know, the healthcare system hasn't been very engaging. It's very hierarchical, patrician — the doctor's in charge. But COVID has also, in many ways, changed how we view health.
I wanted to ask you about that because that's, in many ways, what you're doing here, at Walmart. How has that definition of "health" changed?
Pegus: As physicians, we know that everyone has a different threshold for when they'll see a doctor. We also know that many people may not understand that having diabetes is not something everyone in your family is going to get. No, you're not all going to need a wheelchair later on. But even though we physicians know that, we don't always know where to start with someone to prevent any of the sequelae of disease from occurring. We're so accustomed to [seeing patients when they're] sick. We're accustomed to, we'll see the person when they come in to our office.
Walmart's approach is very different. If you're coming in to our store, even at the front door, we're sharing with you that there are healthy foods that you should be able to eat.
If you go to the optical site, which is also in the same store, and you get your eyes examined and you say you have a family history of diabetes, we're also directing you to the lowest-cost over-the-counter test strips, to make sure you're aware of that. While you're there, there's education.
There is almost an environment of everyone feeling that they have a role in keeping the people who come to us healthy.
Whyte: I want to turn specifically to Walmart and give some statistics which I think are very impressive, which people want to know. You've opened at least 20 medical clinics.
Pegus: That's correct.
Whyte: Over 200 million people — correct me if I'm wrong — use Walmart, either in person or online every week.
Pegus: Every week.
Whyte: You've been talking about an omnichannel approach to care. What does that mean?
Pegus: I think we're all aware that for being able to seek healthcare, if you can take the day off from work and go to your doctor's appointment, and you can schedule it 3 months in advance, that's how we provide care in the United States. That's what it requires. It requires time. It requires planning. And then on top of all of that, you need to be able to afford it.
Whyte: So, do it all on the doctor's terms.
Pegus: It's all on the doctor's terms.
Whyte: Their time matters.
Pegus: This is different. This is saying to people, "Would you like to get care on Sunday evening at home?" Because you're trying to decide, Should I go to work tomorrow? Am I too sick? Or, I have a child who's sick and I'm wondering, should I stay home? What do you do at that point? What are your options on a Sunday night, today, in healthcare? You go to the emergency room. You may try calling a physician and hope you get a response back from a physician who's on call, if you happen to have a primary care physician. And we're all aware that in this country, about 25% of people don't have a primary care physician. So your options for being able to solve in real time something that will help you — not just maneuver through the healthcare system but actually lower cost, because the highest-cost option is going to the emergency room — they're quite limited. What we're trying to do is give those options. We're not trying to take away emergency rooms, or healthcare systems, or existing primary care. We're asking, how do we expand that infrastructure so that people get care when they need it?
And the ways we're doing that, you've mentioned; it's not just through brick-and-mortar sites, the 20 that we've opened. We're adding five sites in Florida this year, and we're adding two more sites in Arkansas. We're continuing to build out.
But in the past year we've also acquired a virtual health company so that on Sunday night, you've got someone to talk to who can see you. And by the way, our pharmacies are open at night as well if you need to receive treatment.
So when we say "omnichannel," it's not omnichannel from what we provide; it's omnichannel from how you access healthcare. You can access it any way you'd like. And so we're looking at virtual health. We're looking at in-person health. We're looking at what pharmacists do. We're also looking at what our community health workers do.
We're building out a model that, we hope, allows everyone to practice — everyone stays at the top of their license — but what we're actually saying is that it allows you to practice without burnout because we're giving you the support systems around you. And that's what we're building when we think omnichannel.
Omnichannel is: I need help figuring out how to afford food. We've got a community health worker who will help you and who will stay with you until we figure it out. And by the way, we deliver food to you, and food is health. That's part of our omnichannel strategy. So that's what we're really doing. It's, what do you need to stay well in your community, and how are we doing that for you? That's what we're trying to do.
Whyte: Well, let's see how well Walmart is doing. I want to read you a quote from you. You say, "Walmart is in a unique position to provide quality, affordable health and wellness services to all Americans where they already live and shop."
Now the pushback would be from big, prestigious, academic institutions or doctors' offices that will say, "Dr Pegus, they don't want to go to Walmart where they shop. They want to come in to the doctor's office. They want to come in to the big, prestigious academic center." Who's right?
Pegus: If everyone in this country had a place to go for healthcare and if everyone in this country had a primary care physician, healthcare would not cost $3.8 trillion. There isn't an either/or. It's that we don't have enough to provide care for people who live in this country. Period. And so what we're attempting to do is help fill gaps but become part of that ecosystem. We're not going to replace all the primary care practices. But people in the communities where we are, that are HRSA-designated medically underserved areas, they don't have enough primary care physicians. So we're building sites for them to have those.
Whyte: And these are not same-day clinics, so people know. You're getting your primary care.
Pegus: You're getting your primary care. And you can schedule it online. You have follow-ups. Frankly, 50% of our visits are follow-up visits. There are people who seek their care at our sites. And why is that? Our sites are open 7 days a week.
Our sites allow an integration of telehealth with in-person care. We're one of the few companies that's already doing that. We have integrated optical and dental right in one place. So if you come in for your appointment and you have your family with you, people could be shopping for groceries while you're getting your eyes examined. That matters to busy families. It matters to people who are caregivers who are bringing in elderly members to receive their care.
Our goal here is, how do we help expand best-quality care? Our results to date — it's not just return visits — our NPS scores in our clinics average between 78 and 81.
Whyte: That's pretty good.
Pegus: We've had a 150% increase in the volume of people utilizing our services. We are NCQA accredited for the work that we do. So I would say, for those of us in healthcare, we want to give the best-quality care. It's that within our current infrastructure; we need to expand that. And we need to expand the definition of where you receive care.
Whyte: I want to move to that and I want to talk about social determinants of health. You and I met many years ago — I won't say how many — when we were talking about HIV and the disparity that persisted then that still persists now, primarily in people of color.
But you and I also share this concept that health happens when you leave the doctor's office. And that's a mindset change. There's a lot more attention now focused on social determinants of health, more than has been in the past few decades. But to be a little bit of a cynic, what's different now, Cheryl? What's going to change it? Because people have been studying it for years. We don't need more studies. So what are Walmart and Walmart Health doing that's going to be different, that's going to have an impact in addressing the social determinants of health, which we know have an incredible impact?
Pegus: It's probably the question that always keeps me up. I think many people know that I entered healthcare to address social determinants of health, to improve health when—
Whyte: When it wasn't popular.
Pegus: And it wasn't popular. It was almost like it was a club of people saying, "Hey, we've got health disparities." Do you remember when we used to say it?
Whyte: There was only a handful of people.
Pegus: All of us in the same room.
Whyte: That's right.
Pegus: Always having that conversation. What we have right now is COVID showing people that if we address health disparities, if we address social determinants of health, we could change the trajectory of healthcare. It's the first time I think the data are not just in the scientific domain on the people who care; everybody has seen it. Everybody has seen the data. Once the data have been shown publicly, everybody's got to think about what we do.
I think what worries me the most when you talk about what happens is, can we sustain this 10 years from now? Right now, everyone's interested in it. Will everyone be interested 10 years from now? And so what's different about Walmart? Look, when you go see the doctor, that's for a finite time. It's a 15-, maybe if you're lucky, 20-minute visit every 4 months, maybe twice a year, maybe once a year. But you're living a healthy lifestyle outside of a doctor's office.
So healthcare and wellness do not occur in a doctor's office. What you're getting is treatment for a specific condition. But if you have a chronic condition, you have to go home and manage that condition. Who's helping you do that? I think doctors have been trying to do all of it. They know they've got to talk about food. They know they've got to help people understand why they take their meds. But you need a team.
Whyte: But that's not what we talk about in the typical healthcare environment. But you're focused on that.
Pegus: This is my focus. If you think about what 100% of health is, 40% is social determinants. What does that mean? Access to fresh food. Access when you need help: You pick up the phone and you call. Someone says to you, "I'm here to answer your questions." Thirty percent is about personal behaviors. If you had high blood pressure today, do you know that you should be measuring your blood pressure at home? Do you know how to do that well? I don't need a doctor to tell someone how to do that. Only 20% is going to the doctor. So just think about that: 40% is social determinants of health, 30% personal behaviors, and only 20% is clinical. That's 90% of healthcare. What's the other 10%? It still is environmental and genetic things that, frankly, we haven't cracked the code on yet in healthcare.
Whyte: How are you going to change that? What's it going to be from the work that you're doing?
Pegus: We want people to know that access to fresh food is one of the core determinants of great health. And at Walmart, we are the largest provider of organic fresh food at the lowest price in the country.
Particularly as we're looking at 2022, we are partnering not just with payer organizations, not just with health systems.
Whyte: That's back to your partnerships, right?
Pegus: With community organizations. If someone is thinking of becoming pregnant, fresh food matters. If you have diabetes, fresh food matters. If you have high blood pressure, fresh food matters. I think sometimes we forget to say that in the physician's visit because we're thinking of, "Are you taking your medicines?" And even if we said it, many of us don't have the time to help someone walk down the aisle and pick out the right foods. Well, if you're shopping with Walmart, I've got a community health worker who will do that with you, who will ensure that it's being delivered to you if you can't travel to come get it. We will make sure that happens.
The need to take insulin is a growing medical issue in this country, and one of the main reasons is the cost. Walmart, definitely even before I started just thinking of commitment, knew that was a major issue and developed a Walmart-branded insulin that is 75% less expensive than what's out in the market. And we have all of the test strips and everything that you would need, at the lowest price in the country. So our goal is to make it accessible 7 days a week, to make sure that if you need someone to help explain to you why you're doing it, it's someone from your community. Our community health workers and everyone that I've mentioned, they live and work in the community — culturally appropriate, health literate, assuring that you have the right information. We want to make sure we're delivering it to you however you'd like to receive it and so now it's ingrained. That is what we're working toward. And we are very comfortable saying, "Oops, we have to try that again." And we're doing that.
Whyte: What about people who will say to you, Cheryl, that you're making health care retail, that healthcare isn't like buying a car or a dress. What's your response to that criticism, that mindset of how healthcare is different?
Pegus: What I always say to people is that it's not that what you said and what I said are opposite; it's that they're complementary. If someone needs to manage heart failure, you're right — they should be seeing a cardiologist. Our goal would be to get them to a cardiologist. If someone has severe rheumatoid arthritis, our goal is to get them to see the best specialist. But people have other needs. If you have rheumatoid arthritis, you need your eyes examined. If you have heart failure, you probably need to be checking not just your weight but your diet. Who's doing that when they're not with you? We're complementary.
Whyte: I want to turn to you and your story. As I've said, I've known you for many years. You're an immigrant from Trinidad, raised by a single mom. Now this I actually did not know: You were a double major. I'm impressed. I'm always impressed when someone's a double major, but you were a double major in biology and African American studies at Brandeis, got an MD from Weill Cornell Medical College and an MPH from Columbia. You're now in the C-suite of the US's largest private employer and a woman of color.
Pegus: I think my mom is probably helping you write some of that.
Whyte: Let's be honest: There aren't many women of color in the C-suite. There certainly aren't enough. There aren't enough women CEOs of healthcare systems. You've broken many of these barriers.
Pegus: So how do you get here? I think you get here not by yourself. And I knew I was going to go into medicine. I had my grandfather who was really sick when I was younger, and we couldn't afford healthcare. I was 12 years old. Today I'd say it was probably a diabetic ulcer. But I was doing wound care at 12 years old. I think it stuck with me — something I never, ever wanted to see another child have to do.
Throughout my career and my life, I have found people who will help me get to where I want to go. I probably have a little bit of tenacity in me. But look, I was the first Black female cardiology fellow at Weill Cornell.
Whyte: And that's not that long ago.
Pegus: It's not that long ago. I remember interviewing for those roles and people going, "We've never met anyone like you who wants to do that." Going back to Cornell, there were people who said, "Don't let anyone tell you that you can't do it. Don't let anyone say no." And I also had at home a family who said to me, "Every day you get up, you do the best you can and then you're done." I think that allows you to get up every day and be really optimistic. And I am an incredibly optimistic person. But I'm incredibly fortunate as well because I get to do what I have always wanted to do. And that's been incredibly heartwarming.
Whyte: What does health — specifically using that term "health" instead of "healthcare"— look like at Walmart 2 years from now? Instead of saying 10 years, everybody wants to know that; I just want to know, what's it going to look like in 2 years?
Pegus: You'd be sitting at home and your Walmart.com app opens and tells you, "Hello, good morning. You're going to have a great day. Hope you took your medicines. By the way, we recognize you weren't able to afford the last prescription. We called your doctor for you. We've gotten it at a better price. Do you want it delivered or do you want to come by and pick it up? We also notice that you haven't had your blood pressure checked in a while. We're sending home to you an ambulatory blood pressure cuff so that can happen. Have a great day."
Whyte: Wow. With you in charge, I'm sure we'll get to that. Well, Dr Cheryl Pegus, my good friend, I want to thank you for taking the time today and for all that you're doing at Walmart Health and Wellness, and really changing how we think about health and how healthcare is delivered. Thank you.
Pegus: Thank you so much. I really, really loved and enjoyed having this conversation. It was great.
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Cite this: Change Makers: Dr Cheryl Pegus on How Walmart Is Rethinking Health - Medscape - Apr 06, 2022.