Mikelle Moore: Hello. This is Mikelle Moore. I'm Senior Vice President of community health for Intermountain. I'm pleased to be here with our president and CEO, Marc Harrison, MD, and my friend and colleague Adaeze.

I'd like for each of them to introduce themselves briefly, and then I'll tell you a little bit about what we're talking about today.

Adaeze Enekwechi: Thank you Mikelle. My name is Adaeze Enekwechi, Phd. I am vice president at McDermott + Consulting here in Washington, D.C. Prior to joining McDermott, I ran health for President Obama in the Office of Managing and Budgeting. I was the head of the health division, and have spent many years thinking, talking about social determinants of health, which is the capacity in which I'm working with Intermountain. It's very, very exciting.

Mikelle Moore: And Adaeze was in the audience today, as Dr. Harrison and others spoke about the social determinants of health. Marc, you probably don't need too much of an introduction.

Marc Harrison, MD: Internally, at least. So, I'm Marc Harrison, MD, I'm president and CEO of Intermountain Health. I try to keep up with you Mikelle, and today felt like a really good day. It felt like a day where we learned a lot. Sort of on the theoretical side of SDoH, from Karen DeSalvo and others. I did a great interview with Adam Boehler and I tried to get a sense for what a highly motivated healthcare system is actually doing in this space. Probably less academic, but hopefully it felt really real to folks. It felt real to me.

Mikelle Moore: I think it did. And, the day was all about bringing people together here in Washington D.C. to talk about the social determinants of health, and what we as health systems need to be doing, but also how government plays a role in that and how private citizens play a role in that. And I loved that today was co-hosted by the Hatch Center for Civility and Intermountain Healthcare because we're, I hope, talking about taking a bipartisan approach to some of the problems that are affecting Americans. That felt like what today was about, and it was both policy with Dr. DeSalvo talking at a national level about how we need to influence things. And then Marc your real application and discussion of what we're doing here at Intermountain to make a difference and the social determinants for people but also affordability in other components.

Marc Harrison, MD: So probably my favorite part of the day was the fact that our conversation felt apolitical. You know, this is a divisive time in U.S. politics and sometimes we're not seeing the very best of people in my estimation. Today's conversation, however, was really about doing the right thing and I was thrilled that it feels like it could have been a democrat or a republican giving the comments that Secretary Azar gave. I'd love to hear from a prospective of somebody who's done this for a long time on a national level. What did it feel like to you as he made these incredible comments about social determinants of health?

Adaeze Enekwechi: I think that, your sentiments are exactly right. This did not feel like a political topic, because quite frankly it isn't. Right, this is a long history -- Mikelle's heard me say this before, we've got a hundred years’ worth of literature and science backing this up.

Mikelle Moore: That impact of the social components influence health

Adaeze Enekwechi: Social determinants of health are the fundamental causes of health. In fact it's called a fundamental cause theory. If you understand that, then you know that, then you know that's not a political statements. It's just that, when people walk inside the four walls of any hospital, they come with a whole host of resources that could be advantages or a lack of resources that could be disadvantageous in terms of the ultimate encounter. Backing away from that academic summary if you will, you have a day like today where we saw people who are actors in the policy space, folks who are actors in the health system and ultimately would be responsible for implementing some sort of an intervention, coming together and having quite frankly a very frank discussion.

I was elated, and I don't use that term lightly, to hear secretary Azar talk about what honestly sounded like a strategy. We didn't hear social determinants sprinkled into our speech, it was a recognition that in order to do this and connect it to their mission, which is value-based care -- I think we all agree that's our mission -- we ought to be thinking about social factors that impede access and quality of good healthcare. We out to be thinking about patients, what's best for them -- patient-centered care. Prevention -- preventing you from using hospitals unnecessarily, incurring unnecessary costs. We ought to be thinking about navigators. He talked about potentially having physicians and clinicians serve as navigators of the healthcare system, but to complement that, social services navigators. Honestly I was surprised to hear that today.

Marc Harrison, MD: I was blown away, I wrote it down. Medical and social navigators.

Mikelle Moore: Yes.

Marc Harrison, MD: You two are experts, what do you think enabled today's conversation? Is it intrinsic leadership from Secretary Azar? Is it work that has gotten started in the delivery and insurance space? Is it the groundwork that was laid with the ACA? Today felt special and important to me as well, but things don't generally happen like a lightning strike, there's usually an enabler or a prelude.

Adaeze Enekwechi: I'll start.

Mikelle Moore: Please do.

Adaeze Enekwechi: I do think it's all of those. I do think that the ACA -- a lot of these things were actually happening pre-ACA, but the ACA inserted almost, it lit things up, it infused resources. We had the prevention fund to basically catalyze a lot of different types of experimentation. We of course had CMMI, that's a product of the ACA. And that is essentially putting research, fact-finding, demonstrations on steroids, 10 billion dollars over 10 years, and letting a thousand flowers bloom, and what can we learn?

The Accountable Health community's demonstration is a product of CMMI, and Secretary Azar mentioned that as well. But they own it, a new administration could have come in and abandoned what had been done with the last eight years. They didn't. So I'd be remiss if I didn't give him credit for taking leadership and ownership of this and basically creating this vision for HHS and the agency, and quite frankly tasking Adam with moving forward with CMMI -- Adam Boehler the head of CMMI and tasking him with moving forward and thinking very creatively around what they could do with Model One, which Adam talked about at a previous session. Basically, put the patient first and then provide as much flexibility as is needed and as is necessary to make sure that that individual has everything they need for optimal health.

That is the secretary's vision from what I understood today and that to me is very gratifying.

Marc Harrison, MD: So based on what you heard, we're sort of the tip of the spear on this and we like that, we want to lead out on this. What advice would you give us, you know having worked in government, having this perspective of history and listening to secretary Azar, what do you think our marching orders should be?

Adaeze Enekwechi: I think, I'm certainly not in a position to tell you what your marching orders should be, but I will say, I think Intermountain is in a very unique position to help us get way beyond proof of concept. We've got lots of pilots, we've seen lots of things done on a smaller scale, with smaller resources because the money ran out. We've proved efficacy for a particular intervention. Intermountain has the name, the resources, and now the leadership and has put money towards a vision or endeavor like this. And is in a unique position to prove that in a healthy state where you manage to figure out that you do have challenges with social determinants. When we think about the states at greatest risk --

Mikelle Moore: Utah doesn't come to mind.

Adaeze Enekwechi: Utah is not on there.

Mikelle Moore: But we have disparities as well.

Adaeze Enekwechi: But you've got disparities like everyone else, right?

Marc Harrison, MD: Because we're humans.

Mikelle Moore: And everywhere in America does.

Adaeze Enekwechi: Just like we know everywhere in America does. So even in Utah you figured out that there are some counties, some communities where we have an opportunity to deliver. The marching order now is to deliver. What can we do, how can we spend these millions of collars and demonstrate that we can do this and that we can do this right. And by the way we might make a mistake or two.

Mikelle Moore: Most definitely. And that's OK

Adaeze Enekwechi: And that's OK, that's OK. If I had a charge that I'm quite frankly just excited about, it's that -- let's deliver.

Mikelle Moore: Yeah you said something to me, Adaeze, the first time we met actually, I think we were having breakfast, and you said, you actually left me feeling a little intimidated because there's a hundred years of evidence that the social determinants do produce health. And you now have this golden opportunity at Intermountain to demonstrate it. And if you miss it -- and I don't think you were being specific about Intermountain but you were saying more, as a healthcare industry, we've got the attention of the people for the first time, and if we don't deliver during this golden opportunity then we could miss it. And to see the secretary and Adam Boehler so enthusiastic today and that this is the time and they're going to open up the field of possibilities for health systems, it really is the time to deliver. And Adaeze will be upset with us if we don't.

Marc Harrison, MD: Well we better get our act together.

Mikelle Moore: We better.

Adaeze Enekwechi: No one will be upset, you know I'm sorry.

Mikelle Moore: No, I'm teasing.

Adaeze Enekwechi: The point is, I wrote a piece about that actually. It was in [inaudible 00:11:58] Basically it's a call to action.

Mikelle Moore: A call to action.

Adaeze Enekwechi: And the point was, we are very good about fads in healthcare. PDS -- there's a whole list of stuff that we've tried. And that we've abandoned.

Mikelle Moore: Lots of acronyms.

Adaeze Enekwechi: Lots of acronyms, we can all rattle them off. And I was worried that this could fall into that category. Because people would try a couple of things, they wouldn't see the results right away they'd get frustrated, and you know CEOs, their board would basically tell them. So that was the concern I was highlighting that we have a unique opportunity, but we should stay focused.

Mikelle Moore: Do you think that's a real concern, Marc, for Mountain?

Marc Harrison, MD: Look, we're going to deliver, we have to.

Mikelle Moore: We have to.

Marc Harrison, MD: I think the imperative is even bigger than that. We are seeing a decline in life expectancy amongst populations that we've never seen before. We have people killing themselves at unprecedented rates, we have opioid addiction, we are seeing increasing disparities based on intergenerational poverty. All of these lead to poor health or are symptoms of poor health. We have a social imperative to deliver. And we have the skills, we've got the resources, we have the will. Now we just got to do it. I would like for us to be, and this sounds corny, but this is an Intermountain thing I'd like for us to be a shining light to others to see that they can deliver too. Because their communities need this as much as ours do. So I think we have to do this.

Mikelle Moore: There was a question today in the audience about what are the attributes of the health system that will do this, that will think about things in this direction. And I really think back to, Marc, our charge to be a model healthcare organization. We can't very much be a model if the communities are unhealthy as a result. And I think that our volunteer board really feels ownership, how could there be a 10-year life expectancy difference from one community to another when we've created access to all regardless of ability to pay.

Marc Harrison, MD: So I think, those are all true. And my concern is, why don't other folks feel this impetus. So we're doing this for some very interesting reasons, we've got a super motivated board, governance is terrific, management is on fire, we see the opportunity, we've got the substrate. And I still think it's too easy to make money doing the wrong thing. I said it today, the system is perfectly designed to get the results it's getting. And we're getting pretty crumby care, uneven care at too expensive a price and so we're getting the results that our system is designed for, how do we light that fire in others to recognize that, to take the risks that are necessary, to deliver good health to people and deliver more affordable care? And I think the best we can do, is we can be an example.

Mikelle Moore: Let's close with one last question Adaeze, given that we need to be that shining light and that example, what do you think, given what secretary Azar laid out, what Adam Boehler laid out, what should health systems like Intermountain propose to CMMI?

Adaeze Enekwechi: Propose, well, so that's a trickier question than it sounds because there's a way that CMMI works and certainly the agency, like all agencies, seeks input from stakeholders. But I will tell you as a former OMBer, it's difficult, we're learning this with a [inaudible 00:16:05] called PTAC right, Physicians-Focused Technical Assistance. It's difficult to really sit in the seat of the analyst, economist, statisticians who are in government thinking about designing these models. Because what they're looking at, the way they think about these problems is quite different from the folks in health systems.

They're looking at savings estimates, they're looking at generalizability, they're looking at how many participants can we get, right, at the end of three or five years will this tell us anything, and would we have saved a decent amount of money relative to what we invest? So these are technical questions. However, I think to the extent stakeholders are engaged, they should be at the table, in their offices, telling them what they have done, what their constraints are. Because no model is going to be deployed in a vacuum. So it needs to reflect what is actually possible on the ground, telling them where resources in terms of private sector commitments could come to bear, what that might look like, so that when they're putting models together they can at least have the good sense of what's realistic and what's not. They should be telling them about governance, how much is a CEO on board? How is the board on board, if they're not, what are their concerns? Again, thinking of this more as sharing ownership.

Adaeze Enekwechi: Yes and sharing the private sector's perspective is critical, because otherwise, if something does get designed and deployed it can land with a thud because it's not feasible. And I think we should do everything we can to avoid that.

Mikelle Moore: Well thank you. It's a pleasure to have been with you today, and to see that it is possible to have a non-political conversation in our country about ways we can improve health for people that we serve.

Marc Harrison, MD: It felt good that today happened as we were celebrating Senator Hatch's career. When I reflect on his career, in my mind, the very best of what he did was create cross-aisle dialogue to generate best practices for people who are vulnerable like children. And I see today's remarks by Secretary Azar and others as consistent with that part of Senator Hatch's career and it felt good that it happened today.

Mikelle Moore: I agree. Thank you. This has been a podcast centered around healthcare. If you'd like more information around Intermountain's work to address the social determinants of health you can go to intermountain.health.