Speaker 1: 00:01You're listening to Intermountain Healthcare's podcast channel.

Mikelle Moore: 00:07 Hi, I'm Mikelle Moore, Chief Community Health Officer at Intermountain, and I'm delighted to be here with Vince Ventimiglia of Leavitt Partners. Vince, thank you for joining me for this podcast.

Vince V.: 00:17 I am so glad you're here. This is going to be great. Thank you.

Mikelle Moore: 00:20 Well, I would love for us to share how we know one another first and why we're having this podcast. I have really enjoyed getting to know you in the context of the Alliance work that we're doing in Utah primarily, where we're trying to understand the impact of addressing social needs on health outcomes through our Alliance for the Social Determinants of Health. You and I get to work together here in D.C., where we are today.

Vince V.: 00:50 Yes. Yeah, Leavitt Partners, your audience probably knows, runs a number of alliances. NASDOH, the National Alliance to Impact Social Determinants of Health, is one of those alliances. Intermountain was a founding member of that, and you all from your leadership throughout the organization have been really deeply involved in that and we've appreciated it. NASDOH, you probably know, you know-

Mikelle Moore: 01:15 Yes.

Vince V.: 01:16... our audience probably knows, is working at the federal, state, and local levels to try to impact social determinants of health so that we can improve the lives of Americans by addressing social determinants, not just medical needs of folks, but upstream in social determinant space.

Mikelle Moore: 01:35 And I think the term "alliance" deserves a little bit of commentary because it's been so foundational for what Leavitt Partners has done, and I think in the spirit of what we're trying to do in Utah with our Alliance for the Determinants of Health is really create something that isn't just Intermountain trying to drive for an outcome, but really a convening of people with common interests who believe that something different is possible and will come together to try to meet the total needs of the people that we serve by addressing social needs, understanding how they connect to medical needs, and create something that serves the community more effectively. And so it's been really important for us in the Utah Alliance, or our Alliance for the Determinants of Health, not for ... It's Intermountain convened, but it's not an Intermountain initiative. We really want it to be a community initiative. How does that relate to Leavitt's role with NASDOH?

Vince V.: 02:36 It's a very similar inspiration, I would say. It's been said that healthcare is complex, and that is certainly true. Social determinants of health take the complexity just a another level, and it touches really folks from all walks of life and not just folks in the healthcare sector, but in the social services, mental health, behavioral health sectors and beyond. When we think about social determinants of health, we're thinking about food and housing, transportation and employment, and that's in addition to medical care.

And we've seen the power of these convenings just as you have in getting folks from the different sectors together around the same table, really to spark some conversations and bring collaborative creativity to the table so that we can begin to deal with some of these really challenging situations. So much as you're doing in Utah, we're replicating that at the federal level with players like Intermountain, of course, plans and payers, but also social services agencies, state, local, federal players, patient organizations, folks that represent doctors. And we think together we're going to be able to begin to solve this problem much better than if we tackled it alone.

Mikelle Moore: 04:02 I agree, and I've really appreciated the opportunity to be a part of NASDOH, where we can see what others are doing in this space, but then also bring our collective ideas together to influence federal policy. I'd love for you to explain a little bit about why is this important in our shift from fee for service to value. Why is focusing on addressing the social determinants of health a part of that overall strategy?

Vince V.: 04:34 Yeah, it's a great question. First, I suppose we have to think a little bit about what it means to shift from fee for service to value, right? It begins to contemplate paying for results and not just the number of procedures that are done. And when we say we're going to pay for results, we're really looking at improvements in the health of the patients that we're working with. So quality and outcomes become very important, and it's clear to all of us that medicines and medical devices and surgeries and hospitals are critical components of delivering that good quality healthcare. But I think many of us have begun to realize that, beyond that, the places that we work and play, how we live, our spiritual health and our mental health, our bodily health is all impacted by much broader considerations than just the medicines that we're taking, to put it a little bit too simply and crassly.

So we're really looking, okay, upstream, what are the interventions that we can all work on together that deliver better outcomes, better quality of care for folks, and potentially even at a lower cost than what we're doing now when we just treat the back end of symptoms and problems in that person's medical condition? So with luck, we'll be able to intervene upstream in some of these other areas and drive much better health in a value oriented way.

Mikelle Moore: 06:09 And I think that relates really well to the why Intermountain chose to get involved in the Social Determinants of Health. We see it as very connected to this transformation to value, that if we are really thinking about how we improve health outcomes for people in a value payment methodology, we'd be rewarded for that. The incentives would all be aligned. And we're not there yet for all patients we serve, yet we think it's the right way to serve people. And yet figuring out what are the barriers and the opportunities to addressing people's social needs, whether it's giving them access to food, improving their housing situation, maybe helping them address their working opportunities. Doing those things, we know intuitively, the literature tells us if we do those things we will improve medical outcomes. And yet the role that we take as a health system in doing those things is maybe regulated a little bit by policy.

Vince V.: 06:09 A little bit.

Mikelle Moore: 07:22 A little bit. And I think there's also a question of how much should a health system take on, because healthcare already costs plenty. Do we need to spend more on these spaces, or just spend differently? And I don't have the policy background you do. I'd love for you to tell us a little bit about your policy experience, but then describe in what ways do policies coming from our federal government enable this work, or maybe get in the way of it right now? And what are we going to do about it?

Vince V.: 07:54 I'm going to pick up on a point you also just made, which is these collaborations really are great places, not just to identify the problems you were indicating, what are the causes of some of our challenges, but begin to very creatively address what potential solutions are. How do you modify payment systems to allow you as Intermountain, for example, to do the right thing in this space? I think it's why we find these alliances so valuable. The multiple perspectives that get brought to bear on a challenge produce very fruitful solutions.

Much of what we're working on in the federal policy space involves federal systems. We're hoping that that impacts the space that you're operating in at the local and state level. So at the federal level we mentioned food, housing, transportation, employment, of course healthcare as well. But we're seeing the federal government in 15 agencies engaged in at least 30 activities that cluster around-

Mikelle Moore: 09:06 15 agencies?

Vince V.: 09:07 It's pretty incredible.

Mikelle Moore: 09:09 I can't even think of 15 agencies, Vince. What are some of those?

Vince V.: 09:13 Medicaid, Medicare. You know those.

Mikelle Moore: 09:16 Yes, I do.

Vince V.: 09:17 But it goes beyond. The office of the national coordinator, who is involved in regulating how our data, medical data, is transferred among players. There's actually a separate chief technology officer also engaged in that space, so two agencies tackling much of the same activity. The Department of Health and Human Services has, not just a health side but a human services side, so the Administration for Children and Families is involved in welfare programs and social services. SAMHSA, the Substance Abuse and Mental Health Services Administration, is dealing with those types of issues which also get into social determinants of health. So the list-

Mikelle Moore: 10:02 It goes on and on and on, doesn't it?

Vince V.: 10:04 ... grows very fast. It really does. Research organizations like NIH, we could go on, but we've identified 15 agencies, many activities already underway, and it's 30. We could list them all, but they tend to cluster in, I'd say, four or five different areas. One is, frankly, just finding additional funding. There's no substitute for more funding to support the good work that could be done in this space. And so a number of them are working to free up that funding and dedicate it to social determinants of health, really worthy activity.

In addition, there's a series of efforts in the Medicaid program and the Medicare Advantage Program to give more flexibility to the recipients of funds so that within those programs with the funding that they have already, they can divert funds from less effective healthcare interventions to more effective and more cost effective [crosstalk 00:11:05].

Mikelle Moore: 11:05 Which should help improve the affordability of health care in total if we're allowed to think in less expensive interventions that might not have a billing code attached to them today and trade that for some of the unnecessary care we're providing medically.

Vince V.: 11:19 Exactly. And capitated payment systems like Medicare Advantage are the perfect place for plans and others to begin to identify the opportunities and work with them. There's very limited financial exposure for the federal government, and that flexibility has the real potential to drive results, and the plans are paying attention. They're not going to waste their money on ineffective interventions, so dedicating them to food related activities, housing improvement for that senior citizen who may fall and incur incredibly expensive medical care, just a simple adjustment in her bathroom with a fall bar, for example, can reap real rewards for the broader system.

So just some examples. More funding, flexibility in funding, eliminating barriers so that between social services organizations and healthcare organizations, there can be greater exchange of information, services, some very fruitful opportunities there. And then I just might note the bully pulpit, speaking from a federal platform and saying, "This is important. We encourage people to move into this space. You will have our help," is a fourth way that is incredibly powerful in a society that sometimes is skeptical about trying new things and going in new directions. That bully pulpit can really be of great assistance.

Mikelle Moore: 12:54 It is. It's of real value. I think about when you and I first met a couple of years ago, I think we thought that the bully pulpit was one of the most important things we needed to do in this space. And as we launched the Alliance for the Determinants of Health in Utah, we did so for ... I think of your examples of how you think of the federal policy agenda. It's really similar to the intent of the Alliance. We were thinking, "Let's identify two communities in Utah where there is an opportunity to address health disparities by identifying people's social needs or nonmedical needs, addressing those needs with partners and thinking more holistically and improve outcomes for those people.

And we knew we'd run into issues of where do we have latitude to do that. And we knew we would need everyone around the table to do that effectively because we don't have the authority to do all of those things. We also hoped that we would be able to identify what are the systemic problems in being able to do this, and what are the solutions to get around that and think about those at a really local level. How do we organize things differently in Washington County and Weber Counties, but also what needs to change at a state level, or what needs to happen federally to enable this?

But we thought we'd be spending just a lot of our time speaking to why it matters. Why are social needs important to address our medical expense problem we have as a country? Or, why is this the right thing to do? And from the time we started our work to now, social determinants of health has become this topic that is ubiquitous. It's everywhere. And it wasn't the case when we started the work. Is that because we were really effective right out of the gates with the bully pulpit, or what's happened here?

Vince V.: 15:02 Yeah, it's a great question. I do feel like we showed up with a hammer and nails and a little bit of wood saying, "We're going to have to build the bully pulpit and then find somebody to stand on it and begin to push the message." And I think, you should correct me if I'm wrong, we were a little surprised that when we showed up with hammer and nails, there was actually a crowd on the pulpit saying, "We should get going." What they didn't know was where they should begin to operate, and I think that's where we were most effective, was saying, "All right, you all are ready. You're convinced that there's a value based play here in the healthcare space if you tackle social determinants of health."

But they didn't really know where to go with it. A lot of our early meetings were, look at the Medicare Advantage Program, look at flexibility with Medicaid, please help deal with some of the barriers that the Stark and antikickback rules may be imposing on folks. And help us exchange data so we can understand better what's effective and what isn't and please increase funding. So I think our ability to get a broad range of stakeholders identifying opportunities is what actually got things going well. There was a bully pulpit ready to be used. That was the great news, but we did have to give them a little guidance on where to go.

Mikelle Moore: 16:27 Where to engage. And that seems really similar to what we found when we formed the Alliance. When we started the conversation in Utah, we thought we might find people who thought we were a little up in the night trying to organize this approach, and we found the opposite. We found community based organizations and even local governments saying, "Absolutely, this is the right thing. We want to join with you. Please choose to do this in our community." We were really pleasantly surprised to find that, but then getting to that next step of what do we actually do and how do we meet the needs of the people that we serve and what do we need to tie these things together took a little more detailed thought.

Vince V.: 17:16 So much of social determinants really plays out at the local and state level. It is very different at each locality. Federal level, it's a little bit more academic. It plays out in different ways in each community. What have you seen as being the most important opportunities in Utah, for example? And if you were to speak to the secretary of HHS and say, "Change one or two things," what do you think are the biggest barriers for Intermountain in Utah?

Mikelle Moore: 17:50 You know, I think about that, Vince, on two levels or paradigms. There's the flexibility that we need to actually meet the needs of an individual human being that we're trying to serve. And in the Alliance, one of the first things our partners said they needed was an ability to communicate with one another. The social services system is very fragmented, and they don't feel that they're able to communicate with the healthcare system effectively, and the health system feels the same way. They can identify resources to send a patient to for food or housing, but then knowing that that resource actually results in a positive outcome for a member or a patient is a different story. So we built a digital platform to support that communication, and that just started. We're now about eight months into the Alliance, but the digital platform we've only had in place for two months. So that's been fairly new. That digital capability for partners to be able to communicate with one another was something that was seen as essential, and now we're continuing to face ... We've got, I think, 52 of the 75 original partners that we said were essential to this working on the platform.

Those that aren't on the platform are not on the platform because they're fearful that sharing data and information, even with an individual's consent to do so, isn't enough and that they're going to be admonished for being connected in this way. So we think about it at that level. How do we just create greater flexibility, greater opportunity to work together without compromising privacy? It would be detrimental to all of this work if the people we served became afraid of any of us as providers. So we need to be very careful there.

But then there's kind of this second level, I would say, of how do we change the ability to meet the social needs of the individuals we serve by changing policy at a very national level? The biggest barrier we're finding for the people we serve is housing. Affordable housing is the problem that our community health workers say they don't know how to solve. They can get someone a voucher, but then they're waiting to actually be able to use that voucher for months. And there isn't capacity for affordable housing.

Vince V.: 17:50 It's a supply problem.

Mikelle Moore: 20:30 It's a supply problem, and maybe it's not a supply problem in total because we're in the West. You can always move out and find affordable housing, but when you move out of the urban setting or whatever the population center is, then you don't have transportation infrastructure, food infrastructure, employment. All of these things are hard to obtain. So we're also thinking about how do we change the incentives, which I think are primarily at the state and federal level, to change the supply of the things that we need in order to solve the social needs for an individual.

Vince V.: 21:13 Yes. The first challenge that you raised, we've been really clear with the department. Where the department thinks, "Hey, we have not prohibited it. You can go ahead and do it," we remind them, these are very sensitive areas. You need to do more than not prohibit it. You need to make clear that it is permitted. And it seems like a minor distinction, but the affirmative permission to go ahead and engage in certain activities, approach a challenge in a certain way, is often what organizations need at the state and local level. So your example I found really compelling.

Mikelle Moore: 21:56 I think it's really true and it's been, I guess, helpful to realize that in healthcare we approach that very conservatively. But that's not true just in health care. Any sector that has this regulatory component behaves in much the same way.

Vince V.: 22:11 Right. Very true.

Mikelle Moore: 22:12 We want to make sure we're following the rules.

Vince V.: 22:14 Very true. Your second barrier, it becomes a societal challenge almost, right? It's big. It's a hard thing to put on the local hospital to solve all the problems you mentioned, housing, employment, transportation. Food is a big one, right? So somehow, the broader enterprise has to be brought in to assist in that regard. I don't think NASDOH intends to solve all these societal problems, but, boy, we do see opportunities at the human level back in the urban environment. It may not be decent housing, but it's housing. How can we get the quality of that housing improved so that they don't have to move out into the hinterland? They can stay in that home that they grew up in. We can make it a little bit safer and a little bit healthier for them, and we think the impact then will be quite dramatic on their health without solving all of society's problems. Maybe that is something we can tackle together.

Mikelle Moore: 23:22 I think the two are so connected, and yet we have to focus on what we can solve. But I do think, as you mentioned, those 15 agencies that are involved in this work, some of those agencies have the ability to affect the broad societal-

Vince V.: 23:37 Very true. Yes.

Mikelle Moore: 23:39 ... issues, right?

Vince V.: 23:40 One of the things NASDOH has worked on with the federal government is to begin to say, "Don't tackle this with 30 different activities or 15 agencies. Begin to think about having a little bit more cohesive and comprehensive strategy for tackling it. Make sure that your housing and your food and your transportation agencies are working with HHS." We're beginning to see that message resonate, so that instead of having to deal with a whole bunch of agencies and activities now, we may soon see a much more coordinated and cohesive approach.

Mikelle Moore: 24:18 That makes me very optimistic.

Vince V.: 24:21 We can continue to hope, right?

Mikelle Moore: 24:23 We can, we can. We're often talking about how do we make Intermountain work more effectively together. We refer to it as a one Intermountain approach. How do we ensure that we're all working together? When I listened to you describe the 15 agencies, I just got really worried that we don't think one United States kind of way about how we meet the needs of the people who live in the United States and create opportunities. What's your indicator that it is going to start to work better together?

Vince V.: 24:58 Yeah, so we get back to the bully pulpit, which is a secretary now that is saying, "We have to tackle this as a very important part of [crosstalk 00:25:09]."

Mikelle Moore: 25:08 And you're referring to secretary Alex Azar?

Vince V.: 25:11 Yes, right, the federal HHS secretary. From the top, he has driven this notion very articulately, I would say, and I think the foundational statement actually occurred at an Intermountain sponsored event here in Washington maybe a year ago, right?

Mikelle Moore: 25:30 Yeah, about a year ago now.

Vince V.: 25:33 I think that articulation, it was very complete, very heartfelt. We were in the room when he made the speech, and you could tell he felt the passion for this. So from the top, there is this directive, get going. We saw a bunch of activity result and spawn from that. What we're now seeing is that the secretary has actually designated a player in the department to carry this forward, and I think that the coordinated approach, the hallmark of Alex Azar, but also essential for any enterprise, it's going to succeed. The naming of a person who will take these under his wing and drive things forward.

Mikelle Moore: 26:20 And drive it ... Right, and do you feel there's staying power to that decision, given what we see going on here in Washington with people changing roles frequently?

Vince V.: 26:31 What I'm heartened by is your and my interaction with agency folks. In Washington they're called career officials. These are the folks who will be here regardless of who's president, regardless of who's secretary. They may not be lifers, but they're here for a long time, and we're finding significant numbers of folks in the career positions at HHS who also feel this passion. They're pleased that the secretary has given them that direction, and they are actively working in making Medicare, Medicaid, the social services agencies, better oriented toward this challenge. I'm hopeful that they survive any administration for many years to come and that you and I all have a place to work with folks on this [inaudible 00:27:27].

Mikelle Moore: 27:27 That really has struck me. I don't have the experience that you do here in Washington, and yet through my work with NASDOH have gotten to spend some time here. I've been really impressed by the smart, dedicated people who really understand the need to shift to value, who understand the relationship between social needs and health outcomes, and are as dedicated, if not even more dedicated, than us to making this happen. And you're right, they are people who have worked in this space for longer than this president's been in office, and that longitudinal commitment inside of our government gives me hope as well that we can make transformation real even while there's political changes around us.

Vince V.: 28:21 I agree. One benefit we have from this effort is how intuitive it is that taking care of the whole person, taking care of them early, addressing housing or employment or transportation concerns early, will reap health benefits. We all know this, I think, in our heart-

Mikelle Moore: 28:42 Yes, we do.

Vince V.: 28:42 ... and we see it in our elder parents and our grandparents, and children who if we don't take care of them early, develop much worse. So there's an intuitive level that I think really works in our favor. Of course, in government you always need to prove it. The value of evidence and data is really important, and I think for anybody in the health plan environment, the health system environment, they do want to see data and evidence. And that's our next challenge, is taking our intuition, which I think is really well grounded in what we all know, and developing an evidence base to support the types of work and interventions that we're talking about.

Mikelle Moore: 29:28 And that seems like a good place to kind of bring this to a close, both the people that we're trying to improve outcomes for, which is, all of us in the U.S., and how maybe the Alliance can help be a proving ground. And by that I mean the Alliance in Utah. Why is it so meaningful that we create an evidence base there that then can help change federal policy and impact the effectiveness of NASDOH?

Vince V.: 30:02 Yeah. We already said, these things play out at the local level with real human beings. They're not abstract policies. So first incredible value is that your Alliance in Utah is playing this out at the local level and gathering information. So that's critical. It won't happen anywhere else except out in the field and on the ground. And then policymakers here in D.C. appropriately want to see evidence. So as you capture payment information and outcomes of interventions, the cost and the input and the value that comes from it, these all help us identify what is effective and then we can go back up to the federal level and say, "Make sure the policy reflects this good intervention, supports that good intervention." We're very much looking forward to the results of your work.

Mikelle Moore: 30:58 Well, we are as well. Thank you for those comments. I think it helps us remain focused that we really need to do what's right for the communities that we serve. As the communities help us understand what the needs are and how to adjust our strategy to respond to the needs of the people that we serve, we are wanting to be very responsive. And we need to make sure that we are true to the evidence collection so that we can demonstrate that what we've done has had impact. Creating that balance has been something that we knew would be a struggle for us as we launched the work, and it remains important that we do something meaningful for people, really meaningful for people, and that we develop the evidence base in a way that can be trusted by people outside of our state, even, and at a national level.

Vince V.: 31:58 I was going to say it's really important to have leaders at the local level, like Intermountain, but also like Intermountain, leaders who can speak at the national level with this voice that connects local to federal policy. There are not many situated like that. You all are, and it's a really important role that you're playing, being out in the field but being able to bring the evidence and the message back to folks who can impact federal policy.

Mikelle Moore: 32:28 Well, good. I'm optimistic, as are you, I can tell, and I think we can do some good things together. Vince, thank you so much.

Vince V.: 32:28 Thank you.

Mikelle Moore: 32:36 This was a great pleasure to speak with you and to share what we've been doing together with our listeners. I want to thank our listeners. If you have questions or comments about today's episode, please share them with us on Twitter. Our handle is @Intermountain. We would love to hear from you. This has been an Intermountain Healthcare Podcast episode with the Leavitt Partners' Vince Ventimiglia and Mikelle Moore. It's been a pleasure having you.

Vince V.: 32:59 Thank you so much. Look forward to talking again.

Mikelle Moore: 33:01Thanks, Vince.