Mikelle Moore, Intermountain’s senior vice president for Community Health, talks with former Utah Governor Mike Leavitt about the social factors that influence people’s health and what Intermountain is doing to make a real difference in communities. They discuss the Utah Alliance for the Determinants of Health and the collaborative solutions and opportunities that can be found by forming partnership, both locally and at a national level.


Mikelle Moore: Hi, I'm Mikelle Moore, senior vice president of Community Health for Intermountain Healthcare. Today I have the pleasure of having former governor Mike Leavitt to talk about some of the healthcare challenges we're facing here in Utah and across the nation, and how we're working together in some cases to make a real difference for our patients, our members, and also our communities. Governor, could you introduce yourself?


Mike Leavitt: Well, I am a Westerner by birth. I grew up in Utah, and this is my home. I’ve had a few careers in my life. The first was in the risk management world. The second was in public service. I was the governor of Utah. Then I spent time in the federal government as the head of the Environmental Protection Agency and then the Department of Health and Human Services. Since that time, I have continued with the health theme in my life, and I established a firm called Leavitt Partners. We think of ourselves as a health intelligence firm. We spend our time thinking about the future of healthcare.


Mikelle Moore: In those roles, and particularly in public service, what role did you have in making our country a healthier place?


Mike Leavitt: I was governor, as I mentioned, and I don't think there's a more intimate job in American politics. People have a relationship with you that they expect will, in fact, be personal. You learn about their lives in very personal ways, and a lot of that is health. Obviously, you're overseeing programs like Medicaid, but you're also involved in public health. People have a reason to complain to the governor if they don't think things are going well. That may have been the most important public experience I had, but both departments I ran in the federal government, I thought of as health agencies.


The Department of Health, or rather, the Environmental Protection Agency is all about public health. In fact, I learned as I went through that process what a powerful influence it was on American health. Of course, the Department of Health and Human Services is also all about health and America's health. I was surprised by many things. I was surprised by the breadth of that department and also the many different ways in which Americans depend on what goes on there.


Mikelle Moore: It's interesting that you worked in so many facets of public service and that with your background you started a health intelligence firm. Why a healthcare focus after your public service?


Mike Leavitt: I came to understand while I was governor and involved in lots of health reform issues and public health issues, that it was meaningful to me. I suspect it's because it affects the people I care about deeply. I think it's also a key to a nation, or a state, or a community's economic health. It's one of those significant ... I call them big gears. If you turn that big gear, all the little ones that are connected to it spin. I think health is a highly leveraged topic. If you can affect healthcare in a positive way, you can affect everything about a community.


Mikelle Moore: Which is exactly why we're sitting down talking together is because of our relationship in working together in the Utah Alliance for the Determinants of Health. I think you've helped us come to understand the opportunity, perhaps the responsibility, to think about the impact health has on many other determinants of health and how those things - education, income, housing, and food - in turn influence health. I'd love for you to explain a little bit more about what the Utah Alliance is and what sparked the idea for you to go about thinking of healthcare in this way.


Mike Leavitt: Well, first, I think we should acknowledge that Intermountain Healthcare is a very large and important institution in Utah and the Intermountain area. It's one of the institutions that has adopted (and not just as a part of their mission but as part of the ethos around which the company operates) to produce both a healthy population and an area where there are jobs and where people can live out their lives in a way that meets their aspirations.


It was not surprising to see Marc Harrison and many others at Intermountain seek to do just that. Marc and I were actually in an automobile ride in Chicago, just by coincidentally ending up on the same airplane, and we began to talk about ways in which Intermountain could fill that mission.


We began to discuss the social determinants of how things that are happening in the community affect the health of a community beyond just hospitals and clinics. As we talked, our enthusiasm grew that an institution like Intermountain and a state like Utah truly could identify some areas and begin to deliver services that went beyond the traditional help, that would have an important capacity to keep people healthy as opposed to simply treating them after they're sick.

We found a common purpose in this, and I've been delighted to see the state become supportive of it. I've begun to see communities starting to revolve around it too. I think we're onto something big here, and Utah is a place where I think uniquely we can make a collaborative effort to help keep people healthy, economically strong, and provide emotionally happy work.


Mikelle Moore: I agree. I think I can remember where I was when Dr. Harrison called me after that ride with you and said, "Hey, we've come up with a really brilliant idea, the governor and I. Do you think we can make this happen?" That began a conversation that really ramped up pretty quickly.


Mike Leavitt: I'm surprised at how quickly this has captured some steam. We're going to start with something that's manageable, but I think what's at stake here is that we could begin to redefine the way healthcare attaches to people's lives; that it's not just about a clinic visit. It does have to do with things like transportation, and access to food, employment, and housing. Those things all affect our health, and that's just not a suspicion. That's borne out in statistical evidence time after time. This is about getting, as they say, upstream to prevent things happening to people's health as opposed to having to deal with them after.


Mikelle Moore: There's something as we formed this that really stood out for me. At Intermountain, we have often helped people with some of these social determinants of health through our charitable giving or through our partnerships. I think you really helped us understand the opportunity we have to create an economic model for if we do this, then this happens. As a result of creating that economic model, we have the potential to create something scalable and replicable. Can you tell a little bit more about how you see that?


Mike Leavitt: It's important to see what we're doing at Intermountain and in Utah in a larger context. Perhaps the most important change in healthcare in the last 75 years is a change in the way healthcare gets paid for. Rather than paying hospitals, doctors, and clinics just to see patients, we're now beginning to say, "Let's pay in a way as to create health." Some of what is paid in health could be best used in keeping people healthy. That's a very basic change. It changes the incentives for everyone. I remember when I was governor, we were in the early stages of trying to work this out. I found, for example, that there were families who were receiving state services that sometimes would have as many as six different caseworkers, and none of them would know what the others were doing. I also found that there were common-sense solutions to problems that were just dropping in the cracks because no one had a program to figure that out.


So, you'd have a family that didn't have health insurance. And they didn't have health insurance because they didn't have a job. And they didn't have a job because they needed a pair of steel-toed shoes to qualify for a job, or they needed a car that could get them to work. There was nothing in the existing system that would allow us to help them with that problem, realizing that if they would find self-sufficiency, they'd get a job, they'd be able to support their family, they'd get health insurance, and they'd stay healthier. It's a matter of being able to think about this holistically as opposed to programmatically. That's the big change is that we're going to begin to integrate and seek common-sense solutions that will just help people stay healthy.


Mikelle Moore: Yeah, I think it's helpful to focus on the people and the families as opposed to the programs. We can align a lot of programs. I think it's interesting that we chose the word alliance. You've written a book on alliances. What does that word mean to you, and how does it describe differently if we were to call this the Utah program to address the determinants of health? What's different about an alliance?


Mike Leavitt: At the root of the word alliance is the word ally. Ally means someone with a common goal, or at least some form of common problem. As I've been in public service, I've seen good solutions to lots of problems and every one of them happened collaboratively. When a group of people with a sense of common pain, or something that they share, come together to solve a problem together, they have many more resources and they become much more resourceful when they can coordinate and seek a solution. To me, an alliance is simply a group of allies who are attacking a similar problem and can bring the combined effort of their force together to solve it.


Mikelle Moore: Have you seen an alliance make a different kind of impact with that approach?


Mike Leavitt: Alliances make that kind of impact on our lives every day. I think because the incentives are now being changed in healthcare, we're beginning to see more and more communities and situations where people are saying, "We can solve this problem if we work together. It's going to be difficult if we're all on our own." I will say that having worked on problems like this all over the world on many different subjects, we have problems that are not particularly unique, but what we do have in Utah is a willingness as a community to work together. We're seeing that in our alliance. We're seeing communities, cities, towns, local health authorities, insurance companies, or other on health providers who’ve traditionally not always worked together perfectly, but who are now that are beginning to say, "This could be good for all of us." A good alliance is a circumstance where the outcome serves everyone reasonably well. Sometimes not perfectly, but everyone is improved by it.


Mikelle Moore: When you think about what success will look like for the Utah Alliance, what do you think is realistic in three years to expect that we can say we've accomplished or done?


Mike Leavitt: I think we will be able to, in a statistically provable way, say we improved the health of people who live in a certain geographic area - and we did it with at least the same amount of money and, hopefully, a little less, because if it's a little less we can put more into the lives of other people. I think we'll, hopefully, be able to say we’ve redefined the way the community works together to stay healthy.


Mikelle Moore: Yeah, I agree with you. I think there should be some qualitative and quantitative outcomes that translate. How do we apply those, in your mind? You've worked at a state level as governor, a national level as secretary. How can the work with 8,000 people in Ogden and St. George help us change the way we think as a state and as a country?


Mike Leavitt: When my children were in the fourth grade, it seemed like every year we did a little science experiment at home where we would build crystals. We would saturate water with sugar by boiling it, then we would wait to see if it turned into a crystal. Well, it never did, but we learned, and this was the experiment, that if you dropped a tiny string into the beaker of water, that very soon the crystals in the sugar would begin to cling to that string. Once they were clinging to the string, they would build on each other. Within a couple of days, the entire jar had built crystal, upon crystal until the entire jar was a crystal.


I think that's the way improvement happens in society. It doesn't happen in society all at once. You have to find examples, and then people begin to copy it and improve it, and iteratively find ways to expand it. That’s the model here. Do something profoundly different in St. George and in Ogden, learn from it, iteratively improve it, make some mistakes, figure out what works. Once we start providing better health outcomes, people will begin to copy it, and expand it, and improve it, and that's the way communities and society gets better.


Mikelle Moore: How much of that figuring it out and problem-solving do you see happening at a state level versus a national level?


Mike Leavitt: I'm of the view that any kind of effort works better when it's within driving distance. If you can talk to people, know your neighbors, and work together, that's a lot better than when you're trying to figure something out across greater distances. I've worked, as you pointed out, in Washington. It was a great experience, but you're dealing with policies and words, and intentions and money. Where you really learn to work things out better is at a local level. That's why, yes, we have to work with those in Washington to allow us to do experimental things, but in the long run it'll be what we do at a local level in Ogden and in St. George that will start this iterative process of improvement. It'll get it started.


Mikelle Moore: When you think about this work that we're focused on, improving the health of the community, what are the biggest barriers, biggest challenges, in doing this work?


Mike Leavitt: Interestingly, I think there’s a handful. One of them is tradition. That's just not the way we've always done things. Another is regulation. We've written words down that tell us how we need to do things and those sometimes have unintended consequences. I think another part is just the culture. That's a little different than tradition because it's a flavor of how we do things. It's often a culture that we do things on our own as opposed to doing it together. Now, you can't change tradition, regulation, and culture all at the same time across the place, but once you begin to come up with a way of making things better for everyone, that's called a collaborative solution. Over time, those things follow.


Mikelle Moore: So, you can see some culture change while also seeing some change in regulation. It happens together.


Mike Leavitt: That's right, we're going to have to have a little of all of that.


Mikelle Moore: We are.


Mike Leavitt: I mean, there are certain programs that we're going to have to ask the federal government to give us a waiver or give us permission to do something a bit different. I wish it weren't that way, but it is. There's a good reason for that. There are places where we'll have to ask the state, which has a specific program, to do something different. The good news is, they've signaled a willingness to work with us. This is kind of a grand and bold experiment but I'm optimistic we're going to do some good here.


Mikelle Moore: I am too. We've talked about the role of government a little bit in the role of healthcare. What role do businesses or other community-based organizations have in being part of the Utah Alliance or improving community health?


Mike Leavitt: That may be one of the more exciting parts of this to me, is that a lot of the business and organizations in the state have said, "It's in our interest to have our employees at work be healthy and productive. We're partners in a community and we want to help." Many of them have stepped forward and pledged, “I might add substantial resources, to this.” I think they like that we're all working together. They like that we have not just a major healthcare organization, but also state government, local government, and various others working together. They want to be part of it. There's a kind of northbound train here, and I think people want to be on it. I'm glad, because that's what makes it work.


Mikelle Moore: Yeah, I agree. I can't help but think that our low unemployment rate and the need for having education and talent develop in Utah will be a motivating factor for us as well.


Mike Leavitt: Well, this is not only a good place, but it's a good time to be doing this.


Mikelle Moore: It is.


Mike Leavitt: In times of economic abundance, people feel just a little more generous, and they also have the capacity to be more flexible.


Mikelle Moore: It seems to me, just as we wrap this up, that this term the social determinants of health is one that we're hearing more than ever before. Is that directly as a result of our shift to value or is there something else going on as well?


Mike Leavitt: It's a phrase that if you're in healthcare you're hearing. A good example might be that 30 years ago, if you were to ask, “What things caused mothers to have unsuccessful outcomes, and in many cases, die themselves?” Back then, you could point to two or three very specific medical conditions. Now we know that the biggest cause is different. It's opioid abuse, for example. That's a social determinant. It's hypertension. It's the tendency we have now to become bigger, physically, and to be less healthy. Those are social determinants of our health.


A lot of attention is being paid to this now. We must be careful that we don't try to boil the ocean here and just make a perfect society. We've got to find the things that make a difference. We know, for example, that transportation is an important part because you can't get to the doctor if you don't have transportation. We know that food is important because if you're not nourished correctly, you're not going to be healthy. Finding the things that produce, what we call in the business world a return on investment, is a very important part of this because we don't have unlimited capacity. We have to find the things that truly make a difference.


Mikelle Moore: Yeah, I agree.


Mike Leavitt: Could I add a lot of this sounds like a program, but it’s changing hearts. It's not just changing your heart. It's changing mine. It's changing the way we think and care about it, and what we're willing to do ourselves. I have to, for example, learn to eat better. I need to be more conscious of my own health. That's part of this, reeducating, reorienting, trying to help us all understand what our responsibilities are to ourselves.


Mikelle Moore: I think that's really true. Something you said really stands out for me. Thinking about our role of not just changing our own behaviors for ourselves but creating a sense of community in terms of how we think of these social factors.


Mike Leavitt: Well, we know one thing and that is that people like to be part of things that are successful. Now, we'll go out, and we'll make this successful, and we'll all be a better state.


Mikelle Moore: We will. Thank you for being advisors to us and for talking with me today.


Mike Leavitt: Well, I'm very proud of Intermountain. When I was the Secretary of Health for the United States, it was with great pride that I told people that I was from the state with Intermountain Healthcare. It's a great organization with a profoundly good reputation.


Mikelle Moore: Thank you. We will maintain our commitment to trying to make healthcare more affordable and making communities healthier as a result of being in them. We appreciate our collaboration with you and lots of other community organizations in this Alliance to make that happen.