Marc Harrison:
So Aparna, we have a bit of an unfair advantage in that our system and our operating model is really set up to achieve what LAN would like to do broadly. And we do it in a microcosm. We’re a pretty big system—you gave some statistics. About half of our revenue now is completely aligned with taking full financial and clinical risk for people. As much as I hate what the public health emergency has meant to so many people and how much I mourn the loss of so many lives in the United States, we’ve been bound and determined all the way through to make good come of this. Some of that good is really leaning into what a model that’s designed to keep people well can do to increase the resiliency of our healthcare system.
We’ve seen again and again in the last 20 months or so systems, particularly on the provider side, that are organized around keeping people well, having had the agility to navigate actually quite well, both clinically, socially, and financially. Whether it’s telehealth, digital transformation, distance work and care, [or]organizing around community health workers—all tools are at our disposal, and we’ve deployed them quickly, pretty thoroughly. We’re trying really hard to make sure that, as in some ways, the world goes back to some semblance of what it was before. That we don’t go back to the same way of delivering healthcare, that we use this as an opportunity to make this catalysis stick.

Marc Harrison:
So first you have to have the people who are providing care believe that there’s a problem. Some people were smacked in the face by it, like the folks in the emergency department and like folks in the ICU (intensive care unit). But we also did a lot of listening. We listened to people of color with a story on caregivers and listened to patients. And we heard some pretty incredible stuff. That in combination with reading the healthcare inequity literature, much more broadly, we went back to our clinicians, and we said, ‘well, we have an expectation that each of our clinical programs are the same as an institute or a service line.’ That’s our parlance at Intermountain. We want everybody to do at least one project where we take a hard look at our performance and understand how we’re doing. We had many of the same problems that the rest of the country’s had, whether it’s around maternal mortality, infant mortality. We actually are identifying some differences in stroke outcome that we haven’t completely parsed out yet. I think the thing that’s been really enlightening for us, and unifying, is that this doesn’t become a set of political statements or a bunch of feelings, and politics are important. Feelings are very important. But, we started to have a common fact base amongst all the people who provide care at Intermountain, regardless of their political persuasions. Nobody who’s a healthcare provider wants somebody to have worse outcomes based on the color of their skin. They just don’t. It has provided a background for us to normalize the discussion of healthcare inequities and start to work on it, just like we’d work on anything else—falls line infections, pressure, ulcers, you name it, surgical site infections. I think we’re starting to make real progress because we’re treating this with great deal of respect, but in the same way we’ve had success in some of the other areas.

Marc Harrison:
This is where it’s hard not to sound preachy, Aparna. I’m a pediatric ICU doctor, and let’s say I understood that there was a superior way to treat sepsis in children. One that was less invasive, less painful, more successful, less expensive, and I chose not to do it because I just liked the way I was doing things before. That’s exactly what payers and providers are doing right now. They’re doing what’s comfortable for them. They’re not actually doing what’s best for society, and they know it, most of them. They are lacking either courage or the ability to focus, or they’re focusing way too much on how they’re currently being paid. Now the problem is, not only is this the wrong thing to do, they’re going to run out of road here before too long as increasingly our government-paid patients are moving into at-risk models and some commercial payers—thank heavens—are beginning to change their expectations around keeping people well instead of just taking care of them when they’re sick. And if they don’t change now, there are gonna be a lot of disruptors who are going to come in and eat their lunch. They really need to get moving, even if they’re only caring about their own existence.
It’s a moral, economic, and social imperative to do this.

Marc Harrison:
I think there’s actually an analogy with how encouragement towards the vaccination has worked, during the last section of the pandemic. I think we initially all hoped that everyone would get vaccinated because it was right. And a lot of people did, but not everybody and not enough people did. Then we thought, well, let’s really encourage people. Let’s run lotteries, let’s give bonuses. And guess what? That didn’t work that great either. And In the end, there are going to have to be some sticks involved. I think we’ve come a ways, I give enormous credit to the federal government of moving us towards this direction of value-based care. They have made this part of the conversation. I think we’re at the place where we’ve tried it, cause it’s the right thing to do.
We’ve talked a lot about upside risk at times, it’s time to just get down to it. If one thing I’ve learned about the payers and the providers in the United States through the pandemic, they’re really smart and they’re really capable and they did wonderful things when their back was against the wall, and many of them came out really quite strong. I think we need to make relatively swift definitive change and that these should be a lot less choice and a lot more action. And I guarantee you that the creativity of my colleagues will result in a massive shift in how healthcare is delivered in the United States. And it will be good.

Marc Harrison:
I would ride that. I mean, it’s the play the winner strategy, it’s worked before. And there’s probably lessons to learn in terms of adoption of EMR (electronic medical record). Was it done perfectly? But it became a must-do, it was a financial imperative. I think there’s some things that we would do differently based on what we’ve learned around the early days of EMR adoption. But it did work, and they are ubiquitous now. So what I would say is take some of the lessons from what we’ve learned about public reporting about EMR adoption, incorporate them into some relatively rapid change around health equity.

Marc Harrison:
Well, I wouldn’t presume to ask them to be like us, but I would ask them to think about what they say is important and where they spend their resources. For some of the big, fancy institutions, for them to build multi-billion-dollar hospitals, that they then need to support with operations, the same time they’re saying they’re having a hard time affording to pay for more analytics and measurement, their audio and their videos [are] not matching. And being a leader is about prioritization. And your strategy is a lot about what you’re supposed to do, but it’s about what you decide that you’re not going to focus on and what you’re not going to resource. If people really do care about equity, they really do care about affordability, then they’ll change their operations to match that.