September 14, 2020

The need to address health inequities among racial and ethnic minorities isn't new, but it's recently received a lot of attention. In this episode of Radio Advisory, host Rachel (Rae) Woods sits down with Intermountain Healthcare CEO Marc Harrison for part two of their conversation. In this episode, Harrison gives his take on the best ways for health systems to approach health equity.

Rachel (Rae) Woods: Marc, let's talk about social determinants and health equity by taking a lens to technology. In our previous conversation, you talked a lot about the impact of telehealth, and AI, and the mobile experience, but—honest moment—much of that push for a more digital patient experience comes from patients who look like me: young, healthy millennials who use Uber in non-pandemic times, order ice cream off Postmates, and are looking for a similar experience with health care.

But it's important that we also make care accessible for vulnerable populations, for rural populations. And that means we have to acknowledge this digital divide and the very real concern that tech-enabled care delivery could actually worsen health disparities. How are you thinking about bridging that digital health divide at Intermountain?

Marc Harrison: That's a superb question and not an easy one to answer. It's a multifactorial approach, Rae, particularly for the rural communities. We still have areas here that don't have fiber internet, and it becomes very difficult. Now, what's interesting is that when we have a hospital in a community, we need the fiber, and we get it, and that actually can open up access in an indirect fashion for neighbors and communities. We advocate at a state level, and then we have helped provide economic support, for getting rural areas connected.

You know, I think the bigger issue is around personal devices and what it means to be able to access care on your phone, iPad, laptop, or whatever. We're finding that's actually a little bit less of an issue than we thought it was going to be because people are prioritizing them—I think very appropriately—as integral to how they have to live, which means they may even be pushing other things down their priority list. It turns out the connectivity is close to one of the basic Maslow's hierarchy of needs along with housing, and transportation, food, and personal security.

Ultimately, I think one of the bigger issues is ensuring that digital care culturally competent—considerations such as how many websites are available in Spanish, how many chatbots are available in Spanish, English, or the language needed? I think that any sense of complacency around care model evolution has to be framed in terms of what's right for the person and for the community, but I hope people realize it's a matter of survival as well.

Woods: I think this push towards serving rural communities isn't just about, "How do I bring the doctor directly to the patient's phone?" You have shared with me in the past a bit of an innovation that you all have done with serving rural communities while keeping the doctor in their home practice. Do you want to talk to me a little bit about that?

Harrison: Yeah, I'd love to, Rae. We have a very dispersed footprint, and even more now that we're expanding our presence in Idaho and Nevada, and digitally across the whole Intermountain West. Our 24th hospital was a virtual hospital. Now, we have more than 50 tertiary and quaternary services that are delivered virtually. And in the last year and a half, we've added about 20 or 25 affiliate facilities outside of Intermountain, with another 25 or more in the hopper. So that's going really well.

And I'll give you an example of how our clinicians were moved by the plight of some of patients in rural areas to really innovate and be creative with a solution. Nurses at a hospital in Central Utah, which is about 100 miles away from the nearest town in any direction, were noting that old people in their community with cancer were choosing to die instead of get chemotherapy because they didn't want to drive hundreds of miles every week for infusions. They didn't want to waste the end of their life on the road; they wanted to be with their family. So, these nurses, they said, "How do we do this better?" And they ended up putting together a tele-oncology program.

So in this program, patients were willing to go and get staged at one of our big centers, and then were able to, after a televisit, have their chemotherapy, infusions, and checkups done at the local hospital. And the patients liked it; they did really well, and they didn't "waste the end of their life driving all around." And the collateral benefit is that the rural hospitals did better economically. And so, now we've got about eight or 10 oncology clinics scattered across the Intermountain West and people are staying close to home.

Woods: And we've been talking about efforts to improve the health and life of rural populations, but we also know Covid-19 has been a catalyst for change and reinvigorated the fight against structural racism. I'm curious how you are thinking about the future of health care and addressing some of the racial disparities that we see in the health system.

Harrison: The first thing we're going to do is make equity and addressing health disparities part of our value system and part of the fundamentals of care that underpin all of our strategies. So, we will be addressing equity and health disparities in the way we address everything else—consumerism, affordability, access, innovation—with discrete goals around what are we going to do for people.

Woods: Can you share some of the practical things that you're going to start doing to make progress towards minimizing those disparities?

Harrison: So, one of the things we're going to do is start measuring disparity in our population in a very biomedical fashion. So, as a very first step, we have documented what others have found around maternal-fetal medicine and risk to women of color in terms of their own health and the health of their babies. Now, our obstetricians have taken great pride in providing everyone the same care regardless of who they are, but this has showed them is that, in certain populations, they may need a different or more intense approach to achieve those same outcomes and that just having everyone get the same care is probably not enough to have people's health end up in an equivalent place.

Woods: Can I jump in on that? So, as somebody who works with physicians every day, alarm bells are going off in my head for the frontline physician who's saying, "But you can't ask me to treat my patients differently. It feels like cherry-picking," right? And I'm imagining the pushback that you could get to physicians who are completely strapped for time right now. Did you get that pushback? How are you helping those physicians provide differentiated care to those vulnerable patients who need it?

Harrison: You know, this speaks to the quality of human beings whom I work with, because this effort was actually driven by the doctors—this was the head of our Women and Newborns program. After he read about the disparities and outcomes from Covid-19, he and his colleagues pulled their data and were horrified to find much the same outcomes as have been reported in the literature, so they've taken it upon themselves to begin to address this. Now, these are early days, we don't know what the solutions are. But what I can assure you, Rae, is the most Intermountain thing in the entire world is to identify a clinical problem, look at the information, and then relentlessly change until you get superior outcomes. I mean, that's our history, we've done it for decades, we do it as well as anybody, I believe, and I have a belief that our clinicians are going to figure this out.

Now, it's up to me to make sure that they have the tools they need to do their job, and it's up to them to partner with me effectively so that we give them exactly what they need—but no more than they need, because we don't want to drive up the cost of care.

But I'm really excited about this, Rae. This is the right thing to do. And I tell you, I think our clinicians are going to be all over this because this is a totally non-punitive thing, this is only a doing-good kind of thing. You know, people are framing the racism issue as a political issue. It's not a political issue, it's a human issue. Hate has no place in healing, none. Together I think we can do good, we can do well, we can do the right thing, and it doesn't matter what side of the aisle you sit on. We went into this business to help people, and I'm convinced that's exactly what we're going to do.

Woods: You mentioned that making equity one of your strategic goals was one big effort that Intermountain is making, but I don't think that was it.

Harrison: No, we will be recruiting a Chief Equity Officer. And there are folks who just slap that person onto their leadership team. But we've been extremely thoughtful about crafting this role; as we've created the job description, we want this person to have an impactful, meaningful job. What committees do they need to sit on? Who are their partners? What are their roles and responsibilities?

And we will also be putting in place an Associate CNO for Equity and an Associate CMO for Equity (although the title may change a bit). These will be enterprise roles that address how we deliver care, recruit people, and create workforces that represent our communities. I think it's going to be very impactful. We will also invest in developing pipelines, because change doesn't happen overnight. So while we will make key hires that are diverse, I think what's even more impactful is how you change the economics of an entire community by creating pipelines to jobs that are going to change the trajectory of families for generations. And we're really excited about that.

Woods: You're actually starting to talk about what my next question was, which is hopefully an opportunity to get ahead of some pushback that I think people might be thinking or considering right now—Intermountain is headquartered in Salt Lake City, which isn't necessarily known for its diversity. You also have some benefits there, right? A healthier population, perhaps more favorable social determinants of health than other parts of the country. What do you say to that pushback?

Harrison: So if you actually look at Salt Lake County and the Wasatch Front, it's extraordinarily diverse. We have really robust Latino communities, South Seas communities, Indigenous people, and there is a growing Black community here as well. What you said may have been true when I trained here 30 years ago, but it's not true anymore, and saying otherwise is just an excuse—and I'm not big on excuses. I'm big on identifying a problem and then making inexorable change.

Now, for people who don't believe in our model, there's a reason we added HealthCare Partners Nevada—now Intermountain Nevada—to our family. We wanted to learn from their ability to keep people well, but we also wanted to demonstrate that the integrated Intermountain approach is viable in other geographies. And what I will say to your listeners is watch us grow and apply this model to diverse geographies, do the right thing, and demonstrate that population health and value-based care works regardless of where you are.

Woods: And Marc, I think that brings me to my final question. It is one that I ask at the end of every interview here on "Radio Advisory." You and I have covered a lot today about the future of health care. So, my question for you is what should leaders in health care be focusing on right now?

Harrison: Rae, I'll answer that a little bit indirectly. It wasn't so long ago that I was at a meeting of health care leaders and there was a roundtable conversation about the things that were worrying each of us. And I'd say, out of about 20 people there, 19 gave self-interested answers or institutionally interested answers—you know, how much we're getting paid, what's the regulatory environment like, sort of pissing and moaning about the technology disruptors and how they're making things a lot more difficult. Nobody talked about how they could use the privilege of their position to make the lives and the communities around them holistically better.

So, I don't care what your political bent is right now, I'd say that our political system is fractured and there's a real schism. The people who are listening to this podcast are really responsible for lots and lots of lives and lots and lots of dollars. My question for them is what are they doing to make systematic social change that's going to help heal some of those divides and to provide a refuge for civil, thoughtful, collaborative conversation? And you know, I think we should take the ability to collaborate that we have rediscovered during Covid-19 and we shouldn't give up on it.

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