George Brown, CEO of Legacy Health System
Oregon's unique environment
Q: One challenge our members often face is that there's a mismatch between rhetoric and reality in terms of how many systems are actually operating under full delegated risk. Everyone is talking about value-based care, but this rarely entails downside risk. You and your counterparts in Portland are not in that camp. What is it about this market that predisposes systems to go after risk?
Brown: I think you're right—there is something unique here. There's a much higher receptivity to risk than elsewhere. When I came to Legacy, I discovered that Oregon is very enlightened about actually having a state health care policy. Former Gov. John Kitzhaber, a doctor, and his legislative colleagues developed the Oregon Health Plan (OHP), which called for expanding insurance for low-income individuals, setting up coordinated care organisations (CCOs), and also participating fully in health care reform. As part of that, we promised and delivered on two things: bending the cost curve of medical inflation from 5.4% to 3.4% and decreasing unnecessary ED utilisation.
OHP considers each person as a whole being: physical health, mental health, and dental health. In the absence of any one of those, you're not a healthy individual. We also seriously consider the social determinants of health, such as housing, food insecurity, and transportation. I think this predisposes systems to have confidence to take on more risk.
Q: You raise a good point—addressing the social determinants of health seems to be one of Legacy's signature attributes. Along with four counterpart systems, Legacy has put up $21.5 million to subsidise 380 housing units to help reduce homelessness. Legacy also instituted a grocery programme to encourage healthy eating and address food scarcity. What's behind all of this civic engagement?
Brown: This is deeply important to me. My formative experiences taught me about the importance of community. My family and I received health care through the New York City community health system, and I felt a strong sense of community in my childhood neighbourhood. If my parents were working, the neighbours would pull my parents aside later and tell them, "George was throwing water balloons out of the window again." The community looked out for each other.
Throughout my career, I've also observed how some communities try to isolate wealth behind gated communities. What that says to me is they're trying to keep problems out, rather than tear down the gates and actually deal with the issues to create a better society. In our small way, we've tried to do that at Legacy.
Urgent care outside of the hospital
Q: Let's talk about another example of a non-traditional partnership Legacy is pursing—your affiliation with the urgent care provider GoHealth. I can't think of another market in the country that has such a concentration of urgent care centres—more than 75 in and around the Portland market alone. You're doing some unique things in urgent care, not least of which is in accepting patients who have public insurance, through your GoHealth partnership.
Brown: Correct. The other distinguishing aspect of that partnership is our Epic electronic record is integrated, and the GoHealth medical staff are part of the medical staff at Legacy.
The leadership of GoHealth knows how to run urgent care. It's a great partnership, and we have actually performed better than our expectations.
Q: That's interesting because most systems that have pursued a retail strategy are not at breakeven on that business as a standalone entity. Without divulging anything proprietary, could you describe the economics of the sites themselves? Or does it only really make sense strategically when you're thinking about longitudinal care or care across the continuum?
Brown: It looks like it will make sense from a standalone perspective, particularly if you look at those mature centres. I think the added benefit is the longitudinal care. The Legacy GoHealth centres are just an entry point to the larger system. They're convenient. And if you need more, we've got a continuum.
We chose GoHealth for a reason. We had a number of start-stop conversations with a major pharmacy chain that led nowhere because of leadership changes, and we also talked to ZoomCare, but we took issue with some aspects of their model, particularly that they do not accept patients with public insurance.
I don't think anybody knows everything about everything. We just thought we would try with GoHealth. We've offered a couple of ideas for sites and they've said they'll look into it. And they come back and say, "We don't think these will work." I've been impressed by that. They've been a collaborative partners.
Q: Collaboration and community certainly seem to be recurring themes across your career. Now that you've announced your retirement, I have one last question. As you reflect back on this incredibly distinguished career, what are you most grateful for?
Brown: The people who were willing to help and teach me. My parents were my first mentors and coaches. Their guidance was essential to my development as a person. I was and remain fortunate to have many mentors from whom I have learned many lessons. Input from others helps me remain grounded and curious. That's what I'm most grateful for.