Episode 3:
Patient Care, the Cost of Healthcare, and Academic Medicine
Marna Borgstrom, CEO of Yale New Haven Health System
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In this episode of Fireside Chat, we sit down with Marna Borgstrom, CEO of Yale New Haven Health System. Marna talks to us about improving patient care, the price of healthcare, and academic medicine.

Marna Borgstrom has served as the Chief Executive Officer of Yale New Haven Hospital and Yale New Haven Health since 2005. With revenues of more than $5.5B, Yale New Haven Health is the largest health system in the region. Marna began her career at Yale-New Haven Hospital over 40 years ago and served in a variety of staff and operational roles prior to her current position. Read more…

Transcription

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Marna Borgstrom 0:00
My dad is actually the reason that I’m in healthcare. And I think the key thing that I learned from my dad and he started practicing in the early 1950s is what we’re focusing on now. It’s all about the patient.

Gary Bisbee 0:16
That was Marna Borgstrom, President and CEO Yale-New Haven Health System. And I’m Gary Bisbee. This is Fireside Chat. Marna joined Yale New Haven 30 years ago and was appointed CEO in 2005. Stay tuned for Marna’s answer to the question has longevity as CEO been an asset to your leadership? And if so, how? We discuss the care signature program with one employee being assigned to advocate for each patient or family and how it is influential in New haven’s culture as an ongoing theme. In our podcast we explored how health system business models are evolving. Marna referred to rapid cycle performance improvement projects as a key part of Yale New Haven strategy. Marna has excelled in coordinating with the Dean of Yale medical school and the president of Yale University. And we’ll discuss her approach to both leaders. Let’s welcome Marna to the show. Well, good morning, Marna.

Marna Borgstrom 1:09
Good morning, Gary.

Gary Bisbee 1:10
Welcome to the podcast. Great to have you here on this rainy day in New Haven, and you are a Connecticut person.

Marna Borgstrom 1:17
I am. I grew up here. My Dad was a community physician.

Gary Bisbee 1:22
We were talking a bit earlier, and I just love to ask the question, What lessons did you learn from your father, given the fact you’re now the CEO here at New Haven?

Marna Borgstrom 1:32
Well, you know, my dad is actually the reason that I’m in healthcare. And I think the key thing that I learned from my dad, and he started practicing in the early 1950s is what we’re focusing on. Now it’s all about the patient. You know, it was different than they had fewer technological assists to do things for people. But it was all about the patient. Then my dad was an ophthalmologist. He trained at Hopkins, but he came back to Meriden, Connecticut, because his parents were aging my parents, my mother’s parents were aging. And so he was the only ophthalmologist if you can imagine in that entire city. And, you know, back then when they did cataract surgery, now, if you have cataract surgery, you go out to breakfast, right? Back then he would put patients in the hospital the day before they had surgery. And then they would stay in for a couple of days. And if they were having the second done they would stay in over the weekend. I mean, we can’t imagine Medicare doing something like that now. So what happened was after he would discharge these patients, many of them were older, obviously, and they couldn’t get around well, so he would do house calls on the weekends. Which was very common with his bag and he would load us up in the station wagon to give my mom a break. And we kids would go with him. And you know, he learned a little Yiddish, a little Polish, a little Italian, a little Spanish, you know, whatever he needed to be able to communicate with his patients. And his patients were just lovely. And you know, they loved seeing his kids, they would feed us when we were there. So, you know, you really learn about the patients about their families about it, you know, so that’s what I loved about healthcare then and I still love it now.

Gary Bisbee 3:23
Is your brother also an ophthalmologist at this point?

Marna Borgstrom 3:26
Well, he’s he’s, he now runs the American Academy of ophthalmology in San Francisco. But he practiced in academic medicine until his mid to late 50s.

Gary Bisbee 3:36
Okay, and I noticed you went to Stanford to get your biology degree. Were you thinking about medicine at some point along the line?

Marna Borgstrom 3:44
I was definitely thinking about medicine. And then I clashed with organic chemistry.

Gary Bisbee 3:52
Don’t we all. But at what point did you think about coming back to Yale to get your MPh?

Marna Borgstrom 3:59
So unlike today’s kids, I was fairly directionless. I came out of Stanford with a degree in human biology, which, you know, makes you qualified to do nothing. And so I went to work at lady sportswear, Macy’s in the Stanford shopping center. And then I started working with a couple of my undergraduate friends who had gone right on to an MBA and I was helping them do data analysis for risk management study at Stanford. And then I decided that, you know, I really liked the environment. And so I applied to become a unit secretary at Stanford University Hospital. I probably committed incredible acts of malpractice. Because at that time, everything was handwritten. The docs would come and they would throw orders for pharmacy for labs for radiology, handwritten on pieces of paper, and I would transcribe these onto a kardex and then you know, when you think about it’s just amazing how unqualified I was to be doing what I was doing. But that was the healthcare standard. But you know, you’ll learn how hospitals work 24 by 7, and you learn at an hourly rate where you’re working evening shifts, weekends, and I loved it. So then I decided to come back to graduate school. And you know, I had been on the West Coast for six years, and I thought I’d come to Yale.

Gary Bisbee 5:25
Never thought about staying out in California?

Marna Borgstrom 5:27
I did when I graduated from when I went to Yale, my now husband, then boyfriend, was on the West Coast working. And I promised him that, you know, after I finished graduate school, we would go back to the Bay Area. And then when I got a residency (now they’re called fellowships) at Yale New Haven Hospital. We were married, then I promised them we would stay here for no more than two years, and we will go back to the Bay area that was 41 years ago,

Gary Bisbee 5:56
Right? Well, the one thing when you look at your career longevity, here at Yale is really very impressive. And kind of tick your way up. When you started your fellowship. You ever think you’d be the CEO here?

Marna Borgstrom 6:09
Absolutely not. No. You know, I really just wanted to do a good job, learn and hope I made it to whatever the next level was.

Gary Bisbee 6:21
Yeah, at what point along the line? Did you think about becoming CEO? Not necessarily here, but just, Hey, I would I think that’s a good place for me?

Marna Borgstrom 6:30
You know, I have always referred to myself as an accidental CEO. Because I don’t think I ever sat and said, I wanted to be the CEO. And the first time that I actually had that active conversation was when my predecessor came to me and told me that he was announcing his retirement, and that he had been working with the executive committee for a while and believe that I was the right person to succeed him and said, I assume this is something you want to do. And you know, I did on one level, but on the other level, I wasn’t sure I had what it took to do this job, I loved being a COO, I loved it. And so you know, but then I started thinking about it and realize that as the board set out to do a national search, if they did select somebody from outside the organization, it was quite likely that a person like that would bring in their own team. So then I actually, for the first time, at a CEO level actively started looking into other jobs.

Gary Bisbee 7:38
Interesting. So when you became CEO, how did you set your priorities? You’ve been a chief operating officer, you knew the place, you know, all the people? How did you kind of make that change from chief operating officer to CEO and setting your priorities?

Marna Borgstrom 7:55
You know, it, that’s a hard thing to do. And at the time that I came in this academic medical center, there the system was, you know, still pretty much a group of independent hospitals and some subsidiaries. But the academic medical center, which really fueled the health system was in crisis. We had a building project that it was being held up because of a corporate union corporate campaign. We were being sued by the Attorney General of the state. So my priorities were to try and restore some semblance of normalcy, normalcy to the workforce here. And to the work that we did, and second to get the cancer center approved and underway. Because you know, as the months ticked by, it was costing more and more money. When we finally did get it approved, it was $40 million, more than it would have been good had we gotten it approved. And I went through a very difficult time negotiating something the unions at that time wanted card check neutrality. And I believed that nobody had the right to give away our employees rights to vote and believe that if our employees wanted to be represented by a third party, they should have that right to vote. So we came up with a very unorthodox agreement, that it then became clear the union was not going to be successful in an election. So they did what unions did at the time. They filed literally about 50 unfair labor practices. We got into a whole litigation battle. I had a US Senator in Congress, people pressuring my board to fire me at the time, it was really a mess. So it was really at that point, I would say that my first two years were survival. And then we started to move forward.

Gary Bisbee 9:59
Yeah. Survival. That sounds like a big motivator. Well, can you describe New Haven health system for those that aren’t familiar with it?

Marna Borgstrom 10:09
So it’s a mid-sized system. If you look at health systems across the country, it’s small in that we have we operate seven acute care sites, we have over 300 ambulatory sites, we have a couple of organizations that are engaged in post-acute care, one inpatient post-acute care, and then we have a couple of DNase that we are integrating. We operate from Westchester County, New York, through westerly, Rhode Island. And we recently formed an integrated partnership with Trinity health care of southern New England, which has gotten us up into the central part of the state and north and into southern Massachusetts. And they now operate a smilow Cancer Hospital up on the St. Francis campus. They do all of a lot of pre and post solid organ transplant care up there. The actual surgeries are done in New Haven just because of you know, the complexity and needing to keep staff and technology here current. And we are now expanding neurosciences and some other things that they’re interested in. So, you know, basically we are trying to cover a broad enough geographic areas so that employers throughout Connecticut Westchester County, Rhode Island, can access Yale New Haven health system providers, almost any place that their employees and their families live.

Gary Bisbee 11:43
So you’ve got New York City and all the academic medical centers there, it’s 100 miles from here, and in Boston, probably about 150 up there. So you’re right between Boston and New York. How does that influence your growth strategy?

Marna Borgstrom 11:58
Well, it certainly makes it challenging. But, you know, I think this is where having a partner like Yale University in the Yale School of Medicine becomes very important. Yale University School of Medicine has always been a basic science powerhouse. And in the last 10 to 12 years with the current Dean, we have really built up the clinical resources and infrastructure. And, you know, great academic medicine is about clinical care. It’s about the patient, but what allows us to do things that are different and you know, both knowledge-based and technology-based, really rises out of the basic science. And at a place like Yale, it’s really unparalleled. So we have been able to create true centers of excellence that I think have served us very well. And we are also the primary community resource for most of Connecticut’s population at one of our organizations or another

Gary Bisbee 13:10
Seems like you’ve had a strong relationship with Dr. Albert and the Dean. You have a new dean now coming in. So I guess there’s a whole building that relationship there.

Marna Borgstrom 13:22
Yes, absolutely and she starts February 1. Nancy Brown, who is the current chair of medicine at Vanderbilt. Very impressive person.

Gary Bisbee 13:30
Good. Well, good luck on that one. One of the questions that that’s interesting is how much change there’s been in healthcare. Some would say the last 10 years more than any other preceding timeframe, would you agree with that? Or how do you view change?

Marna Borgstrom 13:51
You know, it’s funny that you asked that, because every year when I’m editing, I’m an inveterate editor. Our annual reports were on October 1 to September 30 fiscal year, I always get something from our writing planning team that starts with that, you know, in a year of unprecedented challenges and change. And I said, you know, this year, you guys, you’ve got to come up with something different. Because, you know, it is true that it is challenging, and it is changing. But it’s kind of hard to say that every year has topped the other year. So, you know, this is a field full of complexities and challenges. And, you know, I think there are things that make it more and more challenging for me each year, but I’m not sure that I have the historical perspective to say that it’s unprecedented.

Gary Bisbee 14:45
What in the last 10 years, what changes affected Yale New Haven the most, do you think?

Marna Borgstrom 14:51
Um, you know, I think there are a couple I think one is the move to what we call consumerism. It’s a little label that I don’t love. But, you know, I grew up in healthcare when we believed we were patient centered. But in fact, most of what we planned for we planned for the convenience of providers. And I think that that’s a big change. And the biggest change is a cultural change, particularly in academic medicine, but with providers in general, which is getting them to really behave, I think, the way they all believe they feel about patients and patient care. So, you know, I think that’s huge. I think, you know, one of the obvious things that’s also changed a lot is how we get paid for health care. And I worry that we don’t pay for what we value. And that’s going to continue to be a huge challenge for anybody who’s leading in this field.

Gary Bisbee 15:47
So the current discussion about affordability seems to fit into that, that we’re maybe not being paid for, really the value that we’re providing. How do you view affordability? Is that something that you can actually tackle? I mean, it seems like government payers of one kind or another, it’s so complicated, how do you actually deal with affordability?

Marna Borgstrom 16:12
Affordability is you know, it’s in the eye of the beholder. Right. And I’m, you know, we all read the same studies and articles that say that the amount of money that we are spending on healthcare is unsustainable, and it is unsustainable, unless that’s what we want to be spending the money on. And, you know, I’m not sure that people in this country have an understanding of the kinds of choices that we might need to make if we really want to reduce the cost of care, I find it amusing when we hear certain presidential candidates talk about things like Medicare for All is if that is going to reduce costs, that’s simply going to reduce what we pay for health care through the government. And then you know, we’re going to have either change, dramatic changes in the way in which care is provided, or we’re going to have a private insurance industry still emerged, that’s going to be the ultimate cost shift. So, you know, we think we’ve operated at Yale New Haven health system for about nine years with a value equation that says you got to make care, higher quality, you got to make it safer, we can’t keep harming patients, when we know there are things we can do about it. And we’ve got to improve the patient experience. And we’ve got to continue to reduce costs, because I would never suggest that everything we’re doing is perfect. And that it’s just about the payment mechanism. And so we actually in the Yale New Haven health system had bent the cost curve each of the last two years now, you know, it’s small, but the major changes have come not from grabbing the low hanging fruit, which everybody’s done either through systems and supply chain, and yada, yada. But it’s really mining, rapid cycle, clinical performance improvement projects. And I think that, at the health management Academy, you’ve had a couple of our really smart young physicians who have talked about how they’re doing that. And that is both taking costs out, and it’s making care better and safer.

Gary Bisbee 18:14
So really, at the core of what we’re talking about here is the business model is evolving across the largest health systems, roughly now 55% of their revenue comes from governments, probably more than that two thirds of ours goes together. So the question is, as you think about business model evolving, how are you addressing that, and then what you were just talking about really was the core business, you’re changing or evolving or modernizing, maybe even the core business. Some of our CEOs are talking about raising a lot of revenue outside healthcare as a way to deal with this. Others are saying, you know, we really have to address our core business, because that’s the thing that’s going to be kind of at the essence of our business model. So how do you think about this evolution of business model and in where the core healthcare delivery business fits into it?

Marna Borgstrom 19:10
So you know, there’s no easy or straightforward answer. First and foremost, I think our core business and how we define core business has to change a little bit or maybe a lot. When I think about a care signature for the Yale New Haven health system. What I think that care signature can be, should be and I think what people really, really want is for us to say that when you or a loved one comes into our system for care, you’re going to have somebody assigned one person to you or that family, who’s going to be the kind of daughter that I’ve been to my 97 year old father, which is making sure that His appointments are scheduled and that he goes and that I understand what’s happening with him, that his medication orders are filled and that he is taking his medication. I think people want to not have to try and use heroics to work through a very complicated health care system, I think what would really make a difference is if people felt that there was somebody who was advocating in their in their family’s interests. So that’s what I see as the ultimate care signature for the Yale New Haven health system. And in doing that, I also think that we can take costs out because I think that there’s a lot of waste when people sort of hit CES, the system at wrong at the wrong point. And when people are non-compliant, that adds to cost. So I think that, you know, it’s maybe a pipe dream, in the short term, but I think that that can make care much more satisfying to people and less expensive.

Gary Bisbee 21:05
So New Haven has grown from this core academic enterprise to a community network, if we could use that term. Do you continue to see that sort of expansion?

Marna Borgstrom 21:18
I do, although sometimes bigger is just bigger, it’s not better. And you know, one of the things that we’ve also done and this is with the full support of the School of Medicine is our vision is to not be an academic health center with a bunch of community providers, ambulatory and inpatient. But we have chosen to define ourselves as an academically based health system. Because in reality, for cancer care for certain neurosurgical and neural neurological care for Heart and Vascular care, there’s a lot of specialty care that can be provided closer to home for people. And it’s less expensive in those settings. So as an example, we were down at Greenwich Hospital for one of our system board meetings last week. There are now over 100 members of the full time faculty at Yale on the Greenwich Hospital medical staff or putting smilow down there, a subsidiary of our neurosciences Institute, all of the invasive cardiology is provided by full time faculty. They are not people who go down there two half days a week. These are people who provide care and are part of those medical communities. Same thing at Lawrence memorial in New London week, but just put smilow in Westerly, Rhode Island and Geri psych unit in Westerly. And these are partnerships between the full time faculty in the community, But one, you know, it expands the reach of specialty care as well as, you know, primary care that people expect in those communities. And frankly, it’s less expensive for us to provide a lot of that care where there’s volume to support it than it is to pull everybody into the academic medical center. Plus, we don’t have any room here, right. Last week, we hit an inpatient census at the academic medical center 1400 inpatients Well,

Gary Bisbee 23:13
We’ve got the continued growth of the baby boomers reaching that age. So you have to think that the demand here is just going to increase. I mean, how do you deal with that? From the standpoint? You can’t build any more beds around here, can you?

Marna Borgstrom 23:30
Well, you know, I guess you could, but that’s not a good answer. This is where you also get into thinking about systems and, you know, a lot that’s being touted in the popular press about systems or just about health care providers coming together to increase prices. One, I would say to whom are we going to increase prices, because nobody’s really buying that anymore? Certainly not the government. But second, you know, what we are finding is that by coming together as a system, Lawrence Memorial Hospital as an example, Milford hospital, As another example, St. Raphael’s when we brought that in, they were all operating with many fewer patient beds filled, then they could accommodate, they have high all had high fixed costs. So it was just increasing the cost for the fewer number of patients they’ve had. So by building out this academic health system, vision last week, Milford hospital for the first time was full. Lawrence memorial is full. Bridgeport is full, Greenwich is growing. So you know, rather than add beds here, what I would like to do is make more attractive the inpatient resources available in the communities in which people live.

Gary Bisbee 24:53
So can we shift to academic medical centers for a moment. You’ve been very active at the WMC and counseled teaching hospitals there’s a lot of chatter these days that the future of academic medicine isn’t strong. How do you view the next five years or so with academic matter?

Marna Borgstrom 25:17
I’m an unabashed fan of academic medicine. I mean all of us I think should be because all of our doctors and PhDs trained in an academic environment and so we need those academic environments for our future Healthcare person power and I think, you know, that’s critical. I also believe that academic medicine for truly complicated care brings together great minds who can think in very different ways because they’re not looking at each patient and saying, I’ve seen five or 10 of these, you know, you’re looking at one that’s really complicated as the daylights and and you hear these stories regularly about these, you know, incredible ways that they were able to sleuth through things. So I think academic medicine has made us the greatest sick care system in the world. And because of academic medicine, we’ve grown because we are keeping people alive longer. We are treating formerly fatal diseases as chronic diseases. You know, that’s got a good and a bad side, depending on your point of view. But I think most of us would say that’s good. But I also think that academic medicine, you know, needs to continue to evolve with the rest of the healthcare system.

Gary Bisbee 26:48
What about the decision makers in Washington when you talk to them legislators, people, the agencies, do they you think they have a good feel for how important academic medical medicine is?

Marna Borgstrom 27:00
I don’t think that they, they in general, do there are a couple of people, you know, Senator Schumer, from New York, Senator Murphy from Connecticut, there are others who really understand it, I actually think that, you know, the political, the, the incentives, or lack of incentives in the political process are part of what’s hurting academic medicine, because as the government has been looking to try and cut its healthcare expenses, it has disproportionately done so on the backs of academic medical centers. because, frankly, when you look particularly at the US Senate, you know, they’re concentrated in fewer states. So you’re going to have less political opposition. I don’t think that represents good public policy. And I think that challenge of having public policy debates on what do we want to have people to have access to? And what can we afford them to have access to? Those are important discussions that have to be had, at some point sooner rather than later. But I don’t think in the course of my career, I will see that kind of debate happen.

Gary Bisbee 28:11
You sit on AHA board now. And just to put my colors on a table, I don’t think we’ve done enough as an industry to spend time in Washington and really, this isn’t meant to be critical about AHA, but I don’t think our health system executives have spent enough time in Washington to really engage the decision makers there. But you’re closer to it, perhaps than I am. How do you view that?

Marna Borgstrom 28:38
I don’t know that I have clear evidence that we have or we haven’t, I think, you know, it’s challenging. It’s challenging, because when we are in Washington, we tend to homogenize healthcare and healthcare is too heterogeneous. You know, I think, for an organization like the AHA, I mean, they represent academic medical centers, they represent northeast urban organizations, they represent rural hospitals in Mississippi and in North Dakota. And frankly, you know, one of the things that’s opened my eyes the most is I’ve been on the AHA board is learning about the challenges in rural health care, is learning about the health challenges with far less compliant patient populations than we have in Connecticut. And so I think it’s difficult, you know, I chair this group called the coalition to protect America’s Health Care, which is all of the as the Federation is in it. Premier and vizient are in it. And what we’ve tried to do is come up with some of the core big messages about patient care. But you know, and it has its place when you’re dealing with big pieces of sweeping legislation, but it isn’t nuanced enough. And I think that for anybody to think that there is a healthcare system for a country as large and diverse as the United States is a fool’s errand.

Gary Bisbee 30:08
Yeah, I think that’s right. Well, remember I was at tha is president of HR 80. Some years ago, there’s no question that the CEO of the HR has got to be the toughest job in Washington. Such a diverse group, and Rick, I think, is doing a terrific job. It’s just, I think we all have to spend more time there. And I just worry that, that we’re not, but on to leadership, if you were to train today, to take if you’re just starting and you wanted to train yourself to become a CEO, sometime, what kind of experiences would you would you pursue seems like more diversity and experiences better? Maybe than it used to be? What advice would you provide younger people who aspire to become a CEO of a health system?

Marna Borgstrom 30:57
So again, I don’t think there’s one path that’s interesting. And I know you’re aware of this, Gary, but I have a 34 year old son who is in this field. And, and I talk with him regularly about how to advance his career. And, you know, one thing I do believe is you need to understand healthcare, if you’re not a clinician, you need to understand how it works. He’s had great experience operationally, you know, not just working with clinical services, but you know, infrastructure, services, facilities, food services, these are, you know, very diverse and complicated things, you need to understand management, because I think all of us have the same strategies, roughly, in in medicine and in health care. But I think execution is the Holy Grail. And you have to understand what it takes to implement things through human beings who are very complicated, and certainly not always compliant. And you know, I’m a believer in doing the hard work in saying what you’re going to do and doing it and doing it well, because I think the people that we advance are people who have a combination of a track record in terms of what they’ve been able to accomplish, but also a track record and how they’ve been able to accomplish it with humility, not leaving bodies in their wake. You know, there, there are so many things, collaborating with people rather than trying to be a star. So, you know, I may be too old school about this. But you know, I think there’s a lot of hard work. And I think that there’s a lot to the how we do what we do, as well as what

Gary Bisbee 32:47
Well said. I’d like to ask one governance question. And then one personal question, and we’ll move on thanks for this terrific interview governance. Question is, the enterprise risk if I could use that term of our large health systems is clearly increasing. Anyone of a number of ways. How do you how do you talk to your board about that enterprise risk? Are they concerned about it? How do you manage that?

Marna Borgstrom 33:16
So I would say, with some humility, that we have one of the best enterprise wide risk analysis processes and updates of any organization that I’ve seen, and we regularly include it in materials that go before our board committees, and we regularly update our risks. And we talk about that a lot. And you know, there are risks in patient safety and clinical quality, there are risks, revenue risks, there are facilities risks, there are you know, reputational risks, there are all kinds of, you know, what we try and do is heat map all of those and keep those updated. And, you know, I think, frankly, and this is just an opinion that some of the academic medical centers that have increasingly found that their university partners are trying to move away from farther away from the flame of direct patient care, is because you know, great universities in this country look at risk differently, and there is so much risk in being a direct provider of healthcare services that I’m not sure that the two are always congruent.

Gary Bisbee 34:28
Yeah, that’s, that’s a good point. Well, final question on a personal side, who knows how many awards you’ve won in your life? Does one stand out, as you know, really honored to receive that particular award?

Marna Borgstrom 34:43
You know, it’s it’s hard and I don’t want to just sound arrogant, but you know, I think there are two that standout. One was probably the first big one I got, which was in modern healthcare up and comers award, because it opened my eyes to thinking about what I was doing and what the people who were also being honored with me were doing and, and I got, I got out of my office and started engaging with people nationally, which I think was was very helpful for my perspectives and for the organizations I represent. I think the one that was the most meaningful to me was getting a leadership award when I was the chief operating officer in New Haven, and it was then about being involved not just in academic medicine, but in community based health care. And, you know, we are only as good as the communities we serve. New Haven and Bridgeport, Connecticut are two of the top 50 poorest midsize cities in the United States. 45% of the people in New Haven are on state, Medicaid. The needs are great, and we are the largest employer in the the communities that we serve. And we have an obligation to be a good community partner. And so being recognized as somebody who cares not just about health care, but about our communities was very meaningful.

Gary Bisbee 36:14
So Marna as a Connecticut resident, we appreciate everything you’ve done for health care in this state. You’ve just shown great leadership throughout here, you know, so well done.

Marna Borgstrom 36:26
Thank you very much.

Gary Bisbee 36:28
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