Episode 81:
We’ve Created a Vaccine Buddy System
Marna Borgstrom, President and CEO, Yale New Haven Health System
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In this episode of Fireside Chat, we sit down with Marna Borgstrom, President, and CEO, Yale New Haven Health System, to discuss the growth of regional health networks, the threat to academic medical centers posed by the payment system, telemedicine, the likelihood of M&A caused by the coronavirus pandemic, and the role that health systems are playing to support the public health infrastructure.

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 0:03
We’ve created kind of a buddy system. So there’s a Pete’s Coffee kiosk up above my office, which I can’t live without. And one of the women who works up there is a single mom, African American. And I said, “Dom, are you vaccinated?” “Well, no, I’m not.” I said, “How about if I go with you?” And other people are doing that too. Because I think that for some people this is very personal and you have to meet them where they are.

Gary Bisbee 0:27
That was Marna Borgstrom president and CEO Yale New Haven Health System reviewing the buddy system which is Yale New Haven’s informal approach to those employees who may be interested in receiving the vaccine, but who have not yet sought it out. Yale was asked by the state of Connecticut to create the capacity to administer 40,000 shots weekly, but supply has only allowed 6,500. The intermittent vaccine supply makes it very difficult to plan for the staff and resources required to administer shots. Marna covered the waterfront with views on succession for executives and the board of trustee, the growth of regional health networks, the threat to academic medical centers posed by the payment system, telemedicine and the similarity to home visits made by physicians of previous times, the likelihood of M&A caused by the coronavirus pandemic, and the role that health systems are playing to support the public health infrastructure. Marna and many other guests of this show are openly questioning the current positioning of payment carrots and sticks for consumers and providers. Let’s listen.

Marna Borgstrom 1:32
The lack of relationship between who we want to insure, what we want to insure them for, and what we want in outcomes, and what we pay for is seriously broken. And we didn’t get here overnight; it’s gonna take a while to change it.

Gary Bisbee 1:51
I’m delighted to welcome Marna Borgstrom to the microphone. Good afternoon, Marna, and welcome.

Marna Borgstrom 2:01
Thank you for having me, Gary,

Gary Bisbee 2:03
Great having you here for the second time, so we appreciate your willingness to do this more than once. Why don’t we dive right into COVID, which is taking up a lot of resources and mindshare pretty much across the board. What’s the status of the surge in New Haven and all of the Yale New Haven markets now?

Marna Borgstrom 2:24
I think like almost all of my colleagues with whom I’ve spoken, we’re going down. Today we have 262 COVID positive inpatients in our health system. You put that in context – at the peak in the spring, on a single day, we’ve had 840 COVID positive patients. And at the height of this second wave, which was probably the second or third week in December, we had about 435. So we’ll pick up a couple of numbers ticked down, but it is coming down pretty steadily. But one of the things that I always remind myself and other people is that in all of the ICUs, there are still a number of people who are ventilated, who are being probed, and who are really sick. And I just ran into one of our nurse managers in the hallway who two and a half weeks ago lost her 55-year-old husband to COVID in the ICU. And that’s when you realize that we can celebrate the numbers, but the people are still being impacted in very personal ways.

Gary Bisbee 3:30
Do you have your own epidemiologists or what’s the thought about will there be more surges coming up?

Marna Borgstrom 3:37
There are as many models out there as I have fingers and toes to count them on. And we look at them. But we do work with the Yale School of Epidemiology and Public Health pretty closely. They have also collaborated with Harvard on a model. And then there’s an MIT model that’s been pretty reliable. And you see all of the other ones. The Yale Public Health School did a wastewater analysis focused primarily on the New Haven area. And we’re able to correlate an increase in the presence of COVID in the wastewater with small spikes that would then follow in COVID-related disease. Right now, knock on wood, the wastewater analysis, and the other projections we’re seeing suggest that we should be stabilizing and then continuing to go down ever so slowly.

Gary Bisbee 4:29
Well, you spoke about the caregivers who have been under stress now for almost a year, even though it’s lighter now than it was, but you make the point they’re still sick patients and they’re all feeling it. What’s your view of the caregivers? Is this going to be something that they can put in the past or is this going to be hanging on for a while in terms of just their general stress level?

Marna Borgstrom 4:52
I’d love to say it’s in the past. I don’t think that that’s true. I think people are pretty burned out. As you pointed out last March, Connecticut was one of the early states to basically shut down. But throughout all of it people who worked in key healthcare positions left their families, kids learning at home every single day that they were scheduled to work. And they were in and they were trying to find PPE and they were worried about their own health, they were worried about what they were bringing back to their families. And it never let up. So that other people who, they didn’t enjoy their breaks. I think people got very tired of being in the small insular world, but for the healthcare people, they never had the opportunity to experience that and they’re tired. And I think that even though COVID is going down when I round, they’re more tired than ever. Because in the first wave, we all voluntarily shut down electives and our ambulatory clinics were basically bare, everything was moving to telehealth. And so while we had 840 patients, you could deploy people and focus on these really sick patients. We also paid for that financially and many of our colleagues did. So as we came through a little dip in the summer and then went up this fall, we did not take down electives. But what we found was our case mix index was going up because the presumption is there were people who deferred heart procedures, cancer treatments, and other things that caused them to be sicker when they came in. So you’ve got not just the sick COVID patients, but you’ve got a lot more really sick patients who are in and if I give you a perspective this morning in the Academic Medical Center, the overall occupancy is 96%. So there are almost 1,400 inpatients. Medicine is at 108%, occupancy, heart and vascular is at 100%, neurosciences is at 100%, psychiatry is always at 100%. So they are really tired. And you hear about people saying, “I love my job, but I’m going to step back.” And that’s particularly true in the intensive care unit. So I worry about our future staffing and supply of qualified, trained people to do that work.

Gary Bisbee 7:22
Just along that line, how’s the nurse staffing? A lot of places have had to go deep into nurse staffing agencies. Has that been the case here?

Marna Borgstrom 7:33
We are using some travelers, but you know, you can’t find travelers. They are so expensive now because everybody needs them. We have, with some pushback from people, required people who can to redeploy. So if you were once an intensive care unit nurse and now you’re a research nurse for the solid organ transplant program, you are being pulled in and asked to do four weeks in the intensive care unit. And frankly, our staff have said that they would much rather have people like that than the travelers because what you get are people who know the layout, who know the Pyxis systems, who know Epic, but that’s come at a cost because a lot of these people left inpatient nursing because they were tired of it. So I think a big issue facing our entire field is how we’re going to stimulate the growth of people interested in nursing practice.

Gary Bisbee 8:30
Well, that leads to the next question which is what are the top lessons that you’ve learned from this COVID experience?

Marna Borgstrom 8:38
I thought about that a little bit and I thought about three things that have come to mind. One is humility. I mean, I think leaders always have to be humble, but man, this has been a humbling experience. Because you’re making it up, in a lot of cases, as you go along. People are looking to you for answers and the information is evolving as it goes on. Second, I learned, not that we didn’t know it, but had reinforced the power of communication and transparency. So when I would do town halls for various parts of the health system or when we would do a press conference, which I used to really hate doing, I would do all this prep, and they were very structured. And since last spring, I do a system-wide town hall at least every week. We will get as few as 2,500 people on a single town hall and they are also recorded so people can look at them. And we’ve had as many as 7,000 people on a town hall when things were pretty tough. And we’ve done press conferences every other week. And now we have sort of developed relationships with the press too. They’re better informed, there’s more of a dialogue, the reporting is more accurate and it’s smarter and they’re getting better. So I think that communicating and starting off with, “I don’t have all the answers. I’m going to tell you what I know. And it’s going to evolve, and we’re going to change it,” I think is important. And the fourth thing is the power of partnerships because nobody can do this alone. And even in a health system, we’re a mid-sized health system, but we partnered with competitors on many aspects of this pandemic because it was the right thing to do.

Gary Bisbee 10:21
On that latter point, which I’ve heard from others of your peers, will that continue in any way? I mean, do you see this collaboration around this crisis being carried forth or is it just only when there’s a crisis?

Marna Borgstrom 10:36
I think time is going to tell, Gary. I’m an optimist and I think that some of this can and should continue. I think there are things we should compete around, there are things we should collaborate around. We are continuing to collaborate around vaccinations, as an example. But time will tell.

Gary Bisbee 10:54
Well, on a happier note, we have vaccines. What has been Yale New Haven’s role in vaccines to this point?

Marna Borgstrom 11:01
Well, I suspect, like many of my colleagues with whom I’ve spoken, when we first got emergency authorization for Pfizer and Moderna and understanding that the storage and prep requirements for them were pretty sophisticated, what the state of Connecticut did was they relied on the hospitals to do the lion’s share of the vaccination, obviously, for our own caregivers, employees, essential frontline workers to support vaccinating emergency medical responders, first responders. And then CVS and Walgreens were brought in to work with the nursing homes because they did not have the infrastructure to do it. Over the course of this, we did really well. If you look at some of the national data, depending on what week you’re in, Connecticut is either number two or three in the country in terms of greatest utilization of the amount of vaccine material we’ve gotten in. The governor asked us probably 4 or 5 weeks ago to gear up to do 40,000 vaccinations a week. This is a new business for us. We’re, we haven’t been where we have been in the big-scale vaccination business, but we did it. We don’t use MAMS, we used Epic. We built systems in both for scheduling for immediately booking second appointments, as well as first appointments, for doing follow-up. Built it all into MyChart and we have used every single dose we get. The problem is, we’re not getting enough of it. So we geared up to do 40,000 a week. Our best week we got 6,500 doses.

Gary Bisbee 12:36
Any visibility on when that will increase?

Marna Borgstrom 12:40
We have a good working relationship with this governor’s office. I don’t mean to suggest we don’t. But this question of transparency of vaccine material is “they went thataway.” The federal government isn’t telling us. We don’t know up until 48 hours before what we’re getting. When it gets into this state, how do they decide where to distribute it? I think it’s one of the things that has to be fixed because it’s a dark hole. And we shouldn’t be operating that way. It isn’t a business that we’re going to make a lot of money in, that we wanted to go in. But we’ve got the ability to do it and I think that the ability, also to have this recorded in charts, in people’s medical records is very powerful for a whole lot of reasons.

Gary Bisbee 13:21
Let me follow that up. I was actually going to ask this later, but the public health infrastructure in a country is obviously virtually non-existent for anything like this. Then you have your health systems, which do have MyChart and you do have people and you can gear up to 40,000 a week or more. Will we see going forward, do you think, the health systems playing a more important and stated role in public health architecture or infrastructure?

Marna Borgstrom 13:53
I don’t know that I’m that smart to be able to answer that with any surety. But I think that it depends on where you are in the country and what infrastructure does exist. So again, in the northeast, most people around the country think of Connecticut as Greenwich, and Westport, and this very wealthy area. We have 3 of the top 50 poorest midsize cities in the United States. We do not have a good public health infrastructure. What we have done is developed very good working relationships. And so as an example, I hate to keep using New Haven because this is working in Bridgeport and in New London and elsewhere, we have formed a partnership with the New Haven Health Department and with the two federally qualified health systems. We are all using our same Epic platform for booking appointments, for tracking patients through, for working together to look at the diversity of the people who are accessing our appointments and getting vaccinations. And I think we are in a good position to be a partner more in some of the public health work that needs to be done.

Gary Bisbee 15:00
My guess is, over time, particularly when we focus more on social determinants of health, that sort of thing, that the same support that the health systems can provide will become more and more important. What about the declination rate among the Yale New Haven employees and staff? How is that?

Marna Borgstrom 15:19
When I last looked, which was yesterday, I didn’t get a chance to get into my computer before we started talking, we had about a 65.5% `acceptance rate, vaccination rate. Among minority employees, we have just under 40% of our African American employees who have been vaccinated and almost 57% of our Hispanic employees have been vaccinated. The declination issues are different in each case. You’d scratch your head and say for Caucasian professional employees, “What’s the deal?” Well, there are still people, we have a lot of women of childbearing age, and there’s still a concern that the vaccines were not tested on people who were pregnant/planning to get pregnant. And even though our Chief Clinical Officer Tom Belcezak who you know well and our infectious disease head say, ACOG says “Get vaccinated.” It’s much better, there’s a lot of concern that we don’t know everything. Among minority employees, you can’t generalize, but a lot of it is anti-vax sentiment, worried about what’s in it, still have people saying, “Will it make me sick?” and you can go through, this is not live or dead virus and…but it doesn’t matter what I say. And so what we have tried to do throughout the communities and in our own organization is have people of color who are experts available to answer questions. Not to talk at people, but to answer questions, and then to go out and engage. And we’ve created kind of a buddy system. So there’s a Pete’s Coffee kiosk up above my office, which I can’t live without. And one of the women who works up there is a single mom, African American, and I said, “Dom, are you vaccinated?” “Well, no, I’m not.” I said, “How about if I go with you.” And other people are doing that too. Because I think that, for some people, this is very personal, and you have to meet them where they are.

Gary Bisbee 17:23
Love the buddy system. That’s just a terrific idea. I imagine the Yale Cultural Ambassadors Program has probably been helpful in their communities as well.

Marna Borgstrom 17:33
Tesheia Johnson is a rock star, as you know. And she has been hit by gel with us in all of the work that we have been doing in New London, in Bridgeport, in New Haven. And she and her ambassadors are great partners.

Gary Bisbee 17:49
Why don’t we move to Yale New Haven. You described it as a mid-sized health system. It’s a pretty good size, mid-sized health system. But can you describe it in more detail for us please, Marna?

Marna Borgstrom 18:01
We grew up as largely, many of us did, a hospital-based system, bringing hospitals into our health system. We have 7 hospital campuses that operate under 5 provider numbers. We have 200 and some odd outpatient sites – way too many, not an effective way, but things have a way of growing and amalgamating in and then restructuring them as always a bit of a challenge. We have a long-term care facility. We have home care. We are the primary partner with the Yale School of Medicine, which is a very large training, research, and clinical practice organization. We have our own physician foundation that has over 1,000 providers, physicians, AP/RNs, and PAs. Probably, in terms of the buckets, look like many of the health systems that you talk with. The challenges are, so I always say we’re mid-sized because we’re $5.5 billion top-line revenue, but so what. I mean, what does that really mean? I think that the issue is how you can leverage this kind of scale and what additional scale do you need to be able to be successful in meeting the acute care needs, which will always be there and evolve other care systems to meet patients where they are?

Gary Bisbee 19:24
How has the scale worked during COVID?

Marna Borgstrom 19:28
I know that you’ll find this with my other colleagues. So much of the resistance by the individual parts of the system to the system’s telling me to do this or making me do that went away. Because in the pandemic, the only way that you can make good real-time decisions is, we had an incident command structure across the system. Two senior people led it for the system, who are both direct reports to me. And then there was an incident commander in each of our so-called delivery networks and for the physician practice and Yale Medical School had somebody. And we met virtually three times a day at least, during the height of COVID. And then there were subgroups of this. And so, things like, we had an independent hospital down in lower Fairfield County that was really struggling. They were going into a weekend, they had doubled their ICU capacity, they were afraid they were going to run out vents, I called Tom and Vic Morris on a Friday evening after talking to the CEO and by 10:00 that evening they had stood up a regional incident command center that was not just the Yale New Haven Health System, but included two other health systems that had hospitals in that region. So the system is, you cut through all the hierarchy, “May I, may I not? What do you think?” And you did what needed to be done. So there were a lot of good things we learned from that. We also spent money like drunken sailors. That was, maybe, it was the right thing to do. Because we went into all of this and said, “The guidance that we have for everybody is to keep our staff safe and our patient safe. And anything’s justified after that.” I think that where we’d like to settle out is a hybrid. And we’re going through the process of saying, “What did we not engage that, in fact, wasn’t going to be very helpful for us? So how do we get rid of that?” None of us are very good at stopping doing things. But also, “Where did we get a little lax or sloppy?” And so how do we make sure that we’re aligning some of the checks and balances better?

Gary Bisbee 21:34
So you’re located more or less midway between New York and Boston. I mean, Yale is obviously a top-tier academic medical center. Is it problematic at all for Yale to be midway between New York and Boston with their academic medical centers or is it not an issue really for you?

Marna Borgstrom 21:53
It depends on the reason that you’re asking. I think for academic medical centers that are doing high-end, specialty, tertiary, and quaternary care service and are using cutting-edge care and technology to do that, scale matters. And one of the challenges that we have is that New York City and Boston are much larger metropolitan areas. And you might pick one or two sub-specialty areas where we have developed such a niche that you’ll get people traveling from those areas. But fundamentally, there’s much more overlap in what we all do. And so making sure that we maintain a critical mass to do an excellent job in terms of advancing clinical care and clinical knowledge is critical. For the basic work that keeps all of us alive, whether you’re academic or not, 85% or more of what we do is primary/secondary care. We’ve got plenty of our own challenges in the northeast. And unlike other parts of the country, we don’t have any public or county, city hospitals. So we are the safety net providers. There is no other provider. And we are the secondary, tertiary, and quaternary care providers. So it gives us a little cognitive dissonance. So would I rather that Boston and New York could just push out a little bit and not overlap quite as much. Yes, I would love that, but I don’t think that’s realistic.

Gary Bisbee 23:27
Well, under your leadership, the critical mass of Yale has grown appreciably, much more relatively than any of those institutions in New York or Boston. So congratulations on that. Marna, what do you think about M&A going forward, not even as much for Yale, although that would be interesting, but nationally. I mean, you’re on the HA board, you talk to your colleagues constantly. Do you think M&A as a result of COVID is going to accelerate over the next several years?

Marna Borgstrom 23:57
Yes, I think it’s going to. I think the reason I’m hesitating is because I think that some of the things that we’ll have to figure out with the Biden administration is how the FTC interprets some of this M&A work. And I think that a lot of it may not be as traditional M&A – buying rooftops or building healthcare systems around traditional hospital rooftops, but it may be acquisition or exclusive alliances with other providers along the continuum to extend the continuity of care and the integration of care that we’re all seeking to provide.

Gary Bisbee 24:36
Well, let’s move to leadership. And what I’d like to dig into here is that clearly COVID was a shock to the system, virtually any segment within the healthcare system. Thinking about the CEOs of health systems, do you think the next generation, not your generation, but the next generation, the incoming group. Are the boards of directors going to be looking for a different skill set because of COVID with this next generation?

Marna Borgstrom 25:07
It’s a really insightful and appropriate question to ask. And I can tell you as I work, I spend a lot of time on talent development and succession planning in our organization. I had a board chair who has since retired who once said to me, “You really ought to be spending a quarter to a third of your time on this.” And I said, “How do you do what I do if you’re doing that?” Well, guess what I’m doing. And I think it’s really, really important. And what we have tried to do is build, I just happen to have it here, I didn’t know I was going to use this, what we call our strategic leadership success factors. Because we’re pretty good at defining the “what” – people need to have experiences. If you’re going to do high-level leadership, you’ve got to understand medicine, you’ve got to understand finance, you’ve got to understand strategy. What I’ve argued with our board is as important is how people do what they do and how the accomplishments that they can describe, reflect the how they did it. Because you’re hiring people for what they can do going forward, not what they did in the past. So the fact that they can check a box and say, “I oversaw this $500 million building project” or whatever is great. But how did they do that and other things. And so our 5 buckets here are, you have to lead with humility. And part of that builds off of high-reliability standards. Defer to expertise. You know, none of us knows everything. Be self-aware. The things that as human beings can make us particularly susceptible to failure, I think are found in a lack of internal questioning and self-awareness and a belief that you’re not really better than the other people around you, you just happen to be sitting in a different seat. Demonstrating courage. And demonstrating courage as we defined it is not just going out and doing the latest new thing. But size things up. Don’t let conflict avoidance keep you from doing something or don’t rush headlong into it. Don’t let fear of failure keep you from doing something that you know is right. The times that I have been most disappointed in myself are when I did not listen to my gut, which had told me to be a little more courageous. Driving alignment and collaboration. That’s key to anything. Nobody does it themselves. And I grew up in an organization that said, “There are no stars being carried off the field on somebody’s back. It is the team that pulled it off.” Modeling diversity, equity, and inclusion. Big issue because in our field, the challenges are enormous. And we need to not just talk about doing it, we need to look at it. I think if you looked at our senior team across the Yale New Haven Health System, I would say that you would be challenged to find a more diverse leadership team – gender and race. And that is intentional. We didn’t go out and hire all these people. A lot of this has been built internally. I think that’s important. And the last one is driving improvement in innovation. Innovation is not the next patent or something. Sometimes innovation is like the thing we did with a capacity coordination center, which is just saying, “How do we use tools available to us to better manage this very dynamic demand for services we have?” But don’t get comfortable where you are. Keep looking out over the next horizon.

Gary Bisbee 28:43
Yeah, I love that formulation. Let’s turn this question about next-generation CEO and characteristics to the board itself. Will this COVID crisis precipitate thinking about maybe different characteristics of board members in the future?

Marna Borgstrom 29:00
The primary board characteristic that I have been interested in, is having diversity on the board. But in that diversity, people who understand complexity and complex organizations. Because sometimes you can get really smart, accomplished people, but who have been playing in one lane for a long time. That’s not the luxury we have in this business. You’ve got to look to your right, to your left, check behind you. And the challenge of keeping everybody pointed in the same direction is daunting. And so complexity is a big factor. Understanding and managing and complexity are big things I’m looking for.

Gary Bisbee 29:43
That makes good sense. I’ve got a question that I didn’t preview with you, so you can pass on it if you’d like. But I’m really becoming much more interested in decision-making as a factor in leadership. If I ask, “What was the hardest decision you had to make during all of this COVID crisis,” is there a ready answer there?

Marna Borgstrom 30:05
I think the hardest decision, and I’m not sure I’d even call it a decision but recognition was we threw the budget away.

Gary Bisbee 30:11
I’m assuming the board was with you on that.

Marna Borgstrom 30:14
I had great support from the board. And we started with, nobody’s lived through this before. And you don’t check the budget to figure out how you get more PPE in or how you create more negative pressure rooms or whatever. You do it.

Gary Bisbee 30:30
Let’s turn to the whole telemedicine issue, which obviously, was an explosion for all of our health systems. But the question is, and you talked about innovation, as I think the fifth column in your model, but will this explosion in telemedicine actually end up being an important factor for expansion of your innovation to the community? Or is it still gonna be just focused on primary care and that sort of thing?

Marna Borgstrom 31:02
I think one of the great things is it’s here to stay and stories are very powerful. At our last Yale New Haven Hospital board meeting, the academic medical center, a relatively new board member is the chair chief of surgery, brilliant woman named Dr. Nita Ahuja who we stole from Hopkins a few years ago, and she’s just terrific. And Nita had offered, after I asked her to, to tell the patient’s story. And her patient’s story was about the power of telehealth. Because she is an oncologic surgeon by training. And she had a patient who really needed to be seen, wanted to see her. And she got all the patient’s scans and everything else and a telehealth visit was arranged. And Nita was sitting in her office and the patient was sitting with his wife, his daughter, and his son. And she was able to go through and explain what she was seeing. Said, obviously, based on your choice and the outcome of this, I will need to examine you physically. But this is what I’m seeing. This is my experience with it, this is what it means. And she said the power of being able to do that and having these people who are his support network sitting with him and hearing the same information made a very powerful impression on her. So if an oncologic surgeon can do that, and she would also say that post-operative visits, you can do a lot of that rather than taking people, particularly some people who may be immunosuppressed, out of their homes, driving 45 minutes, sitting in a waiting room, being exposed, if you can visualize a wound, if you can get certain vitals. So we’ve also built a Care at-home model that we piloted during COVID so that we wouldn’t have as many people on the acute care, not the intensive care, the acute care floors. And you know what, it works really well. You give people a pulse oximeter, you give them an iPad, you connect them with an AP/RN or a hospitalist. You talk through signs and symptoms. There are a lot of things that you can manage, and patients are happier, and the clinicians feel like they know more than they sometimes do with those short check-ins.

Gary Bisbee 33:22
Well, it’s kind of like the home visits that your father used to make when he was out making rounds, isn’t it?

Marna Borgstrom 33:27
Absolutely.

Gary Bisbee 33:28
On another matter, which is the level of government payments to our large health systems. Many of our health systems 60% or more of your revenue comes from governments, a lot of it the federal government. That’s going to accelerate as we get more and more baby boomers on Medicare. How do you see that going forward? Is that going to be an issue? Is that something you worry about if maybe 70%/75% of your revenues come from government someday?

Marna Borgstrom 34:01
I worry about it all the time. That is one of the key things I worry about. Right now about two-thirds of our revenue is driven by governmental payers. And in actuality, as you know, Medicaid is largely funded by the federal government. So it’s all the federal government. But the lack of relationship between who we want to insure, what we want to insure them for, and what we want in outcomes, and what we pay for – it’s seriously broken. And we didn’t get here overnight; t’s gonna take a while to change it. But what I worry about particularly, is a more rapid erosion of the commercial payment system which I think is going to be a big challenge for academic medicine. Because frankly, they’re the ones, even though they won’t say it this way, who have to find some value in academic medicine and paid more for that. And in the state of Connecticut, you’re probably aware that the public option has made a debut on the agendas of things that the state legislature is dealing with. And when I had a chance to talk with the controller probably about six weeks ago, I said, “Kevin, this isn’t a good thing. And this is not a good time to roll it out and here’s why.” I mean, Washington state’s experience, number one, was that when you get into the hard work of saying, “Who are we insuring? And how much is it going to cost? And what do we need to have for our medical loss ratio?” All of a sudden they priced themselves out of the market. But assuming that you’re smarter than those people and can do it. Well the problem is, what’s driving the formation of this. You say it’s access, but it’s lowering costs. And the way you lower cost is by paying less, not by actually lowering cost. And that’s the thing that I worry about is that we’ve got that constant disconnect.

Gary Bisbee 35:46
Totally agree. And it’s definitely, I think, at the end of the day, going to be the biggest problem.

Marna Borgstrom 35:52
Could I say to your listeners that everything I know about healthcare finance I learned from Professor Bisbee.

Gary Bisbee 36:00
Unfortunately Marna, for both of us, that was a long time ago but… One last question if I could, this has been just been a terrific conversation. One last question, then I’d like to get to leadership in a crisis. And that is the regional health network because really, Yale is a regional health network, do you see that expanding around the country, becoming more popular?

Marna Borgstrom 36:24
I do. My crystal ball is pretty fuzzy, but when I talk to some of my colleagues who are in national systems, there’s a part of the scale argument that they can make that works to their advantage, but not a lot of it. Because healthcare is fundamentally different in Oregon and Washington state than it is in New Mexico than it is in Iowa than it is in the Northeast. And I think scale helps to take certain infrastructure expense and spread it over a broader base to reduce the cost per unit of service of things that are not necessarily making patients better or giving them more access, but are necessary to a well-functioning health system. But I think regional provider networks are going to be really important because there are variations regionally and payment models, payment systems, utilization patterns, and so I think that we will get larger regional networks. But I think, you look at Kaiser Permanente, and I know far less about it than you, but they have been very successful on the west coast. They have been somewhat successful in Colorado. They were not successful when they came into the east coast. So I think that, in coming up with healthcare policy altogether, we just have to keep reminding ourselves that this is a big, diverse country and one size doesn’t fit all.

Gary Bisbee 37:57
Looking at leadership in a crisis I really have two questions. The first is, and you addressed this actually earlier, but it bears repeating. What do you think that the ideal characteristics of a leader during a crisis like COVID are?

Marna Borgstrom 38:13
Ideal characteristics are be visible, defer to expertise, bring this best people around you that you can, engage people in dialogue to try and understand all aspects of what you’re dealing with, but then don’t per separate. Make a decision, move forward because 99% of the time you’re going to iterate that decision anyway, but you need to start moving in a crisis. So goes along with recognizing that, I often would go home and say to Eric, “I can’t believe these people think I know what I’m doing.”

Gary Bisbee 38:51
Well, that’s a statement of your humbleness. But everybody knows you’re absolutely terrific, Marna. So let me move then to the last question. Has the COVID crisis changed you as a leader and/or as a family member?

Marna Borgstrom 39:05
I think you’d have to ask some of my family members how it’s changed me as a family member. I’m not sure that it has, other than I have been so happy when I can get home and just kind of nestle into the place that is comfortable for me. As a leader, I don’t know how it’s changed me, but I think it’s made me more informal. And that informality has translated into approachability, dialogue, and greater support. And I’m just amazed at the number of employees who now will email me, and sometimes they’re big questions. And sometimes there are things like, “That pin that you were wearing was just beautiful, where did you get it?” Now, somebody said to me, “I would never have written an email to the CEO before.” But it’s kind of like being a TV show. You’ve been in our living room and our office for over a year. Tom Balcezak and Kevin Myatt our CHRO and Vin Petrini our communications guy and I get on in advance and they’ll go live. And one of the things I think is most important, and I did mention this same place is humor. And so torturing these guys is one of my favorite pastimes. And you know what? People loved it. And they have loved it and they have played along, and they have seen us as real people, rather than as what they thought we were because of the position we had. And you know what, I love that. And so I think maybe that’s something that I would reflect on.

Gary Bisbee 40:40
Well done. Well said. Marna, thanks for your candor and your time today and keep up the great work.

Marna Borgstrom 40:47
Thank you, Gary. Great to talk to you.

Gary Bisbee 40:50
Fireside Chat with Gary Bisbee is a Health Management Academy podcast produced by Think Medium. Please subscribe to Fireside Chat on Apple Podcasts or wherever you’re listening right now. Be sure to rate and review Fireside Chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating, we’ve found that podcasts are known through word of mouth and we appreciate your spreading the word to friends or those who might be interested. Fireside Chat is brought to you from our nation’s capitol in Washington, DC, where we explore the strategies of leading health systems through conversations with CEOs and other interesting leaders. For questions and suggestions about Fireside Chat contact me through our website firesidechatpodcast.com or gary@thinkmedium.com. Thanks for listening.