Judson Howe Soma, I want to ask you to walk us through the exact moment, perhaps it was a patient or a statistic or an experience, that flipped a switch in your mind and made you say, “I can't watch this anymore. I need to be part of the solution.” What did that moment look like for you?
Somava Saha I think for me, as a primary care doctor and somebody who was creating a community health center, it never occurred to me not to make the system better for our patients and communities. I had the great privilege of designing community health centers that could do that. I had learned from indigenous and Baha'i communities that, in fact, radical system change was possible and could be approached in practical ways. But the moment that I really understood how misaligned the system was compared to the goals and aims of health care was in 2009. We were going through health care reform in Massachusetts, which was supposed to be about expanding access. Of course, what it did was expand health insurance access, technically, without accounting for how that would be delivered. What that meant was the state expanded coverage to four times as many people as intended, and then tried to defund the safety net, because they believed that in the context of everyone having health insurance, people wouldn't choose to go to the places which had, in a trustworthy way, provided care for them for the decades before health insurance access. And so at the time, I was a primary care doctor, was the medical director of a community health center in Revere at Cambridge Health Alliance. But I was also the incoming president of the medical staff. And I remember I was also only at that point, maybe four years out of residency, so young enough to ask, “does the emperor have clothes?” And so I remember being at this table as the governor called us one fine day and said that the $40 million in supplemental funding for this year wasn't looking good, and the $100 million for services already delivered the year before wasn't looking good either. And I remember a year-long period of — of course, advocacy to help explain why the safety net was more important than ever in the context of expanded coverage — but also the process of the organization going through its own strategic planning and change management process of assessing, well, who should we be? And for me, that question as we looked at department after department after department and realized that in the context of this existing system, absolutely no service line made money doing really outstanding care, delivering really outstanding care for a safety net population, except for tiny little program for 250 people, where the payment system was completely different, where we got capitated care with good supports to meet people's needs holistically. Except for that, the entire system was paid for people doing widgets. And in fact, I was mapping what was happening to patients. And because of that system of widgets we had, if you looked at the flow maps of patients and their journeys through the system — I was really into improvement and human centered design and using the footsteps of real patients and communities to see what was happening — those looked like spaghetti. And instead of spaghetti, which was made up of all this patient spaghetti…
Judson Howe I'm picturing a plate with everything everywhere —
Somava Saha …with these heroic healthcare providers — nurses, doctors, etc — working heroically to, despite the system, get the person to where they needed to go. Any time the system worked, it was because people were working despite the system. And then they'd burn out and leave. And none of it was designed, or maybe all of it was designed, to get the results that it gets, which was low-quality care at a high cost, at a substantial not just cost to the healthcare system, but cost to real people in their lives, to real families, to real communities. And that understanding that the entire system in fact didn't work, for me as a change leader, was a perfect reason to say “the emperor has no clothes”, Actually none of it, none of it helps us, in the way we're currently financed and organized, helps us to meet the needs of our patients. Or we're meeting the needs of our patients, but the system, in fact, makes us when we do that, when we, for example, as we had done, reduced childhood hospitalizations by 90% with all of the savings accruing to the payer, resulting in a closure of the pediatric unit because we'd done such a great job with asthma and with vaccinations. That actually doesn't work as a sustainable change. And so my question was, well, great, how do we make what good care is the new norm? And in fact, in a time when the state of Massachusetts is paying for the future, for the health and wellbeing of the communities of the safety net, how can we use this burning platform to actually redesign the healthcare system we need? And that question of the “how might we” led us to a transformation in the way in which Cambridge Health Alliance decided to deliver care. We embraced changing and flipping our business model. We went from zero to 60% global payments. We reorganized everything about the way that care was delivered underneath, driven by the ideas of frontline staff, community members. I was fortunate to get to be the vice president leading that transformation, along with others. And this was before all the programs were there by CMS, like we just went payer by payer and began flipping stuff. Went from zero to 60% global payments in five years, and changed everything about the way care was delivered, not based on some small payer requirement, but by actually saying what better care would look like.
Judson Howe So you're keying in on something really powerful there. But I want to make sure that every listener understands the revenue piece that you're talking about and why that changed your perspective and maybe some of the behaviors and processes. I’m referring to global payments. What is a global payment and why would that affect the way a clinician or an administrator would design the workflows of healthcare?
Somava Saha Sure, so global payment is basically where you get an overall payment to keep someone healthy, versus a widget by widget or service by service payment to help someone when they're sick. That kind of per service payment made sense in the age where actually you had limited healthcare access. You wanted to get people in, say, in the age where infectious disease was what drove most health outcomes. So in that context, somebody getting in, getting to a doctor, getting an antibiotic, that was great. It was actually what you needed people to do. So our healthcare system was designed to, people go in. It's simple, you see them, you get paid. The problem is, of course, any system drives a particular outcome. Over time, what happened was as more and more people realized that the more they could see people, the more they got paid, the more they could put off things until people actually got sick enough, at which point it actually costs way more. We began misusing that in a way, whether we meant to or not, and using that to drive, as we developed a more business model of healthcare versus a service model of healthcare, which was the other major cultural shift, that then began to drive misuse and incredible waste in the system, waste for taxpayers, waste for employers and waste most of all in the lives of patients and communities.
Judson Howe I can relate. But, and can you also give us a specific, pick one specific thing that you changed as you went from zero to 60% global payment?
Somava Saha Oh, gosh. Well, we changed everything, because we were mostly interested in the payment enabling us to do …
Judson Howe Was this a per member per month? Or just here's x dollars per member?
Somava Saha We put everything in this in a bucket. Our idea was freeing ourselves up from widget-based payments. Anything that wasn't about a volume-driven system, which was sort of per unit payment, counted in that 60%. So that could be a capitated payment that was a per member per month, that was a majority of it. That could be from true full capitation. It could be from shared savings programs. It could even be for quality. It could be even the supplemental dollars that could be brought in. But overall, we began reframing our system as being about having the freedom to provide the care that our patients and communities needed. In reality, what we were doing at Cambridge Health Alliance was we were providing great care, especially compared to others around us. We were providing culturally responsive, often culturally driven care, with strong interpreter services, with behavioral health services, all the things that people actually needed to do well, just none of it got paid for. So all of that was in the model where you're looking at the bottom line as the goal, versus health and wellbeing as the goal. In that model, all of the stuff that actually help people to be healthy and well counted against us. So we said, well, what would it look like if it counted for us? What if the incentives of the health system supported us to do what we know is to actually meet our mission to improve the health of our communities? So instead of saying, let's make the mission meet what gives us margin, we said, what gives us margin should support our mission, and we had the courage to go about doing that, and then that gave us the freedom to redesign everything about how we deliver care. So we changed the care teams that were caring for people. We reduced panel sizes, built high functioning teams that took community members who were receptionists and medical assistants and made them quality improvement leads. We took bachelors-trained people from the same communities, and they became the QI leads of the community. Nurses, medical assistants — they all had expanded access and became caregivers rather than vitalists and checker-inners. We really optimized everything. For these 1500 people, we were their team, and our job was to help them be as healthy as possible in an incredibly well-organized way. And I used to always know who was in charge, because if the quality reports came out eight hours late, my inbox would be flooded with emails from medical assistants saying, How am I supposed to care for my patients, if I don't have the quality reports I need to drive their care? We reframed who could provide care. Doctors and medical assistants had shared workflows and shared offices. We changed things so that we were prepared for people before they came, before I ever got into a waiting room or had anything to do, all kinds of their health maintenance was done. Their blood was drawn. The people might have come in earlier, and then after the visit, everything they needed was done. And my time with people could just focus on what was needed to support why they were there. In fact, the receptionist, one of their jobs was to help the person really identify what mattered most for them in that visit. And then in between visits, the visit didn't stop. We knew we still needed to help people in the community, and so people would reach out to them. We would have planned care lists. We would check in and see how people were doing, and we didn't worry about what was in pay for performance. We said, what does this population need to be healthy? Turned out behavioral health and social needs. We developed integrated registries of behavioral health and medical needs. We reduced wait time for behavioral health by flipping the model for delivery from more than 90 days to less than a day. In the two and a half year period, all of the transformation sites had been able to move health outcomes to the national 90th percentile for a safety net population, while taking 10% of cost out of the lowest paid Medicaid managed care system in the state, while simultaneously improving joy and meaning of the work for the workforce at the transformation sites because we didn't make it about meeting some standard here. We gave people permission to redesign care in the way that actually made sense for real people and real communities and gave them supports in that transition so that they weren't just left to do it on their own.
Judson Howe That sounds amazing, but awkward at the same time, because here I'm a consumer of health care or a community member. I'm assuming that what you're describing is how I'm being treated by my physician’s care team. So I have this tension there that's happening. Why isn't this happening everywhere in American health care? What's preventing that from happening? If this is so unique and different.
Somava Saha I didn't say it was unique and different — it was at the time — but the shift to team-based care actually happened all across the country, especially in primary care. It had happened in some specialty sites as well, but there were entire health systems across the country that shifted to this kind of model. We were asked to help support that, but many other teams were, through the Safety Net Medical Home Initiative, through a number of IHI programs, through the Patient Centered Primary Care Collaborative that led that coordinated effort nationwide, this became a norm for patient-centered medical home certification, for example, in primary care. In the Cambridge Health Alliance, transformation went a lot further. Those were driven by, say, an NCQA certification, whereas for us, it was the team-based, patient-relationship model. First of all, it wasn't a physician's care team. We all belonged to the patient's care team, you know, so it's clear who was in charge. Nor was it about primary care alone. It was about how primary care, specialty care, how ER and hospital, how we untangle the spaghetti of the person's experience, and not just through the healthcare system, but in their lives in a way that would promote health. So we were clear that the goal was improved health and wellbeing outcomes for real people, and that's what it was designed around, and that's why I think it got the outcomes it got, because we were not trying to meet some standard. In fact, as a vice president who ended up leading that, the care delivery transformation, I wouldn't even let people see the NCQA standards until two years into the transformation. By the time they saw them, they would all get 96 or 100.
Judson Howe Does that become a checklist? And like, the heart's not in it, if it comes later?
Somava Saha People don’t actually redesign based on what's needed to move outcomes if you're just following a checklist, in my experience. I think the checklist can be helpful once you've developed the culture and process and acculturated things like high-functioning teams. So we have leadership academies that help people understand how to deliver better care, to learn from one another, to learn from bright spots, outside and inside. But it was really about what creates the conditions for great care, for great experience, for confidence. We've had patients and community members and frontline staff integrated into improvement teams at every site early on in the process. And so that actually freed how decisions could be made, and we built an innovation system all throughout the health system. But leadership academies for people, it was a real investment in the workforce and a real trust in them to create change, to try it out, show if it was better, and then actually spread that to one another. It created a lot of joy and motivations. People who were confirmed skeptics came to feel it was some of the most transformative time.
Judson Howe I know a moment ago you said this is happening elsewhere, but I was a healthcare executive for 10 years, and we did try to build patient centered medical homes.
Somava Saha But often, I bet, through some accreditation piece rather than a transformation or redesign process.
Judson Howe Yeah. And there was resource constraints as well. We might be able to find the physicians, but could we find the LCSWs? Might be able to find the LCSWs, but could we find the MA’s. And to your point, we shifted heavily to workforce development, which might be a natural, commendable thing to do, but I'm also sensing that you deeply, personally feel like this is really important, and that might have played a role in the Cambridge Health Alliance's success. What makes you, Soma, so passionate about the patient-centered care that you do today and you were doing then?
Somava Saha I think almost every person in healthcare goes into healthcare to make things better for patients. I know maybe I'm too optimistic about that, but I think that there's tens of thousands of people in the healthcare workforce where that's all they wanted. And when they get into healthcare, and that's not how the system is operating, begin to experience burnout and moral injury. It's why we see, as people experience the structural inequities of the system, or the mismatch between the intent of the system and the impact of the system, that we begin to see people, healthcare providers become really burned out. I think for me, I thought if you saw it, your job was to change it. I thought that's what it meant to be a leader, and so I did my job.
Judson Howe
Do you still think that's true?
Somava Saha Yes. That's why we're leading something called Justice Squared, which is about just leaders for a just health system, which is about helping healthcare organizations understand how structural racism shows up in their healthcare system, and practical tools for what to do about it. What I came to realize is that I'd been lucky to have training in how to go about complex system change, from experiences with community-based transformation in Guyana, with the Baha'i community and with the Guyana Office of Social and Economic Development. So I had had experiences that I could translate in how you redesign a system to meet the needs and the goals that you're trying to have. Not from the perspective of who has power. From the perspective of who the system is supposed to serve. And while I now know that not everybody believes that patients and communities are who the system is trying to actually serve — some people actually debate whether that's the case or not, believe it or not. I think at Cambridge Health Alliance and thousands of mission-driven healthcare organizations across the nation, we still believe that, and I certainly believe that. And so in my training, and what I had been taught was that if you see a gap between how the system is operating and the needs and goals of the people it's supposed to serve, it's your job as a leader to figure out how to bridge that.
Judson Howe When I'm out in my previous tenure, there's a lot of optimism around technology being the solution for access points and for innovations that will improve the patient experience and the physician experience, obviously, as well. But in the heart of what we're talking about right here, what role would technology play to enhance justice and equity in healthcare?
Somava Saha Technology is a tool that can be super powerful at enabling effective design of a system, or super powerful at perpetuating inequities. So the tools reflect what we understand, like our mindsets of what the flow should be. And so we were able to use technology, for example, to automatically make sure everybody across the system who was caring for someone knew when someone crossed a transition point, long before CMS did something about transitions. And we would do that across all kinds of transitions that people had in their lives, and that meant everybody knew, and that people could actually see what was happening and could talk to one another. We used technology in a way that 60,000 people, without any formal educational initiative around it, had conversations about what they wanted for their end of life care. And we used technology to make sure that medical assistants and receptionists had the data that they needed to drive outcomes. So technology can be fantastic if it's used to drive the goals of a better system, but we have to be clear and align the goals of the system to improve the health and wellbeing of people, rather than the profits.
Judson Howe But you said it can also exacerbate existing inequities. Give me an example of health injustice or health inequity that you've experienced or are experiencing in your line of work?
Somava Saha Oh my gosh. Where do I start? One example of that might be who, for example, gets programmed in for you to refer to. How insurance is used in multiple algorithms within healthcare, insurance status, to drive people to longer wait or infinite wait versus no wait. How measurement and diagnostics are driven by, say, race-based measurements about the protocol that's being used to decide whether somebody should or shouldn't get care, about how payment is set based on risk calculations that do or don't include behavioral and social health. Technology is used every day, and AI helps encode all of the inequities that we have baked into the system, because AI is just learning this is how the system is supposed to be based on the past, versus here's how the system should operate based on the goals of effective, equitable, person-centered care that supports one to be healthy across their lifespan.
Judson Howe Earlier you mentioned that the system is designed, or maybe even not designed, for this structural injustice that we're talking about. I just want to ask you directly, do you think there's intentional design in this, or where does this, how did we get to this system of inequity that we have today?
Somava Saha Oh, I think we have encoded the historic inequities of this nation forever.
Judson Howe It just kind of seeps into the way we work, osmosis. It just kind of gets in there.
Somava Saha I think of it like an endemic disease. Like we're actually carriers. It's in our structures and systems. The Flexner Report closed over 100 black medical schools that were serving predominantly black students. That reduced the workforce that was available, for example, to care for communities of color. We had for-colored-only waiting rooms and believed that care should be separate and unequal. We routinely — the modern day version of the for-colored-only waiting room is whether a healthcare system accepts Medicaid or not, and what percent of Medicaid or uninsured patients it accepts. It uses a business justification for that, because when I mentioned that that mind frame shift of healthcare as a service, especially nonprofit healthcare, as a service to a community, versus — because, remember, we're not paying taxes —
Judson Howe Who's not paying taxes?
Somava Saha Health care systems, nonprofits are not paying taxes. And yet they are benefiting from roads, broadband, existence of food and food systems, schools, all that. And so when we are taking that bye on the taxes and are actually treating patients in a way that doesn't actually make people feel welcome if they don't have good insurance, people of color, or they speak another language or are poor. It might be harder if we site our buildings, our healthcare buildings in communities that have a different payer mix than is optimal. I know you as a former CFO can relate to the kinds of algorithms that make up where you decide to open. That's how we continue to perpetuate the existence of for-colored-only, for-wealthy-only, healthcare sites, and a healthcare system that's built for structural inequity.
Judson Howe Yeah, I actually noticed it the other day, Soma. I was in a city in the Midwest, and I heard a hospital president say, we are the safety net hospital for this particular city, metropolitan area. And I realized that in five or six years, I have not heard that term, because I've had the blessing of being in a more rural community where the hospitals that are there are the only hospitals. And it's not better or worse. I'm not critiquing anybody on this one, but it made me realize and reminded me of my time in Los Angeles, where we actually have this two-tiered system between those that are designing programs for payer mix strategies, and like you said, then there's the safety net hospital, and it was just a reminder to me that as far as we've moved, we really haven't moved.
Somava Saha My goal was to make sure that the care that was being provided in our essential hospitals, which is often far more person-centered actually than the care being provided at the big ivory towers, actually was the best care that you could get in the state.
Judson Howe Did you accomplish that?
Somava Saha
Yeah, we did.
Judson Howe How would you measure that?
Somava Saha Outcomes. Based on HEDIS outcomes, quality outcomes -- not face transplant outcomes -- readmission outcomes, hospitalization rate outcomes. We outperformed those systems, and a lot of how other people, those systems, outperformed in quality goals was by taking shortcuts. They just got rid of the patients that had behavioral health issues. We said, how do we care for people with behavioral health issues in a way that their physical care is taken care of, by integrating primary care into mental health homes, by providing that continuum. How do we actually do the real thing of providing a health system that creates health?
Judson Howe Sometimes it feels like structural equity work can be exhausting. Tell us a moment when it felt hopeless. Maybe lack of funds or unsupportive political environment or local environment, I don't know. But how did you find your strength to resolve those and push through?
Somava Saha I don't know anything about challenging political environments or structural environments. Come on.
Judson Howe It's getting easy now in the next five years.
Somava Saha Oh it’s so easy. I think anytime I get confused about how hard it is for me, I just have to sit and listen to one story of a person who is actually navigating these systems. And I can assure you that there's nothing that we face as executives in healthcare or health systems that compares to what everyday, hard-working people, two thirds of whom are working already, have to navigate just to get through our systems. Their lives are way harder than our lives, and honestly, it's our obligation to get it together and fix it for them.
Judson Howe Maybe a moral responsibility?
Somava Saha Yeah, otherwise, we are actually just part of an extractive system that profits, that profits from keeping people in poverty. Healthcare does not lack in profits.
Judson Howe There's a book that I was reading recently by Donella Meadows, just up the street here at MIT, but there's a chapter six in there. I think it's six. Could be seven. It's called “Leverage Points”. But inside of there, she suggests that there are pivot points that exist within systems where, if we can fully tap on them, we can make outsized impact on these systems. Where do you think those leverage points may be in this system that we're talking about?
Somava Saha Okay, I'm going to say one that's going to sound hopelessly romantic or cheesy or something, except I found over and over it works, and it's actually the thing that shifted the most. Because at this point I was a vice president at IHI. I actually got to see health systems all across the world. And for all of them, they had flipped their design principle and their why and then designed around the idea. It was really about deeply going back to mission, and making the mission, not the margin, the core. The idea of “no margin, no mission”, that is one of the most toxic things that happened in healthcare, because it made the margin the thing that we're designing the system around. Actually, when you go back to what is it, when you call people back into why they went into healthcare in the first place, when you ask them to actually make the mission their core, when you invite them to get into relationship with their communities, like deep relationships, and to walk with their communities in an asset-based way, where you stop thinking about everything you don't have and all the things that would potentially cut into that margin. Instead say, well, what would it look like if we used our shared power to flip the system, and then began to really do what was needed, and began asking, “how might we?” Suddenly, healthcare systems find all kinds of other things that's possible. It takes Cincinnati Children's, for example, to deeply partner with their communities in ways that they not only reduce hospitalization bed rates from, say, the Avondale neighborhood, but they're able to actually use that to think about how to improve third grade reading level, to use their QI techniques to help support community members, to reduce reincarcerations, it changes into improved high school attainment rates. When you stop thinking about what you don't have from a deficit frame, and you shift over to, how do we use our power and privilege and all the assets we have? Which is not just the delivery of healthcare. Healthcare is the largest employer in most regions, as you saw, I'm sure, in your rural hospitals. Healthcare has land it can use. Healthcare purchases a lot of things. We could actually use that to drive local economy, if we were to think about how to do that differently. Once we get in relationship, we realize, oh, we have all this policy power that right now we might use for payments, et cetera, but we could actually use it for more than that, if we chose to. Once we did that and realized we didn't have to be the heroes coming up with all the solutions. We have to get in relationship with so many others that are doing this, then you realize you have way more than you imagine, and suddenly you're free from this idea that you're stuck in a system that you can't change, that has you forever doing the thing that isn't why you went into this in the first place. And my experience is that as people taste that feeling of liberation, they don't want to go back. And so the health systems that have been successful at making the journey don't make those transformations about meeting some external mandate or accreditation or something like that. They transform because they deeply want to meet their mission to improve the health and wellbeing of their communities, and they figure out how to make the systems change in order to be able to do that.
Judson Howe It's almost big enough to change and evolve the systems around you, or maybe even change the goals or some of the paradigms that we operate inside. And just to resonate a little bit, there was a time in my career where I was short 45 primary care doctors, and I called somebody that had addressed this in a much more rural community, and said, how did you go about improving your situation? And I remember a moment where that person said to me, what's your mission statement? And I read it to them, it was a faith-based nonprofit. And he said, do your providers feel that way? And I couldn't say yes, and he said, then you're the problem. And it's really stuck with me, and it ties back closely to what you're saying. It did lead me on a journey that I'm still on, but towards what if we went from scarcity on not enough doctors, to redesigning the way care is delivered, so that the many burning out doctors could find refuge in my community and find something different. And not to go too far into that, but it did. We cut the gap in half in a matter of 24 months, and it was really meaningful.
Somava Saha Remember, we did this transformation out of being defunded.
Judson Howe But it's that crisis point. It's that wall that you hit.
Somava Saha Yes! It actually allowed us to let go of the system as it is, to go for it, because it wasn't going to work for us anyway. So why hold on to it? Why are we trying to have the last grasp at staying in the system as it is, versus letting it go and saying, hey, what's the system we want. You have to understand that in Guyana, I was working in the second poorest region in the second poorest country in the Western Hemisphere, and watched as teams of community health workers, villagers and teachers, over a 10 year period utterly transformed their health outcomes.
Judson Howe Give me a sense for your career chronology. So, did you start at Cambridge Health Alliance and then move on to IHI, was it maybe? Maybe walk us through that.
Somava Saha Yeah, so the time in Guyana was when I was doing my master's work. I was doing an MD/master’s. I was doing both at the same time, and that's where I really learned how you create sustainable community change, and sort of how health and human system change could be sustainable over time. I then came to residency out here and saw, for example, at places like Mass General, how the building of creating healing arts programs, for example, could utterly change the experience, reconnect people, healthcare providers. People were starving for that sense of connection, not just to mission, but to their patients, to their families. The entire system was telling them that that's not what it was about. And then I went on to, my first job was to start a community health center at Revere as part of Cambridge Health Alliance. And then went on to become the vice president there. As I told the story, went on from there to IHI, to lead the 100 Million Lives Initiative as a vice president there, and then started Wellbeing and Equity in the World coming out of that initiative. Utterly clear, because I had seen that you could, in fact, improve everything from chronic disease outcomes to incarceration outcomes to educational outcomes by 50% or more. And frankly, within a two or three year period, it wasn't forever, but you had to be willing to actually change the system.
Judson Howe Did that sustain those benefits?
Somava Saha Yeah, in those places that chose to actually change the system. And so I think for me, the understanding that sustainable change requires a shift in mindset, a shift in relationship, and a shift in the system itself. That if you did that, it would actually — it was liberating for people. That I think is the thing that I —
Judson Howe I want to dive deeper. You mentioned that you learned a lot of this in Guyana. Articulate that in a bit more detail. What was it that you learned in Guyana that we weren't seeing or doing here in the United States?
Somava Saha So in Guyana, there were two things that I think came into play. One is they were following, sort of Baha’i principles of community development, which began with the idea that people, every person, every community, had a piece of the puzzle that was needed for the whole healing of the world, that they were noble.
Judson Howe Every person in the community was a puzzle piece for the broader community.
Somava Saha Every group of people, every group. So if you were this village, this indigenous community. They didn't see people experiencing inequities as deficient people who needed to be helped. They saw them as people with great nobility and capacity who were held back based on history and structural factors from being able to express that gift, and when you couldn't express that gift, we all lost. So the process of development wasn't about saving people. It was about freeing all of us and being more abundant together. They didn't assume they had to have all the answers. They would walk, they would see what needed to change, and then they would change that. And then they would know, they would figure out what really needed to change, and then they would change that. And your obligation was, as you figured out what needed to change, you actually changed it. And instead of coming up in a wall and saying —
Judson Howe Who would change it?
Somava Saha The whole community. So the second big factor was they didn't see that health was something that was delivered on the outside to a group of people. It was something that community co-created together, and that really came from the indigenous conception of community and the role of community, of everybody in the community, in building health. So the healthcare system wasn't the hero that created health, which is what the marketing that we put out there does, despite all evidence that in fact we provide sick care and not health care. But what we hear, it was clear that health was created all through the lifespan, that if you were wanting to educate a community about health, the teachers had to get involved. The understanding of who created health and how things like your job, all of the things we now know and call social determinants of health, people could see that those things drove health outcomes because it was all connected. They actually didn't have the money to put them all in different sectors and buckets. And so the idea of you deliver health to get -— if you're looking at health, you have to put those pieces together, and that at the community level, you could build the civic muscle to assess what was needed to bring your assets together. And the biggest piece of insight for me was seeing that actually those who are closest to the problems and in the community had — that every community, first of all, had natural leaders, every community. That if you gave them the confidence and the tools to be able to assess their community and bring their assets together to ask, how might we change this? Actually the solutions they had access to were far more powerful than the ones if you were coming from the outside had access to, that you could walk alongside and learn. I don't know about you, Judson, but teams of community health workers, villagers and teachers with no more than a fifth-grade education and a couple of years of learning how to assess and improve using an asset-based way reduced malaria rates by 90% in one year, while simultaneously eliminating malnutrition among widows. Have you done that recently? Because I haven't. They eliminated acquired childhood developmental delay in four years. They built a health workforce from fifth grade all the way to growing their own doctors, nurse midwives, malaria workers in 10 years through the investment in secondary schools, high schools, because that was the gap. Because they didn't see health as disconnected, they could bring all their assets together to figure out the how might we? And they didn't ask, Oh, that's a hard problem. How do we, you know, what do we do? They were like, if there's a wall and it's hard to do, you better figure it out and get started. They were practical about system change, and they didn't assume that they didn't have the resources to do it. In the second poorest region, in the second poorest country in the Western Hemisphere. That I think, convinced me that it's never the money that actually stops change. That is how the system has taught us, that unless we get paid, we can't do the right thing. That's ridiculous. That's not how the nuns, the sisters, created the health system that you led. They did it because they knew it was part of the obligation to do what was needed by communities.
Judson Howe How do we get back to that?
Somava Saha I think it requires healthcare leaders like you and me, who have seen how the system operates to be able to say it, to name it, acknowledge how much it's been taken over by the drive for profits. Frankly, a very colonial enterprise, and to then say, hey, that's not actually why we went into this. And if our patients are losing trust in us, it's because we have been willing to accept that and do that, and to be able to have the courage to say, hey, the emperor has no clothes. This is how the system is working, and I choose not to support that. In fact, I will use my power and privilege as a healthcare leader to do everything I can to reconnect back to mission and to reconnect my system back to mission, to reconnect my system back to community. And to remember, you don't have to be the heroes. We're not even the experts in how to create health. We can be a piece of the puzzle, but we can use our vast power and privilege to do what would actually be needed to improve the health and wellbeing outcomes.
Judson Howe I want to dive deeper on that, because I want to understand it better. Reportedly, we have privilege and wealth and assets. Yes, that's probably a better way to say that. So we have these assets. How should we, in a culturally sensitive fashion, connect those to people without those assets? What's the right way in your experience to do so, whether domestically or internationally?
Somava Saha Oh, well, how do you connect healthcare knowledge to patients? By getting in relationship with them, right? How do you do that with communities? By getting in relationship. But it's not saying, hey, I have this asset, I'm here to save you. It's actually getting in relationship in a way, where you first understand the context, where you learn, you do the work to decolonize yourself, because otherwise we will actually end up being like, here, I'm here to save you. People are like, oh my God, we've been working on this —
Judson Howe Asking for a friend, not for me, how does one decolonize themselves?
Somava Saha I think by being humble. The good thing is nobody's looking for us to save them. They're looking for us to show up, to ask open and honest questions, to learn. We can do that journey of understanding how, for example, racism has shown up, or other forms of structural inequity have shown up, or even how we've lost trust. You just have to ask patients. It's not hard to find. Every unit has stories. Every family has stories of how healthcare systems have often not cared for them well.
Judson Howe Give me a story from one of your patients, or otherwise, of the healthcare system not taking care of their family well.
Somava Saha It's in every transition of care that people leave without the right medicines or too many of the same class of medicines. I have people discharged from Man's Greatest Hospitals with three beta blockers, with heart disease. Our patients knew enough to know that before they'd go in and be admitted, they would want to know that we had seen what was going on, and that we could actually weigh in on what they had done. There are medical errors which IHI sought to reduce decades ago, are at an all-time high, because despite all the different quality initiatives, the thing that we haven't been able to do as a quality initiative is remind people that the primary thing isn't quality as a technical piece related to a few things. It's about the way in which we create a health care system that's designed to give people a coherent sense of being seen and known and cared for in a way that actually supports them when they're sick and supports them to be as healthy as possible when they're out in the community.
Judson Howe In my time in healthcare leadership, ROI -- return on investment -- was a frequent measurement we would use as a paramount metric to make a decision on if we're going to proceed with an initiative. But if success were measured by human flourishing, what new behaviors would be mandatory for providers, payers and policy makers?
Somava Saha Oh, gosh, first, shifting the way in which care was delivered to really understand what was going on with real people. We've found whole measures around, for example, Cantril’s Ladder. That's the wellbeing in the nation measures, that help, two simple questions that can help people talk about what would create a good life for them. That turns out, every rung of the ladder correlates with morbidity, mortality, costs, thoughts of despair —
Judson Howe What’s this called?
Somava Saha Cantril’s ladder. Imagine a ladder. The bottom is zero, the top is 10.
Judson Howe We want to be higher up on it?
Somava Saha Let's say the bottom is your worst possible life and the top is your best possible life. Where would you say you are today? Where do you think you'll be five years from now? Okay, and then from that, you can have all kinds of questions. Why would you say you're at a four? What would help you get to a seven? It turns out, if you're seven or higher, you're thriving. Four or lower, and you don't think things are going to get better, you're suffering. That's your top three and a half percent, high-risk, high-cost people. Everybody else in the middle is struggling. The people in the middle and the low end of that are much more likely to have poor health outcomes. And if you can ask what's driving that, quickly, you can actually stop doing a whole bunch of other kinds of screening. Keep it really simple. And if you can connect people, the system is designed to connect people that gets there. The system is designed to start with, why is the person there, for them to see you as somebody in relationship? That's just what we had to redesign, to negotiate with 18 labor unions to accomplish that team-based long-term relationship with patients. But as we did that, people came to be known. People understood that Mrs. G was married to Mr. G, and if Mrs. G went into the hospital, that Mr. G, who is 93 and at home with heart failure, is going to be alone. And what we'd find is our team members would be sneaking off to check on Mr. G and make sure he had food and groceries and that he was able to care. It's actually not complicated. It's actually fundamental.
Judson Howe I just want to go back -- if it's so fundamental, why is it not common?
Somava Saha Because we are driving people to run faster and faster on treadmills rather than get off the treadmills, and supporting people to really understand how their health is happening in the context of their lives. The funny thing is, even in the current system, you can actually do that. Much of the change we did in healthcare at Cambridge Health Alliance, we had to negotiate one payer at a time, but we were able to do that. But that required us to imagine that we didn't have to keep running on the treadmill to do well. In fact, that reduction in cost of 10% on a billion dollar book of business would be $100 million more dollars to care for people, half of whom would be saved by the Commonwealth of Mass, half of which would be saved by us and could be reinvested to provide better care. The funny thing is, we always assume that the only way to profit is to be extractive, because we haven't imagined that it's possible for us to thrive together. And by not making that the design principle of how do we actually sustainably create wellbeing, by having the ADHD to look one year at a time rather than a lifetime at a time, by not realizing that one way or the other people are going to end up back at our doors, by not caring about how the health enterprise creates health versus one healthcare system drives profits at the expense of others, by not working together with employers and schools and communities all along the lifespan to invest in the places so that people have what they need to do well all along their life, we limit our options, not to mention our imaginations, and massively reduce our outcomes.
Judson Howe You say extractive, what's the opposite of extractive?
Somava Saha Restorative. And so healthcare systems, in the Healthcare Anchor Network, for example, which I have the privilege of being on the board of, so full disclosure, but that is over 85 of the leading healthcare systems in the country, that has said we're going to use our power and privilege to understand where places have been disinvested in, and to invest in those places. To grow small businesses, to start buying from those places, to start hiring from those places, which then increases the tax base of those places. To support the growth of small businesses and to support nonprofits, to support schools, to invest. States that have become like Oregon, that have invested in Accountable Communities for Health models, like California and others, actually use that model to invest farther upstream in ways that correct the root causes. Healthcare systems in the Healthcare Anchor Network have often quadrupled their investment in health. For a trillion dollar, multiple trillion dollar, three and a half trillion dollar industry, quadrupling your restorative impact in the community is green-lining what was red-lined.
Judson Howe In some of these communities, the hospital is the biggest investor. So those numbers, especially the rural numbers —
Somava Saha And we’re already spending the money, that's the crazy thing. We don’t have to be extractive. We just have to ask, what would it look like if we just used your money smarter, differently, in a way that actually produces health? But you have to ask the right question, not how do we get the most profit, but how do we get the best health and wellbeing? It's literally, when you say profit is the goal, you make … I remember being at that table at Cambridge Health Alliance where that was a thought, let's build cath labs. Let's invest in plastic surgery units. I remember saying there are about as many cath labs in Massachusetts as Dunkin’ Donuts. The people of the Commonwealth do not need that. In fact, I, as a primary care doctor can get, through partnerships with Mass General and others, can get my patient into the cath lab in 10 minutes. So that's not actually what people need. So what is it that people need? And how do we make what people need the thing that we're about? And then how do we justify that? It's asking, how might we? We did it. We flipped our payment model and we built health systems, not sick systems.
Judson Howe So Soma is President or she's Health Secretary, you have this blank canvas. Okay, there's no budgetary issues, because now you're in power, and budgets don't matter.
Somava Saha That really how what it looks like? I don't think that's actually how it works.
Judson Howe So if you had a blank canvas, no budget or policy barriers. What's the first radical move to shift the focus from margins to genuinely improving lives?
Somava Saha I would probably … one, I would realign the incentives of the system, but not before I had mandated that the boards of healthcare systems had to be from communities experiencing inequities, at least half the people on the board, 51%.
Judson Howe People experiencing inequities.
Somava Saha I would create structural mechanisms so that you're redistributing resources from the wealthier parts, that had been the parts that had benefited from hundreds of years of wealth, often at the expense of poor communities. And would have a portion of it, not a lot of it couldn't go back to the communities, but it would get redistributed into the communities that had the farthest gap so that it could be reinvested in, because we would pay for those costs down the line anyway. We're just choosing to invest it earlier so that we're paying less later. In fact, that'll actually keep both communities wealthier over time. And I would build mechanisms where health and wellbeing across sectors were being addressed as part of common budgets that were then being allocated appropriately to be able to improve health outcomes, and that solved for wrong pocket problems and addressing them. So I would have global community budgets, not just global healthcare budgets. In Europe, that's called integration of health and social care. In places like Minnesota, the governor's budget is actually built together across agencies. Here, I would look at how we understood and used data about what was most driving health and wellbeing outcomes, to invest in the things that would most improve health and wellbeing outcomes. And that means that if communities needed to invest in, as they did in Guyana, high schools, to most improve health and wellbeing outcomes, that's what could happen. Or if what was needed was to create a new and strengthen a rural hospital, that's what would happen. And really I would build a health system that was based in primary health that began long before anybody showed up at a healthcare system. And that primary health system would be in schools and workplaces and neighborhoods, by ordinary people who knew how to improve the health and wellbeing of their communities, with promotores, community health workers, from those communities who bring deep lived experience, who could be seen as the health leaders in their community, the health and wellbeing leaders in their community. Every part of this community could have a plan for how to be restorative, to invest upstream and address those root causes, and would have the resources to be able to have at least half their efforts go toward that, even as some of it remained to take care of people who are already sick today. It's not that that doesn't matter, but at some point you gotta stop the generation of poor health and life outcomes if you're going to actually get better. That's a framework that we developed, if you go to publichealthequity.org.
Judson Howe Tell me what are you working on today to address these issues?
Somava Saha I think what we're working on are three things. One is, how do you show that real change is possible when you redesign systems? And that's led us to do things like change and rewire the system for mental health and addictions in Delaware, across sectors, in a way that led to a 23% relative reduction in overdose rates in 2020 compared to other states. It's the kind of outcomes we were able to do in Cambridge Health Alliance, but also helping health systems across the country now address structural racism in ways that are practical, grounded in what communities need and using their assets very, very differently to build strategies that are restorative in communities, that lean on community assets, and joins healthcare systems to be able to address those upstream and root cause factors together with many others in the community. So they don't have to be the saviors, but they can be part of the solution. And then to help health systems, I think, have both working models for the how, along with the training, things like Justice Squared, that show that it's not only possible, but what it means to reclaim soul and role, and then to join with communities experiencing inequities in the how.
Judson Howe Our last guest left you a question. They didn't know it was you, but they said, how do we activate a network of innovators across the country to transform the system of care in our communities? How do you see this taking shape, and what barriers must we break?
Somava Saha That's exactly what we're doing, actually. So over 110 health care systems applied to be part of Justice Squared in the current climate, on January 15. Many of them, even when they were told they weren't funded, asked if they could be part of continuing to be on the journey, because the experience of it was restorative for them. I think the first step of that is calling people in and building a support system that allows us to grieve how far we've come. Then on a basis of honesty and relationship with communities, to say, how might we imagine a more just system? How can we be honest about where we are and how we got here? But also, how can we be imaginative in allowing ourselves to dream and asking how might we, and then on that basis to go about the practical work of changing the system, even if it's hard to do.
Judson Howe I hope to talk to you in five years from now, many times between now and then. But if we were talking in five years, what tangible signs — hospitals, neighborhoods, boardrooms — would confirm that we've truly moved the needle on equity? What would be your benchmark for undeniable progress?
Somava Saha That the outcomes of the health system was measured not based on the profit of the health system, but on the extent to which patients, communities and the workforce, healthcare workforce itself, felt restored to mission, and that the data showed that they were being restorative of health and wellbeing, and the upstream community conditions and root causes that were driving the poor outcomes. I know that sounds like a tall order, but it's possible to do. You can measure are more people thriving and fewer people struggling and suffering. You can actually see what communities don't have, and you can actually work to invest in the things that communities don't have. In fact, health systems all across the country are already doing it, and those health systems, they won't go back, because as they've done that work, it's restored an essential part of them. It's called their mission back in at the individual and institutional level. I think we underestimate the power of calling us back to ourselves.
Judson Howe Before we close, what's the one question about healthcare and equity that we're not asking, but we absolutely should be asking?
Somava Saha What if we imagined that equity was a path to abundance?
Judson Howe This has been absolutely enchanting. Thank you so much.