Judson Howe Scott, you led a multi-billion dollar system. I think you had about 35,000 employees. Why'd you walk away?
Scott Reiner You know, when I started as a CEO, I remember talking to our board very early on, and I said I really only want to do this for eight years. I kind of said, you know, our forefathers had this idea, it sounded good to me: two terms. I don't think the board believed me, but my wife and are quite intentional. So about year six or so, we really started thinking about what's next. I never really wanted to do that job more than eight years. I'd been in the organization for 20 some years. So it was very intentionally designed to reinvent and do something different.
Judson Howe What was that first three to four months like for you personally, and maybe your wife as well. What did that feel like, post executive leadership?
Scott Reiner Wow. Well, you know, I read all kinds of books. I read books on how to unwind your career and how to reinvent yourself. And, you know, I had an executive coach and we worked through all this. In the first three or four months, I was like a fish out of water. You know, my schedules were controlled by my work. My work community had to be tied - my community was tied to health, the health environment, other than family and friends. It was the end of COVID. So I'm bouncing around the house with my wife, and she's not used to me being here, and I’m like a hammer looking for a nail to do something. I need to be in charge of something. So it was actually more difficult than I thought. Even though you can intellectualize doing something different, that shift is actually quite difficult. And, yeah, I think it was actually more difficult than I thought it would be. Even though I wanted to do it, it was my choice, and I had an idea where we were going next with it. But it was a difficult transition. It took a few months or a year.
Judson Howe Was it harder for you or for your spouse?
Scott Reiner It was hard for both of us because it completely disrupted our world. You know, she had the way she did things, the way she wanted to do things. I'm used to being in a work setting. It was difficult for both of us, to be honest with you. We had more time together. But there was also, at my level, probably some frustration, but like, you're used to being in charge of something, and now what?
Judson Howe When you were an executive in healthcare, were there times that you questioned?
Scott Reiner No, I always started with mission, right? So I always felt healthcare was a missional calling for me. And you know I came out of a background of faith, and my father's a minister, my mom was a nurse. And I chose nursing, actually, as a background. I'm a nurse by training. And so I always thought healthcare is amazing. I thought it was the greatest, really the greatest opportunity to affect people's lives. The challenge came into it the older I got and more experienced, I thought we could do a lot more than we were doing in healthcare, and that became a touch frustrating to me. But healthcare is amazing, it's an amazing platform to doing so many things, intellectually, humanitarian, faith, calling. Yeah, it's incredible. So I never, never questioned being in healthcare.
Judson Howe You mentioned just a second ago that there were things you wish you could have done, maybe with some latent frustration there. Give me an example of one of those things you wish you could have got done.
Scott Reiner Depending on where you are, you could be in an urban setting. And where I worked in Southern California, you would have five hospitals. And if you're at a high enough point, you can see all of them at the same time. You can look over the city and see your competitors or your allies, or you know, you know what I mean. Or if you go into a small community, that's very different. Small community, you are the sole community provider. You're the largest employer. You often will have some of the brightest people, not disparaging other people, but you have a lot of well educated and trained people that have resources. And I always saw thought we sub-optimized that, in the some of the communities that we're in. We weren't doing enough, I think, in the community. So that's what created a lot of stimulation around really investing in community health, investing in other health related businesses that could do something for that community in addition to providing outstanding medical care.
Judson Howe What would you say to someone who says that's not the role of a health system?
Scott Reiner Well, I think you'd have to ask yourself, do you have the right definition of health? If you look at health, I think you can look at many different definitions. I think if you want to say you're a medical system, that's awesome. You're providing medical care. It's transactional. Generally speaking, in this country, it's transactional care. You have an issue. We have something to diagnose, something to treat, something to educate. When you go home, we don't stay attached to you very much. Or are we providing an environment in the community that people actually know how to seek care, when to seek care. We have a greater role to play in health. Health has many aspects to it other than the actual delivery of care. So when someone says they’re a health system, I'm going to make sure I see some other things involved, other than surgery centers and diagnostic centers and hospital beds, which is amazing. We have to have that, but that's great medical care. Health means a community is actually involved. They actually have an idea about what health means for them, individually and at a community level, and there's an ongoing dialog and conversation about the role of that provider, or the role of that health system in your community, especially as a nonprofit, even more so. I mean, you are, you essentially are foregoing taxation in order to do something for the benefit of that community that they're not getting taxes for. So you need, there's a little higher calling, I think, than providing only medical care, which I think is amazing, not discounting that, but we have a higher calling. I think I've always felt that.
Judson Howe So you seem to have I'll use the term moral compass, maybe some values that align with what you do. Is there a moment early in your career, or maybe some moments that you could highlight that were impactful to create those attributes for yourself?
Scott Reiner My background is a little bit working in faith healthcare, or faith-based healthcare. I love whole person, physical, mental, spiritual. And I thought physical, mental, spiritual and community. So I think there was four aspects of that that I was trying to ingrain into the work that we were doing. There were people that influenced me, you know, there was individuals, either physicians that I've seen that were very open to and engaging in the community in a different way. There were entrepreneurs that thought about how to take a medical product and to create something that's a different kind of a business that supports the health ecosystem. So there's probably many pieces. There's not -- I don't know that there was one specific person or specific time that was an “aha” moment for me. I think it was built over time. It's over watching things work or not work, or watching the disconnect between someone who comes into the organization and leaves. We don't know them anymore. They're become something. They move back into the community, not to be seen until the next medical intervention. That doesn't feel like health to me, that feels like medical system or medical care.
Judson Howe Many experts note that only about 20% of health outcomes come from clinical care, while roughly 80% stem from social, behavioral, environmental factors. How does that relate with your philosophy around healthcare?
Scott Reiner I believe over time, watching and participating in healthcare, it's very, very true. So if you take an environmental situation, if it's a very poor community, there are very significant aspects to someone who lives in poverty, right? It's a mindset, it's lack of nutritious foods at times. It's education around lifestyle. It's some kind of chronic diseases, conditions that are, you know, that are brought upon because of the effects of poverty. So, you know that could be, that could be one aspect of it. So our environment plays a role in that. Absolutely.
Judson Howe Do you have any experiences where medical interventions were not enough for what you were trying to accomplish?
Scott Reiner If it would be that case, it would be around chronic disease, possibly, thinking about that for a moment. If there's not a community of - if the organization of the health system or the community are in alignment. You think of Blue Zones as an example. They work very hard to try to create an environment in the community that would create nudges or conditions that would allow the person the greatest chance of managing their health. And so that would be a good example of influencing the environment. So when someone is discharged or has a patient experience and goes back, there are certain signals and certain environment around them that demonstrates or nudges them in the right direction for making the right health decisions. So I think there could be a lot more done than has been done in the traditional hospital setting. I think it's a higher calling.
Judson Howe Imagine yourself in front of US policy makers. What's a statistic, a single statistic, or maybe a lesson that you've learned in your career, maybe even your more recent career, that you would want them to remember?
Scott Reiner I think it has to be around health behavior. I know it's very, very hard. We've tried this forever in this country, but we still have to keep working on people taking more responsibility for their own health. And there's a term, at least in public health, that we use, and it's called “health seeking behavior”. And that is starting at a very early age, to train people, to train, educate, encourage, to know the various changes, either as they grow, or the types of when they should seek care, when they should be counting on a health system, or when they should be working or collaborating with other people in their community, around the environment that is more conducive for them solving their own health care issues. And I'm not talking about chronic conditions or cancers or different types of things. But for basic, primary preventative services, I think we could talk about our systems, about encouraging, knowing how to seek health in a different way than we are today. Today, we see we have a condition, we know we can go to the hospital. We know we can get something solved. We don't take as much responsibility, I think, as we could. So policy makers could try to encourage that. It could, through educational systems, through requirements. Hate to say that, even on health systems, to do more for their even for their public benefit, to do something more than only the delivery of the service.
Judson Howe You say, we've known this for a long time. Why have past interventions not moved the needle?
Scott Reiner I'm not a health expert in that respect. It's hard for people to change behaviors when all around them is not giving them the signals to do so. I think there's expressions to the fact, “if you want to be healthy, have healthy friends”. And I think it's very complicated. I think in this country it’s exceptionally complicated because it's a very individualistic community, and we always want to do what is satisfying to us. And everything's available to us. It's a wide abundance. Everything you want in this country is available to you. You want to eat something, you want to do something. I just want to want to be on my computer. I don't want exercise. I don't need to. I can just order it on my phone. So this technology is not enabling natural movement either. So I think there's some things in this country that make it complicated, and what I say is not easy, but we have to continue to work towards that. And policymakers, I don't know, to be honest. It's not going to be something that's going to be driven by policy. It has to be a movement. There has to be energy from another angle that would be motivating to people. A policymaker is not going to motivate anybody.
Judson Howe You talk about a wellbeing multiplier. Which, educate me, but the way I understand that is multiplying a couple different facets, maybe health and wellbeing, or health and income together, and they seem to fuel each other, if I understand that correctly. Where did this philosophy begin for you?
Scott Reiner Well, it didn't start here in the US. It started with our work in Zambia, actually, and this could be very much related to an impoverished community, although there are an incredible amount of impoverished communities around America as well. I think the two things that people hunger most for is health and income. If you don't have health, you can't generate income, right? And if you don't have an income, you're … you know, it goes back and forth. But the idea is, if we can, if people can put food on the table, they can have an income to support their family, and then when there are health conditions that need care -- this especially in Zambia -- when they show up to actually get the care, there's actually the equipment and the facilities are there to actually care for the individual, or the providers are there to actually do the work that they're trained to do. So health plus income has a multiplier effect, so that if you think of wellbeing, there's many aspects of wellbeing. Health and income, or prosperity, are just two pieces of wellbeing. There's education, there's advocacy, there's voice. There's so many pieces of wellbeing, but when you're strengthened with health and income, you actually have the ability to materially enhance the other aspects of wellbeing in your life. The conditions become easier to attain.
Judson Howe I'm thinking back, you know, I've heard many years in that, you know, health investments can arrest poverty in lower income countries, and probably most countries. I think the World Bank has actually used those terminologies. Is what you're saying with this “wellbeing multiplier”, a modification of that research and some of their thoughts around that? And so, you know the World Bank talks about investing in healthcare arresting cycles of poverty. Are you disagreeing with that study, those studies?
Scott Reiner No, I think that health is only one portion of it. You obviously have to have a reasonable health condition for you to work. But honestly, and as much as I hate it, money does make the world to go around. If you do not have income, you can't buy food. If you can't buy food, then you can't have nutrition. In impoverished countries, I don't care how much health care they have, if your growth is stunted because of lack of nutrition and protein and other types of .. you're already behind. So you're going to have a health intervention, but you're already moving towards a chronic problem. So I do think -- I'm not discounting that -- but people also have to have income. We have to be able to help create jobs, or there has to be a way that they can sustainably care for themselves. And you know, health care in these countries is not free either. I mean, while it's a government opportunity, it's not free when you have to go 20 or 30 miles by foot or by a taxi in order to go get basic routine healthcare. That costs you money. Or if you have to leave your family farm, you're not producing income because someone's chronically sick, because the facilities around you do not have the equipment or the supplies or the providers to care for you, or they don't have the diagnostic capabilities. So healthcare, you may not be paying cash at the door, but when it becomes a chronic condition, it's very destabilizing to their income generation.
Judson Howe Do you find the idea that we should be doing both to be unpopular, or do you find support as you're talking about this?
Scott Reiner Well, I think you do both. You have to do both. They go hand in hand.
Judson Howe You know, it reminds me actually of a much older study by a guy named Jay Forrester, and he talks about a different topic. But it reminds me of that, Scott, where for many years the United States would invest heavily in low-income housing. And he was looking at sustainability of systems, and he suggested that you shouldn't just be investing only in low-income housing. You need to simultaneously be investing in meaningful jobs and employment. And if you don't do that, you're actually creating capacity for lower income attributes in your community without any sort of exit strategy for that low-income neighborhood.
Scott Reiner You are self-perpetuating the poverty cycle because you have a roof over your head. And if you don't have an income, you just have a roof over your head with nothing to do during the day. I don't think you can do one without the other. They exponentially support each other. So in our work that we do in Africa, we do side-by-sides. So we make sure, on one hand, we teach people how to financially be more self-sustaining. We teach them a job skill. We can give them micro loans as certain things that get started. We help them take their products to market to get the best value. When they do that, then they have a little extra money to spend on some preventative healthcare things that are not naturally available. It goes back and forth. They go hand in hand. I mean, if you've ever been really poor, which I have not been, or really of ill health, which I can't say that I have been, but either one of those are destabilizing completely. So, they do go hand in hand. I can understand the study if you just have housing without jobs, you just have housing.
Judson Howe A moment ago you said we probably need to define health, maybe differently? Do we also need to define income as well? And how would you define income?
Scott Reiner For us, income would be getting to a level that's not poverty and, you know, there's all kinds of indicators for that. I can speak to the country we're working in. So the average person we're working with is making around $50 a month. That's not enough to sustain food. It's not enough to sustain any acts, any anything else for emergencies, for any kind of extra supplies, for an education for their children. So that's a problem. So I think there are all kinds of levels of poverty lines. What is an income? What is the right income? Our target is to triple the income and to create essentially generational -- for a poor community, it's generational wealth if you can triple their income. You then have something to pass on to your children, and so the children then don't have to do the work of the parents and actually can go to school.
Judson Howe Organizations that you've led have worked or been inspired by the Camden Coalition. And do you think that this multiplier effect would also have been maybe helpful in some of these low-income urban centers in the United States?
Scott Reiner Absolutely. Yeah, I do. I do think so. I think what I love about Camden is it really engages the community as well. I mean, I think so much of -- I know that we're reframing healthcare -- so much about healthcare has been prescribed by really smart people doing really good things. But I don't know how often we really ask our community. I don't know how much we really understand the needs of our community and what they think about health and what would motivate them. So it's been a while since I've seen their work, but from what I recall, that's what they have done an excellent job on.
Judson Howe I mean, where I'm going with that is I'm trying to understand what have you learned in your global health work that you didn't know when you were an executive in an American health care system, and what do you wish you had known?
Scott Reiner Ooh, there's a lot there. So in a healthcare system, what do we call the individuals we care for? A patient. So we've already given them a label, a title of what they are. What I like about the work in the development space, and includes healthcare, they call them “beneficiaries”. And a beneficiary is that we work on behalf of somebody. We do something on behalf, they benefit from our existence. What I think we miss the opportunity for in this country when we spend, what is it, Judson, 20 some percent now of national … I mean, what other benefit are we providing to the communities for 20% of our gross domestic product? What else are we providing in addition to the medical care?
Judson Howe We'll go back to chronology. So, you leave an American health system, peak of your career. What happens next? Where do you go next? Talk us through where you've been the last few years.
Scott Reiner Awesome question. So what we initially started to do was we created the Reiner Foundation. My wife and I have been planning for some time to give back to where we've been blessed, and to do something of support in under-served communities, under-served populations, because we've been so blessed with so many things in our life, but we didn't know what we were going to do with that. We were partially influenced from what we had seen. We traveled the world quite a bit, and we've seen different areas. And of course, we could go right down the street and find different challenging areas we could support. But we kind of developed the belief that this country has so many resources and so many capabilities, and if it kind of got out of its way at times, it actually could take care of itself a little better, but there's so many countries that can't. So we created a foundation. The foundation said, what are we going to do? What are we going to do for work? And so we then kind of focused on this concept of wellbeing, and wellbeing meaning that wellbeing should be common to all. So we created an organization called Common Wellbeing. And that was simply to look at levers, about what levers can be pulled, what things can we do in order to create conditions where wellbeing can prosper in under-served communities? So, we created an organization. We moved to Africa. We spent a lot of time meeting with other NGOs -- non-governmental organizations for those who don't know what NGOs are -- learning what works, what doesn't work, look at large aid organizations, and kind of settled in the idea that we're going to create a couple of enterprises that we think combined together could create the greatest impact, and that's in income and health. So that's what we've done. Our organization is called Common Wellbeing, and it has birthed, if you will, two nonprofit organizations in Zambia, one on income development, ending poverty through women, and the other is health access, improving health access in the community for maternal and child health. All my time was in healthcare, and now we're actually working in development and global public health -- completely different. So yeah, every day is a little different, but we've gone back to school, read a lot of books, and literally moved our family to Zambia for a year do a deep dive.
Judson Howe In one of your newsletters, it says the family dog as well?
Scott Reiner And our family dog, yeah. We moved my wife and I, seven bags and our dog. Moved to Zambia, and we actually stayed in a house that was given to us for a couple months by another NGO. We didn't even have a place to stay. My wife used the word “commitment”, and I didn't know what she meant by that, but I do now. It was commitment. But commitment to me was like, “Yeah, we're committed”. When she said commitment, it was a different level. I mean, we're gonna bundle up the house here and we're gonna grab our stuff, we're going overseas, and we're gonna learn, right? We need -- if we're gonna do this authentically, legitimately -- we have to have a lived experience that's very similar to what we are asking other people to help and support.
Judson Howe What would you say to somebody who might say, “Great, here's another American of means, white, European male going to an African country for a vanity project?” Maybe you've even had questions like that. How do you respond to someone that might question your motives, especially considering you come out of a faith-based system? That might have in the faith-based world, the missionary world sometimes has a bad connotation to it.
Scott Reiner Well, I've learned the older I get that everybody starts from a good spot, and I don't judge people with their intentions. They may not be educated, or they may be very dogmatic in the way they do things. And we've seen there are incredible missionary things that are happening in Africa or in Zambia that wouldn't be done if the missionaries weren't there. There's people want to do good because it feels good. They're not educated on if it's helpful or not helpful. So many things that are done -- there are many, many, many NGOs that don't do much of anything, to be honest with you. They'll go do a few things. They won't measure the impact. But those are the lesser. The majority of the people in the community that we found are incredibly -- other nonprofit organizations working -- are incredibly oriented. They're very communal, even the NGOs working together, they problem solve together. They do a lot of side-by-side partnerships. Imagine if we did that in the United States with our healthcare. We kind of say that we have coalitions, but they're not natural. In this space, people are trying to help people in these disadvantaged countries in a structured, organized way, are very collaborative, and they're very generous with knowledge and information to assist.
Judson Howe I'm not super clear on how a non-government organization compares with a domestic nonprofit. Are there differences in the way they behave?
Scott Reiner You know, it's very much a public health universal term, you know, humanitarian or development is an NGO. It's a non-government organization. It's a nonprofit. In this country, you'd call it a nonprofit. There you call it an NGO. NGOs are generally in the spaces of humanitarian or development work. Nonprofits here could be in the arts. There's many different forms and structures of what a nonprofit can do in this country. Could be academia, could be churches. When you deal with NGOs, it's primarily humanitarian development work or global public health work in disadvantaged countries or communities,
Judson Howe So you started two NGOs. Kuwala and Anchor Health Partners. Kuwala NGO is focused on women in Zambia?
Scott Reiner Yeah, it's economic improvement through women. And the idea is that women can help end poverty. So we provide education, we provide resources for them. We help them create a business or a product. We help them take it to market. And the whole idea here is helping them double or triple their income so they can support their families, and if that continues through business, then their next generation is cared for as well.
Judson Howe Why women?
Scott Reiner Women are amazing for a lot of reasons, but women in Africa -- or we have found in Zambia or in a lot of developing countries -- they are the most passionate about their families. And it could be a culture, like it's very much a cultural thing, but if you want to get something done in rural Africa, you work with women. Women do the cooking. They care for the children. They get the water. They're the heavy lifters in the family.
Judson Howe If they start to ascend economically in the community through income and job training, businesses, etc, does that change the dynamics of their culture or their marriages at home?
Scott Reiner Well, the culture is very communal. So if they do it, they're going to support each other. Women will support the other women. I would say they do, ironically, have to kind of get the support of their husband if they're going to start a business or do something. It's just part of their relationship and how they engage with each other. The women are the ones that are going to be most motivated for change, most motivated to try something different, and they take the higher level of responsibility for caring for their families.
Judson Howe What would happen if you just didn't have a gender specificity and you just invested in job training and education?
Scott Reiner I think there would be, there would be resistance from the men in their rural communities. The women are hungrier because you know what, I think they take a deeper calling for caring for their family. Now this is not general across every individual, but I think if you look at any of these poor developing countries, the women are the ones who carry the heavier water, literally and figuratively.
Judson Howe Have you had any challenges designing programs that actually work for a culture that's not your own?
Scott Reiner Oh, 100%. What we do is invest in changemakers in the country. So our program director for Kuwala Zambia literally came out of a village. She was the first one in her family to ever go to school outside of primary school. And so we invested. So we found her, you know, we were interviewing for roles for the work that we're doing, not exactly sure what we're going to do. We were very inspired by her. When she came, she had major lived experience. She also finished her masters in finance. So the first one out, you have to see it to believe the community that some of these people exist in. In fact, we went and visited her home and with her family. And this is a community that was eating every other day. Their wells were broken because someone put a well in at one point, and they’re literally hand digging a well to try to find water. And this is the environment she came from. And now she's leading an organization that's empowering women to take care of themselves. So all that we do is we inspire as an organization, we invest in them, we do capacity building, we give them a grant to get started, but it's all led and managed by the local people to care for themselves, and when we're successful, we can pull back. We'll pull back over a period of time when they're able to self-sustain their own work.
Judson Howe How reliable are these metrics that you're focusing on, especially in a rural part of Zambia? How does that work?
Scott Reiner Yeah, it's great. So one of the things we're pursuing as kind of a key marker of Common Wellbeing is a “wellbeing index”. So the wellbeing index is both a subjective and an objective measurement of well-being. So what's unique about having your own organization is you can create your own indices. I mean, we could go out, you and I can Google right now, or ChatGPT and find a million indices for wellbeing. What we have done is we've taken a population of about 100,000 -- and we're working on population health with income and health -- and so we're going to measure over a period of time what the wellbeing is. So we're going to ask in advance, and we're going to review as we go. So, how reliable? On an objective scale, they're very reliable. We know how much income they're making versus what they didn't make before. Everything we do is based upon monitoring and evaluation. So we do pre and post and we check along the way. So if it's mortality, morbidity indices, maternal health, maternal mortality and morbidity, or infant mortality, we have all those metrics, we partner with the government. The cool thing about this, though, is I think wellbeing, if it's going to be motivational, has to be very subjective. So we're assessing now various capabilities of doing subjective assessments of wellbeing. And these are people that don't actually read and write. So we're engaged, we're looking at an organization now that actually uses pictures and color like red light, green light, yellow, to determine where they are pre and post. Do they now have the ability to generate an income? Do they now have confidence in the health system that's around them when they show up that Anchor Health Partners has helped support that organization with making sure there's equipment and supplies and supplies and infrastructure to do the work. So I think it's very, very measurable. And what I think is really cool about this is it's just not a sterile piece of data. It's actually subjective. Because, what do they feel? Do they feel their life has improved, that they feel that there's conditions now that allow them to excel, and for a brighter future for their children? And so absolutely measurable. I'm looking very forward to, two or three years out, kind of seeing what we have moved the dial on. And we're going to find some things that don't work, 100%. I mean, we may find just as many things that don't work that do work. That's the nature of the innovation.
Judson Howe Do you have any stories of impact, maybe on a life or a family?
Scott Reiner Well, the one I just gave you, I would say, is our actual program director. If you really could understand the environment that she came from and where she is today and how she's inspiring those people around her to actually do what she has done. That's pretty amazing.
Judson Howe You talk about a “ripple effect”. Is that an example of a ripple effect for this person, this director you're talking about? Does she have a ripple effect downstream?
Scott Reiner She has now broken generational poverty for her family and for herself, and not poverty only in money. Poverty in education, poverty in creating impact. There's many ways we can be impoverished. And so I would say her ability to get an education and her parents’ willingness to push her out the door, out of a typical communal village type setting, to get an education, to aspire to do more, to give back. And what's beautiful about the Zambian people and probably a lot of under-developed countries, they're communal, and they'll do anything to support their brother. I like aspects of individualistic community. I do think we would benefit in this country, having more of a communal mindset at times. But she has broken the generational poverty for her family and then for their kids and so forth. So, yeah, she's a great example of what can be done with education, income, health.
Judson Howe Yeah, you talk about the poverty cycle. Where do you see the poverty cycle cracking in Zambia?
Scott Reiner Cracking in the sense of …?
Judson Howe Beneficial, like the cycle is breaking.
Scott Reiner I mean, you do have to create jobs, and the jobs can't be government jobs. So I think innovation, I think organization. I see it through innovation in the sense of creating new businesses and opportunities. I think that's important. Again, the thing about these developing countries: it's complicated, but they're the same. It's the same recipe. It really is health and income. I mean, you can break the poverty cycle if they actually aren’t dealing with chronic conditions and go to work. You break some of the income cycle by providing training and development and support, either through micro loans and those type of things, they get started. But all of these have to be oriented for them to do their own work and take their own responsibility. It's not an aid organization.
Judson Howe Could a similar model work in the United States?
Scott Reiner I wish our country would be a little bit more communal. I think there's a lot of benefit to having individuals support each other, to know your, essentially know your neighbors. I think there are certain cultures that do that very well. I don't think in this country, it's kind of designed that way. I think there's probably a lot of natural things or things that could be done to make it better. Not sure I have those answers today.
Judson Howe What should we try to do? Maybe the absence of a communal culture in our society is a barrier, but we have other attributes, individualism. How do we use individualism as an advantage?
Scott Reiner I think it starts with “what are you being individualistic for?” Is it for yourself? Or is it for improving something around you? Is it something for a greater social good? Innovation in this country and the intellectual capacity, and -- there's just so much more that can be done. I don't know that I have those answers.
Judson Howe Who does? You know, I mean a health system executive, if you don't -- where are these conversations taking place?
Scott Reiner I think there are a lot of conversations happening. It's hard to get momentum, it feels to me. We're such a divided country. It's really, really hard. I mean, in health systems, it's just, I mean, it is hard to align people. First of all, you have to be inspired, and you have to inspire everybody. It's hard to inspire everybody when 50% want this and 50% want the other. So, if you use the context of how to make change with even the complexity of making change in a large, integrated health system, you have to create a common vision, and you have to inspire people. You have to set a path in a direction, and not everybody's going to go that path.
Judson Howe So I'm hearing you say that you had 35,000 employees that your name was probably on their paycheck, and you still struggled to align those people? That makes no sense to me.
Scott Reiner Well, you can align at the basic level. I think at the individual level, you could take, you know, it's like you could take the greatest good. What is our mission? You know, having a living God's love, by inspiring health, wholeness and health, incredible. How you do that? It's a little different. Everybody has a little different perspective. I would say, to be perfectly candid, I think at an employee level, they get very inspired by a vision and direction of an organization. I think where the challenge happens is when you get into leadership and management.
Judson Howe So the closer they get to you, the more challenging it is for you to align?
Scott Reiner Yeah, it was the most challenging part of taking an organization, creating a new vision, creating a new expectation around performance, a new attitude around performance. Taking an organization that was incredibly gifted but under-leveraged. And creating a common direction based upon a destination that was very numeric and metric-driven. Everybody agreed to that in principle, and the people who embraced it the most were the employees, if you will. When you get into leadership and management, it was tough, And the closer they get to you, the harder they can resist.
Judson Howe Why is that?
Scott Reiner Some people go into leadership to create their own destiny and to create their own direction. I think also it fails at a system level, when there isn't enough voice blended to create a common, direct choice.
Judson Howe Whose voice?
Scott Reiner Let's take an organization of 35,000 people. There are 100 people, give or take, 150 people that really drive the organization forward on a day to day basis. It’s their job. And getting them to agree upon a common direction is more than high quality, everybody should have a great experience, more than the specific things -- but when you're really trying to drive towards performance, that means things have to change. That means systems have to be put in place that break the systems that they had in place before. That means that they're no longer responsible for something they used to be, because now we have an expert who's doing that. That may or may not be an expert, but that's what the belief is behind it. And so I think getting people naturally … the big idea is fine but actually moving to an organized level of performance, and then, if you wanted to change their filters a bit and say “we need to be more than doing health care” when their entire career is oriented around medical care, not health care, it's even more difficult. It's like, you should spend, as a leader you should spend at least 30% of your time in understanding the community around and what the health needs are of the community. Or investing in understanding various stakeholders’ interests and how you're going to make them a beneficiary. It was very difficult. Their mind -- it was very hard to get at times, although we had, I think, some great success -- it's hard to move that.
Judson Howe I was in a meeting where you spoke, probably in 2017 or ‘18. Could have been ‘19. I have no idea. You made a comment that American healthcare was heading for a cliff. What were you seeing?
Scott Reiner Did I say that? Yeah, I probably did. Well, if you took for us as an organization, you had the revenue and expense lines cross, right? I mean, even in 2017 for us as an organization, probably most of the margin was coming off of our balance sheet.
Judson Howe If you don't feel like you said that, we don't have to go that direction.
Scott Reiner No, I can go there. You know, I did all these rounds around the company, very inspiring. Remember One Adventist Health? Employees loved it. You know who hated it was management. They hated it. And I’d tell them, you know, I probably did -- I debriefed afterwards very candidly. I went to them to say, “your staff love it. What the hell is going on with you? What's going on here? Why are you so resistant?” They’d say “Oh, we're not resistant” or be passive aggressive about it. You may not like it, but now we have a vision. You may not like the lineup we have. We got probably over-standardized. We probably got over-centralized. I get all that. I would probably do things a little differently.
Judson Howe What would you do differently?
Scott Reiner I think I would have definitely dialed back some of the centralization. I think what happened was we lost a lot of the individual -- you could lose some of the individual character of the organization by being too prescriptive.
Judson Howe How many hospitals did you have? 24? So you have 24 different fiefdoms doing 24 different things?
Scott Reiner Yeah, it's crazy with 24 different -- and you're as only as good as the natural leader involved.
Judson Howe Did you have 24 different sets of outcomes, aggregate outcomes, quality outcomes? And probably your brand is on that, and you probably couldn't tolerate variation?
Scott Reiner This is an interesting story. So when I interviewed for the CEO job, I had been the chief operating officer. My predecessor was retiring, incredible career with Adventist Health, and we got along great as my boss for a long time. But we did things differently. We saw things differently. I had a huge respect for him, but we were different people, and we saw things differently. So when I interviewed with the board, these logical questions, typical interview about being a CEO. What would you like to accomplish? What's your experience? And I said, are you, as a board, are you willing to change? Oh, sure, we're willing to change. I said, are you no longer willing to accept average as your target? And I said, let me explain. I told them, our quality metrics are average, our patient experience is average, our employee engagement is average. We don't have a unified approach. We're 24 hospitals in the state of California, of which we don't feel like we're a system. We're generally not invited to the big table or the small table. You know, we're not typically up next to the other major health systems in the country. When people call for advice and ask about input from the government or from the governor about what to do, they never call Adventist Health. Why is this? Why are we settling for average? Our mission calls us to do something more. And I said, it will start with governance. I mean, we need to have everything we do, in my thinking, needs to be against top performing organizations. You know, it's the Baldrige mindset. It's like we need to look outside and saying, who's doing it the best? Everything needs to be measured. And I said it was right for this board. I said, are you willing to change seats in this board?
Judson Howe What did they say?
Scott Reiner Well, they were taken back initially, but then they really liked it. I said, are you willing at this board for people to come out of these seats and bring other people into the seats that are necessary to move this organization to a new level?
Judson Howe So you talked to the board saying, are you willing to step out of this board so I can get …
Scott Reiner Not an individual, not pointing at anybody. But conceptually, would we accept the fact that this board needs to be a high performing board? And we're going to go test it to see if it is, based upon all governing board science. There's millions of things out there, you can test things to see whether your board … and are you willing to go through that exercise? Because it starts with you. If you're not willing to do it, how can I get the rest of the organization to say everything goes under an attitude of performance and vision. And so if you're willing to reshape yourself in order to provide the overall oversight and governance of the organization, then I can do my work underneath that. That was very bold. And I left. I thought, oh my gosh, I'm not even sure I kept my current job much less the new one.
Judson Howe Never mind your aspirational goals.
Scott Reiner Yeah, out the door. But from that moment forward, the board subscribed to that. So we started a process of everything we do in the organization can be measured, and everything we measure should be a minimum of top quartile.
Judson Howe So you almost built like a manifest, a mandate.
Scott Reiner We did try to create a manifest, a movement. Well, the movement was trying to create the actual leadership to go there. But we started there, and then we started to radically try to measure everything. And then when you started measuring right, you saw the variability, the variability of an organization that does things at that point, 24 hospitals, 24 different ways. Some are fantastic, some are bad, some are average. It's like, okay, we need to normalize this. There wasn't essentially a common vision. There wasn't a “put a man on the moon” kind of idea, a moonshot, which, in my experience, gets people motivated in order to do something a little outside their normal calling.
Judson Howe What was your moonshot?
Scott Reiner Well, the moonshot was, at that point -- it was evolving. But the moonshot, the idea is that we needed a moonshot. And that was enough. We need a moonshot. And it's something we probably will never completely reach, but it's something we're going to certainly -- if you don't hit the moon, we’re gonna hit the stars. I think that's what we started working on with the idea of, first of all, we had to kind of organize ourselves. And, you know, we created the One Adventist Health concept.
Judson Howe Why did you feel you needed … what were you trying to change?
Scott Reiner You know, the only thing I could do, Judson, at that point, is ask what would motivate me? It came from a very personal level. If I was going to be motivated in order to do something different, what would inspire me? One, I have to have a vision. I'm inspired by a vision, very visionary -- I mean, not saying I'm visionary -- but I love visionary things. I know I'm not going to hit them all, but you have to have a destination that's different and greater than what you are. I cannot stand settling for average. Does our mission not call us to do something more than average? I stand behind that. I think it started from my own internal frustration. After all, I was the CEO of the company. I wasn't moving it forward to that level. I was running a hospital before that, and I didn't want anybody moving my cheese. But when you get into a different seat and you see what's possible, then you have a different level of accountability and responsibility. And that's where it started.
Judson Howe So the first thing you do, if I hear you correctly, you're saying, let's measure consistently across this entire enterprise. What did you see?
Scott Reiner Average.
Judson Howe Did you see highs, lows?
Scott Reiner Thank you. Of course, anything across 20, they're gonna have highs and lows. So the highs would be like highs, how can you help the lows? Well, it's really hard outside of a formalized structure, to get one organization to speak to another, because it's a little bit competitive, right? So the idea is, take the best out of the highs and replicate it across the company. And everybody had a high, everybody had a low. So a high may come out of a small hospital in Northern California and said, you're doing something amazing. We need to roll it across the system, and we need to measure it, and we're going to drive to that level of performance. Or if there's you know, you get it. So it's normalizing, or going outside your own four walls and finding out how others are doing it, because your highs are probably not nearly high enough once you start looking outside your own walls.
Judson Howe If Scott Reiner hadn’t been a healthcare executive on the West Coast, how would the communities that your hospitals were in have been adversely impacted? If we hadn't had Scott Reiner in California, would people have had lower quality healthcare?
Scott Reiner I would like to say-- that's making it very personal, which is fine, meaning that I understand the question, because I don't think it's about me. But I do think over the period of time, we did drive to high results for our patients. I think that our level of engagement with our staff was improved. I think our experience was improved. I think the quality of our care, the level of our facilities improved, and I think we were fulfilling the gift, actually we were fulfilling the trust that we had in a lot of our communities to deliver on health care for them. I do think it was improved. And I don't just think it. Statistically, it was absolutely. We moved to the top decile in many areas in the organization. And because of that, the income model changed as well. When the performance goes up, then, you know, the bottom line goes up.
Judson Howe And yet, what I understand of your leadership, you actually felt you needed to change again, right? So you actually brought in an entirely new mindset to how healthcare should be structured.
Scott Reiner Yeah, so the first part was just, to be honest, Judson, was just catching up.
Judson Howe Catching up to who?
Scott Reiner Catching up to our peer organizations, peer systems that were outperforming us. So part of me is competitive. I think the system was a little bit under-leveraged for what it could do.
Judson Howe What do you mean by leveraged?
Scott Reiner Ah, well, when you're running a $5 billion organization, and you're in, I think, 15 different markets, I don't think we had the respect that was due us given the nature of the work we're caring for. We’re caring for -- 80% of our population was government, so we had a very difficult population. 80% either, you know, Medicare, Medicaid, MediCal.
Judson Howe So were these peers that you are speaking of seeing that similar payer mix?
Scott Reiner I'd say our payer mix was probably -- I'd call it the most “missional” of all of them. I would say another peer system was probably equal -- the Catholic system. Very much like the same kind of idea. We're going to work in communities that are difficult. I have a lot of respect for them. There are a lot of community-based nonprofits that targeted more affluential communities to support, so they could drive up their surplus.
Judson Howe Is that the wrong way to approach it?
Scott Reiner No, it’s just a different way. It depends what your calling is. If that's how you designed your organization, that's the result you get. Our purpose and our mission was really this. I think the populations we served, I’m very proud of who we served. The communities we served are amazing.
Judson Howe Would you have turned down a 35% EBITDA margin hospital on the west side of LA?
Scott Reiner No, not for a second. Because those are the ones that keep the lights on. I mean, let's just get real. They're always in every organization. The year is dependent, but most of your bottom line rests upon 5, or, let's say 20% of your system, the 80/20 rule.
Judson Howe So how did the 80%, and maybe rural bias, affect the way you saw we should deliver healthcare?
Scott Reiner We have to optimize and maximize everything that's available to us under the government structures. So we really, we did it for mission, and we also did it because it worked. It helped us manage our cost structure. The disadvantaged population were actually patients who we received benefit from the government for caring for. So that was actually a wonderful scenario where we could create a little bit of margin to support the work and cared for a disadvantaged population. But if you're talking about -- the evolution of that was we needed to take an organization. We needed to create a vision. Then we had to create an attitude of performance, top quartile performance. That was just to get us to a competitive playing field as an organization. We had to satisfy our bond holders, our bond ratings, all this stuff, everything had to grow. We had to have a mindset of growth. But the next destination, and maybe where you're going, about the cliff in 2030, as I reflect back -- that was a while ago. I think there's a few of us that felt we need to find alternative revenue sources. Because if you're dealing with 80% government payer and you're not closing hospitals and you're not adding a lot of hospitals, there's going to come a time when the lines cross where your expenses are more than your revenue increases.
Judson Howe This is just trajectory of revenue, trajectory of expenses.
Scott Reiner Yeah, you’re in finance, you know that. You hit a line where it's probably uncrossed, but there's only so many costs you can take out of the system. You know, so many costs you can drive out, and you can make a big, deep plunge and take a lot of costs out, but they bounce back up because you still have a growth and you have a revenue problem. So we wanted to do two things. We wanted to extend the word of health into a broader definition of a healthcare organization. And we also felt we needed to start to dabble and find alternative revenue sources that would actually prop up the entire mission, entire ministry of the organization. So we founded a whole new division of the company around wellbeing,
Judson Howe How were you going to monetize that?
Scott Reiner Well, because every asset inside the division of wellbeing had a profit by itself. So it's monetized because every entity itself is a business, and every business throws off a profit margin, and it wasn't so capital hungry. I mean, healthcare is, in-hospital, incredibly capital hungry.
Judson Howe So I'm hearing you say, early on in your 13 years, early on in your time, you're focused on the traditional leverage points, right, which is cutting costs out, running efficient operations, delivering great outcomes. Standard high outcomes. But I'm hearing at some point in time, you shifted to maybe changing the incentives and trying to get into a different game.
Scott Reiner We had done an amazing job in about five or seven years of coming from, I think, an average organization to really a top quartile organization. And while I don't say respected by peers, but having a voice in the game, meaning you have an influence now that you didn't have before, because you're known. We even changed our brand in order to get that kind of that recognition. So we were now in a position of having a little bit more, and our financials had significantly improved. Now, how do we then do two things? How do we really fulfill our mission of whole person care? How do we extend the definition of health in our mission? And then how do we find new revenue sources? So the idea was then to create a new arm, a new thought about how the organization, where it could go. There was even a 2040, that we probably never got to because I left. It could have been a very different kind of organization, where the actual delivery of health services themselves were not what was leading the cart. Leading the cart was actual health, you know, really an organization focused on well capitalized health for the communities, health for individuals, that's monetized, that generates a margin, that becomes leading the cart, if you will.
Judson Howe Where do you think healthcare is going to be in 15 years? American healthcare?
Scott Reiner It's going to take people like what you're doing. It's going to take some thought leaders. Someone's going to have to be really creative. I don't think it's going to come from the government. You know, it kind of depends who's in the White House, who do they appoint, what is everybody's particular biases at that moment. This country is driven -- I mean, it's a medical market but it's driven by our financial model, which is another whole major conversation, which you're more of an expert on than I am, but our financial model is not intended to do what we're talking about. It doesn't reward and incentivize that kind of behavior.
Judson Howe Is there a way to bring that incentivization to our market?
Scott Reiner I would think so. I would think so. I mean, at some point it does have to stimulate from the government. Someone at some point has to declare that this country wants to be the healthiest country in the world. And that means we're going to shift some investments. We're going to shift some policy. We're going to hang our hat on this versus something else, whether it be our military might or whatever else. I mean, what do we want to be known for as a country? Someone's going to have to be very bold, like that. I don't see it coming immediately, and so it has to be done by individual organizations. Or, I guess what could happen, though, there's so much money in traditional provider systems today, that if they do have the opportunity to throw off some margin, they could be very bold. Because there are so many systems that have integrated now, that have come together, and there's enough critical mass if two or three major systems said, we're going to create our own movement to do something a little different, and we're willing to put some of those margins and our big balance sheets to the test to create some innovation, I think you can move some things. I don't think it's going to come from the government.
Judson Howe We're seeing rapid changes, even in the private equity space in healthcare, and somewhat naively here, I think private equity has moved towards value faster than the health systems. If that's true, why do you think that might be true?
Scott Reiner I think it goes back to the payer environment. Most health systems are paid by the government. That's fee-for-service, capitation, cost-based. You build your models around how you get paid, which is sad, but it's partially true. And that's not to say the clinical care is designed, but your business model is designed by how you get paid. You know, private equity is a little different.
Judson Howe One thing you did say, and this one might be appropriately attributed, you did say a few years back we've got to have a foot in each canoe. And I interpret that, in shifting analogies, to be that one canoe is Blockbuster, maybe the other canoe is Netflix. Help our listeners understand what that Netflix is.
Scott Reiner That’s a very good question. So if you take a very large health system that's sitting on a huge balance sheet, and I think you know what I'm talking about, they're large. They're sitting on billions of dollars of cash. And we say that because, well, there's going to be a rainy day, you know, we have to have 100 and, I mean, how many days of cash do we have to have on hand? Really?
Judson Howe It depends on the bond rating you’re looking for.
Scott Reiner Everything's driven by finance. What if one of these health -- what if these large, integrated health systems say we're going to -- and there are some people that are incredibly innovative and doing some amazing things. And I'm just thinking of some systems, like Northwell in New York City, does incredible, amazing, unique things. Yeah, we need them. We need them to step up and create a movement. I don't think it comes from the government. And if the energy and the amount of money that rolls through health systems, they could get venture capital support, some new ideas and some new approaches. So I just don't think we've thought outside the box as overall. Overall, I'm saying. There are those who have and so I just, I go back, I'm thinking back on your question. It's not going to come out of policy. It's not going to come out of who's in the White House. Someone with, sorry, with a big balance sheet and a big desire for social good, and a board that says, yeah, we're going to do something different. We've accumulated all this. We've accumulated this entire balance sheet based upon the margin out of this community, communities. We're now going to reinvest. What if an organization of $5 billion, if you could, it's a nonprofit. What if they're sitting on $2 billion of cash, what if you just put that into an endowment and started doing amazing things?
Judson Howe What advice would you have for the next 47 year old Scott Reiner that's taking over a $6 billion enterprise, and they've got a 15 year run ahead of them? What are they focused on?
Scott Reiner Maybe it's a quick story, but so at 47 years old I kind of thought maybe I'd get the assignment to be the next president of the system. Fully prepared in my head, I knew what I was doing. And about two weeks into, maybe a month into my assignment, I started, I just freaked out. I was getting very anxious, had anxiety. I sort of realized, you know, am I really ready for this? So there's a theme to this and that we're just assuming the individual is ready to do the job. Not everybody's prepared to take on that large of an assignment or that large of an opportunity. For me, it was the fear of failure that came out really pretty quickly. Even though I've been doing that my entire career. I finally realized now that after I've broadcasted what I intend to do, want to do, then you look in the mirror and thinking, oh my gosh. That was me, at least. And then I realized, was I really prepared for the role? Do I really know what it entails? And so I'm a big proponent on coaching and getting people prepared. And so I got an executive coach. It was very instrumental. The first question he asked, Judson, at our first meeting is, why do you want to be a president of this organization? I had to answer him the next week.
Judson Howe You weren't -- you couldn't even answer him.
Scott Reiner Now, this is me. I’m being vulnerable. This is my life.
Judson Howe Was there, like, an emotional, internal, emotional response, as he asked you that question?
Scott Reiner Oh yeah. It’s like, of course I know. Well, it's because I've been groomed to do this. I spent my whole career doing this. And it became that journey of unpacking why I wanted to do something that came to a very authentic -- maybe I didn't question the way you asked it. If someone is going to run a health system or a large organization today that has 35,000 or 50,000 employees, boy, they better do it out of a point of who they are, authentically as an individual. If they're doing it to put a marker -- you know, it's I always wanted to be a CEO, or I believe I can change the world, whatever. I think if they're not personally prepared for it at a very deep individual level, I don't think it's going to go very well.
Judson Howe What do you think would happen to them if they didn't have a why?
Scott Reiner I think they become inauthentic. And I think that they'll start pushing for things, possibly, that are outside their natural, either their natural ability or their natural inclinations. And I think inauthentic leadership creates a problem if you're creating a movement or have a vision about what to do next. Or creating a vision to motivate people to go somewhere else. Inauthenticity, doing it just because it sounds good, or you worked it up on ChatGPT, this is my plan, and it sounds great, let's go -- people will see through it, especially people in healthcare. They're much more in touch with their empathetic side, and they're going to see it. And so for me, it was like, oh my gosh, I could actually fail. And am I ready for this? And why in the heck am I doing this? And then when someone asked me, at a very quiet, deep moment, why did you want to be the president? I couldn't answer. So now, you move that forward a year or two, I can name a million reasons why I wanted to. So to me, when you asked that question, I went to a very deep level. Not so much about hey, I want to be, I want to do this, you know, I’m 47, I want to do. It's like, what do you really, are you prepared? What do you really want to do? What are you personally willing to sacrifice to make that happen? Very different.
Judson Howe So you're 47 again, and you get offered another $6 billion system. What's your answer this time around?
Scott Reiner Well I enjoy what I'm doing right now a lot. Where I would start, honestly, would be governance, advisors. I wouldn't take a role unless I could work hand in hand in creating incredible thought-provoking, our incredible generative thinking board, and I would infuse it with external advisors. Healthcare is so -- I mean, you've been to them, it's like health meeting after health meeting, or conference after conference. We're all talking to each other. I don't think we listen to outside influences enough. And I mean, all sectors. And I think I would use that to frame the board. And I would say, what are we going to do with the assets that we've been given? And it's not that we have to go from 12 to 14 or 8 to 10% EBITDA. It's something much bigger than that. So to me, if I was going to do something again, it would be very much vision casted about driving down the lines of health. It probably would be very similar to what I was doing when I left Adventist Health. I think we have to create new avenues of health, both for service and for revenue. I think there has to be a very different approach.
Judson Howe Would you say that this vulnerability, this learning, this maybe humility that you learned through the job, does that contribute to the work that you're doing today in lower income countries?
Scott Reiner Yeah, I think that's where I've been all along as a person. And I think the problem, the challenge you get when you get into large organizations and bureaucracy -- and I'm hoping I'm not coming across in a negative way – this is the way these things work. Big organizations like this have to have this infrastructure and these pieces, and I'm not downing bureaucracy and structures and governance and conferences, but for me, you can very easily lose track of who you're serving. There's a word, I guess I already used it earlier, beneficiary. I think I may have said that. Who are we entrusted to create benefit for as the leader of an organization?
Judson Howe Do these big organizations need to be that way?
Scott Reiner I think they do, but everybody has a different perspective. What would you feel? You're a patient, you're a consumer in the community. These are community assets, essentially. They're nonprofit. What would you want? What would you think the leader should be like? What would you want of the leader entrusted to do there? What are the characteristics you think would be important?
Judson Howe Well, I think they should have the best interests of -- I used to think the patient -- but I now think probably the ecosystem around the patient probably needs the focus, and I think that's where the health leaders need to be focused, and they need to remove themselves from the center of the conversation.
Scott Reiner I agree. Judson Howe You and I are having this conversation. What would you say to somebody that would say, you two have lost focus on the core product?
Scott Reiner Well, health is not one product. I mean, one thing I'm learning in the space I am is we're very egotistical in traditional healthcare, very egotistical that we have all you just said, solutions to all the problems. We can fix anything in this room today. We can just do it because, you know, we're smart people. We’ve got resources. We’ve got some cash. If we don't realize that we have to have other partners to step up beside of us that have different competencies, that have different interests. I think the next generation of healthcare is actually really defining health and bringing others alongside them. There could be some periods of development that are necessary. There could be education. There could be so many natural pieces. I'm a big proponent of wellbeing. I would hope the next health organizations, the next round, would actually be much broader thinking. Being a patient is actually a symptom of something that's happened. They’re people before they’re patients, and they’re communities before -- communities are made up of individual people and the collective thought. So in the community, I don't mean just natural geographic. I mean community of thought leaders, community of people that are aligned or are engaging in different interests, engaging in different communities that can help influence your work. And so yeah, I think the next generation would be along those lines. I think you answered it.
Judson Howe Can we build sustainable, community driven models in the United States?
Scott Reiner That's a great question. I know we're working diligently in other countries to do so, and I think there is natural innovation and opportunities. I'm not saying they're huge businesses. I think we should certainly strive to do that. If we're going to build community trust, I think we need to put some of our resources in helping the community elevate the new definition of health.
Judson Howe What do you want your legacy to be?
Scott Reiner You know, I didn't even think about legacy until about two years ago. I always thought it was a very egotistical thing. Legacy, why would I have a legacy? A little naive on my part. Legacy is not, of course, that. Legacy is something that you may be known for, or something you leave behind. And I would hope that I would leave behind one authentic person who sincerely wants to help people and all the infrastructures that are man-made or not, and whatever aspect of service that I could provide, whether it's running large health systems or helping individuals in a disadvantaged community in America or in Zambia. I would hope that the legacy would be that you combined social good with innovative thought, and you scaled it to the point of helping the largest impacted number of people you could.
Judson Howe Thank you, Scott, for your time today. Really appreciate it.