Healthcare Needs a Public Health Athlete on Every Team!

Brian Urban:

Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban. And today, on our show, we're having the Chief Public Health Officer and Global Client Service Partner of Ernst & Young join our show, Dr. Susan Garfield. Susan, thank you so much for being on our little show today.

Dr. Susan Garfield:

Hi, Brian. Great to be here. Thanks for having me.

Brian Urban:

This is going to be so much fun because we haven't had too much opportunity to get to know each other before the show, so we're going to do a little bit of that on the show here as well. So, with every new guest, we like to have our audience become familiar with yourself. So let's start with Susan before the Ph.D., before the big title, before a lot of your research and impact across the healthcare ecosystem. How did you get into your work? How did you start to care about public health, and who is Susan?

Dr. Susan Garfield:

Well, I went to university, and I got probably the two degrees that have the most negative earning potential of all time. I was a combination women's studies and English major, and my parents are like, "She's never going to get a job. And my family, my dad's a clinician, my mom's a... the Ph.D. researcher in healthcare, so I, of course, wasn't going to go anywhere near healthcare.

But then, the more I got into it, I ended up working in nonprofits and always really cared about health outcomes for people who couldn't necessarily use their own voices to get the best things out of healthcare. And I also was really starting to see the impact of bad health on quality of life. My sister suffers from some pretty terrible chronic diseases. So the combination of my personal lived experience and the need to pay for a mortgage got me into healthcare consulting early on. And from there just stayed in healthcare health strategy and public health.

Brian Urban:

That is a good center to be able to build off of what your career might be is having a personal touch to a family touch to it. We find a lot of leaders across the healthcare ecosystem have something along the lines of that, Susan. So, thank you for sharing that. And looking at you today, it's probably easy to say you're a public health expert practitioner of means, and you, along with several colleagues, lead the health equity center for Ernst & Young, and it's amazing.

We're going to get into that. But I want to first take a step back and understand, from your viewpoint right now, what have you been able to see in terms of adoption across the healthcare ecosystem? Those investing into SDOH programs, attempting to have initiatives for advancing health equity. What have you been seeing as of late in terms of trends with investment and interest?

Dr. Susan Garfield:

Yeah, it's a great question, right. So we all lived through COVID, and it was horrible. And one of the things that shared lived experience showed us was, "Wow, this terrible thing didn't impact everyone equally." We saw people of color being disproportionately impacted. We saw people with fewer resources being disproportionately impacted. We saw what it meant to live in a one-bedroom apartment with 10 people versus living in a big house, living in a city versus the country.

And all of this shared experience of what health inequities can turn into from the way people live, how they live, the resources they have, I think, ignited a fire in a lot of people. And then it ignited a fire for policymakers, or it ignited a fire for people in industry and for young people going into the field, which is my personal favorite part of the whole thing. And so what that meant is people started to care not only about improving the public's health post-pandemic and beyond, but we started to see people saying, "Hey, I might have a role in this."

And that's what has been really different than what was before. We used to think, "Hey, public health, that's just a government thing, or that's just for healthcare providers in the inner city." But I think what COVID showed us is that the health of populations is everybody's business and that we all have a role to play, whether we're the public sector, whether we're in the private sector. And that's the work that we end up doing at EY Center for Health Equity and my role in public health in the field.

Brian Urban:

That's very helpful because it's no longer public, health that is, something that's put into the corner and just seen as research or just seen as a reference or a source from a public or civil perspective. It's kind of gone even more beyond a trend now that everyone can play a role, like you're saying, and everyone has a part in being able to support, identifying, and helping the needs of others because we all have them on every rung of the socioeconomic ladder.

So I love that you took it from that perspective, and I think that encapsulates where public health is going these days and the value that it has in business. So with that, and we're going to get into the Center for Health Equity that you help run with a few colleagues as well, and it's across the Americas that your purview sits. And I'm curious, before we dive into the Center for Health Equity, what have you seen as the biggest drivers? You touched on a few of them, but has it been tech, has it been policy, social awareness, or is it just a variety of combinations, and it's more relentless now than ever? What's your take on some of the trends here?

Dr. Susan Garfield:

Yeah, I think there's this layering effect happening right now. So you have advances in technology, which let us reach more people in ways that are going to have a meaningful impact on their healthcare experiences, their lived experience. I'm a big fan of the possibility of what AI can do to help us personalize engagement, let people hear information in the voice that resonates with them and the language that resonates with them at the educational level. So I think technology and AI are going to be a big tool in education and engagement and personalization of healthcare information, which is so important to overcoming health inequities. But I think it's beyond technology, right.

So technology is not the end. It's a means to an end. And what we need to do is make sure that our healthcare delivery system is adequately set up to serve a diverse population of people, right. So it's not just about getting the people in from the suburbs to see specialists. It's making sure that we have enough people in the places where sick people are to serve them adequately. And that's not just doctors. That's the whole array of healthcare providers and ancillary care providers. We need to make sure these people speak the languages that patients are speaking, that their families and caregivers speak. We need to make sure that we have childcare near infusion centers. We need to make sure that we have transportation. We need to make sure that rural access is just as robust as urban. So there's all these kind of layered issues, right.

And so I think that helps different stakeholders get more engaged. So it used to be that you'd have people thinking about problems and isolation. But now we see really, really cool intersectionality and collaboration opportunities where you might have a company that focuses on transportation, having a really good partnership with a health system to make sure we can get patients where they need to be. We can see technology providers starting to work with life sciences companies to create educational tools to reach the patients that need them. So all sorts of different entry points, I would say, for different stakeholders in the ecosystem.

Brian Urban:

It's great that you took us there, Susan because you're talking around the whole matrix. And again, back to your point earlier that everybody can play a role, and not every stakeholder has to try and do everything. Everyone has a different part that they can play. And I like the piece that you mentioned earlier too, about knowing a culture of health, what languages are preferred, and understanding race, ethnicity, gender, language. That means so very much to being able to not only gain trust for healthcare but also for the different access points.

You mentioned ancillary providers too. So licensed clinical social workers, those that are special substance abuse disorders as well. There's so many different connection points, but the right place, the right time, and the right coordination that is a public health playbook. I think a lot of people don't realize that. So I think you're just putting this big puzzle together very well for our audience, who mainly our listeners are healthcare technology research, but a lot of health equity impact makers as well.

So this is awesome that you're taking us through this here right now. So, Susan, I want to get into EYs big focus here on advancing health equity. So referenced it a couple of times. I can't wait to get into this. So the EY Center for Health Equity is driven by yourself at an executive level and a few others, Yele Aluko and Belinda Minta. So, first off, tell us what this center has meant for EY and what it's meant for you as well. Just standing it up, let alone actually doing a lot of the work that comes out of it.

Dr. Susan Garfield:

Yeah. Well, first of all, I'm so thrilled and privileged to be working alongside leaders like Dr. Yele Aluko and Belinda Minta, all the other professionals who are basically saying, "In my career, this is something that I care about, and I want to help other organizations move forward in the real world and really advance the practice of health equity, advance practice of public health." So it's been really wonderful work. And the great part about it is it really sits at the industry of multiple sectors.

So we work with government organizations, we work with health care organizations, technology groups, life science organizations, big companies trying to figure out how to advance and support the health of their populations, whether it's their employees or the communities in which they work. So really interesting kind of varied work that we get involved in. And I think our kind of operating model is that feeling good, good health is kind of an essential human right.

And if you start there and you also kind of believe that organizations can advance their own priorities as well as kind of become agents of social good, then we can help companies do well by doing good. And it's kind of tried and old school, but that's kind of the fun part of the Center for Health Equity. So we do a lot with helping organizations understand the business imperative for advancing health equity for creating the business model for certain programs.

We do a lot with data and analytics, capturing the information that you need to measure the health equity challenge or measure the impact that your intervention is having. We also do a lot at the intersection of different sectors or different stakeholders, helping groups come together, creating a standard language of collaboration, measuring efficiency, governance, financial modeling, all of those kind of boring backroom things to [inaudible 00:12:28]-

Brian Urban:

Very important building blocks. Yeah. Well, Susan, that's... thank you for breaking down what the EY Center for Health Equity is and what you all do in terms of services. The one thing that I'm really curious to get your take on, and you've probably come across this numerous times. I have in different ways.

There's a lot of healthcare institutions, integrated delivery networks, health plans that have jumped on the health equity buzz train, and they've put a lot of dollars into marketing, into messaging, campaigning even. But they haven't stood up, maybe a team or an initiative or programmatic work. And I would imagine your work helps those organizations start to put together what an investment looks like or a team or community partners.

Have you come across this scenario a lot that they've invested marketing dollars but not maybe put a vision or impact or strategies together? And can you tell us if you've not only come across that, but you've actually taken that and elevated or accelerated as well?

Dr. Susan Garfield:

Yeah, it's a great question. And so last year, we published our first annual health equity survey where we talked to 500 professionals in the health sector and government sector, public health, et cetera, about where they were on this health equity journey, right. And to your point, many had identified team members to take a role in health equity, or in some cases, others had a strategy stood up, but the execution of that strategy wasn't in place yet. And we're going to be launching another survey and report later this year.

And I think what we're going to find just in listening to the market is organizations are advancing against their health strategies. But they're now struggling to sustain that interest at the executive level, making sure their investments are long-term, not short-term, making sure their programs have the time they need to have the impact on these really tough multidimensional problems, right. You can't solve health equity in six months or a year.

It's 5, 10, 15, 20 years down the road of kind of ongoing investment and commitment. And so I think the work that we are really excited about doing is helping companies and other stakeholders really make sure they have the tools to extend their commitments to the issue and make sure they have the data and the business case and the rationale and the stories of success and the impact so that it becomes a central part of their business, not kind of a fad of the moment.

Brian Urban:

I love that you said extend their commitments to. I think that speaks volumes for helping piece together or even see a long-range strategy and what the phases are needed to be able to achieve that. And it's just so interesting that we have that kind of shared experience and yourself more so in a lot of ways of putting that execution and to be able to help a lot of these different stakeholders follow through with their investment, their commitment. So what's interesting to me is something that I saw EY noted is that health equity is a long-term enterprise value driver.

Just what you said. It's you're not going to see a turnkey ROI or any value realization in six months, nine months. This is the human condition we're talking about here, which a lot of, I think, CFOs are starting to understand more. This is not a healthcare model. It's a social health model. So can you help us understand, I guess for our broader audience, why health equity in terms of an investment is a start right now, not later business? And if you don't, what kind of deficit this would create for you if you're a healthcare organization?

Dr. Susan Garfield:

Yeah, Brian, it's such an interesting thing. Once you see, it's so clear. But if you're not looking for it, you might not notice, right. And so many of our business partners in health, they have a product or a technology, and they see it solving a problem. And in some cases, that's a drug to serve a specific therapeutic area or a technology that unlocks access to information like medical records or a service that people can gain access to. And in all of those offering dimensions in and around healthcare, health inequities exacerbate huge problems that actually undermine most business models.

So health inequities make it so you have a narrow versus broad population you can access because the populations that are affected by inequities don't have the resources to afford the best care, don't have the knowledge of what is out there and available to them, often don't have connections to either individual care providers or health systems where they can go access all of this wonderful stuff. So you have this kind of supply-demand mismatch if you don't address the health inequities, i.e., make sure people are educated, make sure they have equal access, make sure that the diagnostic and treatment cascade is perfected, especially for our patients who are most at need.

So that's on the one side. Then, on the other side, on kind of the affordability side, we have a healthcare system that's massively broken, and health inequities kind of create even more [inaudible 00:18:20] challenges there because you have patients who can't afford appropriate care entering the healthcare system at the wrong time. So instead of early on with preventive care, early diagnosis, they're coming in late advanced stages of disease, multimodal diseases, using the ER instead of preventive care. So all of that type of care when you have patients who haven't been cared for correctly or followed and supported in the best way, is more expensive. It's less efficient, and also it has worse outcomes.

And those poor, more expensive outcomes are terrible for healthcare system economics. So the incentives to get people in to care for them more appropriately, to put these wonderful integrated systems of care around them, actually saves money in the long run and is really aligned with health system care and outcome priorities, but also their economic outcome incentives. So the final thing I'll say there is we look at the massive explosion of value-based reimbursement, and that is ultimately to help overcome health inequities and supports everything that we're talking about here. So a long-winded way of saying, Brian, I think that there's lots of reasons this is important to the business of healthcare, not just the ethical underpinnings of it.

Brian Urban:

And I'm glad you went beyond the philosophy and the ethical, the morality of why. The economics that you touched on. I'm so glad you said that. There are so many great leaders we've talked to recently that have touched on that but not got to the depth that you just shared there. And as you were describing this, I was kind of illustrating a little cost curve in my mind in terms of the model of care, and how health inequities could be addressed upfront, and the downstream impacts in terms of outcomes, spend. We're not even talking about experience or engagement or trust right now.

Those are all things that will be coupled with it as you see the investment unfolding, and why did you invest in health equity? So I just love that you got to that, and I wanted to get into data and analytics, but I want to put that aside for a moment. I want to get your take on this because yourself, very well-educated expert, public health practitioner. In terms of medical education, the next generation of physicians, I want to get your take on this. We've seen a gap.

It's changing now. It's evolving in a lot of great academic affiliated medical centers, different commonwealth schools, that there's more medical humanities, more nutrition, exercise, mental health being integrated into the curriculum, but still not a centerpiece. It's still very much an outlier to the science of medicine. From what you see and who you work with, are you seeing that change? Do you have an opinion, one way or another, if that becomes more to the center of curriculum? I'm curious what you think the next generation physicians need to have in their education and ongoing training as it relates to addressing social determinants of health.

Dr. Susan Garfield:

Yeah, I think it's so critical on two fronts, Brian. The training, which I'll talk about first, but also the funnel of clinicians. So, thinking about the training first, we need to get back to a system that focuses on health care versus sick care. And when we think about healthcare, that really looks at the whole patient and their whole lived experience, both when they encounter the health system, when they're sick, they need to check up preventative or for something specific, and outside the healthcare system. So when I think about training, you're 100% right. You need to understand psychology. You need to understand the lived experiences, the diverse lived experiences of your patients.

You need to understand communication is critical. You need to understand the healthcare system incentive models. You need to understand the economics of what happens if you're a Medicaid patient going to a ER versus a PPO patient showing up. So all of that kind of very practical dimensions, I think, need to be incorporated into the training of physicians, but also clinicians and other care providers that touch the patients. So I think healthcare of the future is going to be less dependent on doctors alone, on clinicians alone, and in much more this integrated experience of case managers, care managers, nurses, nurse practitioners, doctors, in-home services, at site services.

So all of that team-based approach to healthcare, I think, needs to be where we go, especially when we think of those patients who are most at risk or have multiple diseases they need to manage. So I think the training part is so, so critical, and I'm so glad you asked about it. But it doesn't really help us that much unless we have a more adequate [inaudible 00:23:48] representative population of providers so that when patients show up in the office, they see people that look like them or can have stories that sound like the stories of themselves and their families.

And we know there was a recent study that showed that people of color who have clinicians of color actually have longer-term survival than patients who don't. So it's not even an experience. It's actually dramatically impactful to long-term health outcomes. So we need to do better about getting more people into the funnel, getting young people interested in healthcare, whether it is as a technician, as a nurse, as a doctor, as a researcher. There's so many different ways you can get into the field, and I think we need to show young people those multiple points of entry.

Brian Urban:

Again, the depth, I'm loving this because it's easy to say, "Oh yeah, you need public health education in all different types of health, medical sciences." But being able to understand your perspective has been extremely helpful because it's about inspiring and educating the next generation, and bringing them as a part of the journey to what they'll lead one day is critical. And I also really liked the way that you touched on, we need to have a more diverse and dynamic playbook in healthcare. We're at a breaking point. Things just have to change. It's the only way. And there's a lot of great, innovative, creative healthcare systems starting to do that, but speed is critical.

So I love the quick sidetrack. Thank you for letting me go that way, Susan. I want to get us back on the data analytics side of the house here with EY. So for the Center of Health Equity for Health Equity applying data, I see this as being a centric piece to some of the services you provide, the consultative surfaces, the strategic visions you lay out with your stakeholders and clients. Can you help me understand a little bit more about nonclinical, clinical data strategies that you've helped deploy for helping advance health equity for a lot of different healthcare stakeholders that you're working with today?

Dr. Susan Garfield:

Yeah. Data and analytics, I think, are probably at the foundation of most big change that's going to occur in the next few years as it relates to both where we're pointing different health and health equity-oriented individuals and whether or not we know they're working, right. So if, again, we go back to how do we sustain investment in health equity moving forward, we need the data to show what the impact of initiatives and investments are. So a few different ways we've been working with different stakeholders.

One is just baseline. Where are the challenges that they want to target? So assessing either the communities they're serving, the patient populations, or the impact of what they're currently doing to give them a baseline assessment of where the greatest unmet need is. And so those analytic opportunities can really inform your strategy and your investments moving forward. The next type of data and analytics is really around program evaluation and governance. And so what are we doing? How are we doing? Are we doing as well as we thought we were?

And how are we benchmarking against other folks who are doing similar things? That can involve both in-center data and analytics but also community benchmarking. And so when you think about that, there's a data layering aspect to it. So using kind of large publicly available data sets, internal proprietary data sets, and everything in between. So organizations are getting much more sophisticated in how they're aggregating and amalgamating different data and using that to inform the next best action than the next thing that they need to do to improve whatever they're trying to achieve.

So we do a lot to support that. Also, data integrity and cybersecurity is so big right now, and so we can't really talk about data and analytics without talking about risk and risk mitigation. And unfortunately, our healthcare systems have become a major target in this space, so we do a lot on kind of the protective side as well as the strategic side.

Brian Urban:

I'm glad you mentioned that side of it as well. We were speaking to a very interesting gentleman, CEO of Integral, that focuses on compliance and privacy in terms of data for safety. That's usually never at the conversation of a lot of our guests because we're always talking about what types of data sophistication, data comprehension, but that's a critical component of being able to have a governance, a process in place, and how you're doing what you're doing while you're doing it.

So I'm glad that you put that in on the tail end. So, Susan, I want to take a look in the future. Three years out maybe, maybe more if you'd like, what will the EY Center for Health Equity be? What's it going to turn into, and what do you think its greatest contributions will be to the healthcare ecosystem?

Dr. Susan Garfield:

I'm very hopeful that we can continue to have an impact with both public and private stakeholders to help them advance their health equity priorities, to improve the health of the populations that they serve, and to start bending the curve towards better health outcomes, better experiences, and closing some of the gaps that patients are experiencing in the real world. I think we are hoping to help build in terms of build expertise around what is health equity and how do you intervene more effectively, help organizations sustain their commitment to investing in health equity initiatives. We talked about that before.

And I think we would like to keep our seat at the table as conveners and as thought leaders so that we can be continuing to have really interesting discussions with the stakeholders involved, whether technology, life sciences, health government, to push things forward, whether it's on the initiative side or the policy side. So I think three years from now, I hope we will be reporting back on some of the significant impact we've had. I hope we're reporting back that there haven't been any more big significant health issues that everyone's had to deal with. But I hope we're also reporting back on a period of sustained investment and engagement with the topic.

Brian Urban:

I hope so too, and I can't wait to see the development unfold and what you're going to be sharing from the EY Center for Health Equity. So the rising public health celebrity, dare I say, that you are. Dr. Susan Garfield, thank you so much for joining our little show today. It's been a pleasure learning from you.

Dr. Susan Garfield:

Thank you so much for having me.

Brian Urban:

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