Winning in Healthcare is Not for the Faint of Heart

Brian Urban:                                           
Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today we're getting deep inside the world of health equity as usual on the show here. And we're going to do it from an industry and academic perspective. Very thankful to have on our show here today, founder and executive director of Just Equity for Health, Dr. Stella. Safo is on our show here today. Welcome, Stella.

Stella Safo:                                           
Thank you so much, Brian. I'm glad to be on.

Brian Urban:                                           
I have to laugh because I screwed up our intro so many times and now we're finally off and recording and it's going to be a fun conversation here, Stella, because we've gotten to know each other a little bit here and there before the show. But you bring a really interesting perspective. We have a lot of executives on the show that are in health plans, healthcare, running a health tech shop or clinical resource organization, but you've practiced and you teach and you have a really big passion and it shows a lot in your background. I think a lot of our audience will really appreciate your perspectives today. Let's start from the top, who is Stella? And take us before the MD, multiple degrees from Harvard University and why did you get into this space? Tell us a little bit more about who Stella is.

Stella Safo:                                           
Sure. Like many individuals, I think that I came to medicine because I really loved the idea of being able to help people take care of their health. And so I also love stories. I said I was either going to be a journalist or I was going to be a doctor and I chose the doctor route in part because in West African, and I don't know what my parents would've done if I was like, I'm going to go be an investigative journalist. But when I decided to be a doctor, I wanted to follow in my mom's footsteps. My mom is a pediatrician. And from the time that I was young, I watched her take care of thousands of kids in Far Rockaway like they were her own. And she would come home and talk about her patients and talk about how much she loved being a community doctor.
                                                       
And part of it was that she really felt a lot of sadness about being able to practice in Ghana where she's from. When they emigrated to the US many, many years ago, they kind of made the decision to stay here. And so being in one of the poorest neighborhoods in New York, AND actually in the country in Far Rockaway, was her way to give back and to kind of feel like she was doing medicine the way that she would've done medicine back in Ghana. And so for me, becoming a doctor was always kind of in the cards. And I knew that I wanted to do community medicine and be an HIV primary care physician. I went to Harvard for undergrad, med school and public health school. And one of the things that was so interesting about my journey is that I did a primary care residency in the Bronx.
                                                       
And that really changed my perspective because I saw that so many patients come in, sure they come in with pneumonia, but what's really plaguing them is the fact that they have no home. Or they come in with a heart attack, but we can't discharge them safely because again, they don't have any way to be able to take care of themselves well. It made me think a lot about the social determinants, the kind of non-medical realities that impact patient's care. And that kind of led me to a place where I started my journey that's very, as you said, non-traditional. But I'm hoping that it'll resonate with people.

Brian Urban:                                           
It's non-traditional by tradition, but really it's the next generation of practitioners that are tackling social health needs with a medicine background. I think a lot of our listeners are starting to see the need for this type of hybrid utility player in our healthcare ecosystem in the US and abroad. And I love your Ghana roots. I will tell you a lot of great Ghanaian restaurants are popping up around my area. The food is unique, but it's actually shifting culture perspectives in a very old world Commonwealth state I'll say that I'm in. It's beautiful to see that was fluid in your decision to go into medicine. Before we get into Just Equity for Health, I do want to talk about your education background while we're on it. You were doing your MPH alongside your MD in terms of academic and then when you went into practicing a residency. I think this is so interesting. Did this help you get a different perspective on the people you were seeing versus a lot of the cohort that you were in when you started to practice medicine that didn't have an MPH connected to their medicine training? I'm curious on your earlier days coming out of academia with having those two in hand.

Stella Safo:                                           
It's a great question. I think that it's a trend in medicine. Many physicians I think have read the writing on the wall and the medical practice of old like what my mom does where she had her private practice and she just took care of patients five days a week, that is kind of falling out of preference for many individuals who are joining the healthcare ranks now. And I think people are really seeing that to survive in healthcare with how intensive it is, with all of the administrative burden and all the challenges that I'm sure your other guests talk about a lot, you need to really diversify your skill set. And so when I was actually at Harvard, many of my colleagues actually went and took a year in between third and fourth year and did business school because they thought or they saw as a physician, I want to be an entrepreneur, I want to be an administrator.
                                                       
And for me, I was really interested in policy and I was really interested in public health, so I went and did my public health degree, but in part it's because I think we've all, as we've trained, have understood that if you kind of bank on just being a clinical deliverer for your entire medical career, you could burn out and if you burn out, what else is there? It is a little bit of a sad answer as to what I think drives a desire to think beyond just clinical care delivery. But it's, I think, also very practical and for young people who might be listening, I think it's worth thinking about how you as a physician can survive for your 40, 50 career because it's a very different world, I think, than it was historically in the seventies, eighties, nineties when doctors were able to manage their clinical world a little bit differently than we do now when we work for these big health systems.

Brian Urban:                                           
I love that because maybe an unintended impact is a lot of health plans are starting to maybe shift the way they see a lot of their provider relationships and that you're a dual application to the lives you're serving. And it's not just contracting physicians on controlling spend at a population level. It's now being able to identify and address social health needs, not necessarily close a loop, but being attentive to what's happening outside of a traditional clinical setting. And I just love this theme. I hope it continues throughout other medical education curriculum. And we're going to talk about your impact in that space as well at Montefiore. That's really exciting. I wanted to get deeper into Just Equity for Health now. Let's talk about how you developed this and created it. Obviously there's passion at the core, but tell me what you've been up to with this lately.

Stella Safo:                                           
Sure. My work background was in health systems design at Mount Sinai, and then I worked with industry at a company called Premier that really sits at this very interesting intersection between industry and innovation from industry and health systems and kind of passing on innovation to health systems. And so with that background, the thing that I saw that I was really interested in was there was a piece that was missing or it felt like it was missing for me, which was the advocacy piece. And so Just Equity for Health is really meant to improve the healthcare outcomes for populations that have been historically marginalized. And part of the reason why I focus on these populations is both of my orientation as a Black woman doctor, as someone with a chronic medical condition who has experienced healthcare as a Black person, as someone who takes care of individuals who are living with HIV, there is more help rather and focus and attention needed to certain populations that I think unfortunately are left behind in medicine.
                                                       
And so Just Equity for Health really says we want to focus on those populations. We want to use three arms that I can talk about in more detail, but it's how do we design the care models for these individuals? How do we provide education to those who are delivering healthcare, to trainees, to attendings to be able to give better healthcare? And how do we advocate to change policies so that all of us are safer so that we have better healthcare outcomes ultimately because of policies are protecting us? And a lot of the work that I did before had maybe the care model design element or it had the research element or the education element, but it didn't have the advocacy element. And I think ultimately public health says this, and certainly I believe this, all of us who are healthcare deliverers are really advocates, right? We are really individuals who are activating for improvements in our patients' lives, otherwise our patients go out of our clinics and come back in just as stick as the way we sent them out. I think a lot about what we can do around this advocacy portion, and that's why it's part of Just Equity for Health's model.

Brian Urban:                                           
I love that. And we got to get deep into the three prongs here that you just mentioned. You can't just say that, I got to know now, but what I think is really interesting, and it might be a bit of a reach, I think it's realistic, the impact that your work is having in the stagnant nature of achieving the outcomes we want through value-based care contracting. And I think there's a lot of straddling in the world of how physicians get paid between traditional fee for service, pay for performance, and capitated payments are really fixated in one part of the country in the US or a couple parts. But I'm interested, have you seen an impact with your work and how physicians are providing quality of care and being able to, from an economic perspective, maybe control spend or right size healthcare utilization? Are you starting to see that from your work here?

Stella Safo:                                           
Yeah, I would say that I'm definitely starting to see a change in orientation. I think historically, hospital systems certainly used to focus on let's fill our beds, let's take care of patients as they're sick. And now obviously with population health and that focus, we're thinking a lot more about prevention. And the beauty of thinking about prevention is that you cannot think about prevention for your patient populations and not naturally also think about the social determinants of health that impact their health outcomes. And so if you say, as a health system, I'm going to keep my patients healthy, you can't then not engage with the reality that they don't have access to safe foods or spaces to exercise or they don't have access to the kind of education that would allow them the jobs to be able to buy the foods and do the things that would be health promoting.
                                                       
And so it is a world now where we are having more expansive conversations about not just the biomedical part of individuals' lives, but also the kind of totality of who they are and the environments that we're in. And that's really, I think, the intersection that my work and my orientation sits at is to say, what are the conditions that are leading us to this place where we're getting these worst health outcomes? And is it coming from policies that unfortunately disadvantage certain groups? We should address those. Is it coming from the way that we've designed care delivery for these groups? That needs to be addressed. And so it is, I would say to your question, it's a space now and a world now where we're able to have these conversations, whereas I think even 10 years ago it was a little bit less common to just walk into a room and start naming social determinants of health in quite the way that we do now.

Brian Urban:                                           
Yeah. I like how you're seeing it because you have a very good historical perspective, very good tied lived perspective. And then now how are we pushing things forward? Obviously there's phases to any change or progress, but it's cool that you're part of that and I know you can feel that. Along those lines, let's turn your plate a little bit to the right because you have so much on your plate these days. You're also the social medicine curriculum director for Montefiore Health System. A very forward reaching title. Obviously this type of work and curriculum integration doesn't happen overnight and the impacts won't maybe be seen right away. But I'm curious of what you're seeing with your work there and how that experience has been for you because that's very new in medicine in a lot of ways.

Stella Safo:                                           
Yeah. I actually went to Montefiore for my residency and was one of the, I think at the time that I went to residency at Monte, we were one of maybe three to five programs nationally that did social medicine. It just was not very common and most people didn't really know what social medicine was, right? And now you kind of fast-forward a decade plus later and social medicine programs are popping up all over. And so that is again, as you've talked about, the historical changes. It's wonderful to live through a time where we are able to really spread the kind of methodologies that I think used to be a lot more kind to the side or more marginal in healthcare delivery. Social medicine, the work that I'm doing with Montefiore now is really trying to bring in different perspectives. I don't know how much you know about clinical training, but every second of your residency training is really spent.
                                                       
There's such a fight over what you learn because the cardiologists want you to do this and the endocrinologists want you to do this other thing, and everyone's trying to get your time because we only have three, sometimes four years to train you as best as we can to be a doctor. And so social medicine and the principal behind it says, we don't just want you to stay in the clinics only doing the kind of clinical care that's obviously central to being an excellent doctor, but we also want you to understand and have the skill sets, the language, the ability to form communities to be able to be a social medicine doctor. And what does that mean? That means that you are, again, thinking about the context and the environments that are impacting your patient's healthcare. What I've done with the work that I've been doing at Montefiore is really bringing in different perspectives.
                                                       
And we do this in our social medicine grand rounds, which we have every fourth Tuesday. And we decided right away when I came on board that we actually wanted to change our approach, not just have it just be for our clinicians, our residents, our faculty. We also wanted to invite community members. Community members actually join us in our social medicine conversations and they push back. Sometimes we'll be having conversations and we'll say, "You doctors are the problem. You don't help us do X, Y, Z, and here's how we're going to call you out on it." And we have topics that cover everything from reproductive justice to climate change to the criminal justice or criminal injustice system and just different topics that many clinicians and people who are training to be attendings don't necessarily get to think and talk about in their residency.
                                                       
And my kind of argument would be that if we're not teaching people and talking about these topics from day one of your medical training, we're losing you because then you kind of get caught up in the medical system in a way where again, you may not see the patient as a whole person. You may not see all the ways in which the medications and the treatments that you're prescribing cannot work because the environment isn't set up for it. And so the orientation of really being able to discuss approaches to that is something that I work on with a group of other incredible faculty members for a program that has gone through some struggles but is really hanging on and trying to be proactive and innovative in its approach to training residents.

Brian Urban:                                           
And you couldn't get more grassroot oriented community health focused than having this type of social medicine curriculum involving those that actually live in the community. I'm assuming a lot of them are perhaps anchors within the community, could be members of clergy, could be maybe municipal mayors, leaders like that, or other household members coming in. I think that's amazing. And I'm curious because I think there's been a lot of finger pointing at, hey, providers, you can do better, you can do more. But I come from a lot of private health plans I was with in my career. Where does the health plan fit in here? I believe that they have a huge responsibility if they can look at the underwriting risk of someone's healthcare utilization and how you get paid as a physician. They have to step in here and to be able to provide data or a technology investment that removes a lot of the administrative burden. Have you seen that with a lot of the social medicine curriculum you're working? Have you pulled those partners in as well?

Stella Safo:                                           
It's a fantastic question. I haven't seen it with the social medicine curriculum, but I have seen it with my work with Just Equity for Health where I have now seen payers really step up to the plate and say, we will pay for more non-traditional programming. For example, I do work around increasing civic engagement in healthcare, which means getting our providers, our healthcare practitioners, doctors, nurses, front desk staff, et cetera, to actually do more around impacting policy. That's everything from voting to setting up voting booths in the clinical setting, to testifying about an issue that impacts your patients all the way up if people are interested to running for office. But our goal and with a group that I work with called Civic Health Alliance, is really just to increase civic engagement healthcare workers 'cause we are witnesses. We see all of the negative impacts of some of these core policies.
                                                       
And so speaking it back and saying we need to do things differently feels very important. And it's actually been interesting because as we've been pushing out certain projects, we've had conversations with payers who are interested in supporting this because they understand the kind of circuitous nature by which you can then impact people's health and that it starts all the way from increasing civic engagement, then backing into chronic care management and all the kind of things that come with that. I will say that the payers in this are a little bit dicey and it can be a little bit difficult, but I am seeing them show up at the table in our conversations that are quite frankly surprising, but that I think are actually refreshing to see that they're tying back the ways in which some of these initiatives may actually be helpful for patients' ultimate kind of prevention goals, which is ultimately what they want to invest in because that's cost savings down the line.

Brian Urban:                                           
As you're describing this work, Stella, and your experiences here specific to some of the social health curriculum and the stakeholders, it's so interesting. I see your work and your consultative approach as creating this new glue or reducing friction between payers and providers maybe within the same house as an IDN or separately within a larger geographic region. But this is so exciting. I also see you putting a lot of maybe trust as currency back into healthcare for a lot of populations that have shown up with exacerbated conditions or have large hesitancies to have healthcare maybe because affordability or because simply of racism and obviously systemic poverty perspectives that are judgment toward them. I feel like you're putting some currency back into social health trust for healthcare. That's my bias perspective just hearing you talk for the last 20 minutes here.

Stella Safo:                                           
Yeah. I don't think you can do this work without really addressing those issues. I work with lots of different populations that have been stigmatized and discriminated against, and when you start to kind of push into what they want to see, one of the first things that we have to address is just the distrust in our healthcare system. That's been made worse by COVID with all the misinformation and disinformation. And we know for decades now that we've been dealing with things like structural racism that have impacted certain populations more. And so I couldn't do my work without going back to some of the kind of root causes of what got us here and what continues to keep us here, which again is why I think the advocacy portion of this work is so important. I see within healthcare, for those who practice healthcare, who are women doctors and women healthcare practitioners, a lot of gender-based discrimination. That's going to require policy change to keep people safe.
                                                       
I see with some of my patients that come in, the ways in which their ethnic and racial backgrounds impact them differentially. Again, requires us to really think about what we're doing to protect those groups. We also happen to live in a time where there is this movement against certain progressive ideals in healthcare, and I'll just name it, this kind of anti-woke idea, which often, from what I've seen, is so nebulous that it often feels like it's really like anti-Black or anti-LGBT and anti really progress. And it's concerning when we think about the health equity work that's important, that's needed, it's concerning to see how much of a backlash there is. And yet, I like to believe that there's a backlash because in some ways we're moving the needle forward in a good manner. And there's always backlash when you're making good change. My hope is that we can name some of the causes of these things to be able to do a better job establishing trust, because the trust covenant has been so broken in healthcare that I have patients who say to me, "Doc, when you leave this practice, if you ever leave, I'm not going to go see another doctor. I'm done."
                                                       
That's scary, right? What have we done in our health systems that are leaving patients feeling like, I don't want to bother anymore? I'm kind of just disengaged altogether. And so there's a lot of work that we do and a lot of work that's needed, but I think that we're in a climate where that's even harder. My hope is that people don't give up on fighting because I think it's very important.

Brian Urban:                                           
I love the sentiment that you just shared right there with a person interaction right there. It just shows we haven't taken care of each other. Across industries, across geographies for someone to feel, which is a great loving sentiment. If you leave, I'm not looking elsewhere, I can't come back. I trust you so much that that's how I feel. It's going to take a lot of bridge players like yourself and a lot of other organizations from a consultative and strategic perspective to really help advance trust getting back to where it needs to be so we can actually help the lives that we need to help on a very consistent basis. I got to change directions here for a second. Let's talk about data. In my world, data is king in terms of how we're looking at an individual and what's happening outside the four walls of a physician-patient interaction.
                                                       
You span a lot of different things right now oriented around improving health at the individual level and addressing social health needs along with that. Looking at the last five plus years Z codes, there was about nine core codes related to Z codes that are capturing social health needs. There's data flowing in, not sure how well that's flowing into a clinical workflow itself inside a healthcare organization or back and forth between a health plan, but we're getting there. And QA is having an amazing focus on social health screening and the advancements of social health connections. And CMS' huge investment, section 1115, all the money being given out to programs that I hope will continue forward. All this stuff said, Stella, I'm curious, what are we missing though? Is screening the real way to go, or do we need to start ingesting socioeconomic data to validate screening or to be in front of screening to prioritize questions or what's your data philosophy here as we're going into a deeper AI world, we're going into social health referrals??

Stella Safo:                                           
I think that we are at a very interesting point right now with healthcare data kind of needs and innovation because there is a policy push to ensure that hospitals are definitely doing a better job addressing social determinants of health through assessments. And yet what isn't really provided is the follow-up once those assessments are positive. I'll tell you an example. Years ago, a colleague of mine said, "Honestly, I'm not going to do my depression screening clinic anymore." And the depression screen is called the PHQ-II or the PHQ-IX. And I said, "Well, why wouldn't you do that?" It's such a basic part of healthcare and primary care. You have to screen people for depression. It's something that has to be treated. And she said, "I cannot in good conscience screen people for depression because I have no one to refer them to. We have no mental health specialists, we have no therapists, we have no psychiatrists. Everyone has a backup of three to four months, and I'm screening people and then having nothing to do for them."
                                                       
And so what I kind of think about now is we're in a similar place with our SDOH screens where we're screening individuals, we're finding all of these things, and then we're kind of sending them over to our social work colleagues and hoping that they can work magic. But have we put into place more resources for housing. Do we have any ways that we can get people who screen positive for substance use disorder into treatment centers? Do we have access to some of the programs that we need for individuals who are suffering food scarcity, et cetera, et cetera. And I think that one of the biggest challenges that we have right now is that we haven't kind of worked on the, so what happens if you screen positive, portion. Because as a society, and we saw this recently, I think it was Mississippi that just decided to pull money for students who need free lunches or just some of the kind of, again, policies that are really taking away social sector services, right?
                                                       
If at a time where we're asking people to screen for those same SDOH, we're also pulling funds from the services that would allow people to get the help, you can understand why people like clinicians and social workers and others are frustrated and they're saying, "I'm screening left and there's not much that I can do." I think that we're at a point where we have to have these honest conversations of are we screening so we can check a box and tell CMS that we did it? Or are we screening so we can actually intervene upon what we find? The space that I sit in is very much about what's the action. We've talked and talked and talked about inequities for decades, and I often say, we don't need any more water is wet studies. We know, we know that there're inequities. We know that things are wrong. What are we doing to not be able to address them? And so I think that that's where a lot more energy is needed. But I am happy that we are forcing health systems and health plans and others to really take a COH assessment seriously.
                                                       
I think it's working and now it's what do we do about it that we need to focus on.

Brian Urban:                                           
Dr. Safo, it was a beautiful comment there. No more water is wet studies. Yes, there's a very, I'd say, obvious perspective for those that are involved and even a couple of bubbles removed from the work that you do and that we both connect on. It sounds like the infrastructure is not there. My biggest fear is when we push into this new world of heatest measures and social referrals, that there is nothing that a person can get referred to that maybe has the right capacity or the right particular intervention for their need. And then they're just out in the ether. They're just thrown out in a void and we're checking a box though, it looks good, but what are we really helping with? The infrastructure is not there, and I hope folks like yourself, organizations like yours is going to be able to help craft and push a lot of policy change. But man, we got a lot of work.

Stella Safo:                                           
Yeah. And that's my invitation. I think Just Equity for Health. It's a small group now, but it's kind of special offering is that I work in partnership with public health institutions, with health systems, with plans to really think about these solutions and to think about them oriented towards action. And so I think that there is a sense, of course in healthcare now, where they're just coming out of COVID, there's a lot of struggle to make sure the finances make sense and they're being hit with all of these and now do all these assessments to do this, do that. You're not alone. There are organizations like mine and others that are thinking about how to do this and do this really well. And so I think that there's a real opportunity for us to, from the ashes, create something better and something different. And I think that now is the time because I mean, it can always be worse, I guess, but we're pretty challenged and things are pretty tough. And so I think that we should dare to be big dreamers and to really think about how to do this differently.

Brian Urban:                                           
Let's look ahead a little bit here. Just Equity for Health, what does it turn into five years from now? It's already clearly establishing a very strong value with the partnerships you've had and the lives that are ultimately being served here. But what happens in five years from now? What do you think it will be? What do you think some of the greater contributions will be to the ecosystem maybe overall?

Stella Safo:                                           
I think that in five years, what I would love to see for us is how we've partnered with the communities that we want to serve to drive what they're interested in. And so it's hard sometimes to imagine what that is because I am a good doctor, right? I see certain things with a certain perspective. But working with community members, the kind of things that they need are so just different than what I would even expect. For instance, working with a group now, and their request was for something called a Green Book for Health, which is like a manifesto that would allow them to know which health systems are safe for them to use. And it's comes from this idea of the original Green Book, which was created when automobiles are first coming out for Black folks who were traveling around the United States to know which towns were safe for them to go to.
                                                       
I wouldn't have thought in the year 2023, 2024, that individuals would want a green book for health, and yet the feeling of not being safe, of suffering discrimination, of wanting more comfort and know-how is so present that this is what they've requested. And so five years from now, I'd love to see Just Equity for Health in that kind of co-design relationship where we can be responsive to those that we're serving and provide for them what they see as the most important drivers to make sure that they are healthy as individuals and as community members. I'd also love for us at that point to really have made inroads with some of the policy work that we're doing. We are currently advocating for, along with a partner group called Equity Now, we're currently advocating for a bill at the New York state level for gender and racial equity for healthcare workers and what that looks like and how we do that at the New York level. Maybe we can move it then to the national level.
                                                       
I, in five years, want to see that kind of advocacy and policy change portion really established because that's where I think we can make some of the most lasting population level impact that we're interested in seeing.

Brian Urban:                                           
Wow, that is a detailed roadmap. I'm going to hold you to it. We're going to catch up in five years and see where we're at.

Stella Safo:                                           
Yes.

Brian Urban:                                           
Really measure it and share it. I'm just so excited to have had your time here today, Dr. Stella Safo. Thank you so much for joining our show. We're going to be able to share where folks can have more information on your organization and follow you individually on LinkedIn. I think you share a lot of really important information that pushes things forward in a really loving, curious way and thoughtful way. Thank you again for joining our show here today.

Stella Safo:                                           
Thank you, Brian. It was a pleasure.

Brian Urban:                                           
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