Assessing the Impacts of Social Determinants on Population Health with Rob Fields, SVP, Chief Medical Officer Population Health at Mount Sinai Health System

Welcome to the Outcomes Rocket pod cast where we inspire collaborative thinking improved outcomes and business success with today’s most successful and inspiring healthcare leaders and influencers. And now your host Saul Marquez

: And welcome back to the podcast Saul here with a special guest. His name is Dr Rob Fields. He’s Senior Vice President, Chief Medical Officer Population Health at Mt. Sinai Health System. He is really doing some fascinating work. His career began by opening a new practice at a residency focusing on using technology for quality improvement and serving the Latino population in western North Carolina. The practice was the first to use a patient portal on the first to achieve PCMH Level 3 in 2010 which is huge. In 2012, he spent a year teaching at a community health and family medicine residency at the University of Florida. He was recruited to come back to Asheville as the assistant medical director for primary care at Mission Medical Associates. As the ACO planning began in 2013, Mr. Fields but the quality steering committee and helped the initial planning of what was to become Mission Health Partners. He’s done a lot for that community but also across his experience in health care to improve outcomes and it’s a pleasure to have him here on the podcast with us to discuss what’s on top of his mind. So Rob pleasure to have you on the podcast today.

: Thanks for having me Saul.

: It is a pleasure. So what is it that got you into the medical sector Rob?

: Yeah I mean honestly my older brother. I have a brother who’s 10 years older and at one point had wanted to go into medicine and that’s how the idea first got in my head and then had some experiences in high school and volunteering and kind of got a sense that I was pretty sure I wanted to do primary care even then just kind of solidified you know you go through undergraduate have different thoughts but really always came back to medicine as something that was really met all my needs that need for a service and a need for to be renewed my love of science and relationships and all that. So it is a thing to combine all the things I love. And it’s been great, been a great career.

: That’s outstanding man. Yeah it’s such such a great place to get all those wonderful things man and also help people in the process. And so as you’ve worked your your feel for technology as well as you know caring for patients. Tell us what a hot topic you believe needs to be on health care leaders’ minds and how are you guys at Mt. Sinai taking care of that today?

: Yeah. World is changing pretty dramatically. I mean I think one of the things I’ve learned over the last 10 years or so both actually starting with my journey and private practice all the way to working on system kinds of problems and in particular here in New York City is that the world is changing such that really the economics are changing though. Our systems, our government, our society, is running out of money to take to really handle health care and the way we’ve always done it. We need to think differently about how to do it in a particular way in a market like New York City where we have a lot of competition a lot of high branded internationally renowned institutions or really focused on on specialty care and the way the systems have always operated is really about trying to be come up with the newest and greatest thing that is actually a back to basics philosophy that the systems really need to adapt by going back to the basics of relationship-based care. Building Primary Care base is managing population trying to reduce cost and utilization in the hospital in many ways sort of the antithesis of the things that they were built to do. But I think all healthcare leaders that are looking at the way the finances are working around that and healthcare economics and seeing the writing on the wall or are trying to figure that out. How do you change our systems from delivering the kind of care they’ve been delivering to something that really goes back to and I think the basics of population health which are the basics of medicine, a strong primary care, strong relationships with patient and trying to positively affect behavior to get better outcomes.

: Yeah now that’s such a great point Rob and there’s definitely a lot of heavy lifting that’s happening right now and has turned to more value based care and I love to hear some of your thoughts and what you guys are up to over there at Sinai. And just to help improve outcomes and do things differently.

: Yeah there are a couple of things or several things but maybe it’s the basis you have to change the economics of the health system and the financing of the health system in order to change the operations right. So you can’t disconnect the two so much that you try to change your operations in a vacuum. You have to be able to do your contracting and change your contracting to support the kinds of things that you want to do. So we have entered into value-based agreements with all of our payers in some capacity all the way from full arrest to just pay for performance and everything in between. So I think that’s one thing that we started doing several years ago and the second is of course is establishing the right leadership and start to address the cultural issues within the institution to kind of move us towards value. But I think more concretely there are a couple of things. One is really working on primary care redesign. So if we agree that the foundations of Population Health are really about empowered primary care that provides the appropriate foundation then it can’t be the primary care of the lot, 15 to 20 years. I think that led us to physician burnout, it led us to relatively low number of medical students deciding to do primary care. It just needs to change, we needed to improve or empower our workforce. We need to support them a lot more in a star building team based care infrastructure. So we’ve done that you’re kind of starting to introduce the concept of integrated care with behavioral medicine with social work with clinical pharmacy. So we’re starting on that process now for rebuilding primary care in redefining primary care. And then the other big thing among all the things we’re working on that is really important is how we use our information systems and data and analytics to really fuel our operations and top health both in terms of measurement of operations and quality and efficiency but also prediction. Now how do we use all sorts of data to start to predict who is likely to have a better outcome and start to define our population. The idea being given in limited resources and in a place like Sinai your population is potentially infinite right you have people traveling from all over the place to come here. We don’t have enough resources to cope to really deal with an infinite population. We need to use data and analytics to help define our population a little more discreetly and then organize our operations around that. So I think primary design and data and analytics have been bought by our two biggest investment.

: Love that and that super clear focus on these two metrics and feel like is the key to to really drive some great results and maybe along the journey, you guys saw some some setbacks and some learnings. I feel like we learn more from those than than the successes. Definitely want to dive into the successes here by one hour before we get to those learn from maybe one of the setbacks that you and your team had and what you learned from it.

: Sure. Yeah I’m in I’m still relatively new to Sinai but I think some of the challenges here are not unique to either their troop or other large health system. I think population health is soon to be in vogue thing right. Every system says we need to do pop health that are quote not really understanding what that is and often start on the same journey of trying to build primary care. I think where it gets a little law is really undervaluing the what we call the less discrete part. So what part makes primary care so impactful. So I think there’s a general under appreciation for how important those relationships are to improving outcome. And we know that patients generally do better. They utilize less, they have better outcomes if they have a consistent and reliable relationship with a primary care physician and that isn’t often reflected on profit loss statements or balance sheet. So a primary care practice so our primary care division which for most systems often loses money. I think there is a lot of other value there especially when we talk about you know population health model that has to do with having a reliable place for a sick patient to become someone that knows the patient, that knows their social contacts, that can have meaningful conversations that are not just a singular conversation but an accumulation of conversations over years in that relationship that is incredibly impactful but it doesn’t generate our views. So I think our mistakes as a system have often had to do with resourcing decisions in primary care that are based on balance sheet and not about the overall value. What primary care brand. That’s easy to do. I mean when you think about a division that might be losing money out of balance sheet then decide well we can’t afford to resource it differently or build team based care model. I would argue you really can’t afford not to, given the new economy and and it’s beyond the balance sheet. I think that’s a pretty common mistake across systems but I think that I’ve had experience with.

: Wow that’s so insightful and those are the tough calls that visionary CMO and CEOs leadership teams and general ad provider institutions need to be thinking about. You’re definitely thinking about these things and I think it’s key for others to really start sharing into that vision of hey you know it may not make sense on the balance sheet right now but if we take a look at the impact overall, what we could get out of this for patients and just the system that the health care that we’re providing could be big. What would you say has been one of the proudest medical leadership experiences you’ve had to date?

: From a personal standpoint who’s actually maybe for the Sinai and even before a mission. I spent a year as you mentioned at the University of Florida teaching in the family medicine residency program and are my personal proudest moment as a leader was getting faculty of the year there and teaching residents about these kinds of topics and transformation and just having that connection with people. And I was only there for a year and it was a really powerful experience for me in terms of having those kinds of relations so I think that’s certainly one of my proudest. I think certainly that I think in terms of pop health my proudest moment was being in my previous organization. When we we first were able to generate shared savings in our model. And I say that because it was somewhat of an untested model. We worked not exclusively but quite a bit on Social Determinants as the core of our operations and how we dealt with poor management of health. And I think we had uninvolved nationally with a CEOs and there are a lot of people that those that don’t really believe that a social determinant model is really the way to go in managing populations. And so there were some naysayers out there and we were able to generate significant savings despite some significant headwind and that was certainly a proud moment for me that our model tested true and has delivered a result. And we’re working towards the same things here at Sinai and I’m excited to be a part of it.

: That’s awesome. Well you know what, success definitely leaves a trail and I’m excited to see apply some of the things that have already worked for you and your previous teams to what you do at Sinai. Rob there’s no doubt in my mind that you’re going to succeed. So as you work to unravel some of the things that you’ve got going on what’s an exciting project that maybe you want to share with the listeners?

: Sure. Yeah. In taking on some of the social determinants work here at Sinai that the thing is I’m really excited about our how to use the data sources we have and use things like machine learning for example to be able to describe our populations differently and so we’re able to now using our one of our analytics partners able to predict with a reasonable degree of certainty who in our population is likely to end up in the hospital unnecessarily in the next 30 days before. And so whereas most analytics talk about readmissions predictors and other types of I think more common metrics and predict use other common uses of predictive analytics. We’re trying to think more upstream and predict the next unplanned admission to really try to have a more meaningful impact on patients and not only do we are we able to do that but we’re able to do that with a little bit of information on these patients regarding their social determinants so we can actually tell based on more I would say less typical data sources. So like purchased data you know using big data to help provide social context for these patients so not only can we say hey they’re likely to end up in the hospital in the next 30 days but they’re likely to end up in the hospital and also have an issue with housing or transportation or finance. And that way our social workers and our nurses that are trying to manage the population have a greater degree of insight even before talking with the patient and can most appropriately helped them by closing those social determinants gaps. So it’s really sort of an empowered approach to care management and proactive upstream thinking in terms of care management that I’m pretty excited about. Not to mention the opportunity to partner with our nonprofit than New York City to be able to really help close those gaps in a meaningful way.

: Wow that’s super exciting and yeah you know I had a guest who was about a year ago actually and he was talking about you know he had as part of his portfolio a Socio Determinants of Health test and the patient would take it on the tablet when they got to the doctor’s office or the E.R. and based off of that it would give the care team an understanding of where they sat, what the risks were. And this is more like just a piece of the entire vision of what you’re painting. But it seems like it’s at its core I think like a lot of times it’s tough for people to envision these things that you know you’re just laying out for us. But the power behind what a system like this can do is pretty big for the health of people and for the way that hospitals manage populations. If if somebody’s listening to this what Rob is saying is if it’s resonating with you, Rob what would be the best way for them to get in touch with you to to start a conversation.

: Probably by e-mail my e-mail’s robert.fields@mountsinai.org that’s probably the best way to start a conversation or to have a conversation about what we’re working on. I remember working with somebody that worked with vulnerable populations back in Asheville who is credited with the quote that went something like You know it’s hard to take care of your diabetes if you’re living in a tent. And that to me is probably as concrete as it comes because you’re right. I mean I think data and analytics and predictive analytics is kind of out there and some people get it and some people don’t. But I think that line can easily resonate and whereas healthcare, I can write a million prescription. And that’s what I’m trained to do. Somebody has diabetes it’s done under control. I can write a thousand prescriptions for insulins or for other medications all day long and have zero impact because I’ve done nothing actually deal with the priorities that the patient has and just surviving the day. And I think ultimately when I think about what that the core pop health is trying to deal with those basic life needs that you have to deal with, otherwise you don’t get to the right outcome and it just so happens that the way the financing of healthcare is changing that’s more possible today than it might have been 10 years ago in the first purely fee for service environment.

: That’s a great way to put it. Rob and and definitely resonates with me. And folks if you need to rewind us in here again it’s definitely one that I’ll be rewinding and listening to again because Rob’s definitely given us some great insight into population health and the things that matter and the promise that we’re about to see around the corner with the changes in the economic infrastructure and health care. Getting close to the end here Rob, let’s pretend that you and I are building a medical leadership course. And what it takes to be successful in healthcare. The one on one of Dr. Rob Fields. And so we’re going to design a syllabus for questions lightning round style followed by a book that you recommend to the listeners. You ready?

: I’m ready.

: All right. What’s the best way to improve healthcare outcomes?

: Always keep the results in mind.

: What is the biggest mistake or pitfall to avoid?

: Don’t substitute a process for a result. I think we go a good job of creating processes. But again we lose sight of the result that we’re intending.

: Love that. How do you stay relevant as an organization despite constant change?

: Keep your, be true to your mission. Always. I think it starts there.

: What is one area of focus that drives your organization?

: I would say culture and I think this should be true of all organizations. Think you’ve got to get the culture right and that should drive everything else to do.

: What’s your all time favorite book that you’d like to recommend to the listeners on the syllabus?

: Oh man. Lots of great books but I’m going to kind of stick to the basics and I’ll recommend The Little Prince. I think there are a lot of truths about life in that children’s book.

: Nice.

: I think hold true to that today and I credit my older brother for introduce me to that too.

: That’s awesome. Kudos to you older bro. And yet you know I’ve listen, I’ve heard that recommendation once before so now Rob with your recommendation it’s definitely climbed up on my must read list so appreciate you for sharing that. And that listeners, you want to get a hold of this syllabus that we just crafted for you along with a transcript of our interview, just go to outcomesrocket.health/fields as in Rob Fields and you’ll find it there. Before we conclude I love Rob if you could just share your closing thoughts. And then the best place where the listeners could follow you or learn more about your work.

: Sure. Maybe a closing thought is that the thing I’m most excited about in the new economy is that it turns out that doing the right thing by patients turns out to be the least expensive way to provide care. And then when those things align I think good things can happen. I’m excited there and again probably the best way to get me is via email. robert.fields@mountsinai.org and we also have our own podcast that we Mount Sinai partners, Apple podcasts, and Google podcasts as well. That’s helpful.

: Outstanding. We’ll definitely have to check that out Rob and we’ll provide a link to the podcast that they offer on the show notes as well. So if you want to check out this is just the tip of the iceberg ladies and gentlemen. If you want to dive deep into Rob’s thoughts and what they’re doing over there, check it out. Just go to outcomesrocket.health/fields and you’ll see a link to their podcast down there so you could dive deeper. Rob this has been a true pleasure. Really appreciate you taking the time with us today and yeah hopefully we could get you back on in about a year or so to hear how things have gone.

: Sounds great. Thanks Saul. Appreciate your time.

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