In A Second Opinion we engage with the leading minds in healthcare at the nexus of medicine, policy and innovation. In the current series of four episodes we’re hearing from four leading women in healthcare. As president of the Healthcare Leadership Council, Mary’s organization serves as the exclusive forum for the nation’s most influential healthcare leaders to jointly develop the policies and plans and programs to improve American health. Stay tuned to hear how Mary navigates the complexities of running an organization with competing member views and her insights into why we need more women at the executive level.
Bill Frist: A Second Opinion podcast focuses on this nexus between health and health care, coupled with policy, coupled with innovation and entrepreneurship. And let’s talk a little bit about each of those three categories, but let’s began with an issue that a lot of people are beginning to pay more attention to, and that’s the social determinants of health, the nonmedical drivers of health and healthcare in terms of cost and burden of disease. So let’s jump right in and from your perch social determinants mean what, and a little bit of the how and a little bit of the why it is so popular today.
Mary Grealy: Well, it’s been fascinating to me to see how quickly this has evolved and really taken hold, that more and more people are aware of, you know what, just treating someone’s medical symptoms isn’t enough. We really need to look at their health, as you said, not just their healthcare. So where are they living? What are they eating? Are they able to get to their doctor appointments? What’s their transportation ability? What’s their financial security or insecurity? And it’s been stunning to me to see what a large factor that plays in someone’s actual health and I didn’t think we’d be able to convince legislators, regulators and others, we need to make an investment in these kinds of things.
Bill Frist: So actually taking tax dollars and saying health is more than health care and you can’t just put Obamacare out there or health insurance out there or Medicare or Medicaid. You really need to expand much more this concept of what health is all about and what causes it. Why wasn’t it focused on five years ago?
Mary Grealy: Well, I think change we’ve seen is this whole movement to value based healthcare. So we are now telling providers of health care, “You’re not just responsible for your little silo in the doctor’s office or in the hospital. We’re now asking you to truly manage the health of that patient.” So I’ll use Ascension Healthcare, one of our members, they’re participating in accountable care organizations and they quickly realized how do we keep people out of the hospital? If they’re a diabetic, they’re on insulin, but they don’t have a refrigerator to store that insulin we need to buy them refrigerator, or we need to buy them an air conditioner. That is just new thinking. But once they became responsible for that whole patient or whole consumer, they started changing their behavior. And we talked about the federal government taxpayer dollars, but we’re also seeing private insurers and I think they’re really leading the way on making these changes and making these investments.
Bill Frist: Is a, again, a basic question from your organization, which is for-profits and nonprofits for the move from fee for service to value based care, I would think that the nonprofits are moving there faster than the for-profits. What is the truth? And again, it’d be an overgeneralization either way, but the nonprofits you think are more charitable and not as interested in making money. And really gross over generalization, but tell me who’s leading the way.
Mary Grealy: Well, I think they’re in parallel, at least within my membership. And what’s even more fascinating is watching those that we don’t think of as direct providers of healthcare. The pharmaceutical companies, the medical device manufacturers, the distributors, and especially the distributors of healthcare services and goods and the medical device manufacturers. They all realize now their customers are in this value based healthcare system, and they need to be a partner with them and they need to help them manage these patients. So what I find just so energizing is that all the different sectors of healthcare are participating in this movement. It isn’t just those direct providers of healthcare, and I think that’s a monumental change in the healthcare system.
Bill Frist: It pulls lots of different people to the table who historically have not been to the table.
Mary Grealy: Absolutely.
Bill Frist: And how important is payment reform? Again, not just government reform but private sector pay or insurance company reform to incentivize the system out of a fee for service to a value based system.
Mary Grealy: It’s absolutely critical. And I’ll use a Tennesseean as a great example of this. Vicky Gregg, the former CEO of Blue Cross Blue Shield of Tennessee.
Bill Frist: Great friend.
Mary Grealy: On my executive committee. And at that time our chairman was Dr. Denny Cortes of Mayo clinic. Very committed to a learning healthcare system, value based healthcare system. And he turns to Vicky and says, “Why aren’t you doing more? Why aren’t you pushing this ahead sooner?” And Vicky very patiently said, “I am trying my level best, but you have to understand, meanwhile, we have this 800 pound gorilla called Medicare that is still on fee for service.” Well, Medicare is finally moving towards that value based payment and we’re seeing this huge shift, this huge change. I give my members a lot of credit for being what I call the early adopters. They were trying to do these things, Vicky was trying to do these things, before they were being financially rewarded for doing so. Now the government is lining up the incentives. The private health plans are lining up the incentives so that we’re getting to that patient centered healthcare system.
Bill Frist: An issue that I think a lot about, because in Nashville there are a lot of hospital companies that are here. When you think of social determinants, if you have a hospital and the hospital has to stay open and what keeps the hospital open traditionally has been having patients in beds. Now that’s changing. But what incentives do hospitals have in really paying attention to the social determinants? They, yes, affect the health of the patient, but really don’t necessarily, and you’re going to have to correct me with all this, affects sort of what a hospital is all about.
Mary Grealy: Well, it’s only when we make that hospital responsible for the overall care. So not just while that patient’s in the hospital, but their post-acute care, their home care. So they’re getting a payment to manage that patient. So they now have an incentive not to put heads in the beds, but to keep them out of the hospital. And one of the reasons we’re working so hard on these fraud and abuse laws, they want to be able to refer that patient to the best post-acute facility if they need rehab or the best home health provider if they need that, and the current laws won’t let them do that. They’re not allowed to recommend. So to me that’s the big change. And I think of one of our members is Memorial Healthcare, a five hospital system in California, and his comment was, “My goal is to get as many patients out of the hospital as quickly as I can because I understand we need to move outside the hospital.” And it really is taking that longterm view of we need to have a sustainable Medicare, Medicaid and private health care system.
Bill Frist: It really brings to mind when… And the whole purpose of our podcast or A Second Opinion is to look at this intersection between government and policy, and the overlap with the private sector for profit and nonprofit philanthropic in health and healthcare. And I think this movement from fee for service really shows the importance of that merger, that you need that policy set with government. You need the government and not… usually to lead, sometimes to be dragged along, but nevertheless the synergies that are there, and I think what you’ve just described. Medicare Advantage, which when I was in the Senate in 2003, The Modernization Act, we really created the Medicare Advantage approach. First of all, to describe what that is, but secondly, has that accelerated the move to value based care? Is that the sort of the entity that has carried it?
Mary Grealy: It has played a phenomenal role. When I came to the Healthcare Leadership Council, I was given two charges. One, we have got to solve this problem of the number of uninsured that we have. So we need to work on access to health care. But the other thing I was charged with, we need to reform the Medicare system. We need to make it more like the federal employees health benefit plan, where you’re given a certain amount of money and then there’s a whole array of private plans, and you get to shop and decide which one you want. A real uphill battle for doing that. Lo and behold, Medicare Advantage, which is just that. Medicare beneficiaries are given a certain amount of money and then they can choose from an array of private plans, and those private plans are going to provide them a package of benefits, many benefits that aren’t available in the traditional fee for service program, but more importantly, they’re really managing their health and their healthcare. So they’re doing both.
Mary Grealy: And we’re finding two things: high satisfaction among the Medicare beneficiaries and lo and behold, lower costs for the Medicare program. So I really envision this as a win-win. It’s a great model and people are voting with their feet. For more than 50% of the new enrollees in Medicare are choosing to go into a Medicare Advantage plan. So they’re dealing with private insurers rather than the traditional Medicare fee for service. And that is with the Medicare fee for service being kind of the default. If they don’t make an affirmative choice, you automatically go into the regular Medicare program. So I just think it’s a phenomenal success and they’ve had great outcomes.
Bill Frist: Yeah. And I think it does give the flexibility to capture sort of the third circle that we talk about, the entrepreneurship, the innovation, the creativity. Because now all of a sudden the private sector, again for profit and nonprofit have the flexibility to be nimble, to respond to what patients really want instead of a sort of a one size fits all very rigid containment.
Mary Grealy: Micromanaged.
Bill Frist: Yeah. Micromanaged. One, a question, and out of all the guests that I have the opportunity to interact with, you’re probably the best ask this too. Over the last 20 years, again, looking at the policy government arena, do you find Medicare as a corporate, as an institution, more innovative or less innovative than 10 years ago or 15 years ago? Or more responsive or less responsive? And I’m always curious and I’m sure a lot of our listeners are, because you say Medicare is just sort of big entity in Washington DC that touches us if we’re seniors. But what’s your view in terms of the nimbleness of Medicare today?
Mary Grealy: Well, it’s difficult for it to be as nimble as a private health plan. I mean that’s just a baseline given, but I think they are trying to be more receptive to suggestions from the industry about how can we do it better. But they’re constrained. Oftentimes they will have to get the authorization from Congress before they can move ahead. Now, one thing that was part of the Affordable Care Act that I will admit I thought at the time was an oxymoron, and that is to creation of the center for Medicare and Medicaid innovation. But to be honest, it has been a great testing ground for trying some of these new models, and it’s given providers an opportunity to test it themselves. Can I do an accountable care organization? Can I really make this work? And they’ve been very responsive. And unlike the traditional Medicare demonstration projects, if you’re in the middle of the demonstration project you’re getting data that shows, if we did this just a little differently, we think we would get better results, and they are open to making those changes.
Mary Grealy: Traditional Medicare demonstration, Nope, these are the rules, this is how it’s going to work and take it or leave it. And I remember one of the folks from that office meeting with us and saying, “We’ve just never seen a demonstration project that worked.”
Bill Frist: That’s right, and it’s so true.
Mary Grealy: And we know why.
Bill Frist: I had the same bias when I was in the Senate and that was 12 years ago or 12 to 20 years ago. A demonstration project would take five years. It was very rigid. You had to do the criteria. By the time you got the data after five years to apply, it would take another five years. And in this world where innovation is moving so quickly, and again the third sphere we like to look at all of these issues is the innovation. And I think it’s a good example. The CMMI’s, the innovation center which came with Obamacare, a lot of people had doubts on, especially a lot of Republicans. They said, “It’s not going to work. That’s not the position of government.” But I think at under the leadership of Patrick Conway and Adam Bowler and whoever that next person will be, it is a great center that’s fairly nimble, fairly flexible, listening, really has this patient centeredness there. So again, it gives us a great inner-
Mary Grealy: It is, but I do want to say we want to make sure that there are still appropriate guard rails so that these are truly demonstration projects, because there’s a lot of authority there for the secretary to… That’s successful. Let’s and expand it.
Bill Frist: Yeah, that’s right. I think that’s right.
Mary Grealy: But they’re doing great work.
Bill Frist: But I think it’s for our listeners, there’s general consensus that even among doubters that the idea of having the government innovate is not as a possibility but a reality. And again, with the appropriate guard rails around that. Let’s go back to the social determinants because I know that one of the things that you do or papers and you put out, I guess their white papers, and we’ll come back to the leadership council, but you looked at disparities and social determinants. Was there anything that has come out of that in terms of recommendations or suggestions that our viewers and listeners might pay attention to?
Mary Grealy: Well, I think… So within my organization we have all the different sectors of healthcare. So we get hospitals and health plans and medical device, pharmacy out of their silos and working together and collaborating. A whole new group that we’re now working with on the social determinants of health, housing, nutrition, transportation, are local community organizations. And this is new for those that are healthcare providers and manufacturers. So one of our recommendations certainly is we need to develop strong relationships with those that are on the ground. They know the community better, oftentimes. They’re Meals On Wheels, others, that are really interacting with people in the community. So how do we form partnerships with them to manage health while we’re doing the health care? And I think the most fascinating thing is using what are called community health workers. And often there’s a distrust of institutions, different healthcare professionals. These are people that are not necessarily trained medical professionals, but they know the people in their community. And so they can do a pretty good assessment of all right, what are their housing needs? What are their nutrition needs?
Bill Frist: And they’re closer to the patients [crosstalk 00:17:04]-
Mary Grealy: Much closer.
Bill Frist: And culturally more sensitive. I spent years and years working in the Sudan doing medical work for weeks at a time in Ethiopia and Kenya and they’re community health workers. There are no doctors, there are no nurses, a little bit of exaggeration, and the health is delivered by regular people in the community. They get a little bit of training. And what’s interesting to me is that effectiveness of that cultural sensitivity is something we in the United States have not historically used very much. It’s always been a doctor or a nurse or a doctor in a white coat. But now there’s recognition that with social determines, with the important of a housing and food and the local needs, people closest to that are the people in the communities, so why not bring them into the health system, which is a fascinating opportunity.
Mary Grealy: And another strong factor in all of this is what’s called social isolation. And so the ability to use, again, those people that are on the ground to interact and make sure that people are not isolated, that they are connected. And I sort of view them as an early warning system as well. And how do we expand the reach of healthcare providers? There aren’t enough physicians, there aren’t enough nurses to be able to do all these things. There aren’t enough home healthcare workers. So we need to deploy all the resources that are available, and I think this is really an important one.
Bill Frist: I’ll just add, we need our policies, again, coming back to the policy arena, to allow people to perform at the highest level of their license and make sure licensure is not so restrictive that you can’t bring people on the ground who are appropriately trained into our healthcare system today.
Mary Grealy: Yeah, I’ve always been very proud of our physician members in our organization. When we were developing our health reform principles they said, “All right, just want to make sure that we are allowing people not only to practice up to the scope of their practice, the full licensure, we should be expanding that scope for practice.”
Bill Frist: I love it. I love it. Tell me, because we referred to it a lot and our listeners may not be as familiar as is as I am, the Healthcare Leadership Council. There’s nothing quite like in the country really, but a little description of where it is today and its history and the role its playing in shaping policy as we move forward.
Mary Grealy: Well, we’re a unique trade association based in Washington, DC. Our members are CEOs of many of America’s leading healthcare companies, both for-profit and not for profit, but unique in that we represent all the different sectors of healthcare. So we have health systems, Ascension Health, the largest not for profit Catholic health system. Many other hospital systems, academic medical centers, Cleveland Clinic, Mayo Clinic. Then we also have the health plans, Aetna, Anthem, Blue Cross Blue Shield of Tennessee, medical device manufacturers, pharmaceutical companies, the large distributors like AmerisourceBergen, McKesson, pharmacies, CVS is also a member, and then post acute care. A lot of home health companies, that’s a growing area. And then we have really increased our membership in the health information technology arena because that is going to play such an important… It is already, but I think an even role.
Bill Frist: So the unique aspects are all sectors and there’s no other organization that has all sectors coupled with the fact that you have both not for profit and for profit at the table. It’s got to be uni… I mean it is so unique, but I can imagine the discussions are pretty interesting. I know that people sort of put their hats at the door I’m sure when they come in, but to have the payers and the hospitals who leave the negotiating room under these hot negotiations and then come to the conference room in Washington with you and-
Mary Grealy: My nickname is [Brooches Brooches Galley 00:21:06].
Bill Frist: I love it. I love it.
Mary Grealy: But what is fascinating and believe me, that was the question I asked when I interviewed. I don’t get it. How does this possibly work? Because I had been at hospital trade associations, I was used to them fighting with the insurers, with the pharmaceutical companies. I mean it was just fight, fight, fight. But there’s a recognition among our group that if you believe in a strong role for the private sector, if you believe in supporting and strengthening innovation, then we do have to check our weapons at the door and collaborate and find solutions. And what’s really great about the period that we’re in now is that the incentives are now lining up to really make that collaboration even more meaningful and rewarding than it has been in the past.
Bill Frist: And that comes back to the financial incentives, or all sorts of financial and nonfinancial, but the financial incentives where you’re going to more value outcome, patient centered-
Mary Grealy: Patient centered.
Bill Frist: Instead of just a straight fee for service. I came in, I got a treatment and the like, and then what do you produce… So you get everybody together. So you collaborate, you convene and everybody sort of shares ideas. Then what? What is your role? Is it to advocate on at Congress and with the executive branch? Is it to feed them information? Is it to be a resource for them? What do you do after the convening and collaboration?
Mary Grealy: Well, you’ve just wonderfully summed up what we do. So we do advocate. We played a very strong role in, I know you mentioned yesterday during the program, getting a prescription drug benefit for Medicare. As you remember from your time, it only passed by one vote in the Congress. So it was a big challenge. We did a lot of work on the implementation of that. We spent a lot of time not just advocating for things but also educating. So we are viewed as kind of one stop shopping for Capitol Hill staffers. So in other words, they know that if we’ve reached agreement on a position that we’re not just the hospital voice, we’re not just a health plan voice, we’re not just the pharmaceutical voice, we really are the health industry voice. So we have worked out among our members and solved that problem and can bring them a unified position, which is extremely powerful to be able to say that you’ve gotten everyone on the same page.
Bill Frist: Yeah, and again to our listeners, I’ll have to say, in my 12 years in the Senate, I was the only physician in the United States Senate when I came, the last one had been elected in 1928 and I was elected 1994, the only physician there. So people would come to me to ask these basic questions. A, I was a heart surgeon and hopefully a pretty good one at that, but in terms of the overall sector, just being a doctor, you can’t answer those questions. So I would turn them very quickly to obviously people at the leadership council to get that sort of information and to learn. And of course I used it as a huge source and resource. So very practically you had an impact on me, both as majority leader and a United States Senator. So I can imagine how important that is.
Bill Frist: Sort of looking and bringing all this discussion to the very current times. A lot of people have different attitudes towards this administration, talking about regular people here in Tennessee and around the country and it’s very split, very divided. The things that people don’t like about this administration a lot, and then the economy’s great and people are feeling pretty good. Put all of that aside and let’s take health and healthcare and again your vast 30 year experience of being there and watching administrations come and go. How would you characterize either in terms of openness or the reaching out or the receptiveness to ideas that you have?
Mary Grealy: Well, first of all there was a great concern by many that we’re making this progress towards a value based healthcare system. A lot of changes in the Affordable Care Act that helped speed that movement along and was it going to come to a halt?
Bill Frist: And be reversed? I remember [crosstalk 00:25:14].
Mary Grealy: Exactly, yes. Oh no, they won’t… Well I’m here to report that it has been quite the opposite. We’ve been very fortunate. There are extremely talented people that have been willing to take these positions. Alex Azar, our secretary of HHS actually had been on my executive committee when he was at Eli Lilly. Eric Hargan, who’s a deputy secretary of HHS, Don Rucker, who is the head of the Office of the National Coordinator working towards interoperability in health information technology. Seema Verma, just a complete expert in Medicaid. So a very talented group. But we have been struck by their reaching out to us and saying or asking, “What are the barriers that are in the way of you getting to a value based health care system? What can we do? What can we clear out?”
Mary Grealy: And they are willing to tackle some laws and regulations that I never thought in my lifetime would be addressed, such as the Stark and anti-kickback fraud and abuse laws, which really prevent providers, especially in this area of social determinants of health. If you don’t have a special waiver, you wouldn’t be able to provide that refrigerator for the person to support… to store their insulin. You wouldn’t be able to provide them food, you wouldn’t be able to provide them transportation. This administration is looking at those barriers and they are, as I said, coming to us and saying, “How can we help?” Interoperability of electronic health records, absolutely critical. Sharing of data, opening up the Medicare Medicaid database so that those that are trying to do research or really managed care better have access to the information they need. So I’m very enthusiastic.
Bill Frist: It is so interesting, and again, I know that it will surprise many of our listeners because it does even me, and I’m trying to stay very current, that this passing of the Baton, you would think with all of the Obamacare, let’s tear it down and it’s the worst thing that’s ever happened to the country. Your impression would be that this administration is just the opposite. They have their own ideas. They’re no new ideas coming through. So this flow back from the executive branch to the private nonprofit and for profit sector, the nimbleness there and kind of the entrepreneurship that is allowed there is very, very encouraging.
Bill Frist: Let me shift to an issue that I think a lot about, I know that you do and that is women in health and healthcare leadership. And I spent a lot of time in board rooms as you do, and you interact with 50 CEOs that are there. How have things changed over time in terms of the place of women in the boardroom at the level of leadership in the CEO position over the last 10 years?
Mary Grealy: Well, of course I think we all wish the numbers were greater, but I really had the positive experience of seeing change. When I first came to the healthcare leadership council, there was one woman, Colleen Conway-Welch, Dean of the School of Nursing at Vanderbilt.
Bill Frist: Right here in music city, USA, and unfortunately passed away a couple of years ago. I miss her.
Mary Grealy: But what a tremendous leader.
Bill Frist: But she was the only one.
Mary Grealy: She was the only woman out of 50 members and the current chair said, “We have got to do something about this. We really have to focus on getting more women.” Well, it’s difficult when you’re looking for CEO level of large, multi billion dollar organizations. I am proud to say that we now have 10 women out of the 50, so we’ve made a lot of progress. We hope to make more progress. Looking at boards. There is a movement to get more women on boards and I think it’s a smart business decision because women, particularly in healthcare, are the decision makers in households.
Bill Frist: 80% of all healthcare decisions and executions at the local regional family level are made by women.
Mary Grealy: Yeah. And I had the pleasure of serving on Team Health, another Tennessee company on their board, and they were making a concerted effort to have that diversity on their board.
Bill Frist: I think that you’re right, once you’ve hit sort of a certain level, whether it’s your 10 out of 50, you’re limited a little bit because of just the number of women CEO’s.
Mary Grealy: [crosstalk 00:29:55].
Bill Frist: But I think that once you hit the tipping point that it becomes much, much easier because people see the huge advantages and they see it in the board rooms and in the investment world and the private equity world and the venture capital world. Still have a long, long way to go.
Mary Grealy: Yes.
Bill Frist: But even there, I see this world opening it up so quickly, and I think all of us to have our role to play to accelerate to that going forward.
Mary Grealy: Now I’m part of an organization called Women Business Leaders in Healthcare and the goal of this group is to get more women CEOs in healthcare companies, but the first level is to get more women on the boards of publicly traded companies or private equity firms because that really is where that CEO recruitment takes place.
Bill Frist: And the training ground, the training ground, the decision making and-
Mary Grealy: Developing that network.
Bill Frist: Yeah. Yeah. Today, a lot of people, we have people who are listening right now who are thinking about a career in health and healthcare and leadership or become a CEO, and for smart people who are looking ahead, kind of looking into that crystal ball, what advice would you give them, young people in health and healthcare today?
Mary Grealy: Well, number one, healthcare is the only area of the economy that during the recession was still adding jobs, but more importantly we need you. So you well know there aren’t enough physicians, nurses, healthcare workers. So that’s on the healthcare providers side. We need as much talent as we possibly can because we have 10,000 people turning 65 every single day. So we’ve got this baby boomer tsunami moving through. So great opportunity in the direct provision of healthcare services. I think another real exciting area, and especially for young people because they’re so talented in technology, we are moving again out of the hospital, out of the physician’s office and we’re using technology to better manage the health care of patients outside of the hospital.
Mary Grealy: App developers… I mean it is a whole new world. And I know you’re involved with Teladoc, one of our members, again, using technology to reach people where they are and provide those healthcare services. So anything in the technology area, but I would say just keep your focus on patient centered. That really is where our health system is going and where it needs to be. So how can you provide services for those patients that really will help with their health and their well being.
Bill Frist: It’s an attractive village, you said, that’s growing recession, non-recession going forward and kind of… this is an appropriate place to end because the social determinants have opened up healthcare so much from when my dad was a doctor here in Nashville and I started my training, where it really was a doctor and a patient, a patient coming in with an illness and you’re treating them with the knowledge in your head and the experience that you had. And the transformation of that world has focused much more on the patient and the way the patient lives. Lowering the barriers in that ecosystem that they live so that they can live a healthier lifestyle, and that means health careers are not just the doctor anymore or the nurse, it is all those people who are providing the housing and the transportation and the-
Mary Grealy: Nutrition.
Bill Frist: Food itself. Mary, thank you so much.
Mary Grealy: Well, thank you. I was going to say, and what is so rewarding about that for me is it’s so important, and I’m sure your father felt this way, to have that patient as your partner. That you’re not just doing everything to them, but they’re working with you and I think that’s what we’re seeing now is an empowered patient, empowered consumer that is helping you as a provider of healthcare services be much more successful.
Bill Frist: And that’s exactly right. And the neat thing about it is you have now 300 million people out there who are real participants in the system, and not just 700,000 doctors or 4,000 hospitals. It’s really everybody has a role to play. Mary, thank you so much for being with us and look forward to having you back.. Thank you.
Mary Grealy: Well, thank you so much.
Bill Frist: You bet, thank you.
Mary Grealy: Great.
Bill Frist: This episode of A Second Opinion was produced by Todd Schlosser at the Modus Creative Group and Snapshot Interactive. You can subscribe to A Second Opinion on Apple Podcast or wherever you are listening right now, and be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show and our guest and sponsors at asecondopinionpodcast.com, that’s one word, asecondopinionpodcast.com. A Second Opinion broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services, where we engage at the intersection of policy, medicine, and innovation.