Datica Podcast

December 17, 2019

Innovation and Improving Healthcare

On this episode of 4x4 Health we dive into the major issues surrounding health quality, medication assistance, public health awareness, and physician leadership Beth Bortz. Beth is the current president and CEO of VCHI and offers her insight as a leader in these feilds.


Transcript

Dr. Dave Levin: Welcome to 4x4 Health sponsored by Datica. Datica, bringing healthcare to the cloud. Check them out at www.datica.com. I'm your host, Dr Dave Levin. Today I'm talking with Beth Bortz, president and CEO of the Virginia center for health innovation, VCHI. Beth has deep experience leading programs for health quality improvement, medication assistance, public health awareness, and physician leadership. Prior to joining VCHI in 2012 she served for nine years as the executive director of the medical society of Virginia foundation. Her previous roles include senior program officer and deputy director of the Virginia healthcare foundation and the senior associate legislative analyst for the Virginia general assembly's joint legislative audit and review commission or JLARC. Beth currently serves as a public member of the board of directors of the American board of family medicine and on the national task force to reduce low value healthcare. Is this that were not enough, she's also a graduate of lead Virginia and currently serves on its board of directors as well. Beth’s work has been recognized with several awards, including among others, the 2014 Virginia Leader Award from Lead Virginia, the Influential Woman of Virginia award from Virginia Lawyer’s Media and the Stettinius award for nonprofit leadership from the community foundation representing greater Richmond. From this introduction, our podcast listeners can surmise that Beth is on a mission to improve healthcare through her work with a range of nonprofit organizations including medical and professional societies, national and regional task forces, innovation and leadership development organizations, and those that focus on health policy development. In today's discussion, we're going to dive into the major issues these groups are taken on and how their roles are changing and are evolving healthcare system. Welcome to 4x4 health Beth.

Beth: Thank you. Good morning.

Dr. Dave Levin: So to get us started, tell us a bit more about yourself and your organization.

Beth: Sure, so my background is health policy. As you've explained, I’ve had a career that has spanned from working in government to working in the nonprofit sector to the state medical society and now really small business startup entrepreneurial work. And my goal in starting the Virginia center for health innovation with Virginia secretary of health and human resources, Bill Hazel several years ago was really to bring together those different groups that I had been working with. Recognizing that one of the biggest challenges that we face in health care is so many, secretary Hazel used to call them cylinders of excellence, you know, but they all work independently. And so I thought my background lent itself to trying to get the different stakeholders to work together.

Dr. Dave Levin: So you and I were talking before the podcast about your sort of your career journey and recount some of that for us cause it's a really interesting window into these opportunities to influence healthcare that might seem nontraditional or unusual for people who typically think about this I think as provider organizations or insurance companies. But I think it's also an interesting window into how the opportunities to improve healthcare, to pursue your vision have changed over time too.

Beth: Sure. Sometimes I tell people that my biggest opportunity actually hit me as a grad student and I’ve always been trying to catch up to that opportunity. So as a grad student, I was tasked with working with James City County, a local community here in Virginia who wanted their local health department to do more. And at the end of that study, what we created was something now called old town medical center, which combined the traditional local health services brought in volunteers in the community, physicians, pas, nurse practitioners, and actually created a free clinic model for the community. And it was so exciting to see over a three-month period how you could actually get something done. Then at the end of the day, patients got served, people got better care. So that was kind of my, wow, isn't this, you know, exciting. Then I went to work for the Virginia general assembly thinking like I could take that little experiment and apply it at the state. I will say after two and a half years, I was disabused of that notion, recognizing just how hard it is to get things done in a state bureaucracy. So I moved from that role to working for an organization called the Virginia healthcare foundation where on a daily basis my job was to be Santa Claus. I was the grants manager. I got to give away millions of dollars each year to improve healthcare, but that really trained me, one to look at all 140 cities and counties in Virginia and to try to understand what their unique needs were and to work with all different community players, two to try to figure out how do you evaluate if something's successful. You know, sometimes I will tell you people can be excellent grant writers and they're not so great really on frontline delivery. Other times people are excellent at providing services, but they're terrible grant writers. So I learned a lot in that process and then went to run the philanthropic and quality improvement side of the state medical society working with physicians every day. And I joke today that I can still hear physician voices in my head when I'm designing a program about what the challenges will be for frontline physicians today. And then really my current opportunity was bringing all those pieces together. So at the center we have a board and leadership council that includes more than 50 organizations, pharma, lab companies, state government, large and small businesses, advocacy groups, provider groups, health plans, health systems, you name it. And it took the ability to kind of talk the talk with all those folks. In fact, one thing I should've mentioned is we've purposely put our offices for the first two years at the state chamber because I didn't have experience with employers and needed that piece of it.

Dr. Dave Levin: So let's go a little deeper on this. The current organization you're with, because to some degree it sounds like it's that usual thing of, we want to get all the stakeholders at the table because we need to understand these different perspectives and somehow, we need to come together and compromise and find consensus and all of that. But I also imagined this is a classic herding of the cats as well. So tell us a little bit about who's around the table and why and some of the issues that you're taken on and some of the challenges of getting consensus and movement in a group.

Beth: So those of you that know Virginia or Virginia politics at all, we are a, what is called the purple state these days in that on any given election we can swing. We also in Virginia have a constitutional one-term governor. And so that really means that state government does not have a whole lot of consistency or continuity. And so in my role at the medical society, I really started to see that where we were going the transformation that was going to be necessary, I felt in healthcare was going to be more than a two- or three-year agenda. You were going to have to build trust, you are going to have to build relationships. This was going to be slow going. We were going to need data to drive our work and all of that was going to take an entity that lasted more than one governor's term. And so that was really the impetus behind creating the center in Virginia and we were fortunate that Virginia's general assembly and the governor got behind that concept, got behind the idea that we would be nonpartisan but would give us some resources to do the work. And then the idea was start slowing in the sense that it's all about relationships. It is all about getting people to come and sit down and talk about the things that they are willing to work on, what they're not willing to work on together and try to find the common ground. And one of the things that I’ll say is that when we first started, the issue that was the explosive issue in Virginia was whether or not we were going to expand Medicate. That every state was wrestling with that, in Virginia that was particularly toxic. It went on for six years, you know, it overshadowed everything. We chose purposely to choose the 80% that I think most people can find some agreement on and left that issue for others to tackle.

Dr. Dave Levin: There's something really interesting in what you said there and it seems to be a theme in these groups where you've got multiple stakeholders, which is at the beginning come into a consensus on what are the things where we actually could work together and what are the things that are just, they're just too hard, they're too toxic, they're just too radioactive, that it will be counterproductive to the group and we're unlikely to succeed. So let's set those aside. As you said, let's figure out the 80% where we actually might come together and do something meaningful. I think that's a really interesting idea and it requires a depth hand of leadership as well, doesn't it?

Beth: It does. And I think it what it requires is an agreement on focus. We agreed early on that the mission of the center was going to be to accelerate value driven healthcare. That was a pretty easy agreement until we started getting into how are we going to define value? How are we going to measure value, how are we going to incentivize the value? And so we really had to spend the time upfront to build consensus. Just around definitions and data sources and how we were going to measure things and build comradery among the group and acceptance among the group. The other thing I would say is we very purposely chose in the early days, things that we thought might not be huge in scale but would be wins, little wins that everyone would feel somewhat good about. Now, you know, I will tell you the truth and I say this on a regular basis in my office. I'm not doing my job if some member isn't mad at me that day. The system does have to change. My goal is to make sure that the person that's mad is rotating, you know, so that as we're working on things, it's going to change to different folks and that's also how you build trust.

Dr. Dave Levin: Yeah, that's really interesting. I think the definition of a good compromise is everybody walks away a little bit unhappy and that's how you've known that you've done at well. The other thing that's very interesting to me as you talk about all this Beth is, it's clear you are a master of change management that as you've talked about these issues, I mean some of the usual stuff comes up about, you know, we need data and there's some proven ways of going after quality improvement. But to me, what's so striking about what you're doing is it all comes down to leadership and change management in many. How do you get these people around the table? How do you facilitate a productive dialogue? How do you manage your way through some of the inevitable conflicts? So to me, I'm sort of just stating the obvious here. There's sort of two questions that buried in there. The first is in the case of the Virginia center for health innovation, why are these people even at the table? Why are they showing up? You know, none of us have time to do all the stuff we need to do. So why are they there? What's motivating them? And then any little anecdotes or stories or thoughts that you may have about this issue of change management. And as you said, building trust, building relationships, that this aspect of the work.

Beth: Sure. So I’ll start with that first part. Why are they there? And I think there are several reasons that they're there. The first, you know, I think it was critically important when we set the organization up. I spent a lot of time trying to figure out if I could do what I thought needed to be done within an existing organization. The last thing I actually wanted to do was to start a new entity. You know, there's lots of nonprofits, there's a lot of challenges. You spend a lot of time. So my original goal was to see, could we house this somewhere else? And we spent about six months exploring other options. And the truth is that as long as any of those options had a financial interest in the outcome of the group, we were not going to have the credibility that we needed. And so it became very clear that this had to be an entity that had no financial skin in the game at the end of the day. And so that might be one of the best things that we did was to recognize that even if the same person had been trying to do it, if I had been doing it under a different structure, we probably would have failed. The idea of public private partnership was also critical. The fact that we had at the time a Republican governor and a democratically controlled general assembly interested in this work and we got leadership from both parties invested in this. That was important. The fact that the state put some money up initially, $1.6 million gave us some gravitas as we got out of the gate. But really what was important was the relationship. So I mean I’ve been in healthcare for 20 years and I personally went in the early days and asked Nancy Agee CEO of brilliant health system who just finished a term as president of American hospital association to be a founding board member. You needed people that other people wanted to be on the board with or on the leadership council with. That's just part of it. And then I would say the final piece to that was we needed to make sure that every time folks came to a meeting, we use their time exceptionally well, and so we made sure we, they walked away from those meetings feeling like they got things that they got nowhere else. They would know what the latest and greatest was happening in Virginia at a time where healthcare is changing rapidly. That was really the ingredients I would say to getting them around the table.

Dr. Dave Levin: I mean that's just a tour de force and how you do change management and how you bring people together. It's just fabulous. And the other thing that's just striking to me as you talk about this work is there's this theme of leadership and I think buried in that as well, culture as well, and regular listeners to this podcast know that I'm sort of fanatical about these topics. As I often say, I’ve come to believe culture is the work and everything else is a byproduct of that. I also always acknowledge that's kind of an extreme position, but as I listened to you talk about what you've done, it's as much about how you do the work as the focus, the content of the work itself.

Beth: Absolutely. I would say that, you know, one of the lessons that I’ve learned is I am willing to sacrifice what looks to be a short-term win to maintain a long-term relationship with our partners. There was no escape. You know, you're in Virginia, it's a pretty small network. You're going to be working with these folks hopefully for the next 20 years. So there is no grant, there is no project that is worth burning a bridge if there is a way that you can work through to a better outcome.

Dr. Dave Levin: Yeah, gradual change we can believe in. Right.

Beth: Exactly. And recognizing that everyone is going to be a little uncomfortable. You know, we have said that, and you know, as I said, I get phone calls all the time from a partner saying like, "Hey, what are you doing to my industry? You know, my piece of it here" and as long as I can point to three other things, I’ve done to their peers sitting at the table, then they're, you know, willing to continue to talk. And I guess the word that I want to make sure I get out there is transparency. We work really hard to share everything we're doing, all the meetings, we're having all of our funding, all the data sources we're using because if we don't have that, we don't have a leg to stand on.

Dr. Dave Levin: Yes. And it's this trust and transparency in these personal relationships that really are the foundation of bringing these folks together and seeking common ground where you can find it. And I guess this also just points back to the first thing you said about the transparency around this is the stuff that I can work on and this is the stuff that's just really, you know, it's no go, it's a red zone and I can't compromise here or it's just going to be too hard or too painful.

Beth: If I could, I'd love to give you an example early days that I learned so much from, and we were bringing a group together to work diabetes improvement in the state, and one of the first things I found was that I was the first person that actually got the endocrinologist from the different health systems to meet each other, which was shocking to me that they didn't know each other and to have a conversation. And then we brought in some, those days, it was early social determinants of health people at each of the health system and we all sat around the table and started the meeting and I started the meeting with, what are you not willing to do? That was question number one and very quickly what I heard from the different health systems are, we're not going to change our clinical protocols for some project you're putting together. We've been working really hard on them. We think we have something in place that's going to work and UVA, BCU, they're not all going to do the same thing. That was great. Within 10 minutes we had that on the table, and I said, "okay, what will you do together?" And then they all started talking about how when people leave the clinic walls, they need a whole lot of supports and they're all not very good at that and so they would love to partner together to explore that piece of it and that's how we work. We try to find those pieces where they can work together.

Dr. Dave Levin: Yeah, I think there's this really interesting overarching theme in healthcare that we've been on this journey from healthcare basically as something individuals do to healthcare becoming a team sport, and I think it's reflected both at the within provider organizations where more and more the workflow, the discussion, the understanding of delivering quality and value rests on. This is a team activity and everybody operating a top of licensure and all those components, but I also sort of see this in a larger theme of the way you've described these different organizations coming together to figure out how they can kind of be a team as well. Maybe I'm stretching this too far and Beth this is the moment where I always remind my guests, always feel free to call BS on the host. We encourage that. We urge you to be on guard for that, but so, you know, call BS on me or elaborate it as a point.

Beth: Well, it's a team sport, but one of the things I’ve had to learn is it's also there are competitive financial interests here and so you're constantly asking the folks around the table to juggle, that inherent wanting to do the right thing, which I still believe people sitting around the table want to do, that they want to provide better care for patients. They want Virginia to be a top state in every category that we look at. But then at the end of the day, they have to go back and wrestle with market share. And so one of the things that, lesson learned early on, which was fascinating to me when I started looking at grant applications in Virginia, I found that some of our leading health systems and academic medical centers were more likely to partner with a Geisinger or a Mayo or a Cleveland than each other. And so that was troublesome to me because you don't achieve scale in Virginia if it's a partnership between UVA and Geismer. I wanted a partnership between UVA and Carillion and BCU and you know, so I started asking a lot of questions and one of the things I found was as simple as the others could not be the fiscal agent for the others. They would never agree to a grant where let's say BCU got the grant and UVA was a subcontractor, but they would agree to both being subcontractors under me, cause I'm not a competitor for them. And when we figured that out, that's when we won one of the big federal grants together.

Dr. Dave Levin: So to me, I call this the man in the middle solution. And we have all kinds of situations like this in healthcare. So providers and payers, for example, have been fighting over reimbursement since the Dawn of time. It's really hard to get them to sit down and talk about quality improvement and sharing data and these things because of that background. But as you say, there is an opportunity to have a third party. A kind of trusted entity in the middle that can broker that sort of thing. To me another parallel is pharma research where you know, big pharma wants to work with provider organizations and obviously we can do better clinical research that way, but there's trust factors too. And so this is an emergence of these third parties, typically clinical research organizations and others that sort of sit there as the trusted broker in the middle. So I want to take a slight detour into the world of medical societies and professional societies, because I suspect many of our listeners know very little if anything about them. And so if you could take a moment, tell us a little bit about your work with the medical society of Virginia when you were executive director there and your involvement with the American board of family medicine. And just briefly about well, what are these organizations, why do they exist, what are they trying to accomplish and how have you seen things evolve over time as the healthcare landscape evolves?

Beth: Sure and I’ll start as a non-clinician, non-physician. One of the things I had to learn and so might be helpful for many of your listeners is that when you talking about societies, there's typically either two organizations or two arms, so, let's talk American board of family medicine, American board of family medicine is the certification really quality improvement side. The American Academy of family physicians is the legislative lobbying side. Think more trade association representing the interests of their members and that was really an important thing for me to learn because I tend to be much more on that sort of vacation quality improvement than I am the lobbying advocacy side of the house. Within States, there's usually not two entities, so at the state medical society here I ran the philanthropic and quality improvement side of the house. I did not have engagement in the advocacy side, and I think one of the challenges for societies is that, you know, there's always this tension between those roles and I think at times for a variety of reasons that quality improvement, philanthropic side has gotten lost. Sometimes the voices get very loud on the advocacy side. And the problem is, is that when the public only sees kind of that self-interest side, you lose trust in the profession. And I think truthfully, even the profession itself starts to wonder, why am I a member of this organization, it doesn't speak to me. And just in general, and it's not just a case that we're seeing in medical specialties, but really in all professional associations. The current generation has a very different feeling about whether or not I'm supposed to do anything. Our grandfathers joined those associations because that's what you did and they aid their dues, you know and that was it. Today's organizations are much more diverse, both culturally, gender. There's just a lot more diversity. And there's a lot of folks questioning that whole advocacy side of the house. I mean, even at the national level, right? You had the AMA, where you had a whole break-off organization called the national physician's Alliance, which was a younger, more progressive organization. So there's just a lot of turmoil in this society world these days.

Dr. Dave Levin: Yeah. And you know, there's clearly, there's this other theme running through our conversation and it's this paradox about service and the need to want a profitable organization, a sustainable organization. The expression many of us use as we quote the nuns who have run the Catholic health systems who, you know, were famous for saying no margin, no mission. I believe that. But of course if there's no mission, there's no reason to have a margin. And so it's one of life's paradoxes, one of these polarities in life where we have to balance these things. I think you and I both share the view that the vast majority of people in healthcare, regardless of their stakeholder role, are there because they really care about health care and they want to make, they want to make the healthcare system better. But we also have to be realistic about what we can do and the resources we have. And the fact that, you know, and I’ll just be blunt about it, the US healthcare system is a terrible value right now. We pay way too much for really bad outcomes.

Beth: What a fabulous segway into our work.

Dr. Dave Levin: Exactly. So, I mean, the good news is there's huge opportunity for improvement there. And I'm not going to ask you to agree with me on this, but it makes me sad. I think physicians, my tribe have really missed an opportunity in reinventing the healthcare system that we did not step into our power and take a bigger leadership role and ownership of both the need to transform the healthcare system and the ways to do it that would be pleasing to not just to the providers, but to patients and more affordable as well. And again, you know, I know that's a bit of a, you know, I just threw a bomb there. I'm not necessarily, the good news is, I think I see more of this now.

Beth: That's what I was going to tell you. I mean, we have a new project that we have underway here at the center that we have 7,000 physicians, pas and nurse practitioners that have raised their hand and said, we want to be a part of it. So, you know, I think yes, there may have been some missed opportunities, but there's a whole lot still to do. And I do think that if you ask in the right way and you give people the right tools and you meet them where they are, they do want to engage in doing the right thing.

Dr. Dave Levin: And I too have seen this more and more. And I think the other thing is we get better at collecting data that's actually useful and understanding quality and safety and these other things, it gets easier to build consensus around how to use those things. If you just joined us, you're listening to 4x4 Health and we're talking with Beth Bortz, president and CEO of the Virginia center for health innovation. Beth, what's the most important or interesting thing you're working on right now?

Beth: Sure. So I mentioned early on that we are about accelerating the adoption of value in healthcare. And so about two years ago we started working on creating the Virginia health value dashboard, a very limited set of measures that look at three aims. Are we reducing low value care? Are we increasing high value care, and do we have the tools in place to measure and reward value in the Commonwealth? And so we have been purposely narrowing our focus to projects that fall under that rubric if you will. And the biggest initiative that we have and personally the most exciting is that we are doing something called smarter care Virginia. It is an initiative with funding from Arnold ventures that involves six of Virginia's health systems, three clinically integrated networks, a thousand practice sites, 7,000 clinicians. We also have an employer task force that includes Virginia's largest employers all working together. And the goal to reduce low value care. So we have data in Virginia, we use a tool called the health waste calculator and Virginia's all payer claims database where we have looked at the data for the last four years of 5 million Virginians. So a really good data set that includes commercial, Medicare, Medicaid and we can now report on how many of a certain set of what are called low value services that have no clinical value and may actually cause harm to patients. We have looked at 42 of those, we've chosen seven that we want to work to reduce and we're promising to achieve a 25% relative reduction in those. And when we look at, to give folks a sense of the scope of this, when we looked in 2017 at just the 42 measures that physicians themselves identified, so this is the physician community saying we shouldn't do these things. They're unnecessary and they're potentially harmful. Those 42 we've found that cost Virginia $747 million in one year. So to me this is a joke. This is a low hanging fruit. This is the fruit on the ground, right. This is the community saying we shouldn't be doing it. It could be harmful. It's expensive. So let's all figure out why it's happening and how we do less of it because then we can reinvest in the other side of the house, which is the high value stuff, the immunizations, the cancer screenings that we're not doing enough of.

Dr. Dave Levin: Well, what a great example of you bringing together all of these scenes we've been talking about, you know, focusing on places where we can agree, looking for high leverage areas where it really makes a difference. Driving value, so more services, better services at lower cost. It all really comes together there, doesn't it?

Beth: It does. And we could not do this if it weren't for the fact that our health systems and clinically integrated networks raise their hand and said, we want to do this. This is important to us and let's be honest, if we don't change the financial side of the house, which is why we have the employer task force to help us do that, they're actually going to lose money. I mean, in a fee for service world, they get paid for these things. So you know they're doing the right thing there. They're the early adopters with me of working on this. We spent four years vetting the data with people. That was critical. People weren't going to engage in this with me if they didn't believe that we had good quality data. We actually in Virginia can show you for the seven measures we're working on by provider and by NPI number, how much of this is happening. So we can do it by physician, by practice, by health system, by region, by type of insurance. And we've sliced and diced, and people are comfortable now with the data.

Dr. Dave Levin: Yeah, we could probably do a whole show on what I call the Kubler Ross stages of dealing.

Beth: Absolutely.

Dr. Dave Levin: But we'll set that aside for today. Beth, you warn me that I should be careful asking you about rants. So before I turn you lose, I want to remind you that this is a PG 13 show. So I do want to hear your favorite pet peeve or rant, but if you could keep it family.

Beth: Absolutely. Well it actually, you led up to it with your Kubler Ross statement and it goes back to the data. And what I was going to say is we have played 50 ways to deny the data so many times here in the Commonwealth. And so, you know, my conversation has been, please do not let perfect be the enemy of good. If we have data that shows, for example, that we are spending 25 million a year in unnecessary vitamin D screening. If the real number is 26 or 24 it really doesn't matter. What matters is, is we're doing way too much of it and sometimes people get so caught in that space of all the little here, what about these five exceptions that I should have ordered the test for? I'm not saying we need to get that number to zero, but we certainly need to do much less of this. And so that really is my personal, let's use the data but let's not get so caught up in all the reasons we think there might be something wrong with the data to not move forward on the action that we need to take.

Dr. Dave Levin: Yeah, I mean I really think many of us go through the four stages when confronted with data that makes us unhappy and you know, so first we deny it and then we get angry about it and then we try to bargain. And I think that's part of what you're describing is the bargaining of, "yeah, yeah, but what about this exception? And my patients are sicker" and all the other excuses we've heard. And then eventually we get to acceptance and that's when we can really begin to work on the problem.

Beth: Yeah. Well and one of the things that we have found is that truthfully most physicians, when you look at a range of measures, there are very few that Excel in all and there are actually very few that do poorly in all. It's usually, I mean they're all in the middle, but some might do well on one or two and poorly on one or two and they can learn from each other. And if we remove, you know, the gotcha approach to this, I have no gotcha. I am just here to help you do better on behalf of your patients. And usually when we get people there, they become receptive.

Dr. Dave Levin: Yeah. I think this is really important and in defense of our colleagues, I think we also have to acknowledge there's a long history of bad data and using data inappropriately on the like and I think that people got burned by that.

Beth: I think you're absolutely right and I think it's why we couldn't have undertaken the initiative that we are doing now if I had not spent really almost three years doing town halls with every group imaginable and letting them kick the tires on the data.

Dr. Dave Levin: Yeah. I'm going to go on one of my little rants here for a minute and again, I'm going to throw a bomb. I don't expect you to necessarily respond to it. What we basically suck at data governance and data management and healthcare and it's been really, I think, uncovered and revealed in a big way post deployment of these EHR AREs where now we're trying to get the data out and do good things with it. And very often what we find is our data management practices and governance are so bad that the fuel that we thought we were going to use for advanced analytics and other things is dirty.

Beth: I’ll give you a great example. We did an initiative a few years ago with HRQ that involved more than 200 primary care practices across the Commonwealth. All regions, all different sizes. Some were mom and pop, some are part of big clinically integrated networks. What I found was that first of all, 200 practices, 38 different EHRs, so we had to get data from, and even when you say you have, and I won't name a particular system, but such and such. It totally depends on what modules you purchased and what year. And so even when you think you have some harmony, you don't. And truthfully a lot of folks, I will say my opinion got sold a bill of goods. These systems don't do what they were promised they would do. They're very difficult to navigate. And so docs are incredibly frustrated at what they believe is the time they've invested and what they're getting out.

Dr. Dave Levin: All right, so you just threw a bomb I'm not going to respond to, but regular listeners know that I would agree completely and that as I often say, I was both a perpetrator and a victim of those systems and hence part of my dedication to try and to push us forward to the next part. Let's wrap up today and you've already offered a lot of Sage advice today, but what's your most Sage advice Beth?

Beth: The biggest lesson I have learned is that I'm a fairly impatient person. I like, you know, when I see a problem, I want to tackle it, I want to get it done. And sometimes, you know, I err on the push really hard, really fast and one of the things that I have learned in this role has been sometimes to sit with it for a couple of days and then figure out who can help me, you know, who can help either deliver the message about a challenge that we're having. You know, how to approach it and to resist that temptation to just be upset and reach out in the moment. Because again, so much of this change, it's the individual project is important, but it's the relationship and the long-term.

Dr. Dave Levin: Well I think that's incredibly Sage advice and being patient with we and being patient with each other and with the process, yeah, it's been a lifelong for me as well. But I think it just acknowledges human nature and sometimes we make our biggest mistakes, or we provoke the biggest backlash when we try to go too far too fast.

Beth: Absolutely. And you know, and sometimes I'm trying very hard with our folks to be a much better listener because I have learned that how the employer sees it, it is different than how the health plan sees. It is different than how the health system sees it is different than the frontline physician. They all operate in different environments and so it's really important to hear their concerns and take time to work through those and not just sit in my office and design what I think is the perfect program.

Dr. Dave Levin: Yeah. Cause that's unlikely to work cause it's probably not perfect and nobody feels any ownership and it's so it's your program, it's not our program.

Beth: Absolutely. And sometimes in those experiences, the things that you hear are really surprising and its sometimes really little roadblocks or really surprising partnerships that changed the whole nature of a project.

Dr. Dave Levin: I think when you're done, we're going to need to send you to the middle East to broker peace. Perhaps you can resolve the trade dispute with China. I'm not sure.

Beth: Yeah, well I think there's plenty to do and health care still.

Dr. Dave Levin: You know, the other thing that's occurred to me today is you sit in a really interesting environment for this work. I know we both share a love of Virginia, but Virginia provides a real, I think an interesting laboratory, if you will. We're very diverse, geographically diverse, we're economically diverse, educational, pretty much on any dimension, I think. And so if you can make these things work across the state of Virginia, there's probably important lessons and scalability to many other environments around the country.

Beth: It's interesting that you said, because we just had Altarum came and did their consumer healthcare experience state survey in partnership with us. And they said to me, does it seem right that you have the biggest regional differences of any state that we have worked on in terms of attitudes about things? And I said, it absolutely seems right. And one of the lessons, you know that I’ve learned, so next week I’ll be going too far Southwest Virginia to do a training on HPV vaccination. And it would've been really easy to do it in Charlottesville or Roanoke or Richmond, but it needed to be done in Abingdon because I will not get the buy in from those providers if they think this is Richmond on high.

Dr. Dave Levin: That's right. That's right. Well, Beth, this has been really terrific. Thank you so much for taking time today and sharing, the really exciting work you're doing and the bridge building and collaboration that you're fostering. It gives me hope for the state of Virginia for improving healthcare in our state, and I think it provides really valuable insights that others could benefit from. So thank you for that.

Beth: It's been my pleasure.

Dr. Dave Levin: We've been talking with Beth Bortz, president and CEO of the Virginia center for health innovation. Beth, thanks again for joining us today.

Beth: Thank you.

Dr. Dave Levin: You've been listening to 4x4 Health, sponsored by Datica. Datica, bringing healthcare to the cloud. Check them out at www.datica.com. I hope you'll join us next time for another 4x4 discussion with healthcare innovators. Until then, I'm your host, Dr Dave Levin. Thanks for listening.