Trading the C-suite for community impact
Scott Reiner was 49 when he took over as the CEO of the Adventist Health System. Eight years later, at the peak of his career, he walked away. In his conversation with Judson, Reiner reflects on his journey and his work to improve healthcare delivery in communities in both Africa and the United States.
In this scrollstory, we offer some background information and context for selected topics that come up in the podcast. Either scroll down or use the navigation bar at the top to hop to specific topics.
Nonprofit hospitals and the community
“Health means a community is actually involved … there's an ongoing dialogue and conversation about the role of that provider, or the role of that health system in your community. Especially as a nonprofit, even more so. You essentially are foregoing taxation in order to do something for the benefit of that community… So there's a little higher calling, I think, than providing only medical care. I think I've always felt that.”
In the quote above, Reiner touches on the controversy that has erupted in recent years over nonprofit health systems and their roles in their communities. The essential bargain of nonprofit health systems is exemption from federal and some state taxes in exchange for providing “community benefit”. That community benefit is defined by the requirements included in IRS reporting standards, which list criteria that health systems must meet to quality as tax-exempt: 1) benefit a class of persons broad enough to benefit the community; 2) operate to serve a public rather than private interest; 3) operate an emergency room open to all regardless of ability to pay; 4) maintain a board of directors drawn from the community; 5) maintain an open medical staff; 6) provide care for all patients able to pay, including those with Medicaid or Medicare; 7) use surplus funds to improve facilities, equipment, and patient care; 8) use surplus funds to advance medical training, education, and research; and 9) provide free or subsidized care to the indigent.
A number of recent publications have argued that nonprofit hospitals were skirting the intent, if not the letter, of the law regarding these obligations and some authors have called for reform of the standards. The issue finally shot into public attention near the end of 2022, when the New York Times ran a widely read piece on the behavior of the Providence hospital system in the Pacific Northwest, particularly the tactics they used in aggressively pursuing payments from poor patients. Similar practices were reported in early 2024 on the part of the UCHealth system in Colorado, which over a 5 year period reportedly filed almost 16,000 anonymous lawsuits against poor patients on behalf of debt collectors. While both of these hospital systems have vigorously denied wrongdoing, these stories do provide a stark window into the perspectives of patients fighting not only serious illness but also debt collectors and hospital lawyers as they struggle to recover their health and pay their bills.
Wellness and the Blue Zones
“Think of Blue Zones as an example. They work very hard to try to create an environment in the community that would create nudges or conditions that would allow the person the greatest chance of managing their health.”
One of Scott Reiner's recurring themes is the role of "wellbeing" in health. The notion that a broader view of health, one that includes factors like an individual's lifestyle choices and environmental exposures, could be the basis of a more effective healthcare system has traction in many quarters these days. And this view is in many ways compatible with more traditional ideas of preventive medicine, population health, and the role of social determinants of health. The story of "blue zones", though, highlights some of the tensions around these ideas.
Blue Zones is a term that has been used to describe areas of the world in which residents have unusually long lives. The origin of the term was actually just a color mapping choice in this landmark 2004 paper about longevity in Sardinia. The authors identified localized areas in which the number of centenarians (people over 100 years old) was as much as 3 times the average for Sardinia. The paper speculates that such "longevity hot spots" may be a result not only of cultural, environmental, nutritional and lifestyle factors but also of genetic factors brought out by the high rate of inbreeding in these relatively isolated, typically mountainous communities. Interestingly, the unexpected longevity was more apparent in men than in women, raising additional questions about the role of sex chromosomes or hormones in blue zone lifespans.
Over time, though, much more public attention has been paid to the lifestyle and environmental characteristics associated with extended lifespans in Blue Zone communities than to the possible genetic factors mentioned in the original paper. Additional work by National Geographic Explorer and author Dan Buettner later expanded the original list of Blue Zones from Sardinia to include Okinawa in Japan, Nicoya in Costa Rica, Icaria in Greece, a 7th Day Adventist community in Loma Linda, California, and Singapore.
Buettner trademarked the term “blue zones” in 2005, and then in 2008 he published a well-known book on the topic and also established a marketing company named Blue Zones, LLC. In addition to a Netflix series and a number of other books and articles on the topic, the company commercialized the Blue Zone concept into a community/real estate certification program and began offering cooking classes, apparel, and coffee, among a number of other wellness-related “brands and solutions.” In 2020, Adventist Health, under Scott Reiner’s leadership, purchased Blue Zones, LLC as part of a planned foray into the business of wellbeing.
Perhaps unsurprisingly, the successful global branding of the Blue Zone concept has also led to controversy about the validity of the original scientific observations. That controversy is nicely summarized in this article from 2024 from the journal, Science.
Poverty and health
"It started with our work in Zambia, actually, and this could be very much related to an impoverished community, although there are an incredible amount of impoverished communities around America as well. I think the two things that people hunger most for are health and income. If you don't have health, you can't generate income, right? And if you don't have an income …. So health plus income has a multiplier effect."
As you hear in the interview, after stepping down as CEO of Adventist Health, Scott Reiner turned his energies and insights to leading The Reiner Foundation, a family foundation committed to advancing global wellbeing. Through the foundation, he helped launch Common Wellbeing, a social venture lab that builds and tests community-based solutions to poverty by creating mission-driven businesses and nonprofit organizations. Common Wellbeing has incubated two early-stage ventures now operating with local leadership in the country of Zambia in south-central Africa. Kuwala Zambia focuses on skills training and income generation for women in Zambia as a pathway to improving community health, while Anchor Health Partners focuses on strengthening maternal and child health systems through reliable logistic and clinical supply support. In Reiner's words, "both organizations are core examples of Common Wellbeing's model: locally grounded, impact-driven ventures that work to create the essential conditions for lasting wellbeing." While still at an early stage of development, with limited information available to date about the outcomes their work is achieving, these initiatives reflect Reiner's belief in empowering local changemakers, building self-sustaining systems, and demonstrating how health and economic opportunity can be scaled through entrepreneurial approaches.
Judson mentions studies by the World Bank on the benefits of investing in healthcare as a strategy to address poverty in the developing world. The World Bank is an organization that was created in the aftermath of World War II specifically to provide loans to low and middle income countries as a way to increase economic development in those parts of the world. Beginning in the 1970s, the bank re-focused its efforts around facilitating development by reducing poverty, and its interest in healthcare has primarily been secondary to its focus on economic concerns. This World Bank brief from 2014 provides a short summary of the bank’s views on poverty and health. These themes appear again in this 2024 blog post noting that “without access to essential health services, millions remain trapped in cycles of poverty”, an observation that takes on additional poignancy given recent changes in the US government’s commitment to foreign aid.
As a side note, the president of the World Bank from 2012 to 2019 was Jim Yong Kim, a physician who, along with Dr. Paul Farmer, co-founded Partners in Health, an NGO working on community health in the developing world. For readers looking for inspiration to work to make the world a better place, check out the 2017 film Bending the Arc, which tells the inspiring story of Farmer and Kim’s work together.
The name Jay Forrester also comes up in this section of the interview. He may not be familiar to many viewers, and his link to healthcare may not be immediately obvious. Forrester was an MIT engineering professor who did early work on semiconductors, created the first computer graphics, and is considered the founder of the field of system dynamics. He wrote a book entitled Urban Dynamics in 1969, which outlined his thesis that the root cause of economic decay in cities was a shortage of jobs and that creating low-income housing without addressing jobs would worsen rather than improve the economic situation. He later developed models of “world dynamics” that included population, food production, and pollution among other variables. His global modeling work served as an inspiration to Donella Meadows, an environmental scientist at Dartmouth College whose work on systems thinking, and in particular leverage points in a system, has been an inspiration to the Healthcare Reframed team. More information on Meadows' work is available here at The Donella Meadows Project website, and more information on Forrester’s work can be found here at the Systems Dynamics Society website.
Judson and Scott Reiner spend a bit of time here discussing the consequences of poverty for health in Zambia, but it goes without saying that poverty remains a significant problem for health in America too. Check out this article from Health Affairs in 2018, which makes the case that the US is a society with extreme wealth inequality, and that wealth inequality is in turn associated with extreme inequalities in the risks of death and disability. In other words, poverty and poor health are inextricably linked, both in Zambia and in the US. For those interested in a broader take on this problem, check out the 2010 film Poverty, Inc., as well as these two excellent books written by Pulitzer Prize winning author Matthew Desmond, Poverty, By America and Evicted: Poverty and Profit in the American City.
The Camden Coalition
The theme of poverty in America also ties in to the work of the Camden Coalition. A good entry point to the story is this article by Atul Gawande entitled “The Hot Spotters” that appeared in New Yorker in January 2011. The story begins with an observation made by a family medicine doc named Jeffrey Brenner, who was working in the impoverished inner city neighborhoods of Camden, New Jersey. Brenner discovered that healthcare costs and utilization were not evenly distributed across the population of Camden, but that instead a small number of people - who he termed "hot spotters" - accounted for a large percentage of those costs. National studies have since shown a similar pattern, with just 5% of the population accounting for over 50% of US healthcare spending.
Brenner noted that the Camden “hot spotters” tended not only to have multiple serious medical problems but also to frequently have issues with nutrition, housing, joblessness – what we now commonly refer to as “social determinants of health” – and they were frequent users of ambulance services, emergency rooms, and hospital stays. Brenner believed that treating these patients’ complex chronic medical problems without also treating their social problems was largely futile. He assembled a multidisciplinary team to build a “medical home” for the high-utilizer patients – a team that became known as the Camden Coalition. Gawande’s article reported a series of heartening anecdotes about how such comprehensive and integrated care changed the lives of these very sick patients for the better, and in the process saved the healthcare system a lot of money. The article ignited a firestorm of publicity and multiple similar demonstration projects, but hard evidence of the benefits of the approach was missing.
To answer the question of whether the Camden approach actually improved health and reduced costs for the hot spotter patients, Brenner and the Camden Coalition teamed up with Amy Finkelstein (a healthcare economist then at MIT), to run a prospective randomized controlled trial. The study involved almost 800 hospitalized patients and was published in the New England Journal of Medicine in 2020. The study team enrolled patients with complex chronic medical problems who had been admitted to the hospital in Camden. Patients were randomly assigned to receive either routine post-discharge support and care (the control group) or to receive a package of support including home visits, intensive care coordination help, and assistance applying for social services and mental health programs (the intervention group). The two groups were compared to see if the intervention led to any differences in healthcare utilization in the next 6 months after leaving the hospital. To the great surprise and disappointment of many observers, the analysis showed no effect of the study intervention on their study’s primary outcome – the 180-day hospital readmission rate. Interestingly, the reason that the study intervention did not appear effective was that the readmission rate dropped almost 40% in both the study intervention group and in the control group, even though the control group received none of the additional care coordination or support services. Extensive and largely unresolved debate followed about whether the negative study results were due to design and execution flaws in the study, or to unplanned practice changes in the control group as a result of publicity about the topic, or to the basic hypothesis simply being wrong.
Finkelstein published a secondary analysis of the original trial data in 2024 showing that the study intervention did in fact result in intervention group patients receiving more outpatient medical care than control patients. These results suggested that intensive care coordination can increase usage of outpatient primary care services by “hot spotters”, but that change by itself does not appear to be enough to overcome the health challenges those patients face and keep them out of the hospital. Whether a better solution lies in even more intensive and consistent social support to help patients achieve the broader definition of health and wellbeing advocated by Scott Reiner and others, or whether answers for how to best serve these patients lie in other unexplored directions is a question that remains to be answered.
Malcolm Baldrige and "the Baldrige mindset"
Malcolm Baldrige is a name that came up in a surprising number of the interviews in this series, including this one. H. Malcolm Baldrige was an American businessman who was appointed Secretary of Commerce under President Reagan. A devoted and lifelong horseman, he died in 1987 at age 64 as a result a rodeo accident, and he was later inducted into the Pro Rodeo Hall of Fame.
He was best known for being a strong proponent of “quality management", a phrase which in general describes a framework for improving organizational performance across a number of key areas, including leadership and governance, operations, processes, workforce, customers, finance, strategy, organizational learning, and community relationships. His concepts of being focused on "the voice of the customer" (i.e., patient-centered care), of systems thinking, and of visionary leadership that values the workforce are especially relevant to the conversations in this podcast series.
The US Department of Commerce gives the Baldrige Award annually to organizations that demonstrate achievement and improvement in the key business performance areas listed above. Winners of the award have included such familiar names as Motorola, Texas Instruments, Ritz-Carlton, and Boeing. Among the winners in the healthcare division are two awards given to the Southcentral Foundation in Anchorage, Alaska, which is featured in an upcoming episode of Healthcare Reframed.
References
- "Revise The IRS’s Nonprofit Hospital Community Benefit Reporting Standard", Health Affairs Forefront, April 15, 2022. DOI: 10.1377/forefront.20220413.829370
- "Profits Over Patients", The New York Times, September 24, 2022.
- "UC Health sues thousands of patients every year. But you won't find its name on the lawsuits", The Colorado Sun, February 19, 2024.
- Michel Poulain, Giovanni Mario Pes, Claude Grasland, Ciriaco Carru, Luigi Ferrucci, et al. Identification of a geographic area characterized by extreme longevity in the Sardinia island. Experimental Gerontology, 2004, 39:(9), pp.1423-1429.
- Ignacio Amigo. Shades of Blue. Science, 2024, 386:(6724); pp 840-845.
- Best M, Neuhauser D. Did a cowboy rodeo champion create the best theory of quality improvement? Malcolm Baldrige and his award. BMJ Quality & Safety 2011;20:465-468.
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