Renee DeSilva 0:06

Welcome back to the Academy Table. I’m Renee DeSilva, CEO of The Academy and your host. In this episode, I welcome Sarah Krevans, president and CEO of Sutter Health in Northern California. As you’ll hear, Sarah is an incisive thinker, a leader on many of the pressing issues in health care — COVID, maternal health equity, the value of integrative networks, and the future of care delivery. We covered a lot of ground, but I’d like to call your attention to three of my takeaways. First, listen to Sarah articulate the importance of both equal treatment and equitable outcomes. This requires us to differentiate care for certain patients and that can run counter to our DNA in health care. This comes to life in our discussion on maternal health. Next, I love how Sarah used the car analogy to describe the future of care. Do we change the experience of driving or the car itself? Sarah says both and I agree. Finally, the art of the possible can be informed by a view of history. Sarah has a deep respect for not only her personal and family history but also the industry as a whole. Final note, we recorded this episode a few weeks before Sarah announced her retirement. Although I couldn’t congratulate her live, I did want to take a minute here to celebrate her 22 years of service to Sutter. With that, let’s head to The Table.

Renee DeSilva 1:38
Sarah, good morning. So happy to have you with us at The Table.

Sarah Krevans 1:41
Good morning. Delighted to be here.

Renee DeSilva 1:44
I would love to start by understanding a little bit about your career path and how you arrived in your current role today as president and CEO at Sutter Health?

Sarah Krevans 1:55
It’s a great question because when you get to be my age, you look back and often say, “How did I get here?” I’ve yet to meet a child who, when asked, “What would you like to be?” says, “I’d like to be the CEO of an integrated delivery system.”

Renee DeSilva 2:11
Right?

Sarah Krevans 2:11
When I was a kid, such a thing didn’t exist. Even when I was in graduate school, there were very few integrated delivery systems and certainly nothing like what we see in the United States today. As a kid, I had the usual ambitions. I went through the stages of wanting to be a writer of children’s books. At one point I danced very seriously. I dropped out of college and danced semi-professionally for a while. What got me focused on healthcare policy and healthcare leadership was an experience that I had when I was working an unlicensed frontline job in healthcare. At that point, I was thinking about going back to school and going to medical school. I worked as a home health aide and I worked in a nursing home for people who had been moved into nursing homes as a result of the deinstitutionalization laws. These were people who had been longtime residents inside of institutions for the mentally ill and the developmentally delayed. I saw so many gaps in care and so many challenges in the way financing and clinical care came together. I was young and idealistic. I thought, well, the problem isn’t that we don’t have wonderful physicians and wonderful nurses and wonderful other health professionals, the problem is that the American healthcare system is a mess — it’s fragmented, there’s no coordination between Medicare and Medicaid, services for the mentally ill are the stepchild of the healthcare system, and we can do better. I made the decision that I would go to graduate school in public health and business and go into healthcare from that perspective. I worked briefly for the state of Maine; it was a wonderful experience. There was a change in administration while I was there and I had the extreme privilege at a very young age of being the acting director of Medicaid for the state of Maine. I had done two administrative fellowships while I was in graduate school — one at Alta Bates which later became a part of Sutter Health and one at Kaiser Permanente. I was blessed in that I kept in touch with many of those people who helped me and mentored me when I was early in my career. I had a wonderful decade that I spent at Kaiser Permanente working on the medical group side, on the health plan and hospital side, and then I came back to Sutter Health and I’ve held a variety of jobs at Sutter Health and was fortunate about six years ago to become the CEO.

Renee DeSilva 5:06
That’s a great way to come about it in terms of seeing different parts of healthcare in action. I’m sure that informs your work to this day. I know that you’ve now been in your current role at Sutter for five years or so. I want to take you back to when you first stepped into the CEO role. Talk to us a little bit about how you identified some of the key priorities that you were hoping would animate your tenure?

Sarah Krevans 5:31
I’ve been thinking about that a lot lately. When I became CEO, Sutter Health had come together as a system around quality. One of the things we had done well was to look at how we could take best practices in quality and spread them rapidly across the system. We did that first in maternal care, but then in many other important healthcare initiatives as well. I was proud of that and it was something that I knew I wanted to continue. I wanted to continue the work that we’d started on affordability and accelerate that work on affordability, but there were a few areas where I felt we needed to have more focus and a bigger voice. I picked three of those areas early on and then added a fourth. The three areas early on were mental health, diversity and inclusion, and advocacy. Later, because I think it is an accelerant for all of those things and so much more, I added philanthropy. The reason I picked diversity and mental health and advocacy is that as an integrated health care system one of our responsibilities is to ensure that we think about all of healthcare. I have yet to meet a CEO who says something like, “I’m just not that interested in cancer care” or “I understand some people focus on heart disease, but that is just not my thing.” Yet, we have health systems that have no focus on mental health or very little focus on mental health. I think that’s improved greatly in the last couple of years. Now, it’s not that I think all integrated healthcare systems need to provide all aspects of mental healthcare. Indeed, at Sutter Health we’re very dependent and proud of the partnerships that we have to provide many aspects of mental health care. But when we think about our patients, ensuring they have access to mental health care, thinking about their mental health, understanding their mental health, and the same thing very true for our workforce needs to be a big focus. Similarly, for a system that prides itself on its quality, on its safety of care, looking at averages is not enough. It’s not good enough to say we’re in the top 10% of care for people with sepsis or with certain kinds of heart disease or for maternal outcomes. We need to know not what’s happening to the average, but what is happening to all of our patients. Is it different for patients in rural or urban areas? Is it different for patients who are on Medicaid than those on commercial insurance? Is it different for our Latinx population? Is it different for our African American population? Early on, I had a chief medical officer who has since retired who was very focused and an expert on this as well and we’ve continued this work. We started to look at our quality outcomes by ethnicity, by geographic location, and by socioeconomic status. We knew when we did that, and I’m proud of our risk and legal department for supporting us in this, that, of course, we’d see disparate outcomes. Until you see those disparate outcomes and start to understand them, how are you going to improve them? How are you going to change that? How all that links to advocacy, we serve more of the poor than anyone else in our northern California footprint. We serve a disproportionate share of the Medicare fee-for-service population and the dual-eligible population. Advocating for their access to care, their economic access to care, their physical access to care, even in this last year, their virtual access to care. That’s a really important part of taking care of those populations. I’m proud of the work that we’ve done in those areas. There’s, of course, a lot left undone. The pandemic has highlighted how all of those things come together because the pandemic has had a disproportionate impact on our diverse communities. It’s had a devastating impact on the mental health and wellbeing of so many of our caregivers and on the general population as well. Of course, advocating for support both during the pandemic and post-pandemic has to be a part of what every responsible provider does.

Renee DeSilva 10:17
To stay on that thread for a moment, I’m tracking with you that the COVID response, which is very much ongoing, did shine a spotlight on where some of these inequities exist. As an industry, we’re all reckoning with that. I want to talk a little bit about or go a little bit deeper into the statement that you made a moment ago, which is that it is important to prioritize equitable outcomes and to look at that from the subpopulation lens as the way to get at that. The average is not going to be enough in terms of driving that. Talk more about how you approached the change in mindset to get the broad swath of providers across Sutter to be anchored in how to approach that work. You said it took some bravery and then some good focus and prioritization. Bring that to life for us if you could.

Sarah Krevans 11:07
First, let’s talk a little bit about the difference between treating everybody the same and focusing on equitable outcomes. I was raised by parents who very much believed in battling prejudice in every form. My father was a physician, a hematologist in the Army. He had a commanding officer who was, shall we say, significantly unenlightened. Like many people at that time, had him sort the blood by the color of the skin of the donor. Of course, since my dad didn’t want to kill anybody, he’d go in at night and re-sort it by blood type. Prejudice in any form to him as a physician was unconscionable. He believed that the way around that was to treat everybody the same. Honestly, in the era in which he practiced and when he lived, that was a breakthrough. He practiced in Baltimore, Maryland and treating everybody the same was a breakthrough.

Renee DeSilva 12:21
That’s right. He was ahead of his time in that day and age.

Sarah Krevans 12:25
Yes, but what do we know now? We know now that if you treat everybody the same, some people are going to get better outcomes than others. If we treat everybody the same, some people are going to get well and some people are not. What we need to strive for is equitable outcomes, equitable, really good outcomes for everyone. If that means some people need more care or different care or some people need a different intervention or some people need wraparound services and some people do not, then that’s really what it means to have equitable healthcare. It’s not that we treat everybody the same, but we strive for everybody to have the same excellent outcome. That goes against all kinds of things. It goes against how many healthcare professionals are trained which is a community standard of care. It goes against how a lot of data is produced which says, “This is the evidence-based best practice.” It doesn’t say, this is how you would know what to do for this kind of patient. It goes against how many of us were brought up, which is that you treat everybody the same, which is to treat everybody fairly. Treating everybody the same is not fair to some patients and some people. That’s the difference.

Renee DeSilva 14:02
That’s powerful because, to where you’re going, the underpinning of most physicians in the broader organization is this notion of evidence-based care that is standardized and you’re taking out as much variability as possible. What we’re talking about here is to get to the equitable outcome, it is “yes/and” — “yes, and” you have to figure out what certain groups need to help them achieve those outcomes which can run counter to how the organizational DNA for health systems is designed.

Sarah Krevans 14:41
I agree. It’s not to say there isn’t still a value in looking at the average and looking at all of the data that we always used to look at. It is an “and” statement. It’s, how do we go deeper to understand the variation underneath that and then think about how to address that variation in outcomes.

Renee DeSilva 15:06
Staying with an example in this realm, I know that maternal health has been a key area of focus and prioritization from the health equity lens. We talk about this often as an industry that outcomes for black moms versus white moms, there’s typically a gap in terms of that experience. California has been a leader nationally in maternal health overall. Talk a little bit about what you all have learned on your journey as it relates to maternal health as a category.

Sarah Krevans 15:32
Thank you. It’s a great example because it’s one of our first and most poignant success stories in looking at this. It’s also an example for those people who say, “Well, is this right to focus on a subpopulation” to show that’s not really what you do. You focus on the outcomes for everyone and then when you look at where you’re not getting those outcomes, you focus on the subpopulation and everyone is better off. This goes back many, many years. For years in the United States, maternal mortality had been getting better, meaning fewer women were dying in childbirth and we were having better and better outcomes for moms and babies. Then it started to reverse itself. Maternal mortality doubled in a decade. Now, it’s still relatively low, but it doubled in a decade. California’s maternal mortality did something different. That happened, in part, because of some work that was done collaboratively. It was led by one of our physicians from our California Pacific Medical Center, CPMC in San Francisco. They looked at the fact that between 1999 and 2009, California’s mortality rate had doubled and that women who were African American were four times more likely to die in childbirth than other ethnic groups. Think about that. Everyone in California was worse off. The rate had doubled in California, but if you were African American, you were four more times likely to die in childbirth. They looked at all of the things that go into healthy childbirth and they started a coalition called the California Maternal Quality Care Collaborative, CMQCC. They began working together to lower maternal deaths in California. The result was a 55% reduction in deaths in California in the next 10 years, from 2009 to 2019. We worked on that incredibly hard in all of our care settings. When we looked at the last full year of data that we had, we don’t have the data yet for 2020 and we don’t know how COVID will affect this given what we know is the disproportionate impact of COVID on our diverse population. If we look at the year before that, not only was our maternal mortality among the best in the nation at less than 1/10th of 1%, but we also had no differences in outcome by race or ethnicity — no differences in outcome by race or ethnicity. We’re proud of that. We’re trying to replicate that work and replicate that approach in other diseases as we study them both where we see outcomes that can be improved for everyone as well as gaps in outcomes for some populations.

Renee DeSilva 18:39
That’s a great example. Taking us into a little bit of a different direction but related to this, talk about how Sutter’s unique footprint as an integrated delivery network helps with things like that. In some ways, what’s great about that is that when you figure out a model that works, you can hopefully activate that across your 23 plus hospitals. I know that you operate across a pretty broad geographic region of Northern California. Talk through how scale is put to work for good and then maybe just the complexity that that might introduce as well in making that happen across the system?

Sarah Krevans 19:17
One of the things I love about Sutter Health is that we are a microcosm in many ways of the diversity of the United States and the diversity of the United States healthcare system. We have small, critical access hospitals. We support physicians who are in solo and small private practices. They’re valued members of our medical staff and we have some of the largest, most preeminent medical groups in the United States. We serve some of the richest counties in the United States and some of the poorest counties in the United States. We’re in urban and rural areas. I like to think that when we solve or partially solve a quality or outcome problem, that there’s something that can benefit most communities in the United States. That diversity is a gift and a challenge. Things work very differently in a small, rural community than they do in a big, urban, tertiary medical center. You start by measurement. You start by understanding, and we talked about that already, really understanding your data. We have an advancing health equity team that has developed a health equity index. We can use real-time data and combine it with external demographic data and prevalence and utilization to look at our use patterns and to understand where things are different. Our first look at that was on asthma to try to understand what was happening and why patients from certain populations were presenting at the emergency department more often in distress with asthma than other populations. If you have anyone in your family who’s asthmatic, 20 years ago they might have been given what we now call a rescue inhaler and told to use it every day, but they might not have been given any prophylactic information or medication to prevent attacks. The goal was, of course, not to be rescuing all the time but to be preventing. Why were some of our most diverse populations always in the rescue mode and not in the prevention mode? That was some of our earliest work. We quickly pivoted during COVID to apply some of those same tools and techniques to understand what was happening, what were some of the reasons that we were seeing what we were seeing in terms of the impact of COVID. We saw some of the same patterns when we studied it, which is that the first encounter with the healthcare system for some of the diverse populations, and this was particularly true for some of our emergency departments that tend to be in impoverished areas, that often the first encounter with the healthcare system for some of those patients with COVID who were diverse was in the emergency department. What can we do as a society, what can we do as a healthcare system, what can we do with community partners to change all of that? We’ve also applied that as we’ve looked at our vaccination process. We have the vaccine-equity index that we’ve developed to say, what are we doing to be part of the solution so that everyone not only has access to vaccination but everybody has access to good information that helps them to choose vaccination.

Renee DeSilva 22:58
That’s powerful. If we zoom out a bit, you talked about the benefits within Sutter Health which have breadth and depth in terms of serving. I know that you have also spent time on broader advocacy and transformation industry-wide. Let’s talk more about that. I’ve noted, and I have the privilege of working with 100-150 health systems across the country, that if I look back a year ago, health systems and the community of healthcare were lauded and considered to be heroes in terms of the response to the COVID crisis. I noted how many health systems operated as the de facto public health entity in their environment. It feels like that overwhelming public support is also mixed with some skepticism these days. What can we do as an industry to be better at telling the impact that we have on our communities and our patients from your perspective?

Sarah Krevans 23:58
That is a wonderful question. I wish I had all the answers. It is true that in many states across this country, the health systems became the de facto public health system where the health systems really stepped up and helped the states to coordinate the response to the pandemic, stepped in to do screening, stepped in to do vaccinations, stepped in to set up extra capacity, became the voices that were the most trusted for the general population to get information from, to help counter some of the misinformation that was a part of this pandemic. I have to say, I don’t regret any of that. I was proud to do that. I was proud that the state asked us to partner with them and I would do it again. But the end in this is how health systems then tell the story better, how do health systems help the general public and elected officials and regulators understand the value that integrated healthcare systems have brought and do bring to the United States. This is a big challenge. Right now we’re in an era where there’s a lot of skepticism about the value of integration. There is a lot of skepticism right now about whether or not integrated healthcare is good for the United States. Yet, there are so many proof points that show that it is — whether it’s quality, and again, you need to look at the responsible healthcare systems, but if you look at quality, if you look at their willingness to continue to serve communities, if you look at what they did during the pandemic, if you look at essential services that they keep in communities that otherwise might not exist. There is a huge value here for communities and patients. One of the things that puzzle me is the strength of the belief that integrated healthcare systems are too powerful and can push insurers around. In California, four insurers control 80% of the commercial market and many insurers across this country are vertically integrating and buying physician practices. During the pandemic, most not-for-profit healthcare systems were devastated financially. Health insurers had the best year that they’ve had in many, many years. The three largest had a combined $26 billion in profits. We need to do a better job telling our stories. It’s not about insurance companies being bad. People want insurance and they value having insurance. Having good insurance is an important thing for people’s financial well being and their peace of mind. If they have a catastrophic health event, it’s really important to have insurance. I’m a big proponent of everyone being insured or working for an employer who’s self-insured or being on a governmental program. We don’t want to go back to people not having coverage. However, we also need to understand and respect the role that providers play in that safety, in that well-being, and in that access to health care.

Renee DeSilva 27:45
Absolutely. I would also add the impact on communities from an employment perspective. If you think about major health systems as economic drivers and major employers in their market, that is the other place that is often missed in the larger conversation.

Sarah Krevans 28:05
I agree. We need to remember that ultimately, our mission is patient care. We want people to be able to come to us and have wonderful careers. We want to look after their well-being and that is a big issue right now, the burnout of our staff and our physicians. We also have to be willing to change and recognize that there are some things that we do in person or with people that, over time, we also may be able to do with technology. Technology can help to make healthcare more accessible. In some cases, it can be something that patients prefer and it can also help be part of the affordability solution.

Renee DeSilva 28:53
Yes. To wrap up this thread, as you think about and contemplate the future of healthcare for Sutter and the industry broadly, how are you thinking about that in the context of all that we’ve been talking about, the future of care delivery? If you’re projecting out and thinking through a 3-5 year plan with all this uncertainty that surrounds us, what feels like an anchor for you?

Sarah Krevans 29:20
I was talking to this brilliant woman yesterday and I’m going to use her analogy. She was talking about innovation. She said, “One of the things you have to understand is, ‘What are you trying to innovate?’” She talked about driving a car. She said that the car that she drives is nothing like the car she learned to drive on — it doesn’t have the same kind of engine, the electronics are nothing the same, it runs on electricity instead of gas — but her driving experience is the same. If you compare that to a banking experience, the banking experience is nothing like the banking experience that we used to have. You don’t go into a bank to get cash anymore, you do almost everything online. The question for healthcare is, are we trying to innovate the car, are we trying to innovate the driving experience, or both? We need to do both. There is so much we could do to make the internal engine of healthcare more efficient. As we’ve talked about already, how do we improve outcomes for everyone? What do we do to make it less expensive to be a system that is looking after the whole person? We also have places where we need to change the driving experience. How many people complain about wait times or difficulty accessing their physician by phone or by email, not understanding the care handoffs, wondering if they have a loved one with a chronic disease, who’s actually in charge of their care. We need to innovate both. One of the things I wouldn’t want to change is the basic trust that patients have in their caregivers. I want to do this in a way that doesn’t disrupt that trust, that doesn’t disrupt that relationship, and that makes that relationship deeper and more satisfying for both the clinician and the patient.

Renee DeSilva 31:44
That’s perfectly said. I’m going to end on a lighter note. We’re gonna move forward. The first thing that I can’t let pass, and you mentioned this in the opening, is that you were close to a professional dancer. What’s your dance of choice these days?

Sarah Krevans 31:59
I had a hip injury so currently, it would be none. One of my legs has a limited range of motion from side to side so it doesn’t rise above hip level. My exercise of choice right now has been running. I don’t dance at all anymore other than in private, just for myself. I do love to exercise and I have some really good friends that I’ve run with for years. It’s my stress relief, it’s my therapy, it’s my socialization. If one of us is injured we walk, if one of us is sad we have coffee, but I am a big believer in the power of physical well-being, mental well-being, and spiritual well-being coming together. That’s been an important part of my life. Unfortunately, no more dancing.

Renee DeSilva 32:57
Dancing shoes are away. Were you ballet or more modern dance growing up? What did you do growing up?

Sarah Krevans 33:05
I did both. The thing about dancing is that you have to be serious at a young age. I didn’t get serious enough until I was, from a dancer’s perspective, kind of older, a teenager. I did both, but certainly a great source of discipline and focus, some lessons that are good lessons for life. You fail sometimes when you’re a dancer — you try out for things and don’t get the part, you get cut more often than you get chosen. All of those are good life experiences.

Renee DeSilva 33:42
I will say, there’s nothing like an end-of-the-week dance party for one to burn off the stress of the week. I would not say I’m a great dancer, but I do think it’s a good way to sometimes burn off some energy. That’s great. All right. My final question is, part of what we try to create at the table is space for conversation. One of the things that we all missed during COVID was the ability to gather with people that we care deeply for. If you could invite any two people for a conversation at your table, who would they be and why?

Sarah Krevans 34:14
Any two people. One would be my father’s mother who I never met. She died before I was born and she was a physician in Russia. You have to think how unusual that was. My dad was born in 1924. She was a physician in the 1800s in Russia. She escaped on the roof of a train with my dad’s older sister and her husband, came to this country and worked as an aide in a hospital, then eventually worked in the laundry because it paid better and never had enough money to even go back to nursing school or go back to medical school. She looked at going back to nursing school at one point and they couldn’t afford it. She must have been just a remarkable woman. I have to say, it’s a good thing my dad loved being a physician because I don’t know that he had a choice about being anything else. I would love to meet her because I would love to know what she was like. How was she so strong? How did she make that happen? How did she live her life after she had to give all that up to save her children? I would have loved to have gotten to meet her and to understand her. I think that would be amazing.

Renee DeSilva 35:47
Absolutely. The stories that she could tell with all that she would have observed in accomplishing that in that part of her life. That’s amazing.

Sarah Krevans 35:58
She is one. Then, just because I think it’d be a fun dinner to have two really strong women together, there are other people I could choose but I think it’d be really fun to have dinner with Susan B. Anthony. I would love to know if she got discouraged. How did she feel as she went through that? What gave her the courage every day to persevere, to think that what she thought was possible was possible, and to make such a difference for women. I think that’d be a fun dinner.

Renee DeSilva 36:36
That would be a great dinner. Dwelling in the art of the possible grounded by historical lessons. That sounds perfect to me. Sarah, it was great to connect with you this afternoon. I appreciate your time. Thank you so much for joining us.

Sarah Krevans 36:49
My pleasure. Thank you. Have a great day and stay safe.

Renee DeSilva 36:53
Thanks again for joining me at The Table. The Table is a podcast produced by The Health Management Academy. Make sure you catch future episodes by visiting our website, theacademytable.com, or by subscribing on the podcast platform of your choice. If you have suggestions for topics or guests, I’d love to hear from you. Please drop me a note at renee@hmacademy.com. I look forward to talking with you soon.