Joe Fuller: Beyond the most visible signs of the Covid-19 crisis, the pandemic is causing major change in the health care industry. One effect is the more widespread adoption of technologies like telemedicine. In an increasingly virtual environment, how can health care professionals and hospitals work together to reduce disparities in care? What lessons can be drawn from Covid-19? And how can they inform the way we build the health care workforce for the future?

Welcome to the Managing the Future of Work podcast from Harvard Business School. I’m your host, Harvard Business School professor and visiting fellow at the American Enterprise Institute, Joe Fuller. I’m joined today by Dr. Marc Harrison, president and CEO of Intermountain Healthcare. We’ll discuss some pressing issues, such as the ongoing Covid-19 pandemic and the challenges posed by the need to vaccinate the entire population. We’ll also discuss some longer-term trends, such as the challenges of providing quality health care in rural locations and to communities of color, as well as how Covid is spurring the development of delivery systems and technologies. Dr. Marc Harrison, welcome to the Managing the Future of Work podcast.

Marc Harrison: Thanks. Really glad to be here.

Fuller: Doctor, Covid has had a profound impact on the health care delivery system, put a lot of strain on personnel and personnel planning. But, really, the industry was regularly pointed out as one that had skills issues—issues tracking and cultivating the right talent, filling its talent needs—before Covid. Could you tell us a little bit about your sense of the terrain in the health care system back before the pandemic? And then we can move to how the pandemic’s affected all that.

Harrison: As much as I love being a doctor, and as much as I love health care, our industry has not historically been known as a leading one when it comes to human capital. I think there’s very little debate around that. And our frontline people, in particular, really like things to stay the same. They like to take care of patients the same way they always have, they like to document the same way, they like to do their continuing education the same way. At Intermountain, as we’ve gone through our transformation to being a value-based organization—which, in our mind, means we’re actually paid to keep people well, instead of taking care of them just when they’re sick—we’ve really had to learn to be nimble and agile, as far as addressing our people issues. In no way, shape, or form have we figured everything out. But by the same token, we feel like Covid has catalyzed a lot of the things that we were interested in working on before the pandemic.

Fuller: What were some of the things you were doing to infuse more agility into the organization—and also getting a workforce with a very broad spectrum of skills and backgrounds, since you’re dealing with it from board-certified physicians down to health aids and culinary staff—in an environment where there’s also a fair amount of dynamism and technology? How do you get a workforce ready to accommodate new technologies, particularly given resistance to changing practice and the role of expertise and experience in delivering quality care?

Harrison: We’re a reasonably big organization. We’re about 40,000 caregivers. We function in—and that’s what we call our employees, believing that every individual person, regardless of their role, contributes to the care of another human being. We’re primarily in Utah, but we also have significant presences in Idaho and Nevada, and we’ll be continuing to grow. We’ve been hitting all of the big categories that I suspect you’ve talked about with other folks: AI. How do we use bots? How do we do partnerships with companies outside of our own, who can accelerate change much more rapidly than we could ever do that, ourselves? How do we think about retraining people, recognizing the shift from the inpatient of the hospital world to the outpatient or clinic world that’s inevitably happening? And it’s good, because people get cared for in less restrictive and less expensive environments. We’ve recognized that we probably have had an imbalance in terms of where our talent resides. And so we’ve been thinking a lot about retraining, and Covid has actually given us an enormous opportunity to get good at retraining people.

Fuller: As a health care provider, you’re really getting to see both ends of the spectrum of managing in Covid. You have remote workers, corporate staff, right down to physicians and nurses and orderlies and people who are essential to getting us through this pandemic. Can you talk to us a little bit about how you’ve managed that? And you mentioned that it’s helped in areas like training, but how else has it affected your ability to manage and control the organization and the work experience you’re providing your staff?

Harrison: At one point we tried to count up how many businesses we think we’re actually in. It’s probably 200 or 300 businesses. So, everything from, as you said, food service to laundries to pharmacies to operating rooms. I mean, it’s myriad and extensive. I’ll tell you that we went, in about a week-and-a-half period, from having 1,000 people working remotely to having about 11,000 people working remotely. And kudos to our information technology people who actually made the technology work. We stayed stable. But that was an extraordinary experience and experiment. And what’s been very interesting is, we’ve performed well as an organization. Our quality is good, our safety’s good, our consumer customer experience, patient experience, is good, and we’ve been able to not only survive the pandemic, we’ve actually thrived, and we continue to grow. And I think that ability to pivot, and be agile, and to incorporate tele- into the corporate parts of the world were facilitated by the fact that, given our enormous geographic footprint—hundreds of thousands of square miles—we’ve actually used telemed clinically for a really long time. It’s part of who we are. It’s part of our DNA. And, in fact, when I got here, we were building our 23rd hospital—I got here about four years ago, in October of 2016—and we were building our 23rd hospital. And I said, “Look, our 24th hospital is going to be a virtual hospital.” And, in fact, we have built that. And we’ve done well over a million clinical touches now. And thinking about doing things at a distance is not foreign to us. And I think it has really been an enormous benefit as we’ve run the organization. Turns out that our insurance company, SelectHealth, that has about a million members in it, I think about 95 percent or 96 percent of the folks who are running SelectHealth are doing so remotely. And we’ve actually had a great year.

Fuller: Marc, one thing we’ve heard from other executives is that there are growing concerns about behavioral or mental-health issues among workers, that the normal rhythms of their lives have been disrupted for a very extended period. You have people that don’t have great social or family networks, who really rely on work as a locus of where they have human connections and people that care about them. And, of course, my kids are grown, but parents with schools that are only remote are probably wishing for that yellow school bus to start pulling up again so they can have a more regular work life and family life. Are you observing that, or are you seeing that in any ways in your patient population—that there are behavioral health patterns that are emerging as a result of Covid?

Harrison: I would agree with everything you just said. And I can particularly relate. We are empty nesters, ourselves, at this point. And I just think about how tough it would be to be trying to work remotely while I had three young children who were trying to go to school remotely and have a wife who has a career. I can only imagine how stressful it must be. We’re seeing behavioral health issues in our patients, in our members, in our caregivers. And oftentimes, they’re in more than one of those categories. So we take care of the people who are also the people who take care of other people. And it’s really quite tough. I heard somebody jokingly say the three derailers to working at home are the TV, the bed, and the refrigerator. And I think that may be true. But, unfortunately, I think there’s also issues around substance abuse, and the liquor cabinet may be a problem for some people, or the medicine cabinet could be a problem for people. And, certainly, we’re seeing people with underlying anxiety disorders, in who it’s enormously exacerbated. So the resources that we provide for people, whether it’s psychological, psychiatric, social work-type care—which we offer for free to all of our caregivers, and we integrate behavioral health into how we take care of patients and try and keep them well—or whether it’s an employee assistance fund that we have—that if somebody’s not going to be able to make their rent and is going to lose their house and become homeless, we can help them with that—all of those are actually quite taxed right now. I’m glad we have them, and we’re going to keep investing in them, but this is real. People are really stressed, and we’re worried about them.

Fuller: Are there lessons that are being learned in health care delivery and in caregiving that you think are going to have emerged from this pandemic that are going to alter the way you approach delivering health care and caring for patients and their families in the future? Or will it change the way you organize your own work and the types of skills balance you’re going to need going forward in the future inside Intermountain?

Harrison: I had an article in Harvard Business Review from earlier in 2020—I think it came out in late summer¬—that I lay out some of the factors that I think Covid has accelerated. And these are things like: telehealth really works. When there was the huge shutdown in the spring, we actually, given our history of telehealth, were able to spool things up. And we went from about 6,000 visits a week to about 60,000 visits a week. Just under 20 percent of our visits are done by distance, and that’s really different than it was before. It’s kind of funny—we’d been hoping to transition doctors to that style of medicine, and they were resistant. They’ve made change, and the patients love it, and the doctors love it. So for many clinicians, particularly in those who have quite intense work lives—so think about a neonatologist, or an adult critical care physician, or a hospitalist—it’s turning out that, telemedicine, tele-critical care, tele-hospitalist, tele-neonatology, provides actually an interesting break from the grind. And we’re finding that people generally choose to not be 100 percent in one model or the other, but they really enjoy a mix of telemedicine and traditional hands-on in-person medicine. And the other thing that’s actually quite interesting is there a number of part-time people, and particularly younger women who have families, who may actually end up choosing to sit out of the workforce, for whom telework actually works great, and allows them to be in the workforce, and stimulated, and contribute, and make some money. At the same time, as they choose to, have family responsibilities too. And so I think that tele- offers all kinds of different angles. Digital really works. We’ve been on a path at Intermountain for quite a long time, last couple of years, to really become a digital company, a platform company. And we’ve had a digital front door in the works. We’ve had 250,000 downloads just in the first couple months of having it available. We believe we’ll be at a million downloads by Christmastime 2020. It’s all accelerated, and it’s all good. The use of AI. Covid actually made it necessary that we triage people to either hospitals or emergency rooms or to be cared for via a tele-visit based on their symptoms. Otherwise the EDs, emergency departments, or InstaCares would get overrun. And so we created a AI-powered symptom checker. It had hundreds of thousands of hits, and actually dramatically unloaded the InstaCare, so that the doctors and nurses there could really take great care of patients. We’re now using AI much more extensively, clinically, than we ever have. And we have a goal that, over the next couple of years, we will have self-care powered by AI for 10 of our most common conditions. So, again, it’s a catalyzing force that Covid has put in place. And maybe the final two that are really dear to my heart are, we’ve always known at Intermountain, we work extremely hard to make health care affordable. We know health care is not affordable for many Americans. The economic crunch that has occurred and hardship actually makes that even more imperative that we make our health care more affordable. And then the final piece—and this is just a hard lesson for those of us who care for others to acknowledge—is that Covid has taught us across the United States, if you’re brown or Black, you’re much more likely to be hospitalized or die than if you’re a white person. And we have looked hard at our own data, and I wish I could say we’re different from the rest of the country, but we are not. But it has really been, in some ways, a gratifying experience to look ourselves in the mirror and see where there’s an enormous need. And we’re going to fix this. It’s not going to be easy, it’s not going to happen overnight, but now that we know how bad this problem is, we can go ahead and go after it. So those are a couple of examples.

Fuller: Marc, when you talk about digitalizing Intermountain, that’s certainly something that companies across all sorts of industries are doing. Seventy-five percent of CEOs said they were significantly accelerating their digitalization efforts as a result of Covid—in part because, of course, they’re supporting remote workers, but also because they’re shifting their balance of business more to online, more to remote service, especially if they’re in a consumer-facing industry. Companies talk about how difficult it is to take their incumbent workforce and re-skill them, or upskill them, to handle that change. And companies also talk about how they now find themselves competing to hire talent with companies in completely different sectors. Whereas, if you historically were a hospital chain or a retailer, you were generally looking for people with experience in that sector and disproportionately attracted to those types of candidates and tended to get candidates with those types of skills. But if suddenly you’re looking for data analytics Black Belts or digital marketing experts, they’re as attractive and have skills that are just as relevant to a bank as to a hospital as to a retailer as to a manufacturer. What are you seeing in terms of managing your skills inventory? And how do you build the workforce you need for the future while you’re delivering what you have to deliver now? I mean, that’s building a bridge over traffic. That’s a tough challenge.

Harrison: It is. I think it’s a huge opportunity, though. And by the way, our chief consumer officer, Kevan Mabbutt, he’s got marketing communication and digitalization under him. He’s been with us for about three years. I hired him from Disney, where he did customer experience, park experience. And why did I do that? Because I couldn’t find anybody in health care who was really good at that.

Fuller: Who knew what a customer was!

Harrison: Exactly. And he’s been a wonderful influence. So the big opportunity here is, there are jobs that we’re discovering that, just as you point out, they don’t even exist right now. So we’re actually retraining a bunch of people in some forward-looking AI-powered analytics that will help us guide, predictively, where our system is going and what people need. We’ve got actually now a fair amount of experience around retraining, and redeployment from the pandemic. So thousands of nurses have been retrained in different areas, and it appears that once … and many doctors have been retrained, and outpatient doctors have had ICU refresher courses, et cetera. The actual things they’ve learned are useful, but I think more useful than that is the idea that they can learn difficult, new things and be really good at them. And I think once that barrier is breached, I think we can take great clinicians and teach them lots of other skills—it may be easier to do that than take somebody from another industry and teach them what health care really needs. So I remain extremely optimistic. And then the final thing I’ll say is, we’re working actively with a number of institutions of higher learning on certificate programs, particularly around some of the tech-facing needs—whether it’s public health workers or whether it’s work around social determinants of health or whether it’s data analytics. And I’m really excited about this, because in many instances, these are gateway professional jobs for people. They may not have a full college degree, but this would be the first time in their family’s history that somebody has had a job that wasn’t manual labor. And I think we all know that once you make that leap, that changes the next generation’s trajectory. And it feels really good for us as the largest employer in the state to be positively engaged in helping people make that transformation.

Fuller: Marc, if I may, let’s unpack a couple of the points you made.

Harrison: Sure.

Fuller: You mentioned that you’d learned a lot about digital learning and upskilling or refresher courses. Three or four principles that you could share as to what you took away from that, and about how it should work in the future, how that process should be managed?

Harrison: Yes. Before I answer that, my caveat will be the really smart person about this is Heather Brace, who’s our chief people officer. And I know that there are CHROs who listen to this show. Historically, I have found CHROs to often be very policy-and procedure-oriented folks. Very transactional. What are the rules? Let’s not get in trouble with the government. All of which I believe in. I’m not a big risk taker in that. But when I hired Heather, what I told her I needed—and what she just turned out to be—is a really strategic thinker about human capital; that we’ll take care of the policies and procedures, but they’re not going to get us from where we are now to where we need to go. And so Heather’s really been the author, with her team, which is a great team, of a lot of this work. And I think that what we’ve learned is, around the principles of adult education, keep it short, keep it direct, keep it practical, allow people to learn as they’re doing. And one of the things I love that we’ve learned is that some of our old requirements of, you need a college degree for this job, is just baloney. And I think Heather and I both love the fact that experience often counts as much as formal classroom learning. And I think that degree of flexibility has, I hope, really offered many people within Intermountain a lot of opportunity to grow and develop.

Fuller: Well, certainly our research here at the Managing the Future of Work Project endorses what you’re just saying about degrees being a formidable, but often a contrived or presumed barrier to someone doing and being effective in a job, and the data just doesn’t bear that out often, particularly someone with experience. Let me also ask you about what you were saying about how we could revisit and rethink how we serve communities of color, lower economic strata in our society. What are we taking away from this that might be applicable there? Is it, for example, a question of access, where things like telehealth can be expanded? Or are there other ideas that you have, as you’ve confronted that data obviously with a clear-eyed and sober reality. What are you taking away that we might do to reduce that unequal distribution of access to care and quality of care?

Harrison: We’ve discovered that it’s really difficult to reach some of these communities of color. We also know that some of the school-based clinics that Intermountain runs for the community serve whole families, not just the kids who are in the school. But particularly in communities of color, where a lot of people have been “essential” workers during Covid, and then compounded with some concerns around immigration issues in the Trump administration, people have been hesitant to come forward and get care. And so what we trialed—and we think is going to really work—is, we’re actually now using tele- in schools. And for the price of one traditional school-based clinic, we can actually project that across 20 schools. And we’re particularly doing that in communities of color, and it’s actually working really well. So that’s one thing that we’re doing. Another is around use of community health workers. And I’ll tell you a brief story. I saw the movie Bending the Arc, which is about Partners In Health and Paul Farmer, who is a Boston staple and a remarkable person. I think he should win the Nobel Prize one of these days. And his work, and Jim Kim’s work, who was head of the World Bank, also a Boston physician and an infectious disease doctor, really amazing. I saw the movie, and I heard the story about how community health workers addressed really difficult communicable health problems—in this case, AIDS and TB. And what I said to myself is, “We need that same approach for social determinants of health, and particularly in communities of color.” So we bought that movie. It’s on Netflix now. It’s free for anybody who has a Netflix subscription can watch it. So what we’re doing here is, we are now hiring lots of community health workers, generally people who look like the communities and are from the communities that they serve, to address things like transportation, housing, food, people who are going to lose their house because they don’t have money for rent, do they need a prescription filled. And we’re trying to really get ahead of their health problems and turn our system, really and truly from a health care system to a health system. And I think we’re on our way. Sorry for the long story, but I think it’s relevant.

Fuller: Well, I think it is. And, of course, these are problems that have been teased out and made unambiguous, and the subject of widespread reporting over time across the country, so that it’s no longer something we can sweep under the rug and act like it isn’t there. But, of course, we all know that, as you said very early in our conversation, that issues of cost and affordability are barriers to try to extend quality care, and we’re going to have to bring ingenuity and innovation to meeting that problem.

Harrison: I think our business model in the U.S. is pretty much inherently flawed. And you get paid to take care of people once they’re sick. And the more you do for them/to them, the more money you get paid. And the model that we’re in and we’re really pushing is, now about half of our business we’re prepaid. So we get a chunk of money to keep somebody well for a period of time. If we spend more than that, we lose money. If we spend less than that, we have a little bit of margin to put back into the community, because we’re not-for-profit. And that spurs unbelievable innovation and creativity and a recognition that you can buy a lot of air conditioners for asthmatic kids to prevent one asthma visit in the emergency department. And it can just make a ton of sense. And I think that having the jobs to support that preventative work is actually really gratifying, because they become accessible to people for whom professional jobs haven’t been accessible before.

Fuller: Marc, we call our program Managing the Future of Work, and we’re based at Harvard Business School, where we work hard to train leaders who are going to make a difference in the world. And we have a big population of business executives who are alums, and we’re proud of them. When you think about that, you are both an employer and you are a company that serves employers, their employee bases. What’s the role of an employer in trying to advance the wellness of their employee base? There’s a lot of interesting issues here. Should I be permitted to put pressure on a smoker or someone with a substance abuse problem or someone who’s morbidly obese to take better care of themselves? And where’s the line between where I should and could and appropriately go as someone who has a commercial—and, yes, a working community relationship with a worker—versus when am I beginning to intrude in the life of my workers in ways that really exceeds what’s appropriate?

Harrison: Although I frame things, I think, from a relatively socially progressive stance, you may notice I also do it within a capitalistic business model, albeit a not-for-profit one. I think the markets can solve these problems way better than the government can. And I’m a huge respecter of our elected officials; they’ve got tough jobs. But I think we can fix things in a much more nimble fashion. For all those CHROs who are out there, they should be getting away [from] paying for transactional health care. There is so much opportunity to engage people in their own health. And we, for instance, through our insurance plan—we work with lots of companies, large and small, who’ve got products that incentivize everybody: incentivize the worker to stay well, and incentivize the employer to provide an environment where people can stay well. We offer lower premiums over time for people who are compliant, so that they can participate in the savings. It’s possible. The question is, is this a priority for those companies? And I hope it will be, because it’s in the best interest of their workers over the long run. But it does require a different kind of thinking.

Fuller: Marc it’s late November 2020, and we’ve recently had favorable news on a couple of vaccines, one from Moderna and one from Johnson & Johnson, relative to Covid-19. What we’re similarly hearing questions about: How are we going to get people vaccinated? Everything from how are we going to distribute these vaccines—especially the J&J, which has special handling characteristics, needs super cold storage, to how do we convince people who were either historically skeptical about vaccinations or become worried about things they’ve heard about vaccines? What’s your thinking about that? How are you preparing for it? And also, what’s the role of an employer in causing that to happen, to try to make sure that their workforce is getting safe for the future?

Harrison: The easiest thing for us as a health care employer would be if it was mandated that Covid vaccination occurred with appropriate medical exemptions in order to maintain accreditation. I don’t think that’s going to happen. I think things are simply too polarized from a political standpoint. There is an enormous amount of misinformation out there, and we are working hard—both within our company, but also within our communities—to spread accurate information. I do not believe that we will or probably should mandate within Intermountain. We very well may limit people’s ability to work, if they choose not to be vaccinated, and that will have its own set of implications associated with it. Really complicated problem, and one that is, I think, exacerbated by social media, and exacerbated by political leadership to some extent. But I’m hoping that common sense will prevail, and what I believe are the good hearts of our neighbors. Most people really want to help their neighbors, and if they recognize that getting vaccinated may save their neighbor’s life or their grandmother’s life or their disabled friend’s life, they very well may do it.

Fuller: How nervous are you, if at all, about the capacity of our distribution system, of the health care delivery system, to vaccinate 340 million people quickly?

Harrison: Nervous, but optimistic, I would say. It’s going to be a feat of logistics and public health unlike any that we’ve ever seen before. But I think the people who are organizing this—and I’m very aware of what’s going on in our state—they also realize this is an imperative. We have to get this right. And I’m actually nervous but optimistic that we will, in fact, get it right. By the way, we are so fortunate for the innovation and skill of the companies that are making these vaccines. For us to have two mRNA vaccines that appear to have 95 percent-plus efficacy is unbelievable, and much needed.

Fuller: Well, it’s very exciting as someone who’s has spent some time working with health care companies to see the whole concept of messenger RNA vaccination being validated, and some exciting opportunities in completely different therapeutic areas to extend that technology to improve people’s health and life prospects.

Harrison: It’s just great, isn’t it?

Fuller: It’s very, very exciting. And it does strike me that we haven’t seen the industry this aligned and this determined to get to answers and willing to not turn everything into a competitive cage match since HIV/AIDS.

Harrison: I couldn’t agree more. And I think it’s an example for others in that, the virus is the enemy. It’s not the company across the street. In our sphere, we have three other systems with whom we compete, clinically. But, boy, did we collaborate on distributing patients during the pandemic, and we share clinical trials, and our chief medical officers meet once a week to make sure that we speak to the state with one voice that we all feel comfortable with clinically. This is good stuff. And just those extremely strident voices on either end of the spectrum, this culture of conflict, I hope that organizations like Intermountain can actually bridge that and be a voice of trusted information, and hopefully kindness and rationality.

Fuller: Marc Harrison, president and CEO of Intermountain Healthcare. Thanks for joining us on the Managing the Future of Work podcast.

Harrison: Thank you, sir. )

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