 My name is Jeremy Keele, just by way of introduction, I run an asset management firm called actually two asset management firms that have a partner in one called Sorensen Impact, which is really a kind of multi-asset, multi-strategy asset management platform, an advisory platform that's completely dedicated to impact. We have a family foundation, you know, an advisory practice that focuses on wealth management for impact, and then we have a series of third party, you know, managed funds that we focus across asset classes, across impact themes in impact. One of those strategies is specifically focused on the social determinants of health, which is a term that we'll talk about in unpack, it's called catalyst, and it's specifically focused on affordable housing and other sort of investment opportunities upstream in the community that have real sort of health implications in low to moderate income communities. We invest in affordable housing, healthy and nutritious food options, community based health care services, workforce training services and things like that. So that's kind of my background, and that's what I sort of the perspective I bring to this conversation. I'm joined by a couple of friends and colleagues, to my immediate left is Pablo Bravo, who is system vice president of community health at Dignity Health, which recently became Common Spirit Health, but I think we're still doing the co-branding there a little bit. So joined by Pablo, who's a fantastic person and they're in a real sort of thought leader and leading practitioner in this space, and then also joined by Andy McMahon, who's vice president for community investment in health at United Health Care, which is obviously a very large health care system here in the country. Before I sort of get going and kind of pass this off to the panelists to really get the perspective, I'd love to hear just among the audience that we've got sort of what your grounding is in the social determinants health, and I want to do a little bit of a quick and formal survey. That phrase, the social determinants health, how many people have heard that or come across that phrase just by show of hands? How many of you are in a health care or related field or industry? Okay. Let's get out now. So there's some good overlap there. I guess one thing that I would put out there or pause it for the group is that this room is sort of disproportionately representative of folks in the health care industry. A lot of the other folks that are roaming the halls of this conference or other rooms of this conference who are less sort of focused on health care, more generally focused on impact investing, other strategies within that, within impact investing, they may not have heard of the social determinants of health or if they have, it's been very recent, it's a term that's starting to kind of become more common, but this is not sort of widely understood I would say in kind of the broader impact investing community. I think there's a little bit of translational work that has to happen there. I think people understand the concepts, but I don't think they sort of speak the same language that folks in the health care system do around this particular issue. So for those of you that don't understand or haven't heard the term social determinants of health, when I talk about that and I'm sure people will define this differently, what I'm thinking about are sort of the upstream in the community elements or investments or opportunities that affect downstream health outcomes, so things like housing, transportation, education, community health care, again sort of workforce issues, things like that, all those things in the aggregate can translate into real sort of presentable health care outcomes and this is one reason I would sort of argue that health systems are really starting to kind of pay attention to what's happening in the community and starting to put, you know, dollars towards those, to those elements to try to drive better health care outcomes, better results, lower costs for the system and that's really what our guests are focused on in their own portfolios, so I want to kick it over to Pablo actually to start and Pablo I guess what I would love for you to kick off with is sort of helping the audience understand what your specific mandate is within your within your own group and then within the larger kind of common-spirit context, you know, why is the system interested in the social determinants of health, what kinds of investments are you making in the community to address those those determinants? Sure, so first of all I'll give you some perspective around so we are a large health care provider, we're in 21 states we have over a thousand care centers, 144 hospitals, so we are definitely impacted by individuals who have an impact on their health by the social determinants of health and the way we look at the social determinants of health is when it has an impact on individuals it creates an impact on your on your body, your stress, so that therefore breaks down your immune systems and can become sick and end up in one of our care centers. From a community health and that's my area it's really we focus on everything outside of the hospital walls that are impacting the health of individuals that we serve. For example if access to food is an issue we'll try to find a way to address that. We have because we're a non-profit and a significant number of our non-profit hospitals are required by the IRS to do community benefit that means to put back into the community equivalent that we save on taxes so that's one side of the community health. We do that through either doing prevention programs or awarding grants to communities for services but then we have this other tool that we have created as part of the overall investment program for the organization it's it's like a three-legged stool you have the portfolio managed by investment backers etc that funds our self-insurance our employee pension and then there's an unrestricted pool of money that we use to replace capital etc and then we do a shareholder advocacy and then there's a piece here that we take a portion of the unrestricted funds and use it to create this program called community investment which is under community health and the idea of that investment program is really to put money into the communities that we serve in areas that have been impacted by the social determinants of health. What we try to do here is really focus on developing the infrastructure of communities to be able to sustain different issues that are impacting the individuals in those communities. That's great. Andy what did you tell us where you sit within UnitedHealthcare kind of what what your mandate is the the treasury funds that you sit on and kind of how you think about your your role within the organization. Great thanks and great to be with all of you and amazing weather I will take it every day. So yes not what I expected. So Andy McMahon I actually sit within community and state which is the Medicaid organization within UnitedHealth Group but a major hat that I wear is actually partnering with the UnitedHealth Group treasury team. UnitedHealth Group is the corporate entity of all of the various parts of UnitedHealthcare and Optum so we are a very large kind of multi-service business analytics and insurance company so I sit on the UnitedHealthcare on the managed care insurance side. We have Medicaid plans in 32 states covering about more than eight million lives at this point and so I've been there about five years and in the role and mandate I think Jeremy to your question that that I have is in partnership with our UnitedHealth Group treasury team is thinking about where can we make investments in communities that we serve across the country we literally have various components all across the country and the globe and so try to think about where are there social impact investments that we can make that that will align with kind of our organizational objectives and broadly speaking improve community and population health. And so I'll mention a couple things so we do that through I'm sure we'll talk more about it but kind of a two pronged approach so one is we leverage both low income housing tax credits and new market tax credits is part one for the purposes of this conversation today we have a separate large fund for social impact investing that comes out of our treasury dollars I think one of the things that's important to know from where we sit Pablo talked about kind of on you know on the non-profit so he has a lot of our resources actually come from regulated capital that we have within UnitedHealthcare so as an insurer you can imagine we have to have enormous sums of money on hand and because we have to pay claims for things and pandemics do happen and things like that and so you know one of the things that's important for folks to know I think is that when we make those investments I won't get into the weeds but insurance health insurance insurance is regulated at the state level not the federal level so every time we want to make an investment we actually have to go to the state health commissioner and the office there and get approval to say okay you're making an investment that somehow aligns with health care so I'll talk a little bit more our philosophy and approach here a bit and just sticking with you for a second Andy what were the series of things that led to UnitedHealthcare deciding to dedicate a portion of its treasury balance sheet to an impact fund so I think it started with housing for sure it started that was definitely our kind of key way and I think you know there literally is not a person within UnitedHealthcare who does not believe that housing is health care I heard does believe I said that wrong but but you know I think we understand very clearly that if you don't have a safe decent affordable place to live the likelihood that you're going to have bad health outcomes and poor and overutilization of systems of care like Pablo's hospitals that's kind of a foregone inclusion or knowledge and so that I think was the starting point and then as we worked Pablo mentioned food insecurity or some other areas I think we also then realized that another key driver for people around around health outcomes and community health outcomes is access to care so then we thought okay well we need to be investing in in financing and creating more federally qualified health centers FQHCs and other health clinics and underserved communities and and that has then grown I think now you know I'll talk a little bit more in a bit but we just invested 25 million dollars in a neighborhood health equity fund in New England to your exact point Jeremy Wright he's going way upstream it's saying we're going to invest in affordable housing but also that it's close to transit it has green spaces it has grocery stores that are actually going to have fresh fruits and vegetables in them and the likes I think it started with housing and then I think there's been a just a growing understanding that there's these whole set of social determinants that we're talking about that you know have a huge impact if this room almost all raised their hand so I don't need to go through the 80 percent 20 percent business but it is true so that's why we do it exactly but follow over to you do you I mean I assume you there was a similar journey that started for you guys with you know dignity in terms of starting around housing and then kind of innovating and growing from there is that is that true or actually when we started in the early 80s the first few investments were in CDF files when CDF files will be getting to first evolve as a way to get them capitalized now CDF files is a huge industry so from there it was more about leveraging and extending a reach over time as the portfolio allocation you know currently it's a close it's over 400 billion has grown we have broken up into sectors and housing is a significant sector but when we look at housing we look at the whole continuum so we look at how can we invest in recuperative care centers these are centers how many of you know about recuperative care centers these are like step down from the hospital so let's say you're well enough to leave the hospital but not well enough to go back home or if your home is not well enough to go back to the streets so the step down would be from the hospital to respite recuperative care where you engage the individual and you get them to heal and then all the way up to homeownership so we work with organizations to be able to purchase and stabilize neighborhood so individuals a low-income individual actually can buy properties so we look at every supported housing rental etc it's really interesting can you say a word about you know what type of capital you're putting into these projects you know Andy mentioned you know light tech actually buying tax credits do you do some of that do you do that equity we do all of it actually i'll start for example how many of you know mercy housing quite a few so when mercy housing first started we provide the first guarantee for one of the first loans and look at mercy housing now it's huge we have provided pre-development loans for a significant number of large developers pre-development is the most riskiest consider the most riskiest loans banks don't touch it however we put millions and millions of dollars into pre-development to get individuals get started to take advantage of new market so we'll invest co-invest with either a bank that may have some gap financing for 15 years to be able to get the project off the ground so we do whatever it takes to do it safely because we don't want to jeopardize the organization by get them debt and then all of a sudden they can't pay us back and they default and it just creates a whole mess but we want to be able to be there should any communities need us to develop a project when you say just clarify when you say pre-development work you're talking about real estate developers that are building say an affordable housing project exactly trying to get something going in their community there's some upfront entitlement work that has to be done the whole planning yeah the whole licensing the structure so a pre-development loan is get this gets taken out by a construction loan so it's everything to do with prior to construction so it's a licensing the permits the you know the plants etc and that's a that's a there's a barrier to entry there because you need some capital to kind of you know get the project going but until you have a project that's investable it's hard to kind of crack that capital so you guys are kind of gap exactly so we try to fill in you know we always looking for projects because it's a it's a unique program so we're always looking for projects that we without us it couldn't move forward or we're the lender of last resort so we're always looking for those so in impact investing we're we're always talking about kind of the risk return and impact you know kind of uh you know continuum and trying to think about where a particular product or investment sort of fits on that continuum talk to us a little bit about kind of the cost of capital that that you provide and sort of and maybe it's different for each of the different products that you're invested or product types that you're investing in but can you talk to us about sure sort of what the what the cost of that capital is so the the guidelines for the for the program is that we have to maintain the portfolio has to maintain a three-year average CPI currently i'm totally out of compliance because if you look at inflation but um my argument is inflation will come down and then the three average will stay somewhere in between so so we have loans from zero percent to five percent we normally don't go above five percent um but also take you have to take into consideration that we do not charge fees or closing costs or any other so our cost of capital for the borrower is a significant loan okay yeah so just i just want to understand that i just just sort of emphasize that a little bit but from the systems perspective from common spirits perspective this is concessionary money if they put this money out with a kind of institutional you know financial management group you would probably do better than the zero to five percent right oh yeah well i would hope except except right now my portfolio is out doing the overall company portfolio oh yeah um knock on wood we haven't had any losses i mean our portfolio with asset manager i mean if you look at really uh the stock market i don't know yesterday or day before yesterday yeah um what's significant more yeah you're looking good right now yeah um but that's temporary the argument is that that in long time in long term uh you know you'll see double digits i won't see double digits right right but um if you're taking consideration the unknowns here for example if you provide housing for a community chances are that the cost of providing services at the hospital is going to be reduced if you help build a clinic up the street where individuals have primary care access the chances of reducing the cost on the hospital is significant so you have even though it's really difficult to prove that in monetary sense i mean even though there's a lot of scientific evidence it says that addressing some of these issues ultimately reduce the cost i wish i could i could prove to our system of the cost avoidance associated with investing in um in a housing project but i have proven that uh investing in a respite care uh has significant had had an impact on the readmission of those individuals that were originally moved in so so when you take a look at the returns if you add all these extras chances are you you're seeing double digit return and do you i mean in other words actually the answer is a question i was going to ask you which is how hard do you try to you know measure and quantify these benefits it sounds like you you might try but it's very difficult to do it's very difficult to do especially around housing uh housing and healthcare do not talk to each other you know we have HIPAA and housing has all their other regulations however when we invest in supportive housing we have an opportunity to kind of measure or in respite care or some other type of housing you know one of the projects that we did here was mini homes on gulf street these are tiny little homes for homeless and we're looking to see what kind of impact it's having but if we have a direct relationship with the provider we have an opportunity but on on on large-scale housing developments it's very difficult how much does that intuitive sense of the cost savings that you might be driving for the system how much does that intuitive sense play into the sort of the buy-in that you have institutionally to invest these funds at sort of a concessionary rate is that do people think yeah you know they're making investments that are going to re-down to the benefit you know from a dollars and cents perspective of the system or are they just saying look we're a non-profit this is the right thing to do for the communities it depends who you talk to so if you talk to people in my realm community health have staff across the system they'll understand right away if we make an investment on on a project in their community they'll go get it you talk to a strategy a business strategy person and sometimes you'll get this why are we doing this and then you have to send them the articles do so they begin to understand oh i get it and then you have and thank god we have the board in our our leadership team to get it they understand why we're doing this we're doing this because it improves the health of the communities that we serve and we've been in some of these communities for over a hundred years with our hospitals so we've seen the impact that we can actually have and so they understand that they understand that in an effort to really have a serious conversation about keeping health care costs down you need to be that anchor that's investing in those communities super helpful thank you sorry to pick on you so much we're sympathetic of it go ahead yeah super interesting well so i want to compare and contrast with the united health care he's a pair he pays me right which is interesting so i have to give him so yeah well ask your question well it's very similar yeah so let's let's start with the last question i asked pablo which is around you know how much buy-in do you have internally within united health care to do this work and the buy-in that you have is a based on some notion of this sort of strategy driving cost savings for the system or is it you know something else like what what is it like so we very high level buy-in at the kind of top parts of the the organization which is pretty remarkable um but i think there's a few things to drive it for us so one it is very little about cost savings to to pablo's point the problem with cost avoidance is that if you weren't charged it how are you saving it right so that i think i will tell you when i talk to any of our people i say don't come to me and tell me about all the money you're going to save me or my system because it's not going to happen um or we're not going to be able to quantify in any real way and so for us so i think there's there's two big components to it so every single investment we do you know i and our team need to demonstrate essentially the health care value proposition of what we're doing so that everything we do has to align and be about improving community and and population health so that's number one i think for us um we actually i'm going to go back to pablo's in a moment if you don't mind jeremy because he and i are kind of kindred spirits so we too are looking right i'm the big bad fortune five company and he's the wonderful mom profit we're we're conceding return as well and and we're looking to do he's more eloquent than i am i call it but for capital right but for our investment the the wouldn't happen so just a note that we're two very different entities and we're very aligned strategically on how we're trying to do impact investing i think is is important to know you know i get asked a lot you know jeremy to your point when you say okay well what is you know what are the finance folks say if i at least to your point treasurer you guys says well i could get 10 percent and you want me to give you this 25 million at two percent why should i do that right and so that's where i need to demonstrate what what i would call the health care value proposition that isn't about saving us a bunch of money it's about demonstrating the impact that this is going to have on health care and then there's the business value proposition which is that you know for those of you who work in in medicaid it all right where's a lot of health is honestly a lot of us have most of the same providers in the same network but a lot of it is common and so the name of the game in medicaid and procuring contracts is differentiation so i create differentiation for united health care and i'm happy to do it because we're putting our money where our mouth is right we're saying okay i'm going to this state and saying okay we just invested 25 million dollars to build you know affordable housing that wouldn't have happened in jackson mississippi and it's important to know too right just for folks to know because we ensure you know eight million people on medicaid and tons of other people every single nickel of our impact and tax credit investment is what i would call in my new health care land plan agnostic right none of this is prioritized or set aside for our members not a single penny right it's in investing in the community but so for us it's being able to say how can we create these kind of catalytic opportunities in the communities and then and be able to kind of say okay well here's the impact that we had you know so if we it'll give you one example if you don't mind so if we build a federally qualified health center in an underserved community access to care is a huge issue for us and expanding access to care so if i build a clinic and i and i put 10 million dollars to help finance a clinic we can absolutely talk about the number of people who got access to care over a three or five year period um and and one other example on just to carry on with that example is you know like pablo we're looking where we can do it strategically we're extremely interested in conceding return on investment and a good example would be the the fund that i mentioned where we uh financing health clinics where we i couldn't pay for this on an ongoing way on an annual budget but what i did was figure out how we could concede return on investment so that we can pay for community health workers through our investment in the health clinics that we're helping to finance and so for those of you who aren't well versed in in medicaid um bizarrely medicaid very infrequently pays for community health workers so we usually can't bill medicaid for them which means they're really hard to pay for and yet for our most complex care members they're the most important person in the healthcare system and so we're figuring out through our social impact investing how we how i can pay for that community health worker on site through our investment strategy andy can you tell us a little bit about i mean you've hinted at some of these product types that you're investing in but i know you've you've kind of pushed the envelope on the innovation side in terms of doing some really out-of-the-box stuff can you just kind of catalog for us really quickly the types of investments you make you know the flavors of capital that you're putting in whether it's equity or whatever you know return expectations sure so we're probably in a similar range uh on a same return of zero to five uh with uh pablo uh by and large i'm looking at a couple others that are going to be very out-of-the-box where we're actually going to be looking to for higher returns but for really really amazing reasons uh i can't talk about today i'm not trying to be keiji but um but but so we do we also do uh equity lending and we also do outcome space financing so a couple of examples and i'll be brief but so we actually just recently completed and got a return on our investment five years ago we invested seven million dollars and the helton foundation out of la invested two million dollars and we invested in the just and reach initiative uh with the la county jail and we got 359 people off the streets off of skid row and out of the la county jail and into supportive housing uh and and that is a definitely a but for investment but for that investment that would not have happened and we put right i had to i had to risk mitigate a lot up front but we took that risk right if we didn't meet certain there were two criteria around recidivism rates and re-arrest rates which are different things but and housing stability rates and if we didn't meet certain thresholds for that we would have lost you know principle on our investment uh so we and we're also uh investing uh with maycomb capital and the community outcomes fund some amazing kind of pre-k work that they're that they're doing in shelby county in memphis tennessee with a similar dynamic so we do outcomes-based financing um we do uh equity is probably the smallest portion of our portfolio i would say uh and then kind of what i would consider concessionary and catalytic lending is probably the biggest pot right where we're trying to think about where can we make investments um to uh to um provide capital to to projects and and another kind of but for examples that we recently closed a few million dollar investment on uh project in uh jackson mississippi uh it's senior senior affordable housing uh with a co-located federally qualified health center which is like the golden project from where i said i would invest in every single one of those deals i hope they'll be there god has to be more of them because right then you have you have your housing then you have people that takes a hundred unit building those folks are essentially have on-site services honestly and that's wonderful for them more importantly is that you've created a huge amount of access for all the other people that are going to be able to access care uh in that setting and so um uh so those i think are kind of the three main buckets and i and i would just kind of reiterate that if you think about um you know especially i work primarily in medicate but and pop will know this well but you know it's it's honestly it's one thing to have health insurance a lot of people don't it's one thing to have health insurance it's one it's a whole other thing to actually access care and we have millions of people on medicate who have extreme difficulties they they're on our fence but they're it's difficult for them to access care and so these strategies that we do around investment to expand access to care is so critical to supporting uh and again it's not specific to our members but all all the people on on medicate like this is a question for both of you guys maybe we'll start with you Pablo but how how uh strategic you know are you in terms of the investments that you're making meaning you know as a team we're going to not very you can't answer for him we actually partner quite a bit yeah so we're but i guess the question is how strategic are you and proactive about sort of identifying a strategy and then going out and exit you know finding product that sort of aligns with the strategy versus you know opportunistically seeing what comes in there's a lot of interesting things out there you mentioned jackson mississippi i'm thinking immediately about the water crisis in jackson you know do you guys have capital that's sort of flexible and open to kind of react to you know community needs that pop up outside of the core strategy i got so first of all our hospitals are anchor in different communities so my job within community health is always to engage with the community to identify not only through our community health needs assessment but also what the community is actually interested in doing or what's impact in the community i'll give you an example during the real estate crisis dr california was considered ground zero people were losing their homes being foreclosed being threatened a lot of individuals were just leaving their homes we identified a housing provider and we and basically said look i'll give you a two million dollar line of credit you go and talk to the banks and try to buy as many of these properties on ten cents of the dollar unless they stabilize these neighborhoods so that is because we have our connection with the community so it's very important for us wherever we invest is to have that community connection now on issues like the environment it's it's different we know that we can look at a project outside of any of our communities that's going to ultimately impact all of us so whether it's water or fire or what have you like for example it's just i'm currently having conversation about installing solar panels you should be interested in a solar panel and on top of fqac it's federally qualified health care center because of the fire because of the fires in california the federally qualified health care centers which are the primary care providers of a lot of our communities have to shut down because of power also you have individuals who are in live support systems that depend on power so if you put solar panel on fqac's you you're allowed that that clinic to continue 24-7 so you want to look at different projects not only in the way they're going to virtually future impact the community but also what the community wants to engage got it that's a long and that's a brilliant idea annie do you have a 15 second version of that because i have another question i'm gonna ask you 15 seconds for you wow there you go it's on chatterbox over here and you give me 10 seconds um no i mean i think um you know i actually would point to uh the outcome space findings back and i only mentioned a little bit about that we did uh we're doing with maycomb and and looking at the outcomes that that has for kids right and there was a need to address pre-k education and other engagement things in the community and so we certainly are trying to think about where there are needs identified in the community that we are trying to be responsive to that you know we certainly have a set we have a core set of kind of strategies and ways in which we invest um and and i'll just say kind of as anyone interested in talking to us or me later i think one of the things i try to tell people is that i mentioned this health care value proposition that is central to our work and to our investment strategy i try to politely tell people you're allowed to go around the sun once to get me to addressing health care outcomes right i don't want the 19 step logic model that says well if you invest in diet coke and then we do a recycling program and then and then and then we're going to think we're going to do that which we get a lot of and so you know i think we we are trying to be responsive to the community's needs and then you know honestly we try to ensure that we have appropriate guardrails for our investments while also providing the discretion because we don't know what we don't know and what's going to come our way got it so i want to leave a little bit of time for the for the audience to ask a question or two but i just want to end i have to ask this last question because i think this is like for me it's the sort of the root of the conversation as a released impact investing so there's a lot of folks in the room that are that are in impact investing and i think are interested in what you guys are talking about because it is concessionary it is catalytic it does sort of bridge some of these financing gaps and in harder to kind of work in communities and places and so i think it's really interesting what you guys are doing do you and again you know it doesn't have to be a long answer but do you guys think that you are on the van you know in the vanguard of something that is likely to grow in health care to the point that you know andy your fund becomes much bigger at united health care and other you know big systems are doing this and probably your work gets sort of replicated in other systems around the country or will you guys always kind of be you know a handful of of folks doing this you know this work nationally so one of the things that we did several years ago is without with three other health care systems is to create what we call the health care anchor network and that was a way to bring health care systems like ours together to focus on on on on on on certain specific issues so as as these anchors were economies in in our own community so we thought purchasing local purchasing would be a one area to focus local hiring is the other area of focus in community investing would be the other so currently there are 60 members to the health care anchor network started with three it started with three yeah started yeah kaiser dignity health and trinity another 60 and i would say about 30 of those are are tipping their toe into this arena and we try to provide them with as much assistance that we can and one of the areas that we right away we to get them engaged we get them to focus is on community development financial institutions because they're a great intermediary and it's it's almost a painless just make the investment and let it go and let them do the work but if you really want to get down into the weeds you really need to get involved in the communities and look at those projects that you ultimately going to have an impact but also take a look at some funds that normally our treasury department will not look into because there's too small like for example i don't know how many of you heard a black star check it out so it's it's it's a it's a medium-sized fund but not big enough for our treasury folks to pay attention and we're beginning to look at those well and yeah so i think i i would answer it in two ways i think so one i think we absolutely are looking to both expand and diversify our investments i would just say that broadly the the other thing i would say that is is really important from where i sit and and we have some interesting conversations internally because i mentioned the differentiation component to you all earlier but it's also you know and i'm not i hope it sounds whatever but like we're trying to lead by example and we hope others follow and come in and say you know what water's warm if united healthcare can go in and do this and invest here then goodness on earth we ought to be able to do that so honestly i think we are definitely both trying to look to experience but also you know leverage candidly the influence and power of united healthcare to get other entities to act and to invest as well you know i think one of the one of the core i think hopefully kind of roles that we can play with the number of the people we invest in right is it's important the investment that we're making in them and this is them telling me not me bragging but then they'll come like say oh well now guess what they then go tell every potential investor they're talking to well united healthcare invested with us so if we're safe enough and we're good enough for united healthcare we ought to be good enough for you right and so that is you know what i would call vouching right is a really really powerful strategy for growth we've actually had projects where the project individual or someone's talking to a bank and they would say well you know dignity health or common spirit is investing in us and the bank says well why don't you tell us that we'll come in and just do that piece so we actually by the fact that you've mentioned our names the bank was felt safer to do the investment we don't mind right because we're not a banker that that's their job that yeah bring it in i'm sure but right yeah that's great that's really fantastic well i i know we're running out of time i think we have time for just one or two quick questions back here to address the social determinants of health is how are you going to recruit positions to go work that's number one because the burnout rate is 60 percent on the bar there's a there's a supply issue that's one which is there are all sorts of models out there in the Medicare market like Chinmen and others where they've actually just needed and i've gone to global global budgeting so you know i think there's a need for competition of models out there but i'd like you to respond to the issue of how you're going to get primary care physicians to stay and not get burnout and two what are the alternative mechanisms for supporting other innovative models so how much time do you have because i would have to call our HR folks you know getting primary care providers to come to to this world it's definitely going to be an issue we're partnering with morhouse which is a university in an effort to get new physicians and new people involved in health care as so as an entryway but we have seen that practices from individuals of retirement age are closing down we're seeing that the younger physician are not interested in doing their own practice but they would rather be employees there's definitely a shortage not only in nursing or of physicians that's going to be need to address but to give you an answer right off the top of my head it's it's really an issue that it's everybody's trying to figure out yeah and i would say i mean the last time physicians ever we're certainly doing a lot in action around community health workers and nurses and others thinking about where can we support training programs and provide incentives for people to do it i mean the health care worker shortage i think across the board is scary for all i when i say all of us i mean all of us um of where we're at and i think you know to your one question around kind of some of the the global budgeting i mean i think you know from where we sit you know that's part of what i think i understand is as somebody who works in medicaid managed care right we have to continue to evolve our own models and approaches and the extent to which there are others right that that competition is healthy i think that's that's you know fair game i think you know one of the things that we talk a lot about and pablo and i've laughed about but i feel like you know in medicaid i i try to identify a couple of key things so they're when right when we're competing for contracts there are a million and one things that we can compete with each other on that's great you win i win whoever wins went right that and then there's a whole set of things where we unequivocally need to be collaborating on right and and and i'll just maybe my final comment will be because i have this conversation it's not daily weekly for sure with some of our health plan leaderships is to say if you come in and because i'll say oh well we should collaborate with these three other health plans they're like well no i want to do it because then we'll say we did right not our competitors and what i try to explain to them is that no no no if you come in and you provide the leadership and the convening and you and you're the organization our entity pulls the other entity together and we do something it's a huge win for you because guess what the state cares about all its flippant members not just ours right and so if we're creating a solution for all of the states medicaid members and bringing our partners along it's a home run yeah yeah if we have a healthcare provider telling us we'll take all your uninsured yeah instead of just partnering fine take it i think do you want to go with the quick question or oh no no we we earned a return on the investment it was modest but yeah so we we invested seven million dollars and then we had an outcomes-based contract with the county of los angeles with with the board of supervisors in the alley county human services and the alley county sheriff's department it was a thing trust me um it's it's and and but so there we had a kind of so we invested seven million dollars up front our partners right the people who do the real work on the ground let's be clear people who are housing people and connected care to them they're doing the work not me and not any of my yahoo colleagues right so they're doing the work but we we pay for that up front then we demonstrate that we've reduced recidivism and reinvest rates by x percent and then the county paid us back principal plus the modest return on our investment i have to cut it off there but i really want to thank you guys for the conversation today for the great work you're doing in these communities and i think you know just to bring it back something you said like for leading out and and creating an example in this in this area which i and i i i asked that as a leading question i mean i think oh i know this sector is growing i know there's momentum in there i'm familiar with the anchor network and have seen the growth there um a lot of people are getting excited about this kind of work from these kinds of platforms so i think it's uh you know kudos to you guys for setting a great example