 Hello, everyone. Welcome to today's session of the Harvard Medical School Organizational Ethics Consortium. I'm Charlotte Harrison. I'm one of the co-chairs of the consortium together with Kelsey Berry and Jim Saban. Today I have the honor to be your moderator as we hear from three experts on the ethics of hospitals as they go beyond health care to tackle social determinants of health inequity or decide perhaps whether they should do that. First a warm welcome to this series. This is our first program on a full year of programs that will explore organizational ethics. The consortium is now in its eighth year, hosted by the Harvard Center for Bioethics, in which we are really aiming to support and build a learning community of practitioners and scholars around the topic of organizational ethics in health systems. We really hope you'll consider yourselves a part of this learning community and join us again for upcoming programs, which I'll describe at the end of this session. We're back to today. So health inequity is a one of the most persistent injustices of our time, maybe particularly salient to health care organizations like hospitals that are founded on the premise that health matters. Increasingly, however, evidence suggests that what hospitals traditionally do, providing clinical care only determines roughly 20% of health outcomes. It's determined by things that happen outside the health care system. The conditions in which people live and grow, work and play, collectively referred to as the social determinants of health, and unfortunately also in the United States, the social determinants of health inequity. So should hospitals in the interest of health equity be moving toward away from their traditional role, but and toward meeting social needs in addition. If yes, then how in thinking about this question will be guided by three experts, and we look forward to hearing each of them as they'll be speaking from ethics and management theory, as well as from experience in this area. Meanwhile, a word to the audience about your own participation in the program. There are a couple of ways to participate. One is that you can submit questions for the panelists anytime using the Q&A feature and selected questions will be discussed at the end of the panel presentation. As you use the chat box to share your thoughts at any time, and those don't need to be questions we'd like to have the questions in the Q&A to be sure we're seeing them in case there's a lot in the chat but the chat is really important expression of where the audience is is going as you listen and so I think people really appreciate that as well so hope you'll use one or both of those functions. So now I have the privilege of introducing our panelists. First we welcome Dr. Lauren Taylor. Lauren is an assistant professor at the NYU Grossman School of Medicine and the Department of Population Health. Lauren's current work explores the ethical challenges associated with managing healthcare organizations and markets. Her research has been published in academic journals such as Health Affairs, Hastings Center Report and Kennedy Institute of Ethics Journal, as well as in news outlets such as the New York Times and the New Yorker. We're lucky to count her as a regular here in the consortium way way back she was even a member of the Office of Ethics at Children's Hospital in her student days. We have had her with us from time to time. We also welcome Dr. Kelsey Berry whereas usually Kelsey is here in the co-chair seat with me. Today she's here to present with Lauren on some of the recent work that they've been doing together. Kelsey is a lecturer in the Department of Global Health and Social Medicine here at Harvard Medical School. She's also a faculty director for the master's program in bioethics. Her work in population health ethics explores just societies and the role of the healthcare system in them. Finally we welcome Dr. Rishi Manchanda. She is an internist and pediatrician as well as a founder and president of Health Begins, which is a social enterprise that provides training, clinic redesign and technology to transform healthcare and the social determinants of health. In these 2013 book, the upstream doctors detailed a new model of healthcare workers who improve care by addressing patients health related social needs such as food, financial and housing insecurity. We're so thrilled to have the three of you with us and with that I'll turn it over to Lauren and Kelsey to get us started. Thanks Charlotte. I think I'm going to take the baton first and then Kelsey and I will tag team this a bit but it's so good to be back in the organizational ethics consortium. I really do feel like this is in the best possible way sort of a living room, an intellectual living room for me where most of the projects that turn out to be much of anything somehow or another get incubated here. So it's really just one of my favorite places to present works in progress, which this very much is. So, let me share my screen and maybe kick us off here. You know, we titled this something fairly colloquial, which is should healthcare stay in its own lane. And we did that just to try and evoke a sense that this is a timely question and one that for those of you who work in health systems and hospitals, you know, this is often the pushback that you know healthcare should stay in its own lane and so the goal of this paper and therefore this presentation is to try and address that. We think legitimate concern head on and say you know it's not farcical for someone to say yeah healthcare should stay in its own lane. Who doesn't want to be driving on a road in which everyone stays in their own lane that sounds like the safest path forward. But we're going to try and confront that that concern directly here. I should say before I get started, just that the last. Well, I think one of the times I was here Kelsey and I were working on this paper that just came out and Hastings Center report and so we offer this only slightly self promotionally, but more because we figured if people are coming to the center for a discussion about the appropriate role of hospitals and healthcare in quote unquote society, you might also be interested in this paper that is just out in this issue of the Hastings Center report. You'll see the title of the paper on the screen and the title of the talk today, have kind of close connections to one another. What's on the screen is more about hospitals and healthcare systems participation in a kind of public dialogue about racial justice and today's discussion is going to be more about hospitals and healthcare systems getting involved programmatically in what might be called social services or addressing social needs. So that's the distinction between the two but we see them very much as part of one coherent sort of intellectual project that frankly Kelsey and I have been talking about now for, you know, I think going on 10 years. We met when we were wee babes, both, I wasn't yet in the doctoral program Kelsey was in the doctoral program, and we have been noodling on this stuff for a long time. So, let's get to today. So, basically, this is going to be a talk in three parts, and then really, maybe the best part is going to be where Rishi layers on top and provides his comments. But the three parts that Kelsey and I are going to try and do is I'm going to tee up just a tiny bit I'm not giving you the evidence based on social determinants of health here but a little bit about what the growth of social determinants of health programs in healthcare delivery spaces kind of looks like, and then to acknowledge again what I said at the outset is, I think a legitimate debate about whether health systems should be doing social determinants. Kelsey is our resident theorist. I will say Kelsey has an undergraduate degree in philosophy which always makes me highly differential to her reading of John Rawls over my own. I'm going to hand the baton to Kelsey, and she's going to really help us parse through the ways in which a distinction between ideal and non ideal theory. We think can help clarify the terms of debate about whether or not healthcare should be doing this stuff, and what it kind of puts forward as in some ways a managerial challenge, and then I'll try and close us out. I'll try to get a background in management and so try and translate okay if we think this ideal non ideal distinction holds water and is relevant. What does that leave as the challenge for healthcare managers or healthcare executives. Then like I said we'll hand it off to Rishi and he'll, he'll make it all make sense. So let me just say this. When we think about healthcare doing some sort of social determinants of health or responsive to social needs programming. I've already said there's a common critique, which is healthcare should really stay in its lane, you know just do medical care and do it well and do it for something other than an exorbitant cost. And I think there's two ways to respond to that critique, and we're going to really double down on one of them today and not the other. One way to respond to that critique is to say, this is our lane, you know, gun violence is our lane poverty is our lane like it's all our lane, and we should just be more expansive in our thinking about what the mandate of healthcare is. That's one. The second is to say, No, look, I acknowledge that this is us going out of our quote unquote lane, but it's justified. I don't necessarily have a view on which of these is better. But I just want to say that we are clearly taking leave today from that second response to the critique, which is to say, Yeah, we are kind of stepping out of our quote unquote lane. We're not knowing stuff that we may not have like ultimate expertise in, but there's reason for it. And I think again that ideal non ideal theory can help us in making that argument, but I just wanted to be clear about where we're taking leave from. So let me say just a word about these kind of growth of programs and the resulting debate. Healthcare, of course, did not just naturally wake up one day and say, you know, social determinants of health and social needs is really important. There have for a long time, of course, been clinicians and certain health organizations that have been hard at work, taking an expansive view of the determinants of health and being responsive not only to medical but non medical factors. That said, there has been a real change in the policy landscape. I think over the last 15 years that have encouraged and sometimes financially incentivized healthcare delivery systems to be responsive to patients non medical needs. That has happened at the federal level, you could think about something like the Affordable Care Act and the emphasis they were putting or it was putting on readmissions penalty. It's now happening in lots of state policy reforms, particularly around Medicaid redesign. It's happened more locally and then of course some non traditional policy actors like foundations have also really put social determinants of health or what someone call social needs into the water or the zeitgeist. So in response, you see a fair bit of activity on the part of hospitals and health systems, particularly I would say in two main areas. There's a lot of activity around responding to food insecurity. And I think there's a lot of activity responding around housing related concerns. So let me say just a bit about food first. Before I even say something about food. One of the ways in which healthcare delivery systems have opted to respond to this push to think about and address non medical factors has of course been first to take on a large scale measurement effort so it is becoming increasingly common for healthcare delivery systems to ask patients about their potential social needs at various points in the in the care delivery workflow, but it's on the heels of receiving this information and realizing, particularly among a Medicaid insured population, although not exclusively. Wow, there's a lot of social need out there. And so the policy impetus, plus this big data collection effort has really, I think, created conditions for healthcare to step in and be doing some of this food stuff that I'm going to talk about. So when healthcare delivery systems step into the fray and say yeah we're going to really do something programmatically around food, you could think about the following kinds of activities. People are setting up on site food pharmacies, which are essentially food pantries, often with some nutritional restrictions, often on site at the better qualified health center or at the hospital. You could alternatively think about things like mobile markets, or even some home delivered and potentially medically tailored meals programs. I'm not going to go into depth here just wetting your palate, so that when we're talking about healthcare doing social service delivery you have a sense of what that might look like. I said housing is probably the second area that has a fair bit of activity in it, at least from where I sit. And so what does it look like for healthcare delivery organizations to get into housing. Well, here's some examples, right in our, our quote unquote backyard of Boston, you know Boston Medical Center led by Dr. Andel has had a really creative and robust portfolio of activities around housing, including making grants to homeless shelters, but also, you know, really trying to help fund the creation of new affordable housing. So if you're interested in healthcare and housing BMC is certainly someplace to look. You can also think about healthcare delivery systems getting involved in housing other ways by trying to cut through red tape and prioritize high need high cost patients to make them kind of front of line to get various housing opportunities. This is not uncommon but also not uncontroversial for various reasons. You can think about it's rare, but there are examples where healthcare is actually leading or at least supporting the effort to create new housing supply, which is really the bottleneck and a lot of the discussion on housing is, you know, we just don't have enough affordable and low income housing. And so one very prominent example is from a CCO, which is Oregon's version of an accountable care organization where they committed more than $10 million for the creation of new housing. I would say also that there is work in other areas that is not food or housing related workforce development would be one. I don't want to say too much about this only to give you an example like there is a hospital that is actually building a new workforce training center. And so you can, you can understand when this stuff hits the wire how some people say, I don't know is that healthcare is laying are they experts in doing workforce training. So, let me just acknowledge as I have that like there is real debate about whether health systems should be doing this kind of activity at all. And one side of the ledger kind of says, absolutely healthcare should be doing this work right, even if healthcare doesn't necessarily have the skills where they don't have the experience to be necessarily running a mobile market right now. Health systems are really good at learning, and they're especially good at learning when you incentivize them to do things so they'll figure it out. Additionally, you could say like, look, maybe it's not amazing that they're doing this but we're not going to get additional social services funding coming down the pike anytime soon. We know that government and our political climate generally is highly low to want to see an expansion of quote unquote welfare or safety net programs. We're going to expand some of that capacity and do it through healthcare sounds like a good idea to me. And then the third would be to say, look like I don't care how it gets done. There's tremendous moral urgency around this like people living in the United States and incredibly wealthy high income country are living without a safe place to kind of call home or rest their head at night. And so one could take the view I don't care who does it I'm completely agnostic as to whether it's healthcare or something else. There's more urgency and if healthcare is willing to step up to the plate. I will take it. The other side of the ledger is kind of this absolutely not. I would say, you know, really double down on this is not health care's expertise. Anything that healthcare does winds up hugely expensive, right because they're complicated systems and there's just no matter what they do you know you ask for penicillin from CVS and it costs $380. You get it from the hospital across 15 bucks so is that the path we want to go down for these social services. And then you could also have a more kind of political economy concern which is to say, I don't want to give healthcare this kind of power and control right like Lauren you just told me that in Colorado, some healthcare delivery systems are getting into the housing game by putting additional priority on high need high cost patients to get housing over other kinds of people who just happen not to be high need high cost. And that makes me very uncomfortable and I don't want to seed that kind of power over important decisions that are not strictly medical to the healthcare delivery system. So in the debate, I hope I've made clear that they both have parts of them where I won't speak for you but for me they both have parts of them that are compelling. And that's what motivates me to really want to take this on. I'm going to say just one thing here and tea it up for Kelsey to take over but in responding to this question, should healthcare systems be doing social determinants of health. Our take is that a distinction between reasoning towards an ideal world and reasoning in a non ideal world can be clarifying. And I would say kind of our thesis to preview the argument is look in an ideal world, we think health systems are not the first best option for providing food housing, etc. But in a non ideal world, which is very much the world that we live in, it is corrupt, it is unjust, it is fallen in the theological sense. We think health systems efforts to respond to the moral urgency of social needs can be consistent with justice. And so this is a way not just to placate both sides of this argument, but to take seriously that both of them are offering insight and that they can live in some kind of harmony with one another. So with that I'm going to shift over to Kelsey's voice and ask her to take it away. So I guess, you know, quick summary hospitals are doing a lot to get into this social determinants of health game and some say yay and others say nay. And there is nothing like an impasse to impede progress that could be beneficial on all accounts so the first thing that we really wanted to do and kind of turning to this ideal and non ideal theory distinction is just to say that there's value in recognizing that neither perspective is invalid. And ethical theory can really help us see that. And then secondly, if we're able to put these two perspectives in hand with one another, we can actually be more strategic in our efforts efforts towards justice. So we're going to take a brief detour into theory to lay a little bit of groundwork. And specifically, we're going to pick up on this distinction that's drawn by John Rawls in his work on justice between ideal and non ideal justice theory to kind of orient us. And actually, Lauren, if you would advance one more, I think I'm going to start with ideal theory because that's, well, you'll see why. Okay. So, so, so let's just we'll start with ideal theory and sorry about all the text but focus your eyes on the right side of this slide with me for a moment. This is really what Rawls spent a lot of his time developing. And so here the focus is really on visioning the world as it ought to be, and the rules that would govern in that ideal world. And so those rules usually assume full compliance, right, which means that the people who live under them are fully adherent to them, they exist, first of all, and that people actually adhere to them. And so the natural conclusion in this frame is that if we were now to meet the assumption of full compliance, right, everyone simply does what they are supposed to do, then poof, right, we could find ourselves in exactly the kind of world that we're aiming for. So now that's kind of really starting to bring up a good reason not to take it upon oneself to do something rogue, right, step outside of your lane as sometimes critics of hospitals engaging in social determinants of health projects would caution, because then even as well intentioned, right, as that effort might be, you risk becoming part of the problem, right, putting another kink in a kind of tangled social web that has really prevented us from meeting a lot of our goals. So, and maybe one more click Lauren. There we go. Okay, so now ideal theory. It's incredibly useful it's really no small task to figure out what ideally we're aiming for in society, what a just society actually looks like 300 plus years of political philosophy have tried to do this. And that's really the task that ideal theory takes upon itself is to clarify, what is this desired and state where do we want to be ideally. The critics would say that by making some of these idealizing assumptions as part of its methods, right, for example about full compliance with the rules, or even abstracting away from some of the things that we know to be true, right, the non ideal circumstances in which we live. The ideal theory is really setting out this very lofty and perhaps to lofty goal without giving us more useful guidance than saying something like well just do what you're supposed to do ideally, and all will be well. So that's, that's kind of the critique right of this project of non ideal theory. So that kind of pushes us and has really pushed a lot of dialogue and political philosophy over the past few decades towards a non ideal lens, which really traditionally rejects a focus on what they call a dream world right the dream world is ideal theory, and what it looks like and how that dream world runs and zeros in instead on the world that is right in front of us. Right, all of the ways that we are falling down right on our obligations and so the common assumption that non ideal theory is making is that we are not only non compliant with rules of justice but we're likely going to continue to be non compliant with them and so what we actually need are some principles to guide our actions that assume these failings and help us make more pragmatic solutions help those who are willing to make more pragmatic solutions for the world as it is. This is the terrain and the work of non ideal theory works out what duties and obligations apply to us in these situations of partial compliance. So if we know right that people who should be helping the poor or groups that should be avoiding discrimination on the basis of race, aren't doing those things and won't likely be doing those things for a while, then what do we do from there. This is not hard to see and we're sorry just jump back one more Lauren sorry, and this is the this is the challenge of our being sharing slides. So it's not hard to see the allure of this approach, right, the fact that everyone's acted imperfectly. Many people have acted imperfectly over time, and in fact are even acting imperfectly now means that a lot of deviations from the ideal have been stamped on our communities and our laws and on our bodies. And so we have quite a lot of that residue to make up for to make the world better, let alone ideal. So, we need to have some guidance about how to perceive from the circumstances in which we stand, and non ideal theory therefore gives us a pretty good reason right to change tact as a hospital to get working on social determinants because in the real world right contrary to an ideal perspective might suggest as a hospital, I can't simply focus on health care and expect health equity to pop out of thin air. Right, I would need a lot more to be happening around me for that really to be the case. And so non ideal theory is giving us that needed dose of realism. The limitation and this is just the last bullet on that left hand side is that when we inject this realism into our kind of normative theorizing right and we assume the persistence of this widespread social failure. We risk yielding goals and prescriptions that might fall short of our broadest and fullest concessions of what health equity actually is. And what emerges from non ideal theory at its worst is this kind of take what we can get narrative, where the more facts we incorporate about our limitations or flaws are non compliance. The more that the principles we end up with can offer this uncritical acceptance of how we are of the status quo, right instead of pushing us further. The reason that we put both of these on the table is that they are intention with one another, and you can see how they support kind of the two perspectives that Lauren was sharing with us earlier. But the trick is not to live exclusively in either of these two worlds but instead to find a way to bridge them. And so that only brings us to the next slide with this kind of transitional view of non ideal justice. I think great of justice in our non ideal world as it exists, not as requiring us to lower our sites in this kind of remedial way, right that non ideal theory might suggest, or even acting kind of impotently as if everything is just fine. As a more ideal lens would suggest, but actually in this transitional view which needs the two ideas together, where ideal theory is really setting out in the project of defining the end state right setting up as long term goal. And so the task in the project of non ideal theory is not to set our goals lower, or to assume great that we're never going to get better, but rather to look at how to gradually approach that long term goal through smaller incremental steps. And so, on the next slide, there are some benefits to relating the two perspectives in this way in a kind of complimentary rather than antagonistic manner. Right, this approach of transitional, transition only viewing non ideal justice. It does not rule out actions on the grounds that they are not fully ideal. Right, so it allows for a deviation from whatever the ideal set of rules would be. And that helps us avoid making the perfect, the enemy of the good. But then also, it doesn't give up the ideal all together. Right, it still works it in. So by appealing to this idea of what we ideally want that end state, it helps us avoid blowing or lowering our standards to this kind of anything better than status flow goes. Okay. So, with those kind of a big framing ideas in mind we could ask the question well what does this transitional view really have to say, what guidance does it offer us in the kind of concrete or the practical. And so that's where we get to what have been called transitional constraints right so some ideas about what a good policy in this transition from the non ideal to the ideal looks like. So we turn actually to Rawls again in this, it's by way of john Simmons who is a kind of contemporary interpreter of Rawls work, and who really reminds us that Rawls wrote a lot of things, and some of the less productive ideas of ideal versus non ideal theory, actually are in his biggest magnum bogus that puts them in tension with each other in this kind of antagonistic way. Whereas in his love peoples, which is another book that looks at international order, he really fleshes out these ideas of transitional justice connecting the two. And so what he says, right, is that a good policy in non ideal theory is good as transition only just that is as a morally permissible part of a feasible overall program to achieve perfect justice as a policy that is going to put us on an international position to reach that ultimate goal. And so that's pulling out three desiderata against which to evaluate hospital participation in social determinants of health. So on the next slide, I've just listed these three. A specific approach would have to be morally permissible, politically possible or feasible is another way of talking about it, and likely to be affected. Now I will concede there are just endless things to say about each one of these transitional constraints and what it contains and how to analyze it and maybe even critique it. So I just want to give you a quick flavor of how this gives us a little bit of guidance in thinking through, or in helping hospitals, perhaps think through how they might approach social determinants of health. So let's just start with this kind of moral permissibility criterion on one level we could understand it very simply, which is to say not, we don't want to be engaging in kind of activities that are obviously impermissible. Right, so you can imagine achieving a just social order really quickly by starting a civil war that causes the death of a lot of innocence. That is not what hospitals are doing. We know that. But there, but you can kind of use a relatively basic moral sense to say no there are just some things right like murder that are not appropriate policy approaches to moving us to a more just state even if they might do it relatively quickly. Okay. So then, to get a little bit more nuanced, we might also be considering all of the initiatives that we undertake on this kind of path to a better world might have some transitional unfairness in them. You know, so people live under us an expectation of certain rules and activities happening in society right they kind of build their lives under what's going on. And when things change, right, for example, when a new actor becomes involved in an activity that they have not traditionally been involved in. We want to be thoughtful about the way that that may pull the rug out from other people who built their lives innocently right on a different set of assumptions. And so thinking about transitional unfairness as we move forward with policies to try to get us to an end goal. And then just thirdly, this one maybe seems a little bit obvious, right, is to not commit a more grievous injustice in the service of progress on a less grievous injustice. So I won't say very much about that, because it might seem kind of intuitive we don't want to be trading off things that are worse. To get to things that are better. Is that, did that make sense. We can talk about it. Okay. Now I will say that those those are interesting moral constraints. There are also these other ideas that Rawls is introducing that Simmons introduces by way of Rawls, which is that we should pursue policies that are not only morally permissible yes but also possible and likely to be effective. And so you might be saying to yourself, well, we don't necessarily need a lot we need something other than philosophy to answer these questions. We need, you know, economics, we need social scientists, we need some good measurements and some good predictive modeling, which is all true. But philosophy does have something to offer us on this on this terrain in terms of clarifying what success is right so that we can measure against that view of success in the policies that we're considering. So we could either, we can think of kind of two ways of measuring success one would be, how well does this policy do against a narrower narrower goal, eliminating a specific injustice right so for example meeting the needs of individuals who are food insecure. The second way of assessing a policy is as it relates to this ultimate goal, right, the overall achievement of perfect justice and transitional theory focuses us on the ladder, not to say that the former is not important but it really says we need to be thinking carefully about the ladder. So it's going to caution us against choosing policies that only remedy a particular injustice now, but would set back efforts to achieve justice more in the future. So it's really this idea of identifying moral opportunity costs of what we choose to do. So in terms of potential ideal justice delayed, we want to be thinking about whether our policies make it harder for us to make progress going forward. It has a unique implication actually to prioritize this longer term goal and to really think about how what we're doing gets us to that path, which is to say that if we want to put ourselves in the best possible position to make that progress. That might mean accepting worse before better. Right. So we all know and can see in our own lives and many ways that progress is not necessarily linear. Right, a policy might take one step backward and give up something that is good that is working in order to take five steps forward later on, and that would be more transitionally just according to this account. Right, then just taking two steps forward now and stuttering. So with these kind of ideas in mind, I think that they're open to critique in some ways but I also think they help shape our thinking about what hospitals and other health care organizations could be attentive to when they're thinking about whether and how to approach work on social determinants of health. And so to give a little bit more teeth to that idea I'll turn it back to Lauren to make the translation to how this might play in a managerial space. Thanks, Kelsey. I'm just sitting here grinning. It's so fun to work with you. You're so smart. Okay. Let me try and bring home some managerial implications of recognizing a non ideal, a strategy born in non ideal theory as a transition state to try and get us to something more ideal. So basically my thought on how managers in health systems could make use of this set of philosophical principles is to say like managers should basically be wearing bifocal lenses. And they should wear bifocal lenses in the sense that you know standard bifocal lets you see near and it lets you see distance through different parts of the lens. So my sense is, I'd like to invite health care managers to be facile in moving between these worlds. That is, they've got a part of their lens that sees the world as it is and is crafting strategy to be responsive to the moral urgency in the world as it is. They can also raise their vision a bit and see the world as it should be and make sure that the action they're taking to respond to the world as it is is consistent. As Kelsey was telling us with the longer term goals of bringing the world as it should be into fruition. So that's the general kind of managerial takeaway. Let me say a little bit about how I think that can be quite tricky. So let's think about how health system managers typically think, and you could imagine a health system undertaking some kind of let's say food pantry services. So what does success on programs like this typically look like it looks like kind of monotonic growth or improvement right in potentially a various array of statistics so the manager could say like we're going to do this food pantry thing. I want to see numbers on a monthly basis or quarterly basis I want to see how many people are getting screened and screening positive. I want to see how many patients get referred to the pantry, and then I want to know how many people who get referred to the pantry are actually getting services. And, you know, you would do some stuff and then classic management you kind of plan to study act you'd refine the intervention you do some more stuff, you define it and then you do some more stuff. So essentially, you would count as success, like I said, monotonic improvement right so in this kind of stylized example. I've got, you know, more patients getting screened. More patients proportionally receiving food, and, or sorry, more patients being referred to food, and then more patients receiving food and you ultimately hit an asymptote on this bottom right square, where everyone who gets referred to the pantry receive services. And so this is where I think, you know, if I were to just bring my HBS colleagues to the discussion, they would say this this right here is success. And I think one way to kind of dig into this is to say well when you count this as a win, you are implicitly making the following assumption of a lot of people who would otherwise not have received food are receiving food, because of the program we have started here at hospital x, which is a basic human right. So like we have done a really good thing here. The critique of course is, this is a loss health systems are now getting to determine who's deserving of food and who gets access to their fancy food pantry. And you know their view of who's deserving is too narrow, compared to another entity undertaking this work the other entity might be a community based organization who's been at this for decades if not centuries right. So what I'd like to say this is just me graphing those little statistics before the provision of social services on the y axis and time on the x axis is, you know, if you think only about the world as it is meaning you were to exclusively take that non ideal theory lens, you would kind of say like set it and forget it at this point, health systems have successfully learned how to do this particular kind of social service provision. And we have succeeded and good on us and good for the world, because folks are getting food. Another thing that I would like to say about this kind of bifocal lens for managers is the really tricky part is that performance needs to be able to be judged against both the non ideal and the ideal benchmarks, potentially at different parts of the strategy, meaning to really take non ideal theory as a transitional theory, trying to get us to a more ideal world. Well then we should be judging our performance against non ideal benchmarks early in the strategy, and we should be judging it against ideal benchmarks later in the strategy. So what does that look like visually, you know, as I showed you before you could say these x and y axes are exactly the same. You could say look like we learned a lot and we increased our social service provision at hospital x in the sort of near to medium term. But what we really ought to be doing over the medium to long term in taking seriously ideal theory is to say like we should be trying to get out of this game. In an ideal sense, where everyone is compliant with the role to which they are like accorded in society. You know the critics have it right, maybe healthcare shouldn't be the one over the long term providing social services like food and food and housing and workforce. So, where that would leave us is to say, potentially, a really sophisticated healthcare strategy around SD OH engagement is to recognize there is more urgency now that we are at least permitted, maybe not required but permitted to respond to, and that that's not a crazy idea and it's not morally impermissible. The healthcare delivery organizations can start these programs they can even scale them in the near to medium term. But they should do so with a very clear idea that this is not their work forever or it shouldn't be their work forever that other entities should ideally come in and be able to take on that role. There's a debate about whether those entities exist at the appropriate scale right now, and that's in some ways an empirical discussion, but at least to recognize that over the medium to long term. Ideally, healthcare delivery should be doing healthcare delivery and other organization should be doing other kinds of social determinant and social service work. The last thing I want to say is, so this is health system performance you know you could see you could think about the role for health systems in this work, increasing, and then ultimately decreasing. And that's in part because, ideally, we would want to see these non health system actors coming in to really take the lead on this social service kind of work. And so, perhaps this is too abstract but this is visually how I think about the transitional state and the way in which you move from non ideal theory to ideal theory. Through the lens of kind of a strategist, if you will. I just want to say the hardest part about this if I put myself in the shoes of a healthcare CEO, or other strategist is to know, make a judgment call about when to shift their lenses, meaning. All right, Lauren I hear you. We're going to undertake some social service delivery to respond to the moral urgency and take the world as it is that'll be an activity, premised on nine ideal theory. When do I shift my gaze, when do I decide that we should start pulling back, rather than expanding the scope or scale of what we do around social services. And I will say this is something where I have very little to offer by way of like real practical guidance. What I can say is, that is a judgment call, and it's a tough one. And without more specifics I don't know how to offer more guidance, either here or in a paper about when that shift in lenses should ultimately occur. I just wanted to call it out here that like real shift in interpretive lenses would really happen in a kind of stylized sense, at the point in which non health system actors are either ready or are, in fact, taking on a larger burden of social service provision than our health systems. So to recap this, you know, and I'll ask Kelsey to weigh in on this recap as well but I think what we've tried to say is look the question of whether or not hospital should be doing best you H is reasonably contested. But we think separating out ideal and non ideal circumstances can facilitate some convergence by saying like look. In ideal healthcare maybe can and should be doing stuff ideal healthcare probably shouldn't be doing stuff. And we need to come up with a transition plan from one to the other. That's the most sophisticated way to be discussing this issue, rather than just me looking at Rishi saying oh Rishi you're so naive for thinking that healthcare should do this and Rishi looking at me and saying oh Lauren you're so cold hearted by thinking that the healthcare should not be doing this. So we've suggested taking this kind of bifocal approach where you can focus both on kind of responding to the moral urgency and bringing to fruition this more just state. And I'll turn it to Kelsey, any final thoughts before we let Rishi weigh in. I couldn't say anything more than what you have already done so I am so I love I love working with you Lauren so Rishi why don't you jump in we're curious. Let's talk about your thoughts this is a work in progress for us. And so, there's a very real chance that anything that we're asked or or comments will find their way into hopefully a refined version of something like this or even tell us that we're on the wrong track to. Thanks Kelsey and thanks Lauren. There's a lot of wonderful stuff to kind of react against and I think the, if the primary objective is I think you both put it was to present this as a lens to help clarify discussions about what roles and responsibilities live within healthcare and outside of it. I really feel like this has been clarifying for me so let me put on my progressive lenses and say that as a that perhaps if I'm understanding. Again, I'm not a philosopher in order to report to play one on TV. The transitional lens on non ideal justice. If I got that right as you're presenting it. I'm also a progressive lens kind of analysis where there is the ability to kind of stay in between the spaces because that's really what resonates will be the as I was listening to you all. I'm a primary care and public health trained physician. I've spent the bulk of my career working in communities that have been historically marginalized and socially harmed by by structural practices and policies. I was a specialist at an FQHC for several years where I was a primary care clinician and started a social medicine program at the VA, building clinics to help care for homeless veterans. And in the central valley where I helped build and lead clinics and other community programs to improve outcomes for farm workers. So the discussion today I kept, I keep thinking about a few different questions and so let me, let me share my remarks maybe in the context of about 10 minutes about 10 minutes 12. I'll try to go Rishi, whatever you have to hear, whatever you have to say I'm here for it. So, the first question is actually, I was thinking about, you know, who is at the center of the discourse here and the manager implications I think really kind of clarified that for me it's. It's meant to be trying to answer questions for the strategies the CEO is the managers of large healthcare systems and I, I just want to bring in a contrasting kind of framework reference. A couple months ago, I was in the home of a woman named Irlinda Irlinda is in her late 50s she has complex medical and social needs. Several chronic illnesses, including hypertension and diabetes sleep apnea and persistence of your asthma. Her provider had her clinician had prescribed a CPAP machine machine to help her breathe at night obviously because of her sleep apnea and this was imperative not just for the sleep apnea but for her health overall the healthcare delivery apparatus, essentially had prescribed her a device as part of her therapeutic treatment plan to help care for this obvious medical need. I met her in her home and her home was one that had been plagued by a severe chronic persistent infestation of roaches, bed bugs, water leaks and concomitant kind of problems with mold. She herself because mobility issues are related to her medical issues had problems in terms of being able to get in and as importantly out of this hazardous environment in which she was living. When I met her I asked her you know how these conditions are affecting her and she said go take a look at my CPAP machine. And so I went to go look at her CPAP machine and saw immediately why she asked me to go look at it because as I looked at this machine which she had told me she had been cleaning rigorously every night, every day, cleaning, keeping as long as possible. Having just cleaned it a few hours earlier she said now take a look and tell me if you've seen anything again she directed me to go to her bedroom because she couldn't get up. It was just too much to get winded so I went I looked underneath the cover of the CPAP machine took it off and there were roaches. One road she was sitting right there on her CPAP machine and one just in the mouthpiece essentially that she would better knows. And just for a moment center the conversation about this debate about the role right for healthcare to address social determinants of health in the context of her Linda. She had tried for weeks and weeks to try to contact her provider to be able to get a new CPAP machine she finally was successful and yet having gotten that machine she went back in and put that in the same context right. Who's Lane is it. Right, it was not a question I was concerned with at that moment right there. And that's not because of my clinical training or my public health training, but because of like the basic reality of non ideal state perhaps. This was clearly hazardous to your health. And so I want to keep her Linda in mind is asked a couple of framing questions as I go through today. One is, and I'm going to peel the onion a little bit if I can and try to apply a progressive set of progressive lenses to this maybe living in that transitional view. They described. First, let's define terms. As it was coming up for me. The term SDUH has been successfully co opted by healthcare to mean something that it was not meant to be. And so it sets us back actually and thinking about what's in lane what's out of lane and roles. You've alluded to this in the discussion today and I think it's actually really important to underscore this point in this, this course and the dialogues that I'm a part of in our work. And help begins organization I founded and now do work across the country we are a design implementation partner helping healthcare systems and community partners work together to design strategy to manage programs big bold interventions to improve health equity. And effectively to move upstream in order to advance equity. What's implied in that as a recognition of the social and the structural drivers of health equity a term that I use repeatedly in our work, the social and the structural drivers of health equity. There's two things that are really important in terms of terms definitions one recognizes that equity itself, as we define it in our work using an ethical frame is an ethical value grounded in a ethical principle of distributive justice. There's a clear kind of, you know, lens over here and I, I was looking for that and thinking about that as you were talking about the political philosophy. This course, they're all in kind of analysis there. In our work as we think about that equity framing, which is grounded again in these ethical principles of distributive justice. What's right wrong, nor bit of kind of questions. What we then say is well let's look at the ways in which different social and structural drivers actually represent and perpetuate inequities at the individual level it manifests as social needs social risk factors. There's a discussion discussion with those terms and that's food insecurity so that's an illness case that would be housing insecurity and exposure to unsafe housing conditions. Beyond that there are social determinants of health and the way that the frame we use consistent I think with public health kind of literature and the WHO and others trying to push back against the way in which healthcare is effectively co-opted this term. Social determinants of health really mean community level kind of phenomenon defining the conditions that give rise to the social needs right so if it's food insecurity at the individual level food deserts. Why are those food deserts in the first place why are the social determinants there in the first place what shapes those influences those those are the structural terms of health equity. I'm going to use that framing because it's not just a terminology debate but it's because it informs the rest of my comments about now not beyond terms to the next question which is maybe talking a little bit more about what activities are being debated and when folks are bringing up this is it in our lane or not kind of debate. I often pause and say well let's get really clear like what do you consider to be in your lane, what do you what are you really kind of contesting here. And in dialogues we've had around tables across the country with stakeholders as well as in one on one conversations a lot of clients what we usually encounter is a degree of consensus around the fact that health care are our lane if you will health care is to provide the best, most accessible and most equitable care. And this has been illustrated by outcomes like in our care delivery itself has to be the best quality this is the triple in quadruple in now potentially quintuple in defined. And there's increasing discussion now in some cases in the space of a lot of consensus that this has to include now very explicitly being able to as part of care delivery improve equity, where there's more contestation but still being actively contested is whether there's more on that and this is where I think you're really a paper you referred to get to the kind of maybe civic responsibility role the way you're describing it. But you know what does it mean for the institution now to for example in its own hiring practices in its own in the way it treats its own employees, not perpetuate inequities, including racial inequities, not create social needs like food and security among your staff while you're trying to extensively screen for your patients, their institutional kind of policies and then beyond that what does it mean as an institutional actor in your community to address the food desert to address the food apartheid at a structural level. Those are being contested, no doubt defining these terms separately allows us to actually have a debate and clear away is like are we talking about addressing social needs in order to optimize care are we talking about food deserts in order to kind of contest your institutional roles that term definition really helps to cut through and the final activities for the for today it sounds very much like we're talking about care delivery. And I want to just clarify that because what I was hearing was something implied, I think what you're contesting is whether health care should be providing social goods social addressing social needs like providing food providing housing So my contest then is this that when we think about the specific activities we can also then move on to the next thing about specific roles and what we've learned time and again in health care. As for example we looked at behavioral health, where we started screening just recently in this generation we started screening and adopting as normal quote unquote in our lane, the idea of screening for depression or mental health. Or at least on address, it was not in our quote unquote lane in the biomedical kind of view to do that. And what we've realized is and as you expand the aperture of what is considered normal in our lane and health care. We've also seen people reconcile this not ideal or transitional kind of view by essentially saying well maybe it's not about leading or not. It's really about lead partner or support team based care is the transition away from the cowboy model for a reason because it's more effective and efficient is the way in which we've strategically and operationally solved for this. Philosophical debate which really doesn't really manifest a lot. This idea of being able to identify how we lead partner support is something we've done time and again to integrate behavioral health needs to be able to address a variety of needs for diverse and complex patient population. Care delivery in other words rest on a team based care model. And so when we apply that team based care approach in which some people be some people partner and some people support and sometimes those roles shift, depending on the topic. A behavioral health care manager leads behavioral health care management while a physician may lead the prescribing of a particular adjustment of treatment plan. Everybody has different roles to lead and everybody has different roles where they support partner support the same thing that we apply here and I think it can help unlock this question because in my day to day practice and working with hospitals and leaders across the country as well as frontline folks. When we think of for Linda, we don't have time and it feels entirely relevant to debate whether or not we're going to figure out, you know, should we step outside the apartment building now and say well, my job, your job now. It's really about more efficiently saying who's who's lead here who's partnering with supporting and in some communities where the social infrastructure and health infrastructure has been devastated because of longstanding structural practices. Sometimes it's the first to kind of see that issue. Sometimes health care because of ground role where we have to at least be the first to identify if there's a need for sometimes the first to identify whether they need to exist or not. That's different from screening in other words is different from implying that we have to be the always the people who provide right the remediation for the housing, but it does require us to at least figure out whether we are going to lead. If not lead and who we're going to partner with and how can we support. We have to identify our role on a team, you know, and when it comes to addressing patient social needs, rather than being caught in debate about whether we lead or not. If we can't lead, then who else is leading here and how to find that out. Yeah, that raises another question which is, you know, in our lanes, I come, I thought of the, the, the great kind of thing that was in the, in the chat here. Who put this Tim put in this link for the KKTV kind of thing was beautiful picture of these kind of lanes with weird road markings. It made me realize a couple things one, these lanes are being kind of who's defining the lane. And as importantly, what's happening with social needs in particular is healthcare starting to realize wait a second there are other cars in this road there's other vehicles on this road. For the first time, this large behemoth of an industry is starting to realize wait a second, maybe when it comes to social needs and social determinants, there are other bikes on the road next to our giant tractor trailer. We should be more cautious about how we kind of navigate this road together. How do we actually make sure that it's not just about whether it's in our line or not from my perspective is, how do you make sure is healthier system you're not, you're not causing violence on the road and running bikes off the road the social sector off the road in that way and that does require I think more cognizance of the fact that this is a lead partner support environment. If we debate about whether it's in my line or not often speaks to I think the naval gazing that health care is does a lot which is it's about us, it's about us, it's about us. It's not there are other cars and vehicles on the road and so we should just figure out how to like figure out whether we're actually in their lane or not and if they ask us to say hey you know for this particular patient for Linda. Can you tell us if she has any kind of problems with roaches in her CPAP machine. And if so, we got your bet we got that we'll take it. Now we're at now we're problem solving a way that makes sense. It raises two of the last two questions here, and this is about, I'm going to get deeper into the kind of critique in a bigger way. For me, the, this definition of the ideal state one in which health care doesn't or shouldn't do anything related to social needs specifically providing social services. Because what I've seen when this debate gets raised it's often revealing a deeper flawed belief that health is some sort of biomedical construct right and that ergo health care itself should be a biomedical enterprise. In my perspective, anybody who spent a minute caring for person whether as a health care provider or social services and provider knows that health is a bio psychosocial state. We know this we know this intrinsically inherently just takes a moment to interact with a person and with a responsibility to do that. The question really is this, I think what this debate often really fails to acknowledge is that there is no neutral benevolent position which or neutral position which health care is starting from. The whole argue is that what we're talking about here is a scenario in which if we recognize most of health care is accepting a biomedical perspective where in reality health is a bio psychosocial kind of phenomenon. Most of what we're doing, especially in the story of our Linda is providing mediocre substandard care and trying to defend our right to provide that the reality is that we have plenty of experience going back decades, especially looking at populations of patients who have various complex needs, including social needs, HIV HIV AIDS epidemic itself taught us that we needed to develop new models of care that were what bio psychosocial adolescent care bio psychosocial their soul screening assessments, taking care of homeless patients and populations bio psychosocial models. As we the pace model right for geriatric care, we have deep experience recognizing that the best and the highest standards of care actually come when we when we try to recognize and then create models to address the bio psychosocial phenomenon of health. And what I'd argue is because health care is not defined that way what we're really the debate between whether it's my later not really is in fact an indictment of the fact that health care has for for too long been allowed to get away with what has been permissible morally or otherwise has been providing the best standard of care. And so I can test that that what we're really talking about is whether it's not so much about whether it's in our later not it's really about whether the care that we're providing is the best standard of care or not. And I've written about this and what I see that I speak passion about this because of the stories of providers who do this who are at the front lines of this question meeting with patients like our Linda. And I can't tell you how many people cry, not patients providers, when they get a glimpse of a bio psychosocial model of care in which they've at least played a role in helping to identify and maybe whether leading partnering or supporting efforts to address that social need. When a patient with diabetes and insulin requirements comes in time and again to your clinic. And you don't know how to kind of take care of the problem that they really have, which is a lack of a fridge to store their insulin. And all of a sudden you find out in some way you have participated in an ecosystem and integrated model of care to do that. Tears flow. I've seen this providers who've known their patients sometimes for decades, all of a sudden realizing that they're patient somebody they care about deeply has had had food insecurity I never knew about it. And that there's something that somebody in the community can do about it tears. Right. And that's a reflection of the moral injury that we allow to be the permissible standard right now in healthcare that providers consistently put in situation where they're asked to operate in a biomedical without being able to have the tools to address the biopsychosocial context. It doesn't mean that healthcare us do it all, but we have to recognize that healthcare is complicit and perpetuating the biomedical model and substandard care and the last thing is this. This reveals for me this the standard lane versus this is my lane debate often reveals I really love the transitional view the night and I deal kind of lens of that you presented here I'm going to be thinking about this and using the bifocal lens and the progressive lenses as part of my talks. No doubt this is clarifying for me in a huge way. One of the things I'll just add though is that many times this reveal these debates and the discourses I see at managerial levels where it tends to have more space it doesn't really show up so much at the practitioner level. It shows up in different ways it's usually either at their managerial level or the practitioner level level what it shows up as is revealing a deeper sense of a deeper lack frankly of structural competency and an associated sense of inefficacy. That's how to address these structural issues so when I mentioned before food insecurity food deserts, for example and food apartheid. But I acknowledge it's not it's not just healthcare professionals it's also a healthcare administrators and leaders who lack structural competency. We don't understand the ways in which these inequities that were being asked to it to now report on and screen for you know address. In some ways are really the downstream consequences of social arrangements and structures that put that put some groups of people in harm's way. Understanding the structural kind of drivers of these things is something that requires us to re socialize both medical ethics, ethics but also medical delivery right we have re socialize understanding what healthcare is. We're not really familiar with the psychosocial part of it but we have to re socialize our competent and improve our competencies to understand structural issues and it's not surprising therefore when we see that there's a lack of structural competency a lack of a socialized notion of what health is that we should see these debates pop up is not my lane. Healthcare is just about making sure people get the best quality care and we treat everybody the same. Let us do our job. Trust us, even the all all the evidence suggests that healthcare is has done a really bad job at anything perpetuated inequities or allowed them to persist. And that continues to this day. The reality is that without a structural kind of lens, right, a lot of healthcare leaders and managers losing this lens. Throw these questions up there about is it in our land not sure if it's our job really is a sign of something deeper and we interrogate this and one on one dialogues that often turn into a little bit of like psychological counseling and therapy sessions with managers and leaders who are often courageous and doing incredible tasks and their day to day work. What we realize is that they necessarily they haven't necessarily had the time to step back and realize how these inequities they're being asked to address these outcomes that they're being asked to optimize are really manifestations of structural social arrangements. And as they and then realize that they don't need to solve for all that themselves but they need to understand their role, either leading partner and supporting a different levels. One very concrete tool we use to unlock a lot of this is a simple three by three grid. We call it the upstream strategy compass. Levels of prevention of the y axis, levels of intervention micro meso macro, if you will, on the x axis, and healthcare is firmly in the bottom left, especially hospitals, tertiary prevention for individuals. To provide the best standard of care and what you're doing in your box in that three by three grid, you've got to be able to understand and screen for social needs and then figure out how to partner with others in the community to address it. And, as you start to do that now see how you can connect in a structural kind of lens, how to see what role you had to play you have to play to partner or support other efforts for example to address not just food and security for you know patient like or Linda or housing stability but now how to partner to address these other issues, because you have a responsibility. If the DMV, like, provides access to doing voter registration. Right, like, if there's nothing intrinsically democratic about the DMV, if they can do that, right, the DMV can provide voter registration access something that it's not in their quote unquote lane, but makes total sense from a, from a population level from considering what we need in the democracy healthy functioning democracy. Well, it's not too far removed to ask an institution that gets billions of dollars every year to start thinking about how to leverage their responsibility now to start partnering supporting these other efforts. If they lead it. That's that can be problematic and that's where the last point is about accountability who is asking these questions. And oftentimes it's not the people that matter the most or Linda is not allowed to ask these questions as much. And that's the last big point here. The debate happens in whatever rooms that we're all in. Bring your Linda in and then have the conversation about this debate. Because I guarantee you that the progressive lens this transitional view of non ideal is exactly what I hear time and again from the people who have long standing kind of who have long born witness to these inequities. Time and again and what I say time and again from my experience is to counteract this to balance this debate, let's at least involve in a systematic way the participation of those who've been most marginalized and asking these questions and then holding the systems accountable to do that. Because we can't allow hospital leaders to hold themselves accountable for answering these questions or being accountable for delivering on them. It doesn't make sense. We would not expect police departments to be held accountable to hold themselves accountable for racial justice. Why would we expect even most progressive and have an avalanche hospital managers to be solely accountable to themselves to hold themselves accountable for this we need community members and those most impacted to be part of these conversations and be part of accountability structures. That's a word. I'll pause there. I don't know if any of that stuck. Well, thank you so much Rishi for bringing in the structural perspective and also this more integrated model of care and questions of accountability. Lauren and and Kelsey I wonder if you want to respond and perhaps then turn from from our panel to a couple of audience questions before we have to close we have some great questions as well. This has been such a helpful discussion. Yeah, absolutely. If I could ask Rishi when I'd love to talk. Rishi, can you just clarify for me, I think the lead partner support taxonomy is so helpful and I was chatting Kelsey being like we will definitely use that that is going into the paper. In your idea of the ideal state is healthcare consistently in one of those three roles or is it kind of issue and program specific. Yeah, I think we can expect and I think there we should make clear, clarify that there is a clear expectation that healthcare provides the best quality healthcare. And then in that pause and make sure that we're on the same page about what model of healthcare we're talking about biomedical, I was like a social, obviously I have a perspective on that. And I think the evidence bears this out. The other is that the related the other thing that's worth clarifying is that that the optimal delivery of healthcare includes by definition we should make it explicit equity. And the reason that people are talking about these days is not only because of the uprisings and the social movements that have demanded late claim to power to essentially say this has to happen. And I think because of the, the additional kind of intrinsic logic of it. Let me don't take my word for it right right now. A couple months ago in the new general medicine, one of the researchers so that's gone the few others wrote a paper that was analyzing various value based payment models that CMS has put out over the past decade. The evidence has been mixed as they rightly count for in terms of impacts on quality and costs outcomes. What was absolutely also clear is that the value based kind of payment models that are out there which many people were hoping would be the panacea for all the ales of the fateful service system, especially when it comes to social risks and equity. And I think that those value based payment models have actually been regressive, but actually, in some ways allowed inequities to perpetuate or even worsen, because they penalize providers that disproportionately care for those social risks, or they otherwise have undermined kind of this, the, or exacerbated the structural inequities between healthcare systems that care for the poor and those that don't. I don't know what they, what they concluded rightly so in this, in this recent kind of live, this is what's happening right now by this payment is the thing what they clearly say is if equity is not baked into the design and implementation of a policy in this case value statement. It is not going to happen. This is a really important point if you don't make a equity goal in equity as a result. There is no sitting on the fence, in the same way that even Kenny kind of talks about, you know, you're either racist or anti racist there is no kind of sitting on anti racism as a practice. An equity is a practice and if you don't practice it in equity results and perpetuates it has this is how structures work. For that reason, I think that the, as we clarify, like what health care should do. In my opinion, you know, in terms of providing optimal care and making sure that care is equitable. I think that allows us to have conversations around. Okay, well what are the drivers of an equity are any of those drivers things that you're where we should lead is making sure a that you're as you try to drive towards equity that you are not doing things that are driving inequity do no harm first. So for example, are you for example, collecting data on race ethnicity language we just had a conversation with providers in Flint Michigan, great, you know, community organizations over there to spoke with them at five this morning, my time. A lot of providers that we encountered in interviews and conversations there would say things just like across the country like well we treat everybody the same why do we have to collect data on race ethnicity language. And our tour was well, okay, great, I trust you but should we verify whether you truly in fact treat everybody the same by collecting this information. We should lead by doing no harm and that starts by actually verifying that in fact we're doing no harm by looking at the data. The second thing is actually another way to do no harm is to stop suing our patients for crisis. Right, like, we should stop like harming patients in terms of how we triage them into certain kind of services or others. There's a lot of ways health care can actually help, even in the most narrowly defined sense of lane, help with achieving higher quality care and equity, including looking at the question of social needs and social determinants by stopping the harm that we do. If you have an employer base of patient of employees, excuse me that that has high level health plans and they work in your health care system. Right, and most of your own employees now are experiencing food insecurity. You're only screening though for your patients because you're trying to check the box but you're not asking the questions about your employees about whether they're suffering the same thing. You're doing harm. Stop suing patients don't put people into debt, which is of course one of the biggest drivers of economic kind of an equity and therefore, you know, health as well. So I think what we can lead is by starting health care just to acknowledge the structural kind of drivers of this and then being able to own the fact that healthcare has a role to play in doing no harm and that includes also acknowledging the harm we have done. In North Carolina just apologized a few years ago for their role in a lawsuit, more than 60 years ago, where they were accused and validly so discriminating against black residents in their community in Greensboro and surrounding communities. It took them 60 years to apologize for the fact that in fact we're doing that. That's a good for apologizing. How many hospitals around the country how many healthcare leaders who are debating about whether this is my later not actually pausing and realizing whether some of my later not have actually caused harm not just in terms of racial injustice but also social inequities. We in healthcare might be causing more harm. And if we don't stop and acknowledge that that that maybe is a good starting point. Yeah, I was struck. And I know that there are a few questions so we'll go to them but I was really struck when you were making your comments about the idea that saying kind of saying it's not in my lane right as an argument itself is a symptom of our not ideal right where the biomedical model has maybe too long range and so it shaped how we organize and perceive the rightful types of practices that we ought to be involved in, you know demonstrates a lack of appreciation of structural determinants and the possibilities of a social model. And so it's, you know, it's kind of, at least it led me to appreciate in many ways the import of cultural change and there are so many different things that need to move right little movements that need to happen in order for us to even be asking the right questions. So I was, I was just wanted to thank you for kind of bringing that forward, because originally I was thinking oh this is a little bit like saying actually this is the lane, you know that kind of first thing that Lauren started with is to say there are two ways to address a lack of engagement, which is to say, you know this is our lane we should be doing this or, you know, to say actually sometimes we should be deviating from it. And I was struck I had the beginning of your comments you really were pushing me to say maybe we should be thinking about how to redefine the lane that is rightfully held, rather than inviting movements out of it in other ways but So I think just building on that Kelsey I really appreciate that and you're being very gracious I think I was more curmudgeoned than I wanted to be, but you're being very gracious and your replies back I think it is something though about asking like the question, well, who's asking, right, it's not our lane or who's saying that, and then unpacking that because it turns out like at least at the provider level, especially with the quadruple lane. There's not enough of a strong case to be made I've been making this now for over 15 years. When you look at the quadruple lane, excluding even equity as a consideration so you know patient outcomes provider kind of joy and resilience and overall cost of care, and patient, you know the patient experience as we look at experience outcomes costs and provider experience. That's healthcare right that's the North Star for what healthcare should be doing. And it turns out by not at least asking about and thinking about how to integrate healthcare which has now been in this last in a generation really it's been only the past 60 years or so that we have actually gone headlong into a biomedical kind of model attached mostly to the healthcare profiteering kind of incentives the structural analysis allows us to realize this is not a given. This is just a choice that we made generationally. It's also a choice that we can contest and perhaps, you know, start to reevaluate in this generation and next. The givens are that even in this kind of biomedical enterprise. We can make a case that just identifying and being able to think about how to lead partner support with others to address the social needs allows us to actually better achieve each one of those aims. So that's that's a big part of what we do it's like this okay I'll concede your point it's it's you're saying it's not in our lane what's in your lane oh the quadruple lane. Let me make my case right and usually that changes it around what it reveals is a deeper sense of inefficacy just to the same kind of way like I like the counterfactuals so by the way I just announced a big moonshot you know big proposal to try to help government's country to cure cancer. Is that in his lane? Should government be involved in curing cancer? The answer of course is yeah I mean there's there's a lot of factors at play there. As we flip this around sometimes what it reveals is like a deeper sense of like it reveals the structural kind of the world views and paradigms that we hold. One of the reveals actually for me I think the question was interesting but the deeper world views that exposes are more revealing right and worth interrogating. I think you've done an amazing job of introducing a still broader perspective on the question of what our lane was to start with which I think our Kelsey and Lauren had already argued that this was incorporated into their lane but broadening the sense of the structures and the other ways in which organizations could be acting in lanes that are well recognized as their own in order to promote more health equity. And so it's a these are companion questions that's not an either or by any means I want to really recognize that we have five minutes left and I think that I'm guessing that the audience is going to appreciate what they've heard and I know that our panelists have benefited from getting a quick glimpse of your questions I'm going to ask if Kelsey and Lauren want to add any concluding remarks and then we'll wrap up with about a minute on upcoming programming for the year. Yeah, I pull out Kristine Mitchell's question I've been kind of typing some responses to folks, but you know, you're Kristine Mitchell. Rishi you I don't know that you know her but she is the outgoing executive director of the Center for bioethics at Harvard Med School, and just a sage so she asked and I'd love to hear your thoughts Rishi. And, you know, we put for this idea of having bifocal or progressive vision, but how do you think a person in the decision making seat retains that ability to see normatively and ideal, like what the world should look like. But Rishi saying like when you're in the sausage making machine, like how do you not allow the institution to work on you in such a way that it dulls or erodes your ability to keep that ideal in view. And I have a thought or two but Rishi you're like at this all the time how do you do it. Yeah, three things one is community. So, you know, when this is why I started health begins I felt like this is 12 years ago and I was trying to find a way to keep that fire lit and that analysis kind of going this idea of practice and formed by use of distributive justice and social medicine that brought me into this and I found that it was really hard to see that kind of critique and that analysis and translate that into concrete practice in a biomedical kind of paradigm. So community helping staying in touch with, you know, everybody that's on this line as well as others community second is incentives the enabling systems. We need to align incentives to make this more and more possible and that doesn't happen without the third point which is accountability mechanisms both. There are opportunities to increase internal accountability through improvement methods performance measure strategy, all this stuff of HBS I'm sure. And there's also mechanisms to strengthen external accountability and that's what we're seeing happening right now, you know, everybody from jaco to the AMA and others are considering new ways to increase accountability. But the most important audience and this is what Tim referred to is making sure that the accountability mechanisms are available also to those who have the most online right now and that's patients and people with experience. So we need to strengthen mechanisms of kind of especially of community centered governance, because we can rely on good progressive while meeting politically kind of edge, you know, those trained in the philosophies of ideal theory to be able to keep the community, we also need to make sure that their work operating systems and that their systemic participation of those most effective to make sure that on their laziest of days they're still doing better than they would otherwise so community enabling systems incentives and accountability structures from the community. What I add to that in my take is, I think we need as managers to announce our commitment to pursuing the ideal at the outset, such that we create kind of a public commitment on that that people can then come forward as we she's suggesting to call us out on right and say look, when you started this three years ago, you told me that you were trying to achieve the ideal. Here we are three years in, you're still doing the same thing. What gives. And so it's kind of a point just about transparency but beyond that just being very intentional about what the end goal is. And I said in the same big amen and really quickly and say we frame this as courageous leadership mechanisms accountability or acquired and we can go deep into that. And but we recognize in the past three years the people we love working with the people who reach out to us are courageous leaders, they're in these institutions they're managers and CEOs and frontline providers, but they're trying to kind of walk this line between the ideal to the non ideal. And so the foundation is part of the oath in some cases for some professions, right it's part of, we're doing, and that takes courage courageous leadership as a competency and set of skills that needs to be nurtured. And the first way to do that is to recognize it and name it. So I, amen to your point. I would just kind of jump in on this particular point which is to say that it can be really frightening to say that I'm going to commit myself to doing something that I don't know how to do or how to arrive at. I'm not sure if the policy that I propose in this moment it's going to get me closer and us closer to the ideal but I'm going to nonetheless transparently state that that's what I'm going for. And I would connect it back to this idea of learning objectives, right which is just to say that we may not have the capabilities now or be fully confident in being able to identify what about our policies are getting us closer to the ideal. But if we're not using that kind of statement to guide our, what's important, then we will not be measuring, we will not be evaluating, and we will not be looking to the right kind of data to tell us whether we're getting where we want to go. And so it's no guarantee, right that we know exactly what it takes, but at the very least it's a guarantee that we'll make an effort to learn around what matters so that we can do it, perhaps ever better over time. I don't respond to that as well but I realize we're out of time. We want to develop a green room for this but I will say, first of all, really on behalf of everyone here I want to thank the three speakers so the way you have thoroughly explored this question and dimensions that take us into different places that aren't always used to thinking as practitioners in healthcare provider organizations. I want to thank the audience for the really profound questions that you asked that at least you have prompted further plot about. I think that our website will show our future programming we won't spend time detailing it now except to say in January, we'll be looking at the ethics of design choices in the built environment, knowing what we know about the effects of some of those choices on patient welfare and behavior, and then data in healthcare organizations, drawing on a project that was a grassroots project initiated by data engineers when they were concerned about the ethics of their practices. Lots to think about this year and want to thank the audience for everything that you have contributed to our thinking in your comments in the chat as well as your questions, and hope to see you at future programs and hear more for me. Okay. Thanks very much, and good afternoon. Thank you so much. Thanks everybody.