Rae Woods (00:02): From Advisory Board, we are bringing you a radio advisory. My name is Rachel Woods. You can call me Rae. When we talk to leaders in healthcare, we keep hearing and seeing confusion. And frankly, just lack of consensus around some commonly used terms and words. And we believe that this is an issue that we actually can't ignore. Now more than ever, it is crucial that all leaders understand our shared vocabulary, including some of the terms that we should do away with together. To share a little bit of their own experience, I've brought two leaders from Advisory Board, Daniel Kuzmanovich and Darby Sullivan. Hey Darby. Hey Daniel. Welcome back to Radio Advisory. Darby Sullivan (00:49): Hi, glad to be here. Daniel Kuzmanovich (00:52): Hi Rae. Rae Woods (00:53): I think you're both back on the road. Traveling, working directly with our members. Been anywhere cool lately? Daniel Kuzmanovich (00:59): My favorite trip recently is Lincoln, Nebraska. There are- Rae Woods (01:03): Oh my God. Daniel Kuzmanovich (01:04): Five gates at the airport. Not five terminals, five gates. But a lovely experience. Darby Sullivan (01:10): Wow. Rae Woods (01:11): I love a small airport. I'm a big fan of a small airport. Darby Sullivan (01:15): I was also at a small airport, the John Wayne Airport on my way to Anaheim. So I got to see some Disneyland goers. It was a freaky experience. I was like, wait, am I in Florida right now? Because I've never been to Disneyland. Rae Woods (01:38): Well, the two of you are here not necessarily because you are language nerds. Although I think you actually are, but because you are out there having real conversations with health leaders about how they can advance their strategies. And you've both been experiencing a particular challenge when it comes to the language that those leaders are using. Darby, I actually think you had a recent experience about this. When a health plan leader actually kind of pushed you in an unexpected way. Tell us what happened. Darby Sullivan (02:09): Yes. It was a really interesting conversation. So I think it was back in the fall, and I was sitting down with a health plan that was pretty progressive when it comes to the health equity space, which was the topic we were talking about. And whenever we talk about equity with anyone, we expect to receive some type of pushback across the full spectrum. Rae Woods (02:29): Oh yeah. Darby Sullivan (02:29): But this pushback happened almost immediately. Rae Woods (02:32): What were they pushing back on? Darby Sullivan (02:34): They were actually taking issue with the term social determinants of health. Rae Woods (02:39): But isn't that a industry accepted phrase? Darby Sullivan (02:43): Surely. Rae Woods (02:44): You and I both use that phrase all the time. Darby Sullivan (02:47): Yes, it absolutely is. But the group brought up some concerns. It was actually based in a health evolution article that came out some time ago. And the argument is basically that it's hiding the ball in what we are actually trying to say when we say social determinants of health. Should we actually just be saying poverty and racism? That was the basis of the argument, but the smaller pieces where, social, it doesn't really make sense. Should we be saying environmental? And then determinant, does this make it feel like these are unchangeable conditions? Rae Woods (03:19): And Darby, I think I would forgive you if you were first thinking, "Oh my gosh, why are we fighting about this? This is a term that we use all of the time. How is this conversation being derailed immediately?" But what you are pointing out is the fact that by using different language, you could actually be thinking differently about the action steps that you take. Right. Is it environmental? Is it social? Yes. Darby Sullivan (03:44): That's right on. It's not just an academic question that has no basis in the work on the ground. So when I think about language and health equity conversations, or these two buckets of questions, number one, is the language you're using actually harmful for the very groups that you're trying to engage or marginalized groups? Is it actually just offensive? And if so, stop using that language. But the more interesting and nuanced question is around that second bucket which is, the language is not offensive, but does it inspire the wrong action? And that is what I think this group of leaders was trying to tell me that if we're focusing on this phrase, what are the ways in which maybe we are not doing the hard work of addressing the root causes? Rae Woods (04:32): So do you think that we should stop using the phrase social determinants of health? Is that the takeaway here? Darby Sullivan (04:37): No, I don't think. I'm not ready to say that yet. I think it's an interesting conversation and brings up good questions, but that's not my top target for things I think should be eliminated from our vocabulary. Daniel Kuzmanovich (04:51): I was about to say, we just got so much of the industry to start recognizing and paying attention to it. We don't need to whiplash them. Rae Woods (04:57): Exactly. But we know that language is very important, especially when it comes to a topic like health equity, because it can be very triggering for some people, as you said at the outset, Darby. Do we have examples of words that we should eliminate from our vocabulary? We're keeping social determinants of health, but is there anything that we should get rid of? Darby Sullivan (05:17): Oh yes, very many things. But I think probably the first and foremost thing, and you've actually... Rae, I know you've talked about this on the podcast before, but the digital divide. That's something that we at the Advisory Board feel pretty strongly that is a phrase that should be retired because it perpetuates a few misconceptions. So people tend to think, you either have broadband access or you don't. It's this false binary of need. And it sets up this idea that if we solve that broadband problem, that single problem, we have bridged the divide. Rae Woods (05:49): So this is problematic. We should not be calling it a divide. What should we be saying instead? Darby Sullivan (05:54): So we prefer digital inequities right now. And that includes yes, that basic infrastructure, but also do folks have the tools they need? Are they affordable? Is the design of those tools inclusive and accessible to everyone? So it already is setting us up for a more nuanced understanding of how to tackle this. And it doesn't also say, you're either on this side of the divide or you're there, doesn't alienate people who are experiencing this. Rae Woods (06:22): That is exactly why this terminology, when it comes to health equity is so, so important. So I want to give you the chance to just get it all out there on the table. Are there other terms that you want to just put in the no-go category? They do not continue to use these phrases when it comes to conversations about equity in healthcare. Darby Sullivan (06:42): Yeah. I would love to put up cultural competency on this list. Rae Woods (06:47): Really? That's one that I hear a lot of people kind of embracing right now. Darby Sullivan (06:51): Yes. The intention is certainly right behind efforts around cultural competency. But when you hear sort of what the implication of that phrase, it starts to feel a little icky. So when you focus on competency, the risk is that you're actually perpetuating stereotypes because you're trying to become "competent" in every identity or culture in one's community. Say you're a frontline worker, you're told you need to become culturally competent to deliver care to everyone. Rae Woods (07:22): Which is also impossible to become competent in someone else's culture, let alone everyone else's. Darby Sullivan (07:29): Exactly or anyone's identity or lived experience, even if you share similar backgrounds. Or what some programs tend to end up doing is providing a checklist or this reference guide on here's how you should treat X group. Which can actually do more harm than good, because you're relying on that reference guide rather than, okay, how are we actually increasing our communication skills, our empathy skills, so that we can hear from this person in front of us, what they prefer and their experience and how they want to be treated, just those patient engagement basics. Rae Woods (08:03): But Darby, you just said something that's really important and I want to make sure it doesn't get missed, which is that people generally have the right intentions when they use the term cultural competency. And I think that's the way that we should approach all of the buzzwords that we're talking about right now. And Daniel, I know that as a leader in value based care, this is also an area where there's a lot of, let's say good intention, but also a lot of confusion when it comes to language. What has your experience with leaders been like here? Daniel Kuzmanovich (08:36): Frustrating in a word. Darby already pointed out that sometimes the language itself impedes the conversation. Any conversation I end up having about value based care, I have to spend the first 10 minutes just making sure we're using the right terms for the organization for that conversation. Rae Woods (08:52): Oh yeah. Daniel Kuzmanovich (08:53): We found that this was becoming such a rampant issue. We built a custom training that is one of our most popular conversations that we have with organizations on what actually do these things mean? Where does the buzzword actually become a reality? And how does this work for different types of organizations? Because the terms can just feel so broad and so vague and so on applicable, Rae Woods (09:15): Which again is exactly why we're having this conversation. We are not here to split hairs about what is the best word to be using. We're sitting here having this conversation because your two experiences prove that language can impede the way that we talk about our efforts and the action steps that the industry takes. Let me get to what that means for value based care. Daniel is your recommendation that we should stop using the word value? Just like Darby said, we're not saying digital divide anymore. Let's get rid of cultural competency. Are we getting rid of value? Daniel Kuzmanovich (09:47): No way. We've been talking about value for 30 years. We're not going to get rid of that terminology. I think what we need to do is either proceed with caution or maybe even better said, seek first to understand what do we actually mean by value and to whom? One person's cost, a key component of value based care, is another person's margin or revenue. And if we're talking to the person who their cost is actually someone else's margin, we've already gotten ourselves into trouble in that conversation. Rae Woods (11:04): There's an element of specificity that matters, I think for both the conversation around value based care and health equity. From my experience, I often hear leaders use both of these categories of ideals in a very pie in the sky way. We want to get to value in healthcare is kind of like mom and apple pie. We want to advance health equity. We want to make the world a better place. But when we leave things at this kind of gauzy high level, we're not giving the industry enough actionable guidance to actually advance their efforts in either area. Daniel Kuzmanovich (11:57): If care isn't valuable, said differently, Rae, if care that we deliver today isn't valuable, then why do we pay for it or even pay so much for it? The care is valuable. I think the issue is how are we thinking about the terms more specifically? There's a difference between value based care and value based payment. They're related, but they're not the same thing. Rae Woods (12:19): Well, this is your opportunity to define it. So let's actually get into it. How do you want people to think about the difference between those two things? Daniel Kuzmanovich (12:26): When I think about value based payment, I want people to think about a payment model where quality and cost and the relationship between them is used to determine the value of the care provided. When I think about value based care, I think about higher concepts where care elements, how care is provided looks different, but the payment model for that is also different. And so payment model is often an easier place to start. And then you can think about the care that comes off of it. Rae Woods (12:56): Let me bring up another word that often comes up in this conversation, which you haven't actually said yet. Risk. How should we think about that? Daniel Kuzmanovich (13:05): What's the podcast equivalent of throwing one's hands in the air and storming out of the room? That's- Rae Woods (13:11): Dropping the mic. Throwing your headphones on the ground. Daniel Kuzmanovich (13:16): That's what the terminology risk makes me want to do. Not because risk isn't inherently a wrong term or a bad term, but just the idea of risk makes this more confusing. I was just chatting with an organization and they were talking about how they were really moving aggressively into risk. And they were really trying... They were now in downside risk and they were really worried about their margin for the next year as they took on this downside risk based contract. But when you actually looked at the model they were in, they were in a very, very, very easy, very, very shallow upside risk only contract where they could make a bonus, but there was no element of penalty. But because of their understanding of risk, they thought they were going to be penalized. And they were not thinking about the bonus. And so risk was impeding their understanding as an organization of how they made money. Rae Woods (14:09): Daniel, are you saying that the group of people you were working with just didn't actually realize the kind of model they were in? They were incorrect in terms of understanding this particular business arrangement? Or was the problem or the perception of the level of risk that they were taking on. Daniel Kuzmanovich (14:27): I think it's actually option number three. And it was the language. The language of risk said, "Oh, you are now on the hook for something, you are at risk for something." But they were in an upside only model, which meant that there was only a bonus and they weren't actually going to lose money if they missed their targets. Rae Woods (14:44): That's right. Daniel Kuzmanovich (14:45): That's not a risk. That's where we should be talking about bonuses. But because we had talked about risk, they had attached to the idea they were going to lose money when they couldn't actually lose money in this model. Rae Woods (14:57): And by the way, the language just gets even more complicated from here, right? When it comes to the value-based care arena, people are throwing around buzzwords and terminology left and right. What is value-based care versus population health? What is my clinical integration strategy? How should I think about managed care? How do you navigate all this complex terminology when you're working with providers, payers, life sciences companies, people from all across the industry? Daniel Kuzmanovich (15:24): I ask them to define the terms because the language here really is the problem. I love when people tell me that doesn't apply to us because we're clinically integrated. Clinical integration is a legal model by which hospitals and health systems can share resources with independent physicians in a form of a contract. Rae Woods (15:41): Right. Daniel Kuzmanovich (15:41): So when someone says we're clinically integrated, I ask them, what does that mean? And more often than not, that just means we have a service line, not actually a clinically integrated network model contract. Rae Woods (15:52): Or again, they're using this kind of gauzy phrase that just makes us feel good, right? We want to be working with the physicians in our market. Well, that's all good and well intentioned, but that is not actually the same thing as clinical integration. Daniel Kuzmanovich (16:10): There's the difference between the buzzword and the thing. And we've got to get off of the buzzword and focus on the thing that it applies to. And if that is the case at any organization or any topic. Rae Woods (16:21): And one of the specific challenges that you face, Daniel, is what I was getting to is that different stakeholders have different definitions and frankly, they have different goals. How would you recommend our listeners target their language towards different parts of the industry? How should they think about targeting their language on value-based care to payers versus providers versus anyone else? Daniel Kuzmanovich (16:43): It starts with, again, that idea of seeking first to understand. I think the payer, provider dynamic is a perfect example. Provider organizations talk about being at risk, thinking about the story we just went through, that organization was in an upside risk model where they could make a bonus, but they weren't going to see a penalty. So they were an upside risk only, but they thought they were in downside risk. The interesting thing is payers, the payer in that model had previously been a hundred percent at risk. They bore the air quotes risk for the payment and they were starting to share it with the provider. So we've got to seek to understand who is this entity and how does this term apply to them versus other parts of the industry, Rae Woods (17:24): Especially for areas as important as value-based care and health equity where it will require stakeholders with different business models to actually work together. I love that recommendation to seek to understand first. We started off by talking about words or phrases that we should just eliminate. But Daniel now actually, we're talking more about precision, right? We're talking more about specificity and targeting language towards specific stakeholders. So I want to give Darby a chance to weigh in here as well when it comes to health equity. Are there any terms that we should be careful about using, not eliminate, but maybe have a little bit more precision? Darby Sullivan (18:04): Yeah, for sure. There's probably more that we should be careful about using than we should fully eliminate. I'll share my biggest pet peeve in this space, which is the conflation of social determinants of health and social needs or non-clinical needs. And so what this typically looks like when I'm talking to an organization, whether it's a provider, a plan, anyone that has an effort going on, they say, "Here's our social determinants of health programs. Here's our strategy. We screen our patients or our members for any food insecurity needs. And if they screen positive, we'll refer them to a food bank." That's a inherently good thing. Like we should be meeting the needs of the patients that we have in front of us. And we gain all the benefits that come downstream when we do that. However, my argument to that member, and I've had this conversation many times is that you're meeting social needs in that moment. You're not actually addressing the social determinants of health. So there's this difference between saying, "Hey, I'm going to refer you to a food bank," and saying, "I'm actually going to end food deserts in my community." Rae Woods (19:15): That's right. Darby Sullivan (19:16): "I'm going to open a grocery store." There's a difference between saying, "I'll refer this person experiencing homelessness to housing services," and saying, "Actually, I'm going to become a landlord and improve the affordable housing stock in our community." So it's that individual level effort, which is so valuable and so important and has great impact for many different reasons. But it's not the same thing as looking at those broader community wide conditions, the root causes of why we're seeing what we're seeing in the first place. Rae Woods (19:48): I couldn't agree more with that. But I'm a little bit surprised that you didn't bring up another one. I'm a little bit surprised that you didn't talk about diversity efforts. We're seeing a lot of, again, well-intentioned conversation around DE&I that I'm not sure gets to the level of specificity that we want it to. Darby Sullivan (20:08): Yeah. I'm glad you bring that up. So D&I, DEI, I think DEI&C is now a phrase that folks are using. Rae Woods (20:16): What's the C? Darby Sullivan (20:17): The C is culture sometimes. Rae Woods (20:19): Okay. Darby Sullivan (20:19): It's, B, belonging. It's like the alphabet soup as we tend to do in healthcare. But of course it's super buzzy right now. I think that the error that we typically see when folks are saying things like DEI or D&I, is that they say, "We have this big DEI strategy. We are interested in hiring more people of color." And so they're actually just talking about diversity. Rae Woods (20:43): Yeah. Darby Sullivan (20:43): And so they're conflating the two things, which is of course bad, because that's just one piece of the broader puzzle. Rae Woods (20:51): We've given a lot of specific advice when it comes to equity and when it comes to value based care. But I want to take a moment and just step back. How do we make sure that health leaders are balancing the very clear need for precision without splitting hairs so much that we never actually make progress? That we're arguing about? Which letter do we add to our efforts to improve diversity, equity, inclusion, culture, et cetera, et cetera. How do we make sure we're not just splitting hairs here? Darby Sullivan (21:24): Okay. I'm really glad you asked that question, Rae, because this is something I feel really strongly about. Which is, I think that we can get caught in this loop of always needing to say the right thing and needing to be on the cutting edge of the flashiest phrase, especially in the health equity sphere. Rae Woods (21:41): Yeah. Darby Sullivan (21:41): And if we're so focused on that, we're not actually doing the thing that we want to be doing. We're not actually making progress. So that question of, are these changes cosmetic or are they actually important? I think that's a really interesting one. We would argue, okay, like bringing back to those buckets I was talking about. If it's offensive, if people are saying, "Please stop using this phrase about us," stop that like, of course. But secondly, is this shift in language going to result in a shift in your strategy as well? Rae Woods (22:15): Mm-hm. Darby Sullivan (22:15): And if it's adding that precision, if it's changing action steps in a positive way, that's a change we should make. Those are our two rules of thumb. Daniel Kuzmanovich (22:23): I'd agree with that. I think bringing rigor to the language you use is really important, but we also don't want to, as we think about how to better use language to the point that Darby and I have made, and you've made, Rae, we don't want to use the rigor to the point that we don't actually act on the language or that our language becomes so rigorous that it impedes whatever we're actually trying to accomplish as an organization or in the industry. Darby Sullivan (22:48): Or we're gate keeping the work. Rae Woods (22:51): Well, Darby, Daniel, when it comes to language, what is the most important takeaway that you want our listeners to walk away with? Darby Sullivan (22:58): Yeah, for me, and in the health equity space, it's absolutely that you will get your language wrong a lot, and people probably will call you out on it. And that is okay, it's normal. It's natural. It's to be expected and actually embraced. You can then make the decision like we were talking about, is this a change I want to make? But it's worth it to hear, or field those pieces of feedback so that you're not harming your efforts. Daniel Kuzmanovich (23:25): I was going to go with assume positive intent, but I think Darby just stole that one. So I will actually fall back on one I've said a couple of times, and that is seek first to understand. The language is complicated. The work is complicated and it can mean different things to different people. But if we seek first to understand, then we can make progress. Rae Woods (23:46): Well, Darby, Daniel, thanks for coming on Radio Advisory. Darby Sullivan (23:49): Thanks for having us. Daniel Kuzmanovich (23:51): Appreciate you. Rae Woods (23:56): Look, language is going to keep evolving and keep changing. And like Darby said, we are not always going to get it right, Advisory Board folks included. The most important thing to remember is to make adjustments to your language and add specificity when it means that you're going to be doing something different, when it impacts an action step or your overall strategy. We've added some links to the show notes to help you get a start here. Because remember, as always, we're here to help.