A “Mohan Nair Interview” with Dr. Susan L. Turney, CEO of Marshfield Clinic Health System

RamaOnHealthcare August 23, 2021

The plight and potential of the rural medical system

Six Marshfield physicians pooled their expertise in 1916 to form Marshfield Clinic, founding what has grown to be one of the largest private, multispecialty group practices in the United States.

Rural health care was in crisis before the pandemic. Where does it stand now?

Mohan Nair, CEO of Emerge Inc.

Dr. Susan Turney – CEO Marshfield Clinic

Mohan: Welcome Susan, to the interview. You probably have had, like most executives, rehearsed responses to many interview questions and it is my goal not to engage you this way. Mine is more about the real challenges and opportunities that are in front of us and how our obligation for truth drives our responses and actions. So, tell me what you learned from the pandemic?

Dr. Turney: I certainly learned a lot, but more than learning, I think this pandemic was about facing things we knew existed, but maybe weren’t right in our face in normal times.

The inequities felt by certain groups became so glaring, and were so obviously intertwined with their health. Access to healthy food, affordable child care, an environment free from domestic violence, the ability to work from home, the ability to take time off – these are all things some of us enjoy and others don’t. And that made a huge difference in terms of how you experienced the pandemic.

So, I think we knew we had major problems with inequity, but this pandemic really brought that reality home for all of us, and it is our obligation to act on what we’ve learned.

There were very different pandemic experiences for people based on wealth, family support, community resources and other factors that have nothing to do with direct medical care, but absolutely impact health.

Mohan: You run one of the largest rural health systems in the country and you recently declared that your company will use tech to power the identification of social determinants of health needs for your patients and provide tools for them to engage. Why now and why technology?

Dr. Turney: As I mentioned we know social determinants are a huge piece of the puzzle. To address that issue, we first need to understand it fully. We need to know what determinants really matter and are really linked to a person’s health. Technology gives us an incredible ability to gather, synthesize, and apply data.

I think with a focus on social determinants and on AI and predictive analytics, we will continue to see a shift from curing sickness to preventing it in the first place.

And the rural piece you mention is such a critical aspect of our focus. Rural hospitals have been closing at an alarming rate for more than a decade. Recruiting skilled providers and staff to rural communities is an enormous challenge. Rural communities are, as a general trend, older, poorer with higher rates of chronic disease than folks who live in cities.

Rural communities have higher rates of preventable death, childhood death and worse access to care across the continuum, when compared to urban populations. Rural communities also have less access to public transportation than city populations, and are much less likely to have home broadband than folks who live in cities.

With all the systemic factors we are up against, and our patients are up against, we have to leverage tools like technology than can help us bridge gaps, give us actionable information, and help us better understand our patient base.

Mohan: now a broader question. Why did the healthcare academy not recognize disparities, inequities within the system and even in the data for so long?

Dr. Turney: Well, I think there are many reasons. One was not having enough actionable data, and another was a fundamental paradigm shift. You used to go to the doctor when something was wrong, but now we’re seeing a shift to prevention and acting on things outside the care space, like social determinants.

I think there was perhaps a notion that social determinants were not the purview of health care organizations, but with overwhelming data showing the impact of social determinants on health, we have to be active in this space.

Mohan: Much of the challenges we face in the healthcare system is founded (my opinion) on the lack of consumer lens applied to the day-to-day issues within the system. Institutional habits overwhelm us all to the point that the consumer and their families are talked about but not served in their experience in general. Why and what are you doing to lead us away from this blindness?

Dr. Turney: I agree. Health care has lagged behind other industries in consumer experience, user experience, and in making our services easy to navigate and understand. I think that’s a big reason why you’re seeing the Apple’s and Google’s of the world interested in the health care space. They recognize an opportunity to leverage their incredible expertise in user experience to simplify and improve the entire health care experience.

Internally, we are working extremely hard to create movement on this issue. We’ve prioritized consumer experience, from the way we greet people when they come into our facility, to how easy it is to navigate our website and our available mobile tools.

People are walking around everyday with the entire library of human knowledge in their pocket, and with everything they want a tap or swipe away. That includes health knowledge, health-focused apps, and increasingly telehealth availability. Traditional health care providers have to find a way to be on the front-edge of this trend.

Mohan: If you had to build it all again from scratch, what would you want in place first and why?

Dr. Turney: Well, until recently Marshfield Clinic Health System was a purely clinical provider. Since 2018, we’ve changed that, expanding into the hospital space. We now own ten hospitals. So, had that been in place from when I began, obviously that would’ve been one less huge boulder to move.

Similarly, we are in the midst of implementing a unified EHR, after relying on our own in-house product for years. That EHR implementation will be a major lift, and it would be great to have in place if you were starting from scratch.

However, if I could start from scratch, I wouldn’t. I’m a big believer that the journey, not the destination, is what most of life is about and it’s where you learn your most valuable lessons. In some sense, we need the trial and error, we need things not to be perfect, in order for us to learn.

Mohan: Population health was all buzz a few years ago and now SDOH is the thing to gather momentum. We spoke of population health with the belief that we could categorize people into groups and manage them as population when it is often declared in my circles that personalization is about the n=1. How do we not fall prey to the similar myopic perspective to group and to treat rather than to care for one?

Dr. Turney: I think what we need to avoid is being dogmatic about any approach. Population health is absolutely a useful tool, and it can tell us a lot about groups and how to manage general populations. But you have to complement that general knowledge and data collection with the understanding and expertise to also tailor care to each individual person. We all have aspects in common with groups, and things that make us uniquely ourselves, and medicine should reflect this reality.

That’s why, through our research institute, we study groups, and we also study personalized medicine. These are both good tools in the toolkit, and need not be mutually exclusive.

Mohan: What keeps you up at night about the healthcare that your institution delivers and how are you managing to the next opportunity?

Dr. Turney: It’s something different each day. It might be an anecdote I heard about one of our patients, and I am thinking about the care they received and the experience they had. I might be thinking about an important piece of legislation that will impact our communities, or just how to solve the myriad and intertwined challenges of rural health.

We’re in a smart growth phase as I mentioned, and so we are evaluating each new opportunity through that lens. Does the potential growth help us serve more patients, or serve patients better? Does the growth opportunity make long-term financial sense? How does it complement our existing services?

In a general sense when I am thinking through opportunities, I try to keep my lens simple. Will this change help people? Why will it help people? How much? What’s the tradeoff?

When you put people at the forefront of your thinking, that brings a clarity and simplicity to many decisions.

Mohan: Rural Health systems run differently than others? Tell us what is different?

Dr. Turney: Imagine you’re in Chicago and you have a medical emergency. An ambulance and a facility where you can receive care is seconds or minutes away. Resources are all around you.

Now imagine you’re in the north woods of Wisconsin. You’re fishing. The nearest town is 20 miles away and the nearest medical facility is a 90-minute drive. You have a bad accident and cut yourself. Time is off the essence. Compare this person’s situation to the person in Chicago.

Now, that’s the emergency scenario, but the rural dynamic causes more mundane problems too. With limited internet access, more rural people have to be seen in person. But rural communities are very spread out, public transportation is nearly nonexistent, and already we serve a population with high incidence of chronic disease and major socioeconomic challenges.

Just to get a regular appointment, it might mean one of our patients needs to take a full day off from work, pay for child care, and a full tank of gas. That’s all money spent before even getting to the doctor’s office, not to mention the inconvenience of having to balance all these logistics.

Add to this dynamic record hospital closures in rural America, a pandemic, the aging demographics of rural America, and there are just challenges in every direction for rural health care and rural patients.

Mohan: The central premise of all things healthcare is do no harm. Where are we doing harm and how do we stop it?

Dr. Turney: Well I think we are seeing, especially with inequities, where harm is being done. We know health outcomes have shown to be impacted by factors like the race of the patient, one example being worse outcomes for pregnant black women. We need to train individuals and change our systems to help root out this systemic bias, and that is why we have made equity, diversity and inclusion a key strategic focus for our organization now and moving forward.

Mohan: We have data that is dirty and not complete. When we do, we lack vision to how to really deploy it for good use. Data is the new standard for building healthcare platforms to serve. How do you view data and what comes before it and after it?

Dr. Turney: Really, the fundamental question is how do we use the data we have, and how do we build on that. I would argue for applying analytics to the data we collect to understand it in different ways.

There is a fundamental need for integrating SDOH data to help really address wellness. But there is also going to be a big challenge around understanding how what eHI has called “health-ish” data is treated, and how patients’ information is protected.

In addition to the above, another kind of data holds promise if collected and used more creatively (with careful protections): Patient Reported Outcome Measures (PROMS).Gathering and using PROM data has challenges, but links the patient to the Quality aspect of the Value.

Mohan: You are a veteran leader in the field and one that many look to as a strong and compassionate leader. As a woman in the field, please advise women in healthcare on what to concentrate on to rise in the ranks of the healthcare system?

Dr. Turney: To be aggressive in pursuing what they want. There’s the old joke that men will apply to any job even if they’re not remotely qualified and women will only apply if they’re infinitely over-qualified. I say to women, apply for the job. Put yourself out there if you want to lead.

The Harvard Business Review did an analysis of 360-degree reviews and found that “while the differences were not huge, women scored at a statistically significantly higher level than men on the vast majority of leadership competencies we measured.”

In that same article it’s reported that only 5% of Fortune 500 CEOs and 2% of S&P 500 CEOs are women. We need more women, and more diversity period, at the decision-making table in government, in c-suites, and in board rooms around the country.

Mohan: I know you to be very gracious and welcoming of all ideas and people. How do you ensure that the culture of your institutions in all communities you serve do the same? How do you measure its success?

Dr. Turney: We have several culture-related efforts underway. We’ve been working for a number of years to implement the tenets of Just Culture, which is really a framework for relating to patients and colleagues in a human, compassionate and professional manner.

We also build in regular opportunities for feedback from all groups, whether that is an in-person townhall, or digital surveys to gather feedback.

Our Organization Development team is laser-focused on this culture work, and they offer trainings, resources and other tools to help our employees build the skills to lead, voice their views, and to advocate for patients and the mission of our organization.

Mohan: The pandemic taught us that the unknown unknowns can visit and take away our lives and freeze our future. How do you lead your organization in managing risk and opportunity given this realization?

Dr. Turney: Personally, in light of the pandemic, I feel an obligation to lead with gratitude in my heart. Yes, this pandemic was unexpected, but what it really showed me is how we often take the relative peace of the status quo for granted. It’s not granted.

We should be grateful for every day we have, and every opportunity we have to do good. Even when the rug is pulled out from underneath society, we have a chance to overcome our challenges by coming together.

The pandemic also took away the illusion we often settle into – that we have control. We don’t always have control, and sometimes the disastrous happens. That means, as an organization, we have to be mentally, culturally and structurally nimble enough to adapt and evolve.

Mohan: Speak to us about innovation at the corporate level. What is your view of innovation and how can the institution express it?

Dr. Turney: To me innovation is problem solving.

We were trying to solve a problem of providing affordable health care when we developed our own health plan in the 70s. We were trying to accelerate our learning and knowledge when we founded our research institute in 1959. We started telehealth in the mid-90s before anyone was talking about it, because it was an elegant solution to a very real problem for our patients – the distance they had to travel for care.

It could be new tech, a process change, or a philosophy change that spurs innovation.

Mohan: I know you have several platforms to speak to your peers and those who follow your lead. But, indulge us with advice to the healthcare system members on what you wish them to think and do to bring the consumer lens back into view.

Dr. Turney: Imagine you’re going out to a nice restaurant with your significant other. You make reservations, dress up and call an Uber. When you arrive, you’re told the waiter who was supposed to serve you is running behind, and you won’t be seated for at least another hour.

When you finally sit, a menu is delivered but no prices are listed. When you ask for prices, the wait staff informs you they don’t know exactly what a certain entrée will cost and final cost depends on many factors. The descriptions of the menu items are chock-full of cooking industry jargon you don’t understand.

Finally, you settle on ordering the filet mignon only to be informed that menu item is not in your restaurant coverage plan.

When it’s time for dessert, your waiter says you need to go to a separate but affiliated restaurant that specifically sells dessert. Three weeks after your dinner, you receive a bill from the restaurant with a confusing breakdown of what you owe and why.

Of course, this all sounds crazy. Who would ever put up with this from a restaurant? You’d never want to go out to eat again. Yet, this is the experience that has been tacitly accepted in health care for years.

And I think a lot of this has hid in institutional norms, in the medical culture, and it will take time to shift this thinking. But we have to do it, first because it’s what patients want and deserve, and second, because if we don’t, someone else will.

About Dr. Susan L. Turney

Dr. Susan L. Turney is the CEO of Marshfield Clinic Health System (MCHS), taking on that role September 1, 2014. Through its entities, MCHS provides patient care, research, education, health care technology and health insurance for Wisconsin and beyond.

About Mohan Nair

Mohan is CEO of Emerge Inc, about all things business transformation. He is a 3-time corporate executive, 3-time emerging business executive, 10-year Innovation Officer and 3-time author.