Gunderson: I’m interviewing Sanne Magnan, good friend who is co-chair of the Roundtable on Population Health Improvement and we’re talking in the National Academies of Science and a gust place to talk about things that are actually more important than the National Academies of Science and that’s the health of the people that God so loves, the people that are called the public that every government, every religious groups says the highest possible body of work is to improve the whole thing and that’s really what the roundtable’s about.

Sandy’s been a leader, a thought leader and a practice leader in this field for many years and I’ve come to know you now in the roundtable situation. When we tuned up this conversation I explained that the Stakeholder Health people tend to be a kind of wonky, very operational. We all have day jobs where we’re inside some machine, healthcare, public health or community health, and we live in that machine. But when we’re together we want to be brave and not just smart and we understand that transformation is a long-term body of work and so we’re always looking for people who can help us understand how to live our life and not just do a task, and that’s exactly why you’re sitting here. You’ve done that across a body of work and that’s why we wanted to talk.

One of the first things I learned about you was your dad and I think we ought to start there. Tell me a little bit about how you’ve become a health professional in light of a dad who professes health.

Magnan: So my dad is Charles F. Jones, Jr., He is from Oxford, North Carolina, and he ran an independent pharmacy in North Carolina for 60-some years or more. Certainly he was in the health field as a pharmacist, first to go to college in his profession. I grew up and I ended up, I went to Meredith College, a small Baptist college, for two years and then went to UNC at Chapel Hill to be a pharmacist like my dad.

My dad started his store back in the mid 1950s and at that time he was opening another independent pharmacy in town and someone asked my mom, who was his partner, he would say, in opening that drug store, asked my mom, “Are you guys,” they didn’t say guys, said, “Are y’all, are y’all going to serve blacks?” And my mom, without skipping a beat, said, “Well of course we are, but they have to have money.” Now, no one would even think of asking that question today, but that was a common question back then and my dad just saw taking care of everyone in that community and the motto of his store was, “Service with Courtesy.”

Gunderson: Oh my.

Magnan: And he extended that courtesy to everyone who walked through that store. I can remember him having the little file box in the back and people would come in and they’d say, “Mr. Jones, I don’t have enough money to get my whole prescription but would you give me two dollars worth and I’ll pay you at the first of the month.” And my dad would say, “Sure,” and he’d get two dollars worth of medicine, write a little note, put it in the file box. He never sent out any bills for that. People either came back and paid him or they didn’t pay him. So I had that role model of a dad, “Service with Courtesy” taking care of everyone, regardless of their background, socioeconomic or race or ethnicity, in rural Oxford, North Carolina.

Gunderson: What did you do with your UNC light blue degree?

Magnan: At that time I actually was in my fourth year of pharmacy school. I decided I felt I was called to be a doctor so I took a physical chemistry course to make certain I could really cut it. I did fine in that, so I was going to get out of pharmacy school and go to be a physician and enroll in medical school. Times back then, the dean of the pharmacy school wouldn’t sign my permission slip to leave pharmacy school and transfer to the chemistry department. He said, “Your dad wouldn’t want that.” He said, “It’s not a good thing to do.” And he was right. I didn’t have family support or social support.

You’ve got to think about is back then, for women in medicine … I can remember going home and sitting on my dorm bed and just crying and saying, “Lord, I thought you wanted me to be a physician. I thought that was what I was supposed to do.” So I decided instead I would go to graduate school in Medicinal Chemistry and the place that had one of the best schools for medicinal chemistry. So I applied to graduate school and I prayed, “Okay, Lord, whereever you want me to go, provide the most money,” because my parents had five kids and I needed to do this on my own, or I felt I needed to do it on my own with God’s help.

So the University of Minnesota came through and that’s how I ended up in Minnesota, went to, started in graduated school in Medicinal Chemistry and then had met my husband and was married and about a year after we were married the desire to go to medical school came back and now I was in the right place. I was in Minnesota where 40 percent of the entering class was women.

Gunderson: Oh my.

Magnan: And I had a strong supporter in my husband and I was now financially independent living on a TA salary and the little part time pharmacy work that I could do, so I was in the right place. God knew all along where I needed to be to get into medical school and to do that next.

Gunderson: So what did your dad think?

Magnan: Initially, my dad, I think he was proud, but I can tell you … He grew up in the Depression.

Gunderson: He knew it was hard.

Magnan: He knew it was hard and he struggled, like for example, when I was in a really good paying job and I left that job to go become Commissioner of Health for Minnesota and took a huge cut in salary. He was not real pleased with me because in his mind you needed to earn a good living. But my brother, my oldest brother talked to him and said, “Dad, Sandy’s supposed to do this,” and then Dad came around and he gave me his blessing.

Gunderson: Okay, so you sort of buried a tremendous story while we were talking about your dad, so trace a little bit the learning journey from being a doc to finding your way to a significant leadership role for the whole state, and then we’re going to talk about quality when we get to there.

Magnan: Well the quality is part of that. I did finish my PhD in medicinal chemistry and I went on to medical school and ended up, about that time my biological clock, as my husband would say, was ticking pretty loudly, like, “Are you going to stop school here and do anything else?” So I ended up, instead of going on in more academic pursuits after medical school, fellowships or whatever, I took a job as a primary care physician in a county hospital, Ramsey County, now called Regions Hospital, and began practicing there and became pregnant and ended up I had two children in there. Because I was in primary care, focusing on that, I had the wonderful opportunity to work with a physician who was the Quality Improvement Director at Blue Cross Blue Shield of Minnesota and he was very involved in quality improvement. We used to read some of Don Berwick’s original articles together. So I became very interested in process improvement and quality improvement in that teaching outpatient clinic in a county hospital.  From there I actually applied to, I kept doing that work, but I applied to be the QI Medical Director at Blue Cross Blue Shield of North Carolina and had the wonderful opportunity to work people there and thinking around a population and you had a fixed budget, so to speak.

Gunderson: Did you mean North Carolina or in Minnesota.

Magnan: In Minnesota.

Gunderson: Oh, Minnesota, okay.

Magnan: Did I say North Carolina?

Gunderson: Yeah, you went back to North Carolina in your mind.

Magnan: Oh, Blue Cross Blue Shield of Minnesota. Then Minnesota sued the tobacco companies and with the state and they won this historic lawsuit against the tobacco companies in Minnesota. Or the lawsuit was Blue Cross Blue Shield of Minnesota. At that time we needed to recruit someone to lead this effort. We created a Center of Prevention at Blue Cross Blue Shield of Minnesota and we needed to recruit someone and C. Everett Koop was actually advising us during this process. He wrote me a letter and said, “The man you need is Mark Manley and he’s the head of tobacco control at NCI,” National Cancer Institutes. So I called up Mark Manley and said, “Would you be interested? And this is how I got to you,” and it ended up, long story short, Mark Manley came to Minnesota and headed up Blue Cross’s Center of Prevention there.

So I got to sit at the feet of someone who was the father of the tobacco “Five A’s”, process improvement inside a clinic, and an astute policy person who knew how to do policy on tobacco control. So I got to learn from him about how do you effect population health around a key determinant around behavior and tobacco use.

Gunderson: And I love you’re a primary care doc and you’re hard and you’re raising two kids and you’re doing all this.

Magnan: And my husband thought I was crazy and, you know.

Gunderson: Well, it all feels like one thing to me though.

Magnan: Yeah, but it’s also, it can be humbling when I was trying … I was at Blue Cross trying to do this prevention work and I was trying to keep doing primary care. I came home one night after we had implemented electronic health records in our clinic and I came home at 9:30 one night and my 10-year-old daughter stood in the living room and she pointed her finger at me and said, “You’re not here for us.” Stabbed me in the heart but she was right. That was the best thing that happened to me. She’s still as outspoken today as she was back then. But it was true. Even when I was there physically I wasn’t there emotionally, I was just burning the candle at both ends. So I stopped my primary care practice and I devoted myself deeper into policy work in Minnesota and actually did some things around the state, talking around rising healthcare costs and how should we address them from the public’s perspective and what did that mean.

About two years into doing that, having left primary care, I really missed the voice of patients because that really helped me see things more clearly in what I was trying to accomplish, and at that time, Neal Holton, who was medical director at St. Paul Ramsey Public Health Department came to me and said, “You know, I could really use some help in clinic. Would you be interested in coming and working there?” And Blue Cross was willing, Neal was willing. So I went and worked, initially it was primary care and then they closed that clinic and we were devoted totally to tuberculosis control. So I worked there for the next 12 years and worked alongside Neal and doing tuberculosis control, which is another big public health piece and got to learn from him, and the nurses in that clinic. The nurses were the ones who ran that clinic, and the doctors, we just kind of came in and out, but they were the ones to watch in how you took care of patients with tuberculosis and how you prevent it, tuberculosis.

Gunderson: And tell me about how you came to be where we are now.

Magnan: Yes.

Gunderson: I mean, I sort of want to go deeper, way deeper into Minnesota, but I want to get to the federal and the advisory and the curiosity role of the Roundtable.

Magnan: From Blue Cross Blue Shield of Minnesota I became, I left and became the President of the Institute for Clinical Systems Improvement. So I took my quality journey deeper into this institute that was a regional force for how to improve clinical quality and what that looked like. It was while I was there that I got a call from Governor Pawlenty’s office about becoming Commissioner of Health. The previous commissioner had resigned amidst some controversy so they were looking for a person to lead that agency. That was a wonderful opportunity and I will forever be grateful for that opportunity to work with the employees of the Minnesota Department of Health and the people in the state of Minnesota to work on health and wellbeing in that state.

It was through that interaction that I came to know David Kindig and he became an informal advisor, along with George Isham and a huge number of people in that role as Commissioner of Health. So we kept that relationship going. This was when the Affordable Care Act was happening and we wrote a paper together while I was still commissioner and we published it after I had left around achieving accountability for health and healthcare and how do we go about that, how do we actually work on the triple aim, with the triple aim being improving the health of populations as part of the triple aim and what does that look like.

When George Isham and David Kindig started the Roundtable on Population and Health Improvement it was because of that connection that I was asked because of my background in quality improvement and my background as Commissioner of Health to be part of that roundtable. So that’s how I came into this national arena of how do you take that learning to think about… I thought about it as Minnesota with Blue Cross Blue Shield, a population and a budget. I thought about it as I was the Head of Department of Health in Minnesota, population and I have a budget.

Now I think one of our challenges as a country is this inexorable rise in healthcare costs, we need to start thinking about how is this a budget? We need to take care of a population with a budget because otherwise. I saw it happen in Minnesota, is healthcare rise we take that money away from the other social determinants of health and we actually. We’re robbing the social determinants of health to pay for ever increasing healthcare costs and we’re not dealing with the waste and how we could do healthcare more efficiently and then better for the patients and communities we serve. We really listened to what they really want.

Gunderson: So talk to me a little bit about your long term passion for quality and exactly this point about what does quality have to do with what can seem like very broad social goods? So the precision of quality, the big values of social good and population health. Many people have trouble holding those two in their brain at the same time, but that’s really, I suspect, where your passion comes.

Magnan: Yeah, so I always think about quality as meeting or exceeding the expectations of your customers . You can have a lot of different customers in how you think about this. When I think about how do you take …  Quality has two sides of one coin. It’s quality assurance, which is about how are we meeting standards and expectations. Like when a doctor signs up to work in a hospital, how do you make certain they’re credentialed and they’ve got a license and how do you make certain the equipment is running according to specifications and standards and how do you do peer review and utilization review? I mean, there’s standards that quality assurance makes certain we hold to. And then there’s quality improvement and I always remember this phrase, “All work is a process, and those processes make up a system,” and if you begin to think like that you can say, “Where along that process is something breaking down?” And we ought to kind of zero in say, “How do we improve that so that that outcome that the system puts out gets better?”

Gunderson: So the breaking down word always catches my attention because we’re in a time where science and social connection techniques and technologies make things possible that we just couldn’t even imagine. So it’s quality improvement in a context of what is now possible, not what was, so the breaking down is one kind of crucial quality. A lot of the conversations we’ve had in the round table have been very expansive, I mean, sort of mind-bendingly expansive, and that’s the other side of desire for quality.

Magnan: So what I described, and it’s my background and a very biomedical background, can be very linear and I will admit that’s one of my challenges is to not just see everything in very linear process oriented… But I recognize, and that’s why the Roundtable is a great place to bring together these things with people like yourself who write books like the “Leading Causes of Life.”

Gunderson: Yeah, I’m not very linear.

Magnan: I share the story of I took care of my… I was caregiver to my mother in law at the end of her life and it became very apparent to me that what people most value is not put in this linear piece. When a nurse called me, and she was doing her job, called me to tell me that my mother in law needed her, at 85-plus years of age, needed her cholesterol medicine increased. I told myself, “Okay, count to ten before you respond to this nurse.” What I said to the nurse, “I understand that her cholesterol is high, but what I could most use help with right now as a caregiver is someone to come and interact with her. She’s deaf and she is very isolated in the apartment that she’s living. If we could find a deaf person who would come and play cards with her a couple times a week would mean more to her than my increasing her cholesterol medicine.”

So what is most valuable to people is what you’ve described about purpose and meaning and connection and feeling blessed and feeling a part of a whole and what’s my place and where am I now in my stage of life? That’s not something I can put in a process flow piece, but I think that’s one of our challenges here with population health and we’ve now added wellbeing and we’re trying to add that because wellbeing is what people want. They really want that life satisfaction that is more than the drugs they get or the doctor visits, although we have made it to seem like that’s where it all is in our country. And that’s why we’re struggling in all the other economically developed countries who’ve spent like, the Scandinavian countries who have spent more time about community and connections, why they are doing so much better than we are at a better cost.

Gunderson: Well, and there’s process precision in Scandinavia.

Magnan: Yes, yes, you’re right.

Gunderson: They’re way more process efficient than we are in all sorts of things, so it’s not, there’s not a…

Magnan: Not an either or.

Gunderson: There’s not an either or between being systematic about making sure that the work processes include the full dimensions of what you’re trying to produce which is wellbeing and health.

Magnan: It’s a both/and. It’s a both/and.

Gunderson: Yeah, you’ve got to be able to do that.

Magnan: We just haven’t done, I don’t think, the both/and well and I think if we paid more attention to that we would have better outcomes at a cost we could afford.

Gunderson: Well, that’s the work of the roundtable. Now, explain a little bit about the difference between a roundtable and an expert. Because our job is curiosity, not definition, but could you unpack a little bit about that?

Magnan: Yes, so a consensus panel and report at the National Academies actually can make recommendations. It’s a much longer, more involved process that actually looks at all of it and makes recommendations and then they’re done. They’re done. Whereas a roundtable we, exactly like you said, we can be curious about things and go off in directions and explore things. We’re always trying to shine a light on the science and where we are. But we can be a little bit messier, which I think we need to be at this stage of understanding about what needs to be accomplished in a field of a population health that is really a relatively new field. So I think that’s where we are.

Gunderson: So it’s surprising to think of this as a new field but it’s happened in half a career, it’s happened in a brief period of time. In your own experience much of your career predated even the language.

Magnan: Yes. I think it was, don’t quote me, but I think it was 2003 that Kindig and Stoddard actually put out the definition of population health and it was back in the late-1990s or mid-1990s that the group in Canada actually published the publication that talked about why are some people healthier and others not, looking at the determinants of health. But it was in the early 2000s that Kindig and Stoddard said, “If we just look at the determinants, they can almost be too academic to get us to the health outcomes that we need by looking at the determinants of health.” So they coined the definition, which now is most widely used, about population health being the health outcomes of a group of individuals including the distribution of those outcomes, which really gets to equity and really gets to, okay, where are the disparities. Let’s look at health outcomes. Let’s take our eyes to these determinants who are trying to effect what kind of change. It’s actually in those health outcomes.

Gunderson: So as a quality person, you would insist by with what definition that unlike most quality, which is focused on individual outcomes, you would say it’s not high quality unless it moves the distribution too.

Magnan: Right. And if you’re breaking it down and saying these health outcomes… But it’s not just an aggregate, you’re breaking it down across many different variables, race, ethnicity, socioeconomics, geographic distribution. You’re looking at where is this whole population and how are we doing with that whole population. Nowadays people will take population health and they’ll apply it to a group of people with diabetes, which technically by the definition you could. people could take it and look at just their panel, but in talking with David Kindig, they originally meant it in a geopolitical or geographic population is what they were thinking.

Gunderson: Like the way normal people would think. The people who live here or the people who live there.

Magnan: Yes. And particularly if you’re going to affect social determinants you’ve got to think about place and how are you going to do that, but how are you going to look at all the populations that are in that versus just adding them all up and saying we done a good job.

Gunderson: So, you know the cut line of my book, “in a hard hearted time.” We live in a hard hearted time. This is work, intellectual work and academic work and work of bringing together people and ideas to the fore in a time when there doesn’t seem to be a whole lot of market for the kind of ideas that would change the whole, the good of the whole.

Magnan: Yeah.

Gunderson: How do you sustain your moral energy in this period of time?

Magnan: That’s an excellent question. I think I go back to what drove me to begin with, to do good for all that are involved,. That means you’ve got to think about how do you reach the all versus I—and it’s taken me a long time to learn this—versus I want to convince you that I’m right, and that can be part of a challenge of type A personalities, versus saying, “How can I understand your perspective and how can I find common ground, a place that we both could agree it’s good? And maybe it might be for a different reason, but as long as we’re achieving the same outcome,” that’s where outcome is even more important.

The classic one that I always go back to is Sarah Gollust’s work out of the University of Minnesota, looking at what would build policy support for working on obesity. She found that people more of a democrat or liberal persuasion were more interested in looking at the health part and that that persuaded them we should be working on obesity.

When you actually talk to conservatives or republicans, when you framed it as… We now in recruiting people to the military, I think it’s 70 percent or so of the recruits do not pass and one of the reasons is obesity, the obesity epidemic is affecting our kids and particularly one… So military readiness was another way to frame working on policies to address obesity that would bring in another group to say, “Let’s work on this together.” So the reasons were different but the policies and the outcome we were trying to achieve, that we would have healthier young adults, that the outcome is the same, the reasons for it were different. So I think there’s more of that that I think people are beginning to understand. Even though we might not agree with where they’re coming from on it, let’s at least listen to their perspective and…

Another example I remember in talking to a politician when I was in the Minnesota Department of Health and working on tobacco. I was trying to convince this person that we ought to raise the tobacco tax. They actually called it the tobacco fee in Minnesota. And the person said to me, “You know Sandy, I don’t agree with tobacco, I don’t think kids ought to be using tobacco, I don’t think we … but what I disagree with is bringing more money inside government and growing the size of government.” I missed the opportunity at that point, because I didn’t push it enough, to go back to my colleagues and say, “Let’s figure out a way to increase the cost of tobacco without bringing the money inside government. Can we do that?”

But what I kind of found was everybody said, “Oh, that person doesn’t care about tobacco, blah blah blah.” It’s like, no they did. They had a very strong held belief they didn’t want to grow the size of government and that belief hasn’t gone away, but how could we work with that? How could we work with that and still accomplish what I think should be nonpartisan goals around health and wellbeing? But we’ve got to learn to listen to each other even when it makes us uncomfortable or we hear things we don’t want to hear.

Gunderson: It’s been fascinating listening to your story all along the way. You never miss a chance to honor the people you’re learning from. You’ve been a grown up a long time but you describe yourself as a learner. I mean, that’s the undertone of almost all your language, and now you’re co-leading a learning thing, a roundtable. How does it feel to be a grown up?

Magnan: Humbling. Humbling because the older you get the more you don’t know.

Gunderson: Yeah.

Magnan: And the more you need to sit and listen. And sometimes you just want to say, “Oh, I can’t do this anymore. I can’t … I don’t know enough.” And then you realize you’re not supposed to know. But if we wait truth will emerge. I firmly believe there’s a God and there’s truth and even when we can’t see it, even in some of the darkest times, we can, and hope is one of your leading indicators of life, that we can hope in a God who is faithful and we can believe in the strength that he has to bring about his promises. So that sustains me to keep going.

Gunderson: So, two last comments. There’s a poster of Einstein in the bookstore here at the National Academies of Sciences that says, “Wisdom is … ” Roughly, I can’t even get the quote right, but Einstein is reflecting that wisdom doesn’t come from the book learning, it comes from pursuing it across a life time. You’re the embodiment of that. I think, I don’t know if you ever knew Einstein but he would’ve liked you. He would’ve been glad to have you in this role at a building that honors him. The other thing I want to do, because this occurred to me. I’m a wood turner, this is a pin I made out of caribou.

Magnan: Oh wow.

Gunderson: You know, caribou live well north of Minnesota in the arctic tundra and I was up there last summer and came to appreciate the astonishing beauty. Now, this came from their antlers. Both male and female have the antlers and they drop their antlers every year, so no caribou had to die for your pin.

Magnan: Oh Gary, this is wonderful.

Gunderson: So they were generous. But I think of you as a long journey, a generous journey, and no one had to die for your journey, but I hope you like the pin.

Magnan: Oh, I will, I will treasure this. I will treasure this.

Gunderson: And Sandy, we just begun the conversation but this is probably is enough for one chunk for folks listening to a podcast. I appreciate the time and look forward to talking more.

Magnan: Well thank you. It was wonderful to interact with you and I look forward to learning more.

Magnan: We’ll do it. Thanks.

Gunderson: Thanks.