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Interview by Gary Gunderson

Tony Beltran is President and Chief Executive Officer for the Pittsburg Mercy Health System of Trinity Health.Beltran joined Trinity Health in 2016 as V.P. for Safety Net Transformation. Before that Beltran was the Executive Director of the Lake County Health Department in Chicago. At Lake County, he led the effort to achieve public health accreditation and fully integrated primary care and behavioral health services in the department. Before Lake County, he served as the first Deputy Commissioner for the Chicago Department of Public Health where he was part of a team creating the first comprehensive public health strategy for the city.

Beltran holds a Bachelor of Arts from the University of Illinois at Chicago, a Master of Business Administration from Lake Forest Graduate School of Management, and is a doctoral candidate in Organizational Leadership at Northeastern University.

Gunderson: I’m talking with Tony Beltran in his office, which is on the… I had to cross about six or 400 bridges to get here in Pittsburgh. Tony’s not new, but recent to the role of being the CEO for Trinity Health, with regional responsibilities, and I’m eager to talk with you because of your grounding on the behavioral health side of this. I don’t know of many CEOs who come out of behavioral health into a senior executive position, so that in itself is kind of unusual.

What we want to talk about today, these Stakeholder Health podcasts are typically for folks who are trying to do significant things with their lives, but not to be a big deal. They’re trying to do significant things because of what they care for, so they want to be brave and not just smart, and you seem to have been both. Trinity Health, one of the largest organizations in the entire country, has put you in a position of really remarkable regional leadership, so who are you? How did you become this person? Tell me a little bit about how you became you.

Beltran: Yeah, so first I would say I’m not sure that I was smart when I knew I was getting into this. I think I was maybe a little naive, so I’ll get that out of the way first. I really started my career in health care about 30 years ago, and was working in an academic medical center. We did great work at that location in Chicago, but probably about 10 or so years into that, I realized that we were in an area of the city where there were multiple hospitals. And what I saw was that people went to the hospital not based on their need, not based on location. They went to one of those four hospitals based on where they were in the status of their health insurance or other things, right? They would go to the VA if they were a veteran, they would go to the County if they were uninsured. This was 20 years ago, so before ACA. They would go to the premier academic medical center, one of them in the state.

They would go in this small geographic area, really small, probably 10 blocks there were these four hospitals, and I noticed that that probably wasn’t there. What we should think about instead is you should go to the place where you can get the best care, regardless of your insurance, and so I moved over and started working with vulnerable populations. It’s been 20 years where that’s been the focus of my work, is addressing the quality care for individuals that many systems maybe would not care about. Here at Trinity, it really is core to our mission and the work that we do, so I’m excited. I think this is the right place, and especially here and now in Pittsburgh.

Gunderson: What do you do? How do you do that?

Beltran: I think partly it really is understanding what a person needs, not what we as a health system think they need, but really understanding from that individual what is it that they need. We work along a couple of different areas. We work with individuals with intellectual disabilities. We work with people with severe mental illness or substance use disorder or co-occurring, or those that are experiencing homelessness. Many times, the health system has a very specific way to address those, right? If I am in one of those populations, the medical system thinks they know what I need.

Here what we do is we actually figure. We ask the individual person served what is it that they need. If my primary thing that I need as I’m going through the system is around harm reduction, then that’s what we work on. We don’t tell you you have to stop everything you’re doing and change all your behaviors immediately. Instead, we meet people where they are. I think that’s the core of the work that we do, is how do we meet someone where they are and then how do we give them hope for something better. As they’re continuing to improve along their behavioral health journey or their medical journey, we really provide the support around that work, but it all starts with really having reverence for that person in terms of what they think is most important.

Gunderson: We live in hard-hearted times, filled with chaos and splinters and shards of former health policies all over the place, probably as diagnosable as any one of the patients who walks into range of care for you. Your language fits kinder times better, but obviously for 20 years you’ve worked with people whose lives were filled with tough stuff. Does working with people like that help you work with systems like that?

Beltran: You know, I actually think I get a lot of energy from having time with the person served that we have. I can tell you, I’m amazed every time I go out to say our shelter or working with others, the resiliency level that individuals have that are out in the community. When I’m out in an encampment for people that are experiencing homelessness, the sense of community that they have towards each other, the types of things that they can actually go through, the dignity with which they do that, it amazes me. I say to myself I don’t actually know that I have that level of resiliency.

I’m not saying that’s across the board, that everyone does, but I think there is that built resiliency that lots of people that have had challenging lives build. Sometimes it’s not enough, though, and I think you’re right, Gary. That’s the challenge, is sometimes it’s not enough to move them along. I would say it gives me a lot of strength to see that.

Gunderson: Do you actually go and spend time with the homeless now in your new executive role?

Beltran: Yeah. I think for me, one of the biggest things I try to do is spend time out in one to two, sometimes three programs a week where I’m working with colleagues. I’m not always out in the community. Sometimes it’s at staff meetings, to really understand from the direct service individuals what do they need, how do I support them, how do I understand the bigger picture. Other times it is actually going out in the community and doing that work with them as well. I’m not as competent or qualified as them, so sometimes I’m not doing very much when I’m out there, but a lot of it is really giving me information so that I can advocate for them versus advocating for what I think they need. It’s much better for somebody to tell me what they need and then work towards that than for me to assume that I know what that is.

Gunderson: Your career path has led from the parts of the health ecology that now the biomedical folks are imagining themselves integrating. In other words, right now everybody will go, “Pop health, pop health, pop health,” and, “Integrated, integrated, integrated,” and the way that functionally I observe in many systems, they’re taking what still is essentially a biomedical paradigm, a biomedical heart and brain, and putting just a little bit of icing on what they think of as behavioral health and pop health and social stuff. It’s like a formulary with just a few things in it. You’re coming from what they’re now trying to integrate. Tell me about that journey the other way. How does that stuff relate to the biomedical part of the thing?

Beltran: I think it really goes to the core of …

Gunderson: That was like a sermon in a question.

Beltran: That is, yeah. I appreciate that. I’ll take two turns to answer it, then. I think there’s lots of conversations right now about population health. There’s lots of discussions around social determinants of health or social influences of health, and many times different groups are really coming to that. They’re saying in acute care, they’re starting to look at that, and they have been for over a decade. The Federally Qualified Health Centers, the community providers, have said, “We’ve been doing this work for five decades. We know this work and we’ve been doing it.” What I would say is actually I think about Pittsburgh as a city itself, and the Sisters of Mercy. This was the first location that the Sisters of Mercy came to in the United States.

Gunderson: The very first one?

Beltran: It was the very first one. You can find the location where they started downtown. The request from the Sisters to come here, when they came, they really did a lot of that same work. What we think about as very innovative population health work actually has a long legacy. It’s not new.

Gunderson: When did they come?

Beltran: They came in 1840. You’re going to quiz me on the exact date. 1843, I believe it was.

Gunderson: We could say 1840s.

Beltran: In the 1840s, yeah. When Frances Warde came, that was the work they did. When we think about the social influences of health, it is things like health education, addressing poverty, addressing some of the stigmas. That’s really all the work that they did, and they did it out in the community. They didn’t built elaborate places to do that. They really built infrastructure that was community-based. The legacy here at Pittsburgh Mercy is still around that, around that work. The Sisters of Mercy still, on a daily basis, influence the work that we do, and it really is that community-based work. What I would say is it really goes back to that mindset of meeting people where they are.

The other thing I would allude to is we have to think about what is the most important need for that person. To go back to your question about how do we address them, the needs for those individuals. On our behavioral health side what we lately start with is their behavioral health treatment plan, and that becomes the core of the work. Individuals with serious and persistent mental illness often die earlier because of the comorbidities. So they have higher rates of diabetes, obesity, tobacco use, cardiovascular disease, so those are all the medical reasons that they’re dying earlier. In many cases, those are because of their SMI diagnosis.

The traditional model is to treat those comorbidities and then add on the behavioral health piece. What we do instead is we start with their primary behavioral health diagnosis and then we wrap services around that individual. If it looks like they’re becoming prediabetic because of their medications, we think about are there ways to adjust those meds, think about behavioral changes, versus just treating the prediabetes and letting it move forward.

Gunderson: You are a CEO, so the business of this, everything you’re doing first is the least reimbursed part of the entire diagnosable system. Earlier on, I was working a metaphor with socially complex, vulnerable people, but the systems themselves are a mess in diagnosable. From a business standpoint, you’re starting with the stuff that pays the least, and then adding on, almost as a last resort, the stuff that pays the most. That’s a question.

Beltran: It is, yes. I would say for us, since we’re only on the ambulatory, community-based work, even that part, that last part that seems to pay the most, doesn’t really necessarily pay that much. What I will say is that those of us that work in this field, in social services, we have to be extremely creative at pulling together lots of payment structures. For us, we get federal reimbursement. For grants, we have a lot of state funding. Allegheny County is really innovative about the way they think through their social services, and so they’ve been able to support a lot of the work in the county overall, but we participate in a lot of that funding as well.

Then we have the traditional ways to bill, through Medicaid and other forms of payment, so we have to pull all of these components together to come up with a funding stream. We don’t have three or four major payers, we have a lot of different payers which all have their challenges and benefits. I would say the hardest part is that the funding becomes a little… it has a tendency to be siloed. So we may have substance use disorder training in this area and it’s treating those individuals, but really they might have a behavioral health diagnosis or doing more holistic care, and so it requires us to really think through that and the funding is challenged at times to do that.

Gunderson: I’m just struck by your description of the shocking creative capacities of the encampments of the homeless, and what you’re just right now describing as the need for shockingly creative capacity not just in a CEO, who sort of gets all that, but the whole organization has to kind of be tuned to how it is at the trustworthy partner, because the money… you don’t control the world.

Beltran: Right. At the direct service level, they actually are experts at meeting those requirements that we have, but they really do keep in mind what they’re trying to do. They don’t just do the requirements. They’re really thinking, first and foremost, what does this individual need. I think because we start with that as the mindset, our colleagues are phenomenal at figuring out how to do the other work. They still meet all of the requirements we have. I joke with people. I’ve been here for about six months. I’ve had an audit or a licensure review every week since I’ve been here, minus one week when there was a holiday, and some weeks two or three. The group does an incredible job at doing that, but in the forefront of their mind, they’re really driven by what does the person need, and that helps.

Beltran: I think from the direct service, they’re incredible. I’m always amazed by the work they do. At the manager level it becomes really challenging, because that’s where the meat of it is. Those senior managers are having to try to figure out how do they make all these connections. How are they looking at care in one place, and how do they line that up? How do they take a person from Point A and get them to Point B and navigate through that system? Again, our county has a lot of resources in terms of that and the social services has been well funded, and our collaborations with the county and with our community provider has been really good, so I think that that helps, but that senior manager also has a really challenging job.

Then I think for our executive team, it really is about how do we create that vision so that individuals can see the work that they’re doing, how that ties to someone else. We have about 70 different types of programs, and so sometimes it’s hard to understand how Program A corresponds with Program B, and that’s where our executive team spends a lot of time, really thinking about the vision, the goal of the work we’re doing, and then how do we bring these pieces together.

Gunderson: That’s just inside, so those are 70 of your programs. I’m guessing from what you’ve said, every single one of those 70 programs are themselves actually weaving together several, maybe many different threads of partners and partners’ funding, so it’s probably 70 times 70 of relationships that have to be managed.

Beltran: Yeah, it is. It’s definitely managing relationships. I think we’re probably really good. Even though Allegheny County is relatively large, there’s a group of us that meet all the time, and so we have a sense of how to do that work. I think coming here, I noticed that really quickly, that the structures are a little bit more organized maybe than I’ve seen in other places.

Gunderson: You mean the structures of like who would be… who is that?

Beltran: Our other community partners that do behavioral health services, we get together. We have conversations, so we know that. I think it’s easy to have conversations with our county partners and our community behavioral health providers as well as our physical health plans. Those are things that are easy to get on the books. Sometimes it’s hard to get appointments with those groups, but I feel that ours are really open. They have the right intent to do the right work, so I think there is that right intention. We’re large enough as a county to have good resources, but we’re also small enough and have the right intention to work together.

I don’t want to make it seem like there’s no challenges. There always are challenges, and it is difficult, and there’s not always enough resources for us. But I do feel like that we’ve been pretty innovative. Our organization itself has this history of innovation and really piecing things together.

Gunderson: Going a little bit different direction because of your experience and expertise and where we sit, Pittsburgh has positioned itself in the modern mind as sort of the city of the future in many ways. It’s just astonishing how it has reinvented itself. But it’s still an Appalachian hub and it sits in the absolute center of the epicenter of the diseases of despair, where what the data is showing us for the first time, really, since we’ve kept data, that there’s an uptick, an uptick in premature death, exactly where traditionally you wouldn’t expect it. They’re called diseases of despair, which puts them in your ballpark. How do you think about all that, sitting in Pittsburgh?

Beltran: I mentioned social influences of health and those discussions and systems getting together. I think as a community, we’re starting to have more and more of those conversations with our health system, and so the health systems are starting to think about what are the ways that they can impact those social influences, which in many cases are really what’s leading to the despair that’s out there, is this inability to see where there’s hope and how you can move forward. I don’t know that we have really been able to move the needle on those yet, but the fact that we’re actually having conversations and thinking about how to do that together is a really good start.

Gunderson: Those health systems, are they hearing the depth and complexity and the nuanced nature of engaging the psychosocial, spiritual dynamics, that are beyond the biomedical or integrated with the biomedical? Do you get the sense they’re hearing that, or are they just saying, “Could you take care of all these problematic people that don’t fit our work plan?”

Beltran: I think it may be a combination of both. I think there’s very specific efforts that they want around thinking about community revitalization, how do you really address some of those core, fundamental things that are not medical in nature. I think they have an idea that that is a role that they should play. Then when you get further down, I do think that there is an understanding of how do we work together for individuals that have higher need levels. I wouldn’t say it’s perfect, but I would say that there are a cohort of individuals within each of the health systems that really understand that they could work collaboratively with community partners.

I wish it would be the whole system, so if someone would start at the ED, all the way through discharge, that that would wrap every service around them. We’re not there yet, but I think there are some really good steps kind of going forward. There is a sense, at least here in Allegheny and Pittsburgh, that there does need to be collaboration, that we do not need to compete with each other on care for these individuals, but instead we’ll do a better job if we actually collaborate together.

Gunderson: The grand movement, the muddling movement of policy in the United States, with so much language around pop health and integration… So I’m at Wake Forest and we’re in the middle of a grand experiment at the state level of integrating in Medicaid to a new level of social drivers. So Medicaid in North Carolina will pay for things it simply doesn’t pay for in many other places, that are called social but they’re really things, so it’s housing and transportation and this and that, a little bit like a social services formulary. In one sense that’s hugely positive and optimistic. We’re muddling in the direction of paying for a broader range of things that are the stressors in people’s lives. In other ways, I wonder if we risk medicalizing the very phenomenon that you’ve spent your career engaging. Could you comment on that?

Beltran: I think it’s how you work through some of those systems, there’s a capacity. One of the things that we’ve done here at Trinity Health is really think about community hubs, and I wasn’t as involved. It was in one of the areas that I was working with but I wasn’t directly there, but we had several communities where we really looked at how do we provide community assets around some specific policies, so things around tobacco and childhood obesity, and tried to address those.

The team that was leading that work, rather than have it hospital-focused, it was really community-focused. Although the community grants went locally to places where we had hospitals, it was really a community partnership that developed a lot of that work plan in conjunction with the system. The hospitals didn’t just pass it on to them, they integrated it extremely well. The fact that community partnerships were actually building those, each of those eight communities looked very different.

I think the mindset of wanting to address those needs, if you start with what the community needs, give them a really good framework, then there is capacity to do well. Again, those eight communities all looked very different. I was always amazed every time I would see what they were doing, partly because I wasn’t involved in the day-to-day. Each time I saw what they were accomplishing, it looked different from each other, but it was perfect for that particular community because it was driven by them.

I think the problem that health systems could have is trying to define for communities what the improvement should look like. Health systems do have a role in funding that, but it really should be the community partners that are determining what the community actually needs. I think if the health systems work closely with those community partners, you could see improvement really much faster than you would otherwise think you could.

Gunderson: I’m going to go in two different directions. One, it’s really quite a remarkable journey that you’ve had, and you’re still a relatively young person to have a long view ahead of you, so I’m curious. If you were reflecting on who you were 20 years ago, what would you wish you had known? How could you have been warned better or encouraged better, so you’d be even more who you are now?

Beltran: That’s a great question.

Gunderson: Part of the reason I ask, because you’re surrounded by people who are who you were 20 years ago. I’m curious about how you relate to those who are early in their journey, now that you’re in the middle of the journey.

Beltran: I think that one of the things that I would tell myself, or when I have conversations with my colleagues here, is really about kind of doing the right thing. I started maybe 20 years ago. I had this idea. One of the chief medical officers I worked with gave me this idea that if we do the right thing clinically and for a person, we can find the right way to pay for it. I would say, 10 years after that, I continued to believe that was true, but it really was not in my heart. I kind of knew it was true and we could do it, but I didn’t always think it was 100 percent true.

I think now I realize that’s the case. I don’t think there’s a lack of dollars available in our systems for addressing some of the needs of populations that I have a chance to work with. I don’t think that we need to triple those dollars all the time. What I think we need to do better is start with how are we actually using the current dollars that we have, and look at that as a focus. If we can do a better job of actually focusing on that, I would do that.

Gunderson: That’s a radical insight, Tony.

Beltran: Yeah. I think it’s easy, if I ask you for money, to say no, but if I say, “Let’s take what we have and try to do a better job of using that,” where we can save money, let’s reinvest it. My job is not necessarily to save money for other systems, but it’s to say we actually do need to take those savings and reinvest them, because they really do belong for that care. If we’re able to take a decrease in hospitalizations and ED visits, those dollars that are saved need to be reinvested in addressing the core needs for that group as well, addressing the wraparound services that did that, and then eventually really thinking about how are you addressing the social influences of health. I think if we start with that premise, we could change what we’re doing with the existing dollars. It helps us to be a little bit more innovative with what we’re doing.

Gunderson: As a scientist, you would say the science of that causal relationship between what I would call proactive mercy and the savings that result from that, the science of that is really well documented and clear. The bookkeeping, the bookkeeping is really hard, and rests in all these collaborative relationships that you’re describing.

Beltran: It is, and I think sometimes you have to think about it as a real-world exercise of what we’re doing and not an academic one. Sometimes we get a little bit too detailed in if I do A, did it save these dollars, can I 100 percent prove that it saved those dollars? That’s always difficult do in many cases of what we’re doing, but sometimes you just have to take a leap of faith. We were spending these dollars before this intervention, we started this intervention, we’re spending less dollars…

Gunderson: That’s good enough for me.

Beltran: It’s a good enough way for us to kind of think through some of that. If the interventions were based on evidence-based practice or evidence-informed, then it’s really helpful. I’m not saying we toss all of that out. I’m just saying that sometimes you have to take a leap of faith.

Gunderson: Let me ask the opposite question of the young career person, and that is the middle of the career person or the maybe slightly past the middle of the career person. What makes you excited about the next 20 years?

Beltran: I think the way that we provide care for people with substance use disorder, with mental illness, even for the large group of people that we have with intellectual disabilities, I think it’ll look very different in 20 years. I think that we’ll have a better understanding of really how we help people progress, and not only in the sense of we’re meeting them where they are, but that we actually have a good idea that it’s about helping them to achieve the best thing that they can in their life. Not how we’ve done it, but it’ll be defined on what they think is most important.

We’re having lots of conversations locally about how are we thinking through some of the longitudinal improvements that people are having. So we’re focused on things like tobacco and obesity, some of those comorbidities that affect our population, but we’ve also been having a lot of conversation about the quality of life. The quality of life really has to be defined by that individual, but we do need to demonstrate that there’s improvement. Just because someone’s living longer doesn’t mean that their quality of life is good, or just because someone has now found housing, that we’ve solved all of their challenges.

We’re having discussions on really how do we think through the impact on quality of life and using a measurement tool to be able to address that and show improvement there, and I think that’s going to be the standard in the future, is thinking about the quality of life for that individual, and are we actually helping to achieve the best.

Gunderson: I’m linking that to the comment you just made a few moments ago, that there’s actually enough money to do that if we do that.

Beltran: I agree. I mean, I think that there is money to improve. We spend a lot of money on acute services that maybe got to that point because we didn’t do enough in advance. We spend a lot of money on duplicate services because we haven’t coordinated things extremely well. We spend a lot of money on unwanted medical items because we’re not asking the person what they want, but instead trying to decide. “Well, this is the right pathway, so we were taught you go from A to B, so we’re going to get you to B.” But that person may not want to go there and do that. I think that there are enough dollars if we actually focus instead on the right things for that individual. How do we move them along the path that they really have chosen for themselves, and then how do we actually improve their life?

Sometimes it’s difficult stuff. We want to work on things that are part of the medical field, so I’m focused a lot in my strategic plan now on thinking about the reduction of tobacco prevalence and in thinking about obesity. Again, those are issues that disproportionately impact the persons served for Pittsburgh Mercy. It’s important not just because there is a dollar component to it, but because it has a quality of life impact as well. Again, I think when you do the right thing clinically, you’ll figure out how to pay for it. That’s what we’re thinking. If we really think about the quality by getting someone less dependent on tobacco products or having a more healthy lifestyle, to decrease and get into a healthy BMI, then we will save money in the long term that we can reinvest in some of those areas.

Gunderson: Maybe a last question. Pittsburgh has positioned itself as the real hub of autonomous this and autonomous that, and artificial intelligence about this and artificial intelligence about that. You haven’t talked about electronics and all the electronics of the systems. You’ve really talked about how you have listened and watched and heard, and your description of engaging people who we call patients is to begin with what they say. That’s very old-fashioned. There was a question there.

Beltran: Yeah. I think it has to be the starting point, right? We have to get someone. If that vehicle drives them to the wrong place because they didn’t ask them where they wanted to go, it doesn’t matter that it was an autonomous driving vehicle, right? That has to be the starting component, is really getting that right, the intent of the person. It doesn’t mean that we’re not thinking about technology.

We actually have done a lot of work in the last six months since I’ve been here to really think about data resources that we have. We’re pulling together our two Electronic Medical Record systems. We’re putting them inside of a data warehouse and analyzing data, so that we can look not only at the care that we’re providing but the longitudinal outcomes, and use that to do work around our evidence-based programs to tell if there’s efficiencies. We’re trying to pull data from other sources, so we’ve been working locally with our community providers here, our payers, the community cares and ACHE and the county, to draw down additional data for our persons served, so that we can analyze those programs better.

Part of our strategy is really thinking about this technology solution. We’d love to get to the point of predictive analytics. I think with the population we’re serving . It’s newer, but I think there’s a lot of innovation that can actually happen there in terms of that level of work. As an organization, we have focused on really thinking about our technology solutions as well. Technology to me just isn’t a driver. It’s really a tool, and so the driver is asking a person what they want, and then the technology becomes how we do it.

Gunderson: It doesn’t take long to Google Tony Beltran and have community health workers pop up. Is the technology helping you in the deployment and engagement of community as well as patients? I’m thinking the homeless encampments. You know exactly where they are?

Beltran: We haven’t used kind of GIS mapping and things related to that yet. I think as we build our systems, that’s one of the things we want to think through. We are looking at data sources around community indicators. And that is actually happening at the system level through Trinity Health helping us to think through those. We’re learning from our colleagues there on how do that level of work. I think that there will be more work that we can do. It’s on our radar to start to think about more innovative ways. We’re pushing the needle on thinking through telepsychiatry and other aspects. We hope that we can think of a different model related to addressing care for individuals that are experiencing homelessness, that we can have some technology components in there. It definitely is going to be one of the things we have to push as we go forward. Again, the technology will support what we want to do, but I think there’s going to be a lot of exciting ways to be able to utilize technology to better serve people.

Gunderson: I want to thank you for taking your time. I realize I can only imagine how many people probably need you more urgently than I do at this moment. But you’ve been generous with your time and smart with your comments. I’m kind of excited to see what you do with the next 20, 30 years of your life.

Beltran: Yeah, I’m excited. When I talk about the work that Pittsburgh Mercy does, that legacy of the Sisters, and really thinking about the day-to-day work that all our colleagues do, I could probably talk for hours and hours, so I’m glad I’ll be able to at least let you go and do that.

Gunderson: Well, I hope we have the time for more conversation later. Thanks.

Beltran: Great. Thank you so much.