Welcome to the "Lessons from the C-suite" series, featuring Advisory Board President Eric Larsen's conversations with the most influential leaders in healthcare.

In this edition, Eric sat down with Bassett Healthcare CEO Dr. Tommy Ibrahim to discuss how rural health provides a natural incubation ground for digital health, what it means to be a "millennial-clinician-CEO," and how Bassett is charting the future course for U.S. rural healthcare.

Edited by Abby Burns, Expert Partner with Advisory Board

Larsen: Tommy, we have a lot to cover today — I want to talk about what drives you as a leader, your read on the industry, and how Bassett is charting a course forward. But I think we have to start right at the heart of your world and talk about what's going on in rural health.

Ibrahim: Let's do it.

Larsen:  This is undeniably a perilous moment for rural health in America, with longstanding and structural issues – older, poorer, and sicker populations; wide disparities in outcomes and access to care; lower rates of PCPs and specialists per population, etc.  The situation was challenging enough before the pandemic, with 183 (predominantly rural) facilities shuttered in the past decade.  Now the issues are more acute, with more than half of all rural hospitals operating in the red and 453 at risk of closing.  I'm going to dive right in: what is your prescription for how we tackle this?

Ibrahim: It's scary when you say it like that, Eric. The reality you laid out is absolutely true — there are significant challenges to overcome in rural health and addressing them requires an all-hands on deck approach.

At Bassett, we are intensely focused on what we can control, first and foremost.  The first thing we're doing is making sure we are operationally disciplined. There is no room for inefficiency. We've consolidated down leadership structures, integrated back-office functions, standardized key workflows to eliminate waste, and looked to partners to help accelerate advancements in areas we see as non-core competencies, freeing us up to focus more on what we do best: taking care of patients. And, we are intently focusing on our people is.  Taking care of our workforce is essential right now.

Rural healthcare providers must redesign the workforce model of the future and look to technology and automation to counterbalance the effect of the recruitment difficulties. We have to implement team-based care programs. There needs to be an incessant focus on quality and the patient experience, and we need to shift the care models to ones that instill confidence in our community and center on the patient. We're implementing core technologies that extend our reach virtually and into the home and we're investing in the right services and communities to respond to our patients' shifting needs and desires.

Lastly, we need the government to recognize that the alarming rate of closures in recent years is going to fundamentally destabilize the health and economics of rural regions. The disparities that people have become increasingly aware of over the past few years are only going to get worse. We need to redesign the mechanics of financing rural care, and given the payor mix, that means reforming public payment models. We need to recognize that the interventions we have tried so far, have not worked. We have to be bold and go forward cautiously, but differently.

Larsen: A lot to unpack there! You and I coauthored a piece this past August arguing that as dire as the threats to rural providers may be, there are some silver linings.  Specifically, that rural providers are uniquely positioned to capitalize on the 'Renaissance' moment in digital health.  Perhaps you can elaborate a bit on this idea.

Ibrahim: The headwinds are serious, but I also believe that some of the very elements that have conventionally been regarded as disadvantageous to rural systems — wide geographic areas, scarcity of hospital beds and physicians, geographic maldistribution of doctors, insufficient reimbursement, etc. — may in fact turn out to be advantages in a digital health age. 

We are unencumbered compared to urban and suburban health systems: we don't need to justify investments in terms of massive portfolios of high-fixed-cost assets like hospitals. Out of necessity, rural systems may be less bureaucratic and faster-moving. Time will tell how the pandemic has fundamentally affected some of the disparities I mentioned — but I think it's safe to say it hasn't made them better. There's also an element of urgency here. Rural providers have a renewed sense of urgency to fix and innovate on existing operating models, care delivery systems and sites of care. And there's an openness to try emerging digital technologies and methodologies that enable us to do that. From an industry perspective, if we can make digital solutions work in rural settings, we can certainly scale them to resource-rich settings — that's a lot easier to do than the reverse.

Larsen: How are you thinking about the digital health space as a whole and what is Bassett's role in enabling rural-driven transformation?

Ibrahim: At the end of the day, the vision is for Bassett to be the model of care for rural health in the US. We believe we can transform and redesign the care delivery model for rural communities in a way that will reduce persistent healthcare disparities and improve outcomes.

For me, the potential digital health holds isn't on the magnitude of solving one or even many discrete problems, or even fixing a broken system. It's about fundamentally redesigning and transforming the system to meet the unique challenges of the current moment and of rural health. That's what I see as the basis and really the performance target for digital innovation.

Larsen: There's obviously been a lot of activity here over the past two years — capital allocators flooded $72 billion into digital health in 2021. And yes, with the broader macroeconomic headwinds we've seen a marked deceleration in investments in 2022, but we still have almost 13,000 digital health companies that have been created. Real technological breakthroughs in diagnostics, therapeutics, clinical/non-clinical workflow, care augmentation, you name it. You've been an evangelist for taking advantage of these advances. How exactly do you do that?

Ibrahim: I don't think we actually know the answer to that yet, because part of the game is thinking outside the box and not being limited to existing "solutions." But we have plenty of places to start, based on where our challenges are.

A few examples are figuring out how to enable home care, whether it's hospital at home, remote labs, remote patient monitoring, etc. — that's especially important in rural communities, where social determinants like distance from your provider and access to transportation affect a lot of our patients. As an example, we're partnering with a category-leading company called all.health which has pioneered something called "integrated continuous monitoring," really expanding our reach into the home to longitudinally manage patients. We've partnered with Strongline, a company focused on workplace safety, to make sure we're cultivating a safe environment for our employees. Given lower physician rates and staffing shortages across the board, we need to look at how we can automate operational and clinical systems to both improve workflows and augment staff. These are just two examples of investments we've made that will allow us to drive forward strategies that ultimately dovetail into a value-based care model, in the future.

Larsen: You raise a good point about the ability of digital health to "unburden" providers of some of their more administrative tasks — for example, tackling the estimated 75% of a nurse's day spent on non-patient care; or the three hours daily physicians spend fighting with the EHR.

Ibrahim: Exactly. We have to recognize where our boundaries are in terms of talent and skill set — this is where our partnership strategy becomes critically important. Eric, you mentioned the 13,000 startups that have come out of the past two years; we've been totally inundated. Not an hour goes by — not an hour — that I don't hear from one startup or another. It creates an overwhelming environment where we're really trying to sift through the noise — while also navigating all these other crises.

So we decided to partner with a premier venture capital firm – a16z – that is known for their expertise in both healthcare and tech. They are one of the best out there, so we depend on a16z to help us sift through all the noise. Their due diligence narrows the portfolio of prospective companies to help us distill this massive ecosystem down to the critical few players who can best meet our strategic needs and the needs of our community.

Larsen: What I love about this is you're nearly 3,000 miles away from Silicon Valley in Cooperstown, NY, and yet you've found a way to bridge the miles and be ambidextrous in both worlds — health system "incumbents" and digital health "insurgents."  How can the individual investments and partnerships you've made, plus the a16z alliance, serve as an example to other health systems?

Ibrahim: a16z and their peers have access to the brightest entrepreneurs and best innovations out there — I think we would be remiss to omit that entire ecosystem of executives and thought leaders into our planning.

Beyond tapping into their existing portfolio, one of the biggest benefits this partnership will afford is the opportunity for Bassett to roll up our sleeves and dig into solving real-world problems in rural health specifically and healthcare more broadly. We can co-develop solutions that can advance both our strategy and our vision of transforming rural healthcare. This is very much bi-directional. We can serve as a mini-innovation lab for them to beta test and evaluate existing solutions by putting in some sweat equity. And where we identify problems for which solutions don't currently exist, we have access to creative partners who can help up come up with differentiated solutions.

Larsen: This feels on-brand for Bassett. Bassett is remarkable for a number of reasons — it has a rich historical legacy, first named for a female physician who practiced in the 1910s; it serves an expansive, 5,600-mile area (roughly the size of Connecticut); it was a pioneer in bringing academic medical center research and clinical services (through a longstanding affiliation with Columbia) to a rural region.

Ibrahim: Agreed, there's always been a spirit of innovation and a commitment to scientific advancement at Bassett. The story is quite remarkable.  Bassett came to be when a local female physician, Mary Imogene Bassett, pursued her passion of bringing world-class care to patients in rural Cooperstown. To be world-class, she knew she needed to build advanced capabilities, and sought the support of a local community leader, Edward Severin Clark, to assist with the building of a small clinical laboratory that could be used to conduct advanced diagnostics and research.  Mr. Clark answered the call to fund the construction of the clinical lab and took it a step further by building a fully-fledged, state-of-the-art 100-bed hospital — unheard of for a rural area, at the time. Fast forward 40 years and Dr. E Donnall Thomas performed the first bone marrow transplant here in 1956 and in 1990 was awarded the Nobel Prize in Medicine for his transplant work that has been used to successfully treat leukemia. Innovation is in our DNA.

Larsen: How do you see that legacy alive in the organization today?

Ibrahim: For one thing, since the founding of the hospital, we have benefited from the generosity and support of the Clark family, and to this day, we have a member from the Clark family — Jane Forbes Clark — on our board, keeping us grounded in our original mission. I've had the privilege of working with extraordinary board members throughout my career, but Jane stands out not only for her commitment to Bassett, but for her devotion to Cooperstown and the surrounding community. Rarely do I have a conversation with Jane where she doesn't emphasize the priority of patient quality, safety, and the patient experience. She cares immensely about the community having access to excellent healthcare services — that's where her passions lie, and we are all, collectively, fortunate for that.

We're celebrating our 100th anniversary this year, and it's exciting to be honoring this rich history while driving intently to transform for the next century. With such strength in clinical services, innovation, education, and research, and with our continued partnership with Columbia, we are not your typical rural health system. We are driving forward to be a leader in rural care.

Larsen:  I suspect this is a balancing act, Tommy. What I mean is you've structured this bold entrepreneurial agenda, but at the same time, hospitals have almost existential-level threats massing in 2023: a healthcare workforce crisis, supply chains still snarled by geopolitical disruptions, no more "helicopter money" coming from a U.S. government swimming in debt, etc. How do you balance the more urgent and immediate operational imperatives with the future-oriented innovation agenda?

Ibrahim: No doubt about it. This is the central thing that keeps me up at night. It's the concept of "dual transformation:" focusing on the basics while still preparing for the future. Because we started from a weaker operational baseline a couple of years ago, there was, and continues to be, a need for me and my team to be entrenched in the day-to-day operations of the health system. We're working incredibly hard right now to rebuild from within, but with an understanding that we cannot continue to fall behind on where healthcare needs to go.

This is an important discussion we frequently have at the board level, and at various stages, it means reprioritizing initiatives. What's most important is that we are making big gains where it's most important but maintain incremental forward movement on our overall strategic plans.

Larsen: One of the most consequential partnerships you've architected was the Market Performance Partnership (MPP) with Optum back in May 2021.  How does this partnership fit into the ambition you just described?

Ibrahim: We know we can't be all things to all people anymore — and nor should we try to be. The MPP partnership was perfect for accelerating our capabilities across three key service areas: rev cycle, analytics, and IT. Before the partnership, we were doing okay in each, but we knew we had plateaued.  We also knew that making the critical leaps we needed to was going to require significant capital, time, and expertise — all commodities in scarce supply. It had become glaringly obvious that while we had some good wins, by trying to continually build these things on our own, we were leaving a lot of potential on the table. So, when we took a step back and looked at our "build/buy/partner" options, partnership was the clear answer for Bassett.

We didn't want to go down the path of working with multiple vendors and risk cultural integration challenges. We were really looking for a single partner that could offer best-of-breed solutions and capabilities in addition to the investment and expertise in each of those three areas. Optum was the best solution for us.  

Larsen: What about the people side of the equation? I know that's a big area of focus for you. The national numbers here aren't good — 26% hospital staff turnover, 27% RN turnover, RN vacancy rates topping 20% at a majority of hospitals, average time-to-fill for RNs of 87 days — the list goes on. How have you seen these dynamics play out at Bassett?

Ibrahim: The past several years have created amounting challenges across the industry, and we're far from immune to them — if anything, we're more vulnerable to them. We're competing with other industries, we're competing with other entrants into healthcare — and it's difficult for rural providers to attract and retain talent to begin with. Post-pandemic, as healthcare gets more and more squeezed, the burdens of these compounding challenges — the demand to produce, the demand to create additional access, the workforce shortage — are falling to our frontline staff. And at the same time, the administrivia, as you often refer to it, Eric, continues to create mindless barriers to clinicians doing the work that is most meaningful and impactful.

Ultimately it takes the joy out of the daily practice of medicine and why we all went into healthcare in the first place. What we're left with is real demoralization and frustration with the work at hand. So that's why we've invested so heavily in our people and in finding net new solutions through digital health to address the systematic, process-based breakdowns that feed their frustrations. Unless we find ways to get autonomy back into physician and caregiver workflow, relieve administrative burdens, and get people practicing at top of license, that burnout isn't going to go away any time soon.

Larsen: You have a front-row vantage point on clinician burnout, as one of only a handful of physician health system CEOs in the industry.

Ibrahim: Absolutely — this is why I got into leadership in the first place. As an internist, I was taken aback by the ineffectiveness and inefficiency of the systems underlying care and the lack of infrastructure to support a patient-centered model.  I started to see it during residency, but it became glaringly apparent once I was out on my own; there was a stronghold on the status quo, cultural entrenchment, and resistance from administrators and physicians — resistance across the board, really. I think that's what contributes a lot to physician demoralization these days. There's an unwillingness to advance systems and processes to make the care model and overall system work better.

Being in a leadership position doesn't guarantee success, but it certainly provides an opportunity to implement broad change and make an impact, especially when working with people driven by the same values.

That's one of the reasons I was drawn to Bassett. We have amazing people committed to carrying forward our legacy and mission with a determination to transform rural healthcare, and to me, that is inspiring and something I want to be a part of.

Larsen: It strikes me that amid all the workforce headwinds, Bassett managed to receive accolades for being an outstanding employer:  while U.S. clinician NPS dropped from 36 to 19 over the past three years, Bassett at the same time was named to Forbes' list of Best-in-State Employers. Bassett also received the AMA "Joy in Medicine" award for three years running, awarded to health systems that "actively demonstrate a commitment to the wellbeing of healthcare team members by combating work—related stress and burnout." That's a remarkable balance to strike.

Ibrahim: Well, we talked about the journey we're on to transform operations — in order to make those changes, it's critically important to invest in the organization, right? That means investing in new services, new technology, infrastructure, and most certainly, our people. And we've been doing that.

Over the past 18 months, we've put over $50 million in new investments into our workforce through bonus payments and wage enhancements, we've rolled out new leadership development programs, and we've invested in technology to improve workforce safety. Our people know that we have taken to heart the sacrifices they've made over the course of the past several years.

Larsen: What about moving forward?

Ibrahim: Just recently we were awarded a historic $82M restricted grant by the Scriven Foundation that is solely focused on enhancing the workplace environment by investing in things like housing and daycare services — and so much more — to meet the needs of our employees.

We are the largest employer in the region; now we're intent on becoming the #1 employer in the region. We owe that to the community that lives, works, and plays here. We're just getting started, Eric.

Larsen: We're talking about a lot of change in a health system industry that has historically been slow-moving, conservative and "incrementalist." As I think about why you in particular are equipped for leading the charge here, it strikes me that you're one of the youngest CEOs in the industry. Are you technically a millennial?

Ibrahim: Ha! Yes, I think I just make the cutoff. I'm super blessed. Sometimes I wake up and have no idea how this all happened, but I'm grateful for the opportunities that have been created for me.

Larsen: I want to reflect on those opportunities for a minute, Tommy, because yours is already a compelling career story: from graduating medical school in England at the precocious age of 23, to becoming a physician executive before age 30, to now serving as CEO of a Bassett Healthcare — a $1 billion, rural-based health system — and in my view, really being at the vanguard of guiding rural healthcare in America through arguably its roughest period in history.  What did I miss? What drove you into leadership in the first place?

Ibrahim: That's a pretty good synopsis right there, Eric. I was born and raised in New Jersey, I trained in England, and did my residency at Greater Baltimore Medical Center, an affiliate of Johns Hopkins in Baltimore.

I always jokingly (but not really) say that I was drawn into leadership out of frustration. Like I mentioned, as an internist and hospitalist, I'd always encounter issues getting in the way of my standard of excellent patient care, and I found myself taking the initiative to pull together teams to problem solve and make the necessary improvements. Before long, I was leading committees, task forces, and larger organizational projects. That was the beginning of something I never had envisioned or planned for myself.  I actually wanted to be a gastroenterologist and was preparing mentally for fellowship training.

Without fully realizing what was happening, I was rising in the ranks of larger physician executive roles. My first leadership role was serving as a medical director for a brand—new hospitalist program at St. John's Hospital in Springfield, Illinois. Then—CEO Bob Ritz gave me my first opportunity — I successfully launched that program from the ground up, and ultimately became Chief Medical Officer. Bob left Springfield to become CEO of MercyOne in Des Moines, Iowa and recruited me shortly thereafter to be the Chief Physician Officer. I stayed there from 2014—2017 and then was recruited to serve as the Chief Physician Executive at INTEGRIS in Oklahoma City. And that ultimately prepared me for this opportunity to lead Bassett. Everyone has someone along the way that has a catalytic effect on their career, for me, that was and will always be Bob Ritz, who is still a friend and mentor to this day.

To me, it's always about impact. As a physician, I was seeing 16—20 patients a day — that was the threshold of impact I had access to. Now I am able to touch hundreds of thousands of lives every day – but I think because of my clinical background, I still feel that connection to the patient that grounds me in the ultimate purpose of our work and lights a fire within me to make the system work better for the people that depend on us.

Larsen: So to summarize, you're bringing this unique perspective as a clinician—CEO, internationally trained, with a millennial lens on the world — is there any sort of 'proprietary' view that you get on the industry by virtue your background, including being part of what is really the first digital—native generation?

Ibrahim: Well I'm a little biased obviously, but as I reflect on what we're going through as an industry,  dare I say there might be a slight advantage? I have learned a lot over the course of my career, with still so much experience to acquire. I have been a CEO for only three years now, assuming this role in the middle of the pandemic and being thrust into a situation no one in healthcare had managed before.  We all had to learn through that, because we had no experience.

I look at my tenure as a new CEO similarly: doing new things every day. Not having done this before, I make mistakes, but I learn from them. I'm trying non—traditional things that I might not otherwise have tried, had I been a longer—tenured CEO with developed habits and strategies. I still look to my experienced network often for their wisdom, of course, including you, Eric.

Larsen: Tommy, this past July you renewed and added several years to your commitment with Bassett, so you'll be in seat not just until 2024, but 2029. Very exciting, and, obviously, an affirmation of where you're leading the organization. Talk to me about that decision.

Ibrahim: This was a mutual commitment from myself and from Bassett. There's a lot of work that needs to happen here, and I'm committed to seeing the transformation through. This community deserves no less.  

And I'm fortunate to partner with our board on that vision. Our board chair, Doug Hastings, is one of the more astute healthcare minds out there, having served as a prominent healthcare attorney for over 30 years and being active in driving quality and health equity throughout that time.  I've built wonderful relationships with our board members and they have supported me through some of the most challenging moments of my career with sage guidance and patience.

My family and I have grown connected not only to Bassett but to this beautiful community and the region. And we've really become attached to lake and mountain living!  We felt this was an important mutual commitment to make sure that we position Bassett for long—term success.

Larsen: Final question: when you think about your career so far, including but not limited to your time at Bassett, what are you most grateful for?

Ibrahim: I'm grateful for the ability to be a healthcare leader in this environment. As counterintuitive as that sounds – and as complex and exhausting as it is – having the opportunity to shape the future of healthcare in this country and especially in rural America is an enormous privilege.