Regular readers of this site will know, Colleen and I came to Howard County going on six years ago now. Like the person this article is about, Dr. Scott Berkowitz, M.D., we were drawn to it because it’s just an incredible place. So we decided to stay! Scott’s reasons were similar, but he had some practical issues in mind too. This Syracuse native came here for his Internal Medicine Residency, and like so many before them, he and his family made it their home. What struck me during the hour-plus Scott and I spent at Mad City Coffee was that his work at Hopkins in population health is very much a team effort, and he was emphatic about making sure I knew that. Each question I asked him, he was sure to point out, where applicable, he didn’t do it alone.  It’s perhaps the fundamental truth about humanity. We’re all one. As E.M. Forrester wrote in his novel, Howard’s End: “Only connect. Only connect the prose and the passion, and both will be exalted, and human love will be seen at its height. Live in fragments no longer.” Here’s a little about Scott’s prose and passion.

Learning While Doing

Scott is from Syracuse, and that’s where he attended high school. After that he studied at Yale University, earning a Bachelor’s degree in Biology, a medical degree, and an MBA from that school. He did his residency in Internal Medicine at Johns Hopkins University.

Scott met with me, Robert, at Mad City Coffee last week to talk about his roles as Chief Population Health Officer and Vice President of Population Health at Johns Hopkins Medicine.  Scott is also a practicing cardiologist, an associate professor in the Cardiology Division for Johns Hopkins University.  I like first to know what people set out to do when they get involved in whatever is the topic of an article on this website. Simply put, Scott’s work at Hopkins seeks to improve outcomes for patients. It’s not simple. But simply put, that’s what he does. “We work with a thoughtful and consolidated set of goals to not only deliver care to patients, but to measure that,” he said. Scott and his team, try to meet patients where they’re at to improve health and healthcare outcomes.

I’m always curious if where people are at in their lives now is where they thought they would be when they started their careers. So I asked Scott if he went into medicine knowing he’d be involved in something like this.”I wanted to work in clinical medicine,” Scott told me, “but I wanted to do that within a delivery system like Hopkins where I could also shape the way health reform would be implemented and to be able to deliver care to broader populations,” Scott told me. This makes perfect sense to me, because the way Scott and I met was his involvement in Howard County State Democratic Central Committee (HCDCC). It’s an arm of the local Democratic Party–20 volunteers–that keeps the community informed on local issues and the importance of voting. Population Health is a great fit for someone who got elected to Central Committee. Both are about working to benefit a group of people, a population. I wanted to write this article, in fact, because I knew that if I didn’t know a ton about the “population health team” (PHT) did, which is what I’ll call them, at Hopkins, probably a lot of people also wouldn’t. And it’s important to know that there are people doing meaningful work like this.

Related: See what another RoCo, fave Del. Guy Guzzone (D-Md.) told us about his life in politics.

The PHT has an eye on the here and now, but they’re also focused on where they’re going.  They’re keenly aware that they’re moving toward something. In that vein, they have a set of goals, which they arrived at over the last couple years in particular, when Scott evolved from Accountable Care to Population Health. The two are related, sure, but now Scott and his team are looking more at what barriers people who seek care at Hopkins face in getting quality medical care and the way in which care models and care teams are deployed to improve health for populations, and in particular those with greater needs. Scott said in the last two years, he and his team have developed and have now begun to implement a strategic plan to improve health care outcomes for patients in the Johns Hopkins Medicine (JHM) system across the state and beyond. If you live in Howard County, as we both do, you know that many doctors, private practices, and even some public health organizations are connected to JHM.

“We’re looking at social determinants of health, reflecting needs of patients beyond your typical clinical care. These needs often relate to people’s ability to access services such as transportation, food, medications, and can be supported in partnership with community-based and service organizations and assessed by team members such as community health workers.,” Scott said. I smiled, because it reminded me of a book he and I talked about that I gave him. As soon as I gave it to him, I thought, why would I give this to him–he could have written it and knows all about it already! It’s called The Impact of Inequality: Make Sick Societies Better by Paul G. Wilkinson. It’s all about these social determinants of health that the Population Health team at Hopkins focuses on how to deliver quality health care.

I met Scott when I got involved in local politics. Somehow in the six years since then, I didn’t know these facts: He’d worked as a congressional fellow on the Senate Health, Education, Labor and Pensions Committee when chaired by the late Sen. Ted Kennedy (D-MA) , the Senate Finance Committee when chaired by Sen. Max Baucus (D-MT) as well as having  served in state government for the governor of Illinois.

All of this work served, I have no doubt, to help Scott, and by extension the PHT, understand how to deliver quality health care while they actually deliver it. Scott is too humble to tell you, but I’ll say: that’s a big challenge. But it’s clear they’re doing a good job. There is a ton of quality health care across Johns Hopkins, some of which is championed by the Office of Population Health Team, in partnership with others, and Hopkins is one of the leading medical care organizations in the world.

Stand Up And Be Counted

So much of local politics is standing up for principles and people you believe in. That’s why I was struck by Scott’s words when he was trying to help me understand the definition, if you will, of the JHM Office of Population Health. By the way, Colleen’s passion for classical, Medieval, and Renaissance rhetoric is why I know that the ancients had a set of fourteen exercises that teachers of rhetoric used to guide students in becoming skilled at advancing a persuasive point: the Progymnasmata. They were arranged in order of increasing difficulty, which is why the last one was about description. It’s really hard to describe something accurately, let alone an effort with as many moving parts as population health at Hopkins!

“We stood up this Office of Population Health in the last two years, and have assembled an amazing team.  What we’re doing in that capacity is helping bring together different population health efforts across the enterprise, while also developing new capabilities, to deliver on medical care in support of patients in our communities.” Scott and his team seek to improve care for populations, to be able to measure that care and its impact, and to continue to endeavor to understand what works best.

“We want to be able to help, particularly, with populations that have greater needs—with care team members such as behavioral health workers, care management, pharmacists, community health workers, those focused on diabetes management and prevention as well as other support,” he said. Scott’s fellow HCDCC member at one time, local advocate Mary Catherine Cochran co-wrote an article on this topic. “We’re supporting needs around social determinants of health–those are the needs of health that may not just be clinical care. They often relate to people’s ability to access services, or transportation, things that they might need. We’re also looking at post-acute care and how we can improve outcomes for patients after they are discharged from the hospital. And to be able to understand, then, what that impact looks like,” Scott said. He told me that he and the PHT work in partnership with entities across Johns Hopkins Medicine and beyond –faculty groups, community physicians, hospitals, home care, the health plan, among others–to move care forward.

“In the last year, we developed and then got approval for a strategic plan for the next three years. So there’s a very definite set of principles that relate to our clinical services, our analytics, our engagement in value-based care initiatives, as well as trying to promote further health system coordination,” he said, and I realized we were both nodding “yes”. Because, yes!

Going into this conversation, I had thought that Scott oversaw research. And it sort of is, but it’s much more on-the ground.

And: Josh Benson told us some fascinating things about his group, Howard County Dads.

“There’s a lot of research that happens at Hopkins, and there are areas we’re connected to. But our principal focus is on health care delivery operations and seeking to improve the quality and efficiency of that delivery. But there’s no question that trying to disseminate what we learn from our work, and trying to showcase some of the great efforts by our teams, including faculty members, , is an important part of what we try to do,” he said.  We hope that this may help others in the city, state, country or around the world to implement effective programs.

It’s Not What You Say, But What Others Say About You

Someone said that to me recently about how you know you’re doing a good job. So I asked Scott’s good friend and mine too, Jeremy Eldridge, Esq, why he thinks Scott and the PHT team tend to get very good “reviews”.

“Scott and his team do invaluable work. They provide an unbiased, knowledgeable, and professional voice on healthcare-related issues during a time that healthcare has become unfortunately political,” Jeremy said to me in a text message exchange.

Again, Scott very much wanted to highlight that he doesn’t do this work alone. He underscored the team-based approach he’s a part of in delivering health care to patients. I hope I’ve done justice to his instinct to highlight–to uplift–the work of others, including what he noted were the great efforts and expertise of the local Howard County General Hospital team

“The biggest reward in my work is getting to work with such an amazing group of people. Our team, and those throughout JHM for that matter, is really terrific, and it’s a team that’s come together over the last couple of years. It’s a group of very talented people, very mission-focused, who’s really looking to improve health for the populations that we serve, and this is very well-aligned with JHM, at large. And being around them I find to be energizing.” Stop right there. Because I know without having asked him that Scott, based on all my experiences with him and this statement, that he is a Meyers-Briggs extrovert. The Meyers-Briggs Personality test defines extroverts as people who feel energized in the presence of other people–when they need to recharge their batteries, so to speak, do they go be alone (a Meyers-Briggs introvert, me!) or do they go be with people? I find it stunning that some people, like Scott, derive energy from groups. I love being with people, yes, but I find it draining. And I’m so glad there are extroverts around! I imagine the PHT at Hopkins is populated by lots of both.

And This Is the Cause of My Life

This is what Sen. Ted Kennedy (D-Ma.) said about getting affordable health care to people. I know from talking to him about this topic, this is what Scott’s is too.

“We just moved into our office, and we had our first fully in-person leadership meeting. Beyond that, the broader office of population health team has been returning for various opportunities to be together to advance our work.  And just being around all these people and all the great things that are going on is fantastic. Getting their feedback and discussion, I just realized how wonderful it is to be able to be in that kind of environment and to work with such amazing people, and I fully expect that this will help translate to improved care and service that we can provide for our patients and communities,” he said.

Buy-In on Mt. Washington

Mt. Washington, arguably the cutest neighborhood in Baltimore, is where Scott’s team’s new office is. There was a t-shirt you could buy at one time that said, “I Climbed Mt. Washington.” The area’s hilly, as Central Maryland tends to be, but it’s not mountainous. Scott and his team are climbing that mountain, though, of learning about delivering health care as they deliver it. No matter what the work, learning as you’re doing is impressive–especially so when it’s health care, I say, because that’s such important work.

“It’s both a blessing and a challenge when you’re working in a large, very complex organization, like Hopkins is, with many entities and many teams, ensuring that you’re trying to move forward while keeping all on the same page,” Scott said. He said he and his team try, when they’re advancing initiatives, to gain the most “buy-in” possible from stakeholders. That’s a wonderful phrase, because it really brought home the point of our conversation. Scott and the PHT are about serving the community, and part of that is making sure that over 60 strategy partners that were engaged in the strategic planning process from across the JHM system are heard through a deliberate planning process.

Trust Me–No, Seriously, Trust Him

“What we’re doing is about getting good feedback and doing the appropriate vetting to promote greater alignment while guarding against unintended consequences,” he said, “But ultimately it’s about serving as a public trust. We’re trying to improve a central, shared service,” he said. “I think the challenge is how to be very thoughtful, and how best to engage and ensure that all those elements are incorporated in the work that we do in a way that feels like everyone’s rowing in the same direction. There are a lot of moving parts, and it’s a big, complex organization.”

COVID–It’s No Quagmire!

Almost everyone Colleen and I have interviewed over the last few years has said the challenges that COVID presented were the thing that surprised them the most about their work lately. No one has said this, though: “I’ve been surprised at how the team has been able to advance over these last one or two years despite COVID, as the needs only continue to grow.” I could tell he felt proud of being part of a team that’s done important, big work like this during a pandemic.

“I would want people to know that this is a journey, not a destination,” he said. I had mentioned that Oprah Winfrey once said that if she had to identify a through-line in her 30 years as the host of her own talk show, she’d say it was that everybody wanted simply to know, “Do you see me? Do you hear me?”

“We are working with a vision of how we need to continue to come together to advance the health of populations that we serve. This is not going to be a six-month operation or a one-year operation. It’s iterative. It requires the insights and guidance of many stakeholders to ensure that we’re successful,” Scott said. “I want people to know we embrace the complexity of navigating this work, and that will help us to best ensure the right product. We’ll get there, but it won’t all be solved by tomorrow.  And the humility of knowing that we have a lot to learn.” Scott said he and the PHT understand that means listening to their patients, the community, and stakeholders. This is how, he said, he and the team ensure that they’re delivering excellent care (my words): keeping sight of those needs.

“We don’t enter any process thinking that we have any or all of the answers. It’s really just making sure that we keep moving the ball forward. We’re committed to getting this job done and doing it in the right way.”

As with every article, I asked Scott how funding affects his work.”  We’re operating in an environment where our populations have significant health needs, significant social needs” he said. He reminded me about the phrase he’d used earlier: “social determinants of health.” These are as simple and as complicated as the entirety of the work of the PHT at Hopkins.

“It can be as basic as the ability to have electricity so you can keep your medicine and food refrigerated, the ability to deal with pervasive challenges that might have to do with substance abuse or addiction, that then influence your ability to manage your diabetes, or manage your heart failure, or that if you can’t get your medicines, or get to your appointments, you can’t treat your condition,” he said.

He said he and the PHT seek to address, then, what people sometimes refer to as disparities in care, where certain parts of the population may have different access to services than others.

“So I think it’s really critical when we’re thinking about promoting health and wellness and equity, that we’re able to meet people where they are and help to raise them up to be able to get the same levels and types of supports and services,” he said. He said he can’t put a particular dollar-figure on that. This made sense to me. Like Del. Eric Ebersole (D-44), he’s pretty good at explaining–describing, remember?–stuff.

“What I can tell you is that it’s a real need. And we’re mindful of that. We want to be able to help with it and measure it and address it.” And at its core, Scott’s/the PHT’s work is care delivered within the community, certainly. “Community health workers, as well as other team members, go out and try to help patients overcome their barriers to care, helping them to achieve improved health.

I told him that this question vexed me with my articles because I would often say, “If you had unlimited funds, what would you do.” That wasn’t helpful in understanding what people are doing, because what wouldn’t anyone do with unlimited funds. Then I’d try to put a finite amount on it–but what?

“Somewhere between unlimited funds and a narrow scope of funds, there’s a need there related to how can people achieve their best health-self.” He said in that area his organization and American society as a whole has work to do.

“I think we need to start as a society to acknowledge that there are needs there before we can start making gains with it,” he said. Scott’s way of communications is assertive, as the research on workplace communications styles says. Assertive communication is: “Directly, honestly and appropriately stating what your thoughts, feelings, needs or wants are. You take responsibility for yourself and are respectful to others. You are an effective listener and problem solver. You stand up for yourself in a way that does not violate the rights of others,” according to fellow.app. I looked it up because it’s a meeting software, like Zoom, and Scott and I talked about how his typical day at the office includes a lot of meetings. I want to be adamant about how Scott and his team are assertive in their work. They’re going somewhere.

It reminded me of how Scott is a major soccer fan–and former coach!–and I thought how his experience coaching children’s soccer has probably helped him understand how his professional team can best accomplish these goals, which might be nebulous and vague in the hands of someone who doesn’t understand assertive communication, which most occupational/workplace psychologists say is the ideal type of communication.

Search and Research and Search Again

This is sort of why I thought Scott and the PHT’s work was research. I knew that they explored ways to optimize health care delivery. “Measurement is important, outcomes are important, and those are things that we’re particularly mindful of. Because you can’t just have unlimited funds, you need to be accountable for how you’re using it. So you need to understand the impact and where measurement can be important as well,” he said.

“We’re about two years in now, and we’ve been building, thanks to the team’s efforts, a solid foundation when it comes to our delivery of types of clinical services, plus the work we’re doing with analytics and data as an underpinning to understand impact and focus and how you prioritize what we’re doing to help coordination across the system,” he said. The team’s also doing a lot of work to engage in value-based initiatives.

“And we’re typically provided with some funding, through different mechanisms, but then held accountable for delivery,” he said.

Scott hopes he and his team will stay the course in the future but also break new ground.

“Five years from now, to give you just one example, beyond the focus on certain populations for which we have funds, I hope that we would have a care model that would deliver care irrespective of what insurance you might have or who the payer is, because we’ll be participating in enough of these programs so that we can have what we call a ‘payer-agnostic’ model to care delivery and care services.” I love that phrase, I thought, sitting up in my chair! Payer-agnosticism shifts the focus of care from how the recipient of care pays for it to what interventions a doctor uses in treating a patient. This is patient–people–centric. And that’s very much what I’ve always thought about Scott: he cares deeply about people.

“So that irrespective of whether you’re a Medicare patient, a patient with private insurance, or a Medicaid patient, that we’ll have a system of care that will be tailored to your needs and meeting those needs, I hope that we’d have the ability to do that,” he said. And similarly, he told me, he hopes he and his team can help patients with greater needs by connecting them to existing community resources or services.

“When a patient goes from their community to a higher level of care, maybe gets hospitalized and then goes back to the community, maybe they go temporarily to a skilled nursing facility,  in between, how do we better connect that patient so that we ensure there’s a continuation wherever that patient goes? Each of those steps creates the potential for new forms of data that raises  complexity but also opportunity to understand the patient through their full healthcare journey,” he said. “And the delivery around that, the coordination on that, we need to keep getting better at that.”

Scott said that, rightly so, when I asked him what his proudest accomplishment was in his work in population health at Hopkins, that it was tough to answer. I know that. Self-reflection isn’t easy.

“This is because what we have accomplished I don’t take sole credit for. I do believe that what we’re becoming as a population health office, what we’re becoming as a team that is maturing and becoming more comfortable in our work. But I don’t take full credit for that by any means.” A RoCo bestie, Carol Fisher said to me once at a forum for political candidates that we were at with Scott before the county elected him to Central Committee, “He is so thoughtful and kind.” And so his organization is, the one he’s a member of at Hopkins, it seemed to me that day.

“I’m proud that we’re working as an entity, but that we’re doing that as part of a broader organization that is so mission-focused on delivering care to populations. And so I think that, in totality, is something that I would say I’m very proud of,” Scott said. He was careful to say it’s the group. As the saying, attributed to several African cultures, goes: “I am because we are.”

Scott also sees patients in a clinical setting these days. We met at Mad City on a Saturday. Scott said, “Monday for me, I’ll be back in the hospital. I’ll start with a couple population health-related meetings, but I have to limit these meetings when I’m attending in the hospital, so I can be very focused on delivering direct patient care to patients with cardiology needs,” He said he’ll meet with fellow physicians to review certain patients. “And I typically see as a consultant between 5 and 10 patients in a day. I try to do that while still staying plugged into the rest of my portfolio of activities that don’t always connect to cardiovascular care directly. That’s what these episodes look like when I’m in the hospital full-time.”

When he’s not in the hospital full-time he typically has a series of calls or meetings both within and outside the Office of Population Health. “As we now have an office space, I’m hoping to have more of those in person, as makes sense for the team. There are some meetings where there’s a broader team, and others of smaller groups, or typically pillars of focus,” he said, and I could tell in that moment that this work was deeply fulfilling to him. I’m related to a lot of physicians, and I know that look.

“For example, if we’re working on something like care management or care coordination, we might just meet with our leadership group. Sometimes we meet with groups across the enterprise, and that may include 30 or 40 people,” he said, a hint of a smile coming to his face as he leaned over the table we sat at outside to tell me. It was louder on the sidewalk outside the coffee shop than I think either of us expected.

Also: Local legal eagle and advocate Josh Friedman talked to us about being on HCDCC too!

“We’ll meet to talk about those issues and make sure we’re getting input from primary care and from hospitals and home care and from our other entities,” he said. ”

This is as an article about Scott’s professional work, but I know Scott, and his family and friends are very important to him. So his day starts out with kids’ transportation and ends with kids’ practices or after school activities, I joked with him, a kid sandwich. He said this was true, that his days were very full but fabulous!

Politics, Policy, and a Lemon Square

I had to go into the coffee shop and get something to eat. I’m not used to all this serious talk! Scott insisted he buy for me whatever I got, which was a cup of coffee and a lemon square. He got an iced coffee, which was probably the way I should have gone. The temperature that day was in the lower 90s.

“I’ve always been interested in government, policy, and politics, and at various times in my career, I’ve worked in different areas,” he said as we came back to our table with our victuals. Around the time of 2016 presidential election, Scott became more involved with the Columbia Democratic Club and met Maureen Evans Arthurs and Candace Dodson Reed, two local Democratic activists who were getting a group of people together to run as a slate for Central Committee.

“It was around that time I also considered what the opportunities might be like for more local involvement. And through those conversations, I eventually learned about this team that was going to be coming together to run for Central Committee, a team that became known as “HoCo Forward”. I just fortunately became a part of that process. That was an amazing team,” he said. Life has become increasingly demanding with new professional and personal commitments. So, Scott decided now was not the right time to run again for Central Committee. But he’s left open the possibility that he may run again in some capacity in the future. I, for one, hope he does.

When I gave him that book I mentioned above, The Impact of Inequality, it was because I wanted to talk about the issues it addressed. They’re the same ones Scott and the PHT at Hopkins work on. First of all, Scott was beyond decorous in expressing his gratitude for this gift I gave him. We were at the launch event for HoCo Forward and he had a lot to focus on besides me. But books are my thank-you cards, so I gave it to him to thank him for the next four years he’d spend on Central Committee…and beyond!

Thanks for reading! Check back with us here at rocoinhoco.com every week as Robert, Colleen (and pup, Moses) get to know the many facets—one each week–of this prismatic place called Howard County. We want to take you along with us, so follow us on Twitter at @rocoinhoco, join our Facebook group, and follow us on Instagram at @rocoinhoco.