Episode 57

The Margin and the Mission

with Niyum Gandhi

March 31, 2022


Niyum Gandhi
Chief Financial Officer and Treasurer, Mass General Brigham

Niyum Gandhi is the Chief Financial Officer and Treasurer at Mass General Brigham.  His responsibilities include financial oversight for Mass General Brigham’s clinical and academic operations and management within the areas of Corporate Finance, Treasury, Managed Care, Real Estate, and Supply Chain.

Prior to joining Mass General Brigham and returning to Boston in 2021, Niyum served on the executive team at Mount Sinai Health System in New York.  He joined the organization as its first Chief Population Health Officer in 2015.  In that role, he built Mount Sinai’s clinically integrated network, direct-to-employer business unit and consumer digital function.  He later took on the role of Chief Financial Officer for the health system, overseeing the financial operations of Mount Sinai’s eight hospitals and the Icahn School of Medicine.

Before his tenure at Mount Sinai, Niyum was a Partner in the Health and Life Sciences consulting practice of Oliver Wyman, a global management consulting firm, where he focused on financial planning, value-based health care, and transformation strategies for hospitals, physician groups, and health plans.

Throughout his career, Niyum has collaborated closely with a variety of health care providers and payers to help design and implement value-based clinical models, develop new contracting and integrated product distribution strategies, align funds flow and physician incentives, and establish the appropriate infrastructure to support value-based health care.

Niyum holds an A.B. in economics from Harvard University.


The focus on affordability, which we share as part of our mission, means that we have to think more creatively about where margin comes from.



[00:00:06] Gary Bisbee, Ph.D.: Growing up in rural Pennsylvania, Niyum Gandhi’s parents showcased leadership through community action and empathy. He learned that leadership is earned by the way you behave. Niyum shares his career progression, from consulting to leading population health in an academic medical center to being the CFO and Treasurer at Mass General Brigham. Niyum dives into the relationship between finance and strategy. As CFO, he focuses on setting priorities that are specific and narrow as possible to increase achievability and accountability. He believes that it’s important to balance between investing in the future while effectively addressing the challenges of today. We discussed scale for large health systems, how it can be both an asset and a liability. While it’s challenging to integrate at scale, it’s important for health systems to achieve because scale advances the quality of care, and it creates opportunities to diversify business and take a longer term strategic approach. Niyum discusses the relationship between net and gross margin and how the gross margin allows Mass General Brigham to provide uncompensated care and benefits to the community. For young leaders, Niyum emphasizes leading with empathy, which should always be your north star.

Well, good morning, Niyum. And welcome.

[00:01:33] Niyum Gandhi: Thank you. Thanks for having me.

[00:01:35] Gary Bisbee, Ph.D.: Well, we’re pleased to have you at this microphone. Well, can you describe Mass General Brigham for us?

[00:01:41] Niyum Gandhi: For those who are less familiar, when Mass General and the Brigham came together to form Partners in 1994, it was really designed with intentful design to be a holding company. So there was some back-office consolidation and, when Peter got here in ’99, he kind of drove more of that. The ideal was the organizations would have their separate strategies and execute on them. And that served the organization very well for a period of time. And then I think through, through some leadership changes over the past handful of years, there was more clarity on, the future is not that. And that probably was the right decision in the past. But as we go forward to be our best selves for our patients and the communities that we serve, we need to make that change from a holding company to an operating company. And that now at this point, the two big academic medical centers, three specialty hospitals Spalding, McLean, and Mass Pioneer, which are kind of titans in their own spaces, great community hospitals spanning across yes, the greater Boston market, but also into Western Massachusetts, both Nantucket and Martha’s Vineyard, up into Southern New Hampshire. We really felt that if we integrate those assets, drive clinical integration, but also operational integration, that’ll be the next stage of our transformation to achieving our mission of great clinical care research and education. And so it’s, it’s a time of a lot of change. But as the largest employer in the Commonwealth of Massachusetts, largest private employer, the largest provider of care in a time where healthcare is increasingly unaffordable, increasingly challenging for patients, for consumers, we hope that we can have the type of impact that we want to.

[00:03:21] Gary Bisbee, Ph.D.: Speaking of Nantucket, half the CEOs of health systems in the country would love to retire and go up to Nantucket. So if you need a new CEO, there’s a bunch of around there. But in any event, when you take a position like this, Niyum, how do you think about setting your priorities?

[00:03:44] Niyum Gandhi: I firmly believe that, especially in large academic medical centers, and I haven’t really been a leader in any other type of organization, so I can speak to what I know here. I think we often fall into the trap of having too many priorities and having our efforts be too diffuse. And I think part of that is maybe from the bottom up nature of academia and there’s the academic meritocracy of ideas and priorities in research, which is the right way to do research and to advance science. But it’s not a great way to kind of run an organization. And so, the approach that I take to priorities is really thinking about interlock with system priorities, with the priorities of my colleagues, with the priorities of the board, and then being as specific and narrow as possible on the priorities, because if we try to achieve 14 things at once, we will achieve zero of them. And so right now we have set a very specific set of system priorities at the aggregate high level. And then in our role in the finance organization, what are our finance team priorities that line up with those system priorities? And it’s a short list. It’s a single digit number of things that we’re focused on this year. And yes, of course, everybody needs to keep kind of doing the current course and speed. But when we think about what we want to achieve this year, we went through a process through our senior management group, and then cascading down to the next layer of the organization of trying to be as tight as possible on our mission to really be in an integrated academic health system, which is not the starting point that we were starting from.

[00:05:21] Gary Bisbee, Ph.D.: When you think about integrated academic medical system, there’s a number of units, as you mentioned, that comprised Mass General Brigham. Can you speak, Niyum, to the importance of scale in today’s world?

[00:05:34] Niyum Gandhi: Yeah, I think that I probably didn’t appreciate this until I came here. So Mass General Brigham is roughly twice the size of Mount Sinai from a revenue, patient care, research standpoint. But I think two pieces of scale that are important. One, scale can be an asset and maybe a liability. It’s harder to integrate, but there’s a greater obligation to do it. And so we have fantastic leaders of pretty much every type of thing that you could think of. But often we have two or three fantastic leaders of those areas. And so scale and integration can be challenging, but we can achieve more. So clinically, as an example, we integrated our cardiovascular surgery program across Mass General and the Brigham. By doing that, we are bringing the best of what is being done at both of those hospitals to a combined program and the best of that program to patients in a way that we could not, when we were subscale, and not that those programs were small but individually, they were significantly smaller than they are together. And so that advances the quality of the work, it advances the way that we can integrate research infused thinking into our care. And so that’s tangible on the clinical side. I think the other type of scale that is, as we think about the challenges facing not-for-profit health systems going forward, that’s really important is the scale of the balance sheet. And I think we’re fortunate to have some scale there that allows us to think, and again, kind of back to the Mount Sinai example around population health, allows us to be impatient while still being patient and make longer bets with the balance sheet, whether that’s new investments in diversified sources of margin, whether that’s inorganic growth in areas that are not just other hospitals or other physician groups, but diversified businesses that compliment and supplement what we currently do. Whether that’s just weathering a bit of a storm, like what we’re seeing macroeconomically right now. And so I think that scale helps with the idea of taking the longer term view, which we need to do. We saw our first patient 211 years ago. We are stewards of this health system for the future and using our scale to ensure that we are here seeing patients and delivering exceptional care 211 years from now is part of what we need to do, and again, part of the benefit we have from that scale.

[00:07:55] Gary Bisbee, Ph.D.: So you spoke to the importance of the balance sheet and scale and developing new areas of margin and so on. What is the margin profile, turning to income statement here, what is the margin profile of Mass General Brigham?

[00:08:09] Niyum Gandhi: I have a very specific point of view on how not-for-profit health systems should think about margin and I would say, when I talk with my CFO colleagues around the country, they don’t all share my perspective. So this is Niyum’s perspective and it’s aligned with our board here. So in our net margin, and I’m specifically using the word net margin. I’ll come back to gross in a minute. But our net margin is a couple percent, 2 to 3% in a good year, 1% in a not good year. But I think the point of net margin is important because, from a corporate governance standpoint, we are owned by the people and the communities that we serve quite literally, legally. We are granted our not-for-profit tax exempt status through charters that enumerate our mission. And so the same way that a for-profit company, in that organization, if I were the CFO, I would have a fiduciary obligation to increase earnings per share so that I could generate value for the shareholder. And if we had stable enough earnings, we would pay a dividend. I think of it the same way here. We have a fiduciary obligation to increase our earnings and then pay a dividend. And our dividend is the mission work. So we do $1.2 billion annually in community benefit. That amounts to seven and a half percent of our revenue. So if our net margin is 2%, our gross margin is 9.5. And we should increase that, not so that we can increase the two, but so that we can pay a bigger dividend in terms of uncompensated care, uncompensated community health work, in adequately remunerative teaching, unreimbursed research. Those are the pieces of our mission and we do a lot, but we want to do more. And so ideally we would increase that nine and a half percent, not increase the 2, but increase the seven and a half percent dividend, and continue retaining the 2% of earnings to invest in the capital needs of the organization. I feel very strongly about that being the goal. And so I would not want to drive a 5 or 7% net margin in the business because then we aren’t paying the dividend that we need to to our shareholders.

[00:10:18] Gary Bisbee, Ph.D.: Massachusetts is a highly regulated state, as many of the eastern, northeastern states are. But how does that influence your thinking about margins going forward, Niyum? Seems like there’s a fair amount of pressure on any of the health systems there relative to generating margins.

[00:10:38] Niyum Gandhi: The regulation comes from, in my perspective, a really good intent, which is to ensure that the citizens of the Commonwealth are getting what they need, especially around affordability of healthcare because we do have an affordability crisis. We do well in Massachusetts. Our total medical expenditure on a per capita basis is low. Our trend is significantly lower than national. And if you look at Mass General Brigham compared to peers, peer institutions, nationally, when we benchmark on total medical expenditure and on unit price, we are affordable. Now, people may not say we’re affordable here in Massachusetts and we could talk about and debate some of that, but I think the intent is good. What that means, that focus on affordability, which we share in how we approach our mission, is that we have to be more creative in where margin comes from. Again, I actually think that’s really good. I would contend we would do it anyways without the regulation because of the philosophy that I laid out in terms of how we think about mission and margin trade-offs. So as we think about margin growth in the future, one of our north stars is that we want future margin to not come at the expense of healthcare affordability. So what are other ways that we can generate margin? So, as an example, we do a lot of innovation that comes out of our research enterprise. And I would say, historically, academic medical centers have done a lot of research there and seeded the value creation to pharma and biotech. And so we’re approaching that differently when we license: how we license, how far down the development pipeline we take things before we license, because if we generate the value and keep that margin, we plow it back into community health. And if a pharma company generates that margin, they pay a dividend to their shareholders. And so the more we can think creatively about profit pools that do not involve driving up total medical expenditure and reducing affordability, in the context of the regulatory environment, but more importantly, in the context of our mission and values the more we’ll do that.

[00:12:45] Gary Bisbee, Ph.D.: Typically margin has generated from a relatively few services. And I think some of us would look at value based services as not being necessarily ones that would drive a lot of margin. How do you kind of factor those two together, Niyum?

[00:13:04] Niyum Gandhi: Yeah, I think that there’s a few pieces there that are important. One, if we change payment models, we can align at least a little bit more of the margin creation with higher value activities. So we take total cost of care, population risk with meaningful downside, for over 80% of the patients that get their primary care from us. And our risk contracts are a profit center for us. They are margin accretive and we generate that margin by reducing total cost of care and actually reducing our revenue in other parts of our business. But that’s good. The risk contracts are margin accretive. But it’s because we changed the payment model. I think the industry still has work to do on that and we’re out there in front trying to do that in collaboration with our payer partners. So I think there’s opportunity there. The other piece, though, I would say, is recognizing that there are certain things that are high value that will never have margin. We’re the largest provider, aside from the state, of inpatient behavioral health in the Commonwealth. Well that’s a highly valuable service. There probably isn’t enough capacity for the patients who need that service nationally. And we lose money on it. And we’re happy to lose money on it. That’s part of the mission. And so I think kind of balancing those trade offs is important, but I think there’s work again for us to do as an industry in thinking about, okay, so the behavioral health example, should we think about funding behavioral health differently? Yeah, I think we should. Should we invest in upstream behavioral health resources and make those margin accretive to those who provide those services so that we reduce our reliance on the backstop of inpatient, acute behavioral health? Yeah. I think we should do that. And again, unfortunately, to the regulatory point, we have been, in Mass Health, our Medicaid agency, we have a group of like-minded leaders there who are working with us to figure out how to do that, to push more money into upstream behavioral health, to make it not such a money loser so that we provide those services, so that we reduce the burden on the population downstream. So I think we’re probably in inning three, inning two, or if it’s a marathon we’re in the first few miles of kind of the payment model transformation that allows margin pools to accrue where the highest value services are delivered to patients.

[00:15:28] Gary Bisbee, Ph.D.: Yeah, clearly early innings on payment model evolution. Sounds like the whole integration process, I don’t know if you’d say early innings, but maybe mid innings on that. But how do you think about, Niyum, the part of your role, which is to prepare Mass General Brigham for the future, so you must have some longer-term plans, how do you balance those against kind of the demands of the shorter term?

[00:15:54] Niyum Gandhi: Yeah, this is probably no time, more true than right now with coming out of this most recent COVID surge with the macro economic climate, which I think is putting increasing pressure on the short-term, but also unfortunately increasing pressure on the longterm. And so I think that the fundamental economics of healthcare delivery, if I think short-term, are broken. Revenue per unit of service, if we’re committed to affordability increases at a couple of percent a year, at best. Cost per unit of service historically has increased at 3.5 to 4%. On a $16 billion organization, that 2% gap is over $300 million and we figure out the way to close it every year. Historically I’d say we’ve probably closed it by not investing in the future. And so that’s one of the changes that we’ve made recently is, as kind of coming together more as a system, picking our priorities on addressing the future, on investing in the future, the things that will not pay off either in mission or in margin for three to five to seven years, picking our spots, measuring ourselves against measurable key results in those areas, holding ourselves accountable for making the progress. 20% of the progress in one year for the five-year goal. That’s a new muscle that we’ve developed recently. But I think that what’s happened, especially recently, that 4% increase in cost per unit of service is now five or six. 8% inflation means that our employees, who do most of the working and living in these communities, you give them a 5% increase. That’s a 3% decrease on a real basis. They are the largest cost input to what we’re doing, but they are also the people who we need to support. And so that puts ,additional pressure on the cost structures. And so I’d say right now, the process that we’re going through is, how much of the investment in the future can we prioritize while addressing the current challenges? And we cannot take our eye off of the future. And I think that the future, the key, the kind of three pillars of getting to where we need to be to be financially stable are increased operational effectiveness, increased clinical effectiveness, right? So everything we’re doing in terms of taking out back office cost, everything we’re doing in terms of putting our best foot forward clinically and integrating there, which will be more efficient and more effective, and then creating those new sources of margin that are not counter to affordability, whether that’s new clinical businesses, new scientific businesses, or other value added services. Those are all three of those things take time to invest in. And so we’re ensuring that we preserve enough to invest in those areas while dealing with the current. And I’d be lying if I said that was easier today than it was three months ago. It’s gotten significantly harder. It’s probably not lost on others as well that what’s going on macroeconomically is really challenging because we can’t afford to let our revenues index with inflation. Then we’ll just be more a part of the problem around affordability, but our costs do index with inflation. So, yeah, tougher decisions to make. Tougher, fewer priorities to be able to pick. But ensuring that we don’t shut off investment in the future is foremost in our minds.

[00:19:20] Gary Bisbee, Ph.D.: That’s really well said, Niyum, thank you for that. Could you speak to the importance of the relationship between the CFO and the CEO in terms of these kind of issues that you’ve just been laying out, both short term operational issues, as well as the longer term strategic ones?

[00:19:39] Niyum Gandhi: Yeah. Yeah I think that I’m a firm believer that finance follows and supports operations. And so I’d actually, probably the one thing I’d amend to that is, I really think of it as, not that all leaders aren’t important, but there is the partnership between the CEO and CFO is important. The partnership between the COO and CFO is also very critical. And our COO is probably the leader who I spend the most time with. And understanding that part of the prioritization has to be driven by what is operationally feasible. And part of the prioritization needs to be driven by what is fiscally feasible. And so there is a good push and pull there in terms of how we think about dynamic prioritization, tradeoffs, long-term short term. The CEO, and again, fortunate to have a tremendous CEO who I get to work for and learn from, I think is the person who needs to hold us accountable to the north star and push us. And that is a role that Dan plays tremendously well. And the three of us spend a lot of time together working through these issues of where are the priorities. And part of, I think one of the things that I think is good,that is changing in healthcare. If you rewind 10 to 15 years, a lot of CFOs of health systems, it was just the CFO and the CEO, and the CFO was saying, well, we only have so many dollars, so stop spending. And the CEO was saying, no, I have a bold vision. And I think that’s, again, it served the industry for the time. I think a more modern way to look at it is actually, I have short-term and long-term thinking and Anne has short-term and long-term thinking. And so does Ron, our COO. But we come at problems from three different perspectives and that allows us to get to the best answer rather than, I’d say, the traditional CEO has the vision, CFO is the reality, which I think is what largely happened in not-for-profit healthcare for many years.

[00:21:37] Gary Bisbee, Ph.D.: And you’re really speaking to the evolution of the CFO in these large integrated organizations. And your role, your history, really speaks to that, Niyum. The next question would be then your relationship with the board, which is much different now, I think, then a CFO of 20 years ago. But how do you relate to the board? What issues are you dealing with with the board?

[00:22:04] Niyum Gandhi: So I think the biggest one that I spend time with the board on it is how we think about the long-term financial realities of the organization. And so the board, again, as a not-for-profit, our board are the representatives of the community who hold us accountable. And they disproportionately come from outside of healthcare, which broadens the aperture by which they can think about our impact, the levers available to hit that impact. And then part of what I view my role as, and role that I play, is from the financial side, just the same way that my colleagues do on the operational side or the strategic side, laying out the roadmap that allows us to achieve what we want to from a mission standpoint, over the longterm view. I would say our board is appropriately disproportionately focused on the long-term view. And so as we think about some of the things that we’re going to need to do to preserve long-term financial stability, again, I go back to the example of inorganic growth in non care delivery areas. That is something we would have never considered 5, 10 years ago. And so bringing the board along in that thinking, but also getting their best thinking on it. Our board chair is a private equity leader. He understands the value of how to think about margin profiles of inorganic growth. Well, so that’s a way that I can actually test ideas with him, learn from him, but also share how we’re thinking about it and ensure that he and the rest of the board are bought into decisions that we may make in the next year or two that have implications for the next century of how this organization is run. When you start thinking about getting into new types of businesses, those are really board level decisions. So the iteration on that, bringing the board along, having them bring me along in their thinking, that’s probably the largest point of intersection.

[00:23:58] Gary Bisbee, Ph.D.: Niyum, do you think today’s CFO has special responsibility to address with the board, with the senior leadership team, issues of risk?

[00:24:09] Niyum Gandhi: Yes, actually, that’s a great question, Gary. And I think that risk is something that, again, as an industry we are behind in how we think about risk, quantitatively and rigorously. If you look at other operational industries that are complex, highly regulated, have longterm, short term trade-offs, they’re much more sophisticated about this. The energy industry, the aviation industry, those are places where people do think about risk in a sophisticated manner. And it’s actually something we’re working on right now, kind of modernizing our approach to enterprise risk so that we are making trade-offs in a way that is cognizant not just of the expected outcome, but the uncertainty around every expected outcome. And part of the reason that I say that we’re less sophisticated as an industry is, if you look at kind of the risk models, and I can pick on the consultants because I used to be one, but the risk models put out by the consultants or the bankers and they’ll all say, oh the biggest risk is your investment portfolio. It’s like, well, that’s financially accurate in a one-year viewpoint, but I know that’s not right. The biggest risk actually, I would have said, and I think it’s turning out to be true if you would’ve asked me a year or two ago, the biggest risk is inflation. That could be catastrophic in a low margin business or it’s the Black Swan event, right, which we just saw. And I wouldn’t have predicted the pandemic being what the pandemic was, but I think thinking through tradeoffs and then thinking through kind of transparent assessment and acceptance of risks is something that, again, we can learn from other industries. And I think the CFO’s role is pretty central in that in terms of bringing a currency to how we think about risk and risk tradeoffs.

[00:26:02] Gary Bisbee, Ph.D.: Why don’t we get to know you bit, particularly thinking about the foundations that you have as a leader. This show is all about leadership. What was life like growing up for you, Niyum?

[00:26:16] Niyum Gandhi: Yeah. So I grew up in kind of rural central Pennsylvania. My parents were both immigrants, and so first-generation Americans from that standpoint and I have an affinity for small town America because of where I grew up and often miss that in terms of just having that connection to community, growing up with the same people for a long time, many families who had been there for a long time, many generations, and so I hesitate to use cliches like it was a simple life, but in many ways, it kind of was, which was great, great community to grow up in.

[00:26:48] Gary Bisbee, Ph.D.: What about your parents? Did they influence your leadership style?

[00:26:53] Niyum Gandhi: Yeah. So I would say my, and I say this with all honesty, I think my parents are the number one and number two best human beings that I know. I’m not sure who I would put at one and who I would put at two, but maybe they’re tied for number one. As it relates to leadership, I’d say the biggest thing is the part of what makes them such great human beings is that they are the most empathetic people I know. And I think that translates into, and in their own ways, in their own careers and in the community, they were highly empathetic leaders, understanding people’s perspectives, assuming positive intent. And I just saw that every day in the way that they conducted themselves, in the way that they behaved towards us, in the way that they behaved towards friends, colleagues. And I think that that really left a mark on me in terms of that’s the right way to do things.

[00:27:45] Gary Bisbee, Ph.D.: What did the young Niyum think about leadership?

[00:27:48] Niyum Gandhi: I’m not sure the young Niyum thought about leadership. I would say more of the leadership I observed, again thinking about my family was more kind of soft influence leadership. And so my parents were really active in the community, especially in the Indian immigrant community in State College, Pennsylvania, where I grew up, and were kind of informal leaders. I thought of that as kind of leadership is something that you earned by the way that you behave. But I was probably a little too naive to think about, what does leadership mean in big organizations or in complex or formal structures until I found myself in them.

[00:28:29] Gary Bisbee, Ph.D.: Sure. Well, just looking back, do you recall one first leadership experience, one experience that you had that afterward, you said, I’m kind of being a leader here?

[00:28:42] Niyum Gandhi: Yeah, for myself, I’d say my early career was in consulting and it’s kind of like in medicine where they have the whole, see one, do one, teach one sort of model. And in consulting, it’s very similar. So you’re on your first project, you’re the most junior person. You’re on your second project, you’re expected to manage somebody. And I had no clue how to do that. But coming out of that, and I made a lot of mistakes. I feel bad for the poor consultant who worked for me the first time I was a manager. The good news about that is then your manager is pretty fresh out of their time as a first manager and can educate and correct. And that was part of the discussion that I had with my manager at the time, where he just pretty quickly came in and gave me some lessons and said, remember you’re a manager now. You’re a leader now. So you need to behave differently than when you were…I was like, what are you talking about? I’ve been here for six months. But it’s good because you get it in small doses and you’re able to learn quickly from people giving you quick feedback.

[00:29:41] Gary Bisbee, Ph.D.: Did you move into healthcare intentionally or accidentally?

[00:29:45] Niyum Gandhi: I wish I could say it was intentional. It was intentional with regard to the people. So when I was early in my time at Oliver Wyman, found a couple of partners there who I really liked working with, really enjoyed working with, felt I could learn a lot from. I’m still close with them today, three of them who kind of started the healthcare practice there. So I was like, oh, you know, I want to work more with these people. And then I got passionate about the content. But my intentional move into healthcare was following people who I felt I could learn a lot from and whose, actually back to the point of leadership, whose leadership philosophy and leadership style I appreciated.

[00:30:19] Gary Bisbee, Ph.D.: So you became a partner in Oliver Wyman. You were there for 10 years and then you moved to Mount Sinai in New York. What prompted that move?

[00:30:28] Niyum Gandhi: So probably going along with the theme of a lack of intention, my plan was to stay at Oliver Wyman for a lot longer and was actually having conversations with the managing partner of our practice about broader leadership roles within the practice. And I was out trying to sell a consulting project. Itat was my second year as a partner. And had a pitch meeting at Mount Sinai. And we were talking about value based care transformation. And that’s the content that I was and still remain passionate about and that I was doing my most of my work in. And we were talking about the idea of kind of going all in on transforming towards value, embracing financial risk for populations, but also really implementing the care delivery transformation necessary. And Ken Davis, the CEO there, who’s been a great mentor to me during my time there said kind of gruffly, well this all sounds nice, but who’s done this? And I had known him for all of 55 minutes or so at the time. And I said, well, no one Ken. Don’t you want to be the first? Which might’ve been a bit presumptuous of me to frame that question to somebody who I barely knew, but Ken said, and you can’t make this up, he kind of smiled and said, yeah, do you want a job? And I thought he was kidding certainly, until he called me two days later and said, I’m serious. You should come work for us. We have a position open. This is what it looks like and I’d like you to come interview for it. So, I felt like I’d been doing consulting in the space of care delivery transformation for value based care. I had, probably had all the benefits of being a consultant where, if it goes well, you get to pat yourself on the back for a good strategy. If it goes poorly, you say, oh, the client did not implement. And I should probably, if given the opportunity to try my hand at making it happen, I should probably take that on. And it worked out. I got the opportunity to do that.

[00:32:24] Gary Bisbee, Ph.D.: Yeah, that was cool. How do you go about setting up a population health program in New York City at an academic medical center?

[00:32:31] Niyum Gandhi: Very carefully. I think that, and this is actually related to part of Ken’s pitch to me in that conversation, the way he described the role, he said it has all of managed care contracting so that you own the titration between fee for service and risk. It has all the clinical programs required to achieve performance. And then very importantly, the last thing he said, and it has whatever else you say it needs to succeed. And that’s impressive. If you talk about leadership, that’s impressive leadership from him to say, we are so committed to this, that’s the approach we’re going to take. And so that doesn’t mean that, of course we broke the bank on resources and I always joke that change management in an organization like that, it’s not like somebody sends out a strongly worded email and suddenly it’s student body left. But what we were able to do since we had full buy-in from the board is lay out a multi-year transition. And so it’s, you know, we’re talking about big transformation in the culture and processes in operations. You can’t turn on a dime. And the board and Ken understood that and gave us the runway to build what we needed to around, yes, technical capabilities, but also the cultural change, the incentive alignment, the education, the engagement, taking the humility approach and learning from those who have been doing things in and around the space, or may have different perspectives. So we have the, I guess, the mandate and the aspiration to move fast, but the luxury to do it deliberately. And I think that’s pretty critical to success in a big organization.

[00:34:15] Gary Bisbee, Ph.D.: Looking back on it, what were the major learnings as an actual operator of a pop health program versus your time as a consultant, advising others to do it?

[00:34:27] Niyum Gandhi: I’d say the two biggest things I learned both relate to people actually. And when I was a consultant, even as a partner, if I was overseeing three, four projects, say, I don’t know, 30, 40 people across them, I had literally done every one of their jobs before. I had been the analyst building the Excel model. I had been the consultant doing the interviews. I had been the principal writing the PowerPoint presentations. I had done all those jobs. When I started at Mount Sinai, I had 500 or so people on my team. I literally could not do any of their jobs. They all had some level of, not just experience and qualification, but also technical expertise that I didn’t have. We have nurses, social workers, physicians, contracting experts on the team and I had no experience managing people whose jobs I couldn’t do. So that was hard for me in the first few months to learn how to lead people who I had no capability to do their job. And so, figuring out how to test alignment with where we’re going, figuring out what my role was versus their role really. . In a good way, it meant that I couldn’t really fall prey to micromanaging because I couldn’t micromanage. But, but I needed to make sure that I was focused on where I could have the greatest value. And then I think that the second big learning relates to that is I didn’t know how to kind of drive performance management as a leader in an organization like that, where there were diverse backgrounds, diverse perspectives, diverse sets of experience, and how to motivate people around performance management. I was fortunate to have just an absolutely amazing rock star set of direct reports. So it was like training wheels for this work. But in consulting, it’s very easy to use the crutch of saying, when you’re giving feedback, well as you move into the next role or as you want a role like mine, you can do this. Well in a complex organization, that’s not necessarily, what’s gonna motivate everybody. Some people are saying, no, this is my terminal job. This is it. I’ve reached the apex of my career. This is what I want. And so as you’re coaching them, thinking about areas to improve actually, and then understanding that they know the job better than you. ,That was a set of learnings. And again, fortunately, I think of it as training wheels because my team was so good that I got to learn from them as they learned from me, and as I learned how to be at least hopefully somewhat effective leader.

[00:36:57] Gary Bisbee, Ph.D.: Well, after five years in the population health role, you were asked to become CFO. Were you surprised at that?

[00:37:06] Niyum Gandhi: Yes. So this was, and this was almost exactly two years ago. It was late February, right before, three days before we diagnosed our first COVID patient, actually.

[00:37:18] Gary Bisbee, Ph.D.: That’s a welcome aboard moment, right?

[00:37:20] Niyum Gandhi: Oh, absolutely. And I was meeting with our CEO. And he said at the beginning of our meetings, I have something on my agenda that’s probably not on yours. And that’s a little bit of an ominous thing to say at the beginning of a one-on-one with your boss. And he mentioned that our long-time CFO, who had been kind of a transformative leader in the organization, Don Scanlon, was retiring and Ken does not like to use kind of recruiters to fill key roles. He wants strong recommendations from people who he trusts. And so I thought that his next question was going to be, think back to your consulting time. Who are the best CFOs in the business? Who have you worked with? Can you talk to them about why coming here would be great? And so I’m starting to rack my brain and I actually have come up with a couple of names while we’re kind of chatting about Don’s retirement and the legacy and impact he had had on the organization. And then Ken kind of paused and he said, I’d like you to do it. And I was very surprised. And so the first words out of my mouth were actually, well, Ken, you know I’ve never even taken an accounting class. And his response, again, talk about leadership. Perfect response. He said, that’s okay. We have a lot of great accountants here. They’ll do good work for you. I don’t want an accountant CFO. I want a strategy person who knows numbers. And that was his vision for a CFO, but he very quickly said, it’s not about the technical expertise. We have that. We have great people who do great work here. I want you because of this reason and I’d like you to consider it. And so I took a day to think about it, got back to him. And then he announced it the next week, two days after we had diagnosed our first COVID patient. So I think I said yes to one job, got a very different job, but it was great. Great learning opportunity.

[00:39:13] Gary Bisbee, Ph.D.: Well then, within a year, Mass General Brigham came knocking. That was another, had to be another, surprise, maybe not a surprise of terms of your ability to do the job, but just that reach out. You’d only been doing it at Mount Sinai for, what, nine months or something.

[00:39:30] Niyum Gandhi: Yeah, so and that one was tricky and actually a very difficult kind of decision on whether to take that call on a personal basis. And this relates to kind of how I think about trade-offs between work and what’s going on in personal life as well. A couple of months, actually just a month before I got that outreach, we had decided as a family that we needed to get back up to New England for family reasons. And so the thought was, okay, over the next three to five years, it’s hard, you pick a city on a map and say I want to be there. How many jobs come up that you’re both qualified for interested in? And so we gave ourselves a few years to figure it out and we said, okay, within a few years, we got to get back up here. And then a month later, literally, I got the call from the recruiter. And well, this isn’t really the timing I was thinking about. Ambitious agenda of things we want to do at Mount Sinai and felt like we were making great progress as a team, loved working with the team, loved working for and learning from Ken. But ultimately, said, okay, great health system. And given that we want to be in Boston anyways. ,if I don’t pursue this, then, three years from now, when we really do need to make the move, probably going to be kicking myself. And then I had one conversation with Anne, our CEO here and said, okay, this is another kind of transformational leader who I believe in, who I believe I can learn a lot from, and who I’m excited to take on challenges with. Ultimately decided to pursue it. And, candidly didn’t think I was going to get the job. And my wife still holds that over me where, got part way through the interview process. And she’s like, well, how are you thinking about this? And I said I’m probably not even going to get it. We don’t need to talk about logistics or anything. And came back from what I thought was a, maybe a final round interview with a job offer. My wife was not happy. She said we were supposed to be talking about this for the past three weeks. But it worked out well,

[00:41:26] Gary Bisbee, Ph.D.: Well you’re following a good friend, Peter Markell, who was a Dean of health system CFOs. That’s probably not the easiest position to be in.

[00:41:36] Niyum Gandhi: No, it’s not. And again, probably fortunate that I had my first shot at that sort of experience of following somebody kind of legendary and institutional in following Don down at Mount Sinai. And I have to say the thing about Peter is he’s been so tremendously generous with his time and insights. He lets me call him whenever I have questions. We touch base regularly. This organization would not exist if it weren’t for Peter through the transitions of Partners and then to MGB, from kind of the early days of the holding company sort of model where Mass General and the Brigham probably thought of each other as each other’s biggest competitors, to where we are today. And so I owe a lot to him and what he’s done. And again, kind of related to inheriting that great team at Sinai, inheriting just an absolutely amazing team that makes it easier to be a leader.

[00:42:27] Gary Bisbee, Ph.D.: Niyum, this has been a terrific interview and I think the last discussion is a good place to land. I have one other question if I could. We do have young up and coming leaders in our audience. What advice would you give an up and coming leader in healthcare today?

[00:42:42] Niyum Gandhi: So maybe I’d go back to kind of where we started the conversation, which is I think that the north star for leaders should be leading with empathy. And that is empathy for everybody. Your peers and your colleagues, assuming positive intent there. Leadership is challenging. We’re all going to disagree. We have tough problems. But be hard on the problem and easy on the people because everyone’s the hero of their own story. And understanding that everyone’s perspective is valid and that we have to get to where we need to get to around alignment. And that may require tough decisions and some people being unhappy with decisions, but nobody’s trying to do the wrong thing or the obstinate thing. And then that translates in healthcare, I think, also. It’s that same empathy for, again, a not-for-profit healthcare, the empathy for the shareholder, which is the community and the people of the community and the empathy for the patients. We have tough times ahead of us in this industry and we’re going to get there better if we work together. It sounds so cliche to say but I think it’s easy for leaders to fall into the trap of my perspective, my point of view, rather than that kind of that north star of empathy. So that would be my advice for young up and coming leaders.

[00:43:53] Gary Bisbee, Ph.D.: Niyum, I’d say Mass General Brigham is lucky to have you as the CFO and treasurer. Thank you for your time today. Terrific interview.

[00:44:01] Niyum Gandhi: Thank you so much for having me.

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