'Hot Spotters on Trial' Transcript
January 8, 2020
Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!
Dan Gorenstein: By 2014, Dr. Jeff Brenner felt like he had a good handle on the problem he’d been trying to fix for more than a decade.
Jeff Brenner: Why does health care spend so much money on the sickest and most complex people, but they’re not getting healthier?
Gorenstein: Early evidence suggested Brenner had found a way to cut hospital readmissions by 40% for these costly and complicated patients. He’d won a MacArthur Genius grant. He’d created a national center. Now, Brenner was doing something most people in his situation don’t do.
Brenner: We could have coasted, but I didn’t want to do that. We wanted to rigorously test our work.
Sayeh Nikpay: And now, four years later, after testing that work, we have a clear answer to the question. Has Jeff Brenner found a way to keep hard to treat patients from coming back to the hospital?
Gorenstein: I’m health care reporter Gorenstein.
Nikpay: And I’m Vanderbilt economist Sayeh Nikpay.
Gorenstein: From the Annenberg Studio at the University of Pennsylvania, this is Tradeoffs.
Jeff Brenner’s organization, the Camden Coalition of Healthcare Providers, is used to attention. It all started in 2011 when New Yorker staff writer Atul Gawande introduced Brenner as a brash visionary crusading against the health care status quo. Here’s Gawande talking with Dave Davies on NPR’s show Fresh Air after the story ran.
Atul Gawande clip: He said, “Let me just go to the docs and say, who’s your hardest, hardest, worst of the worst, as he put it, patients and let me see them.” And they were more than happy to hand them over.
Nikpay: The Coalition’s work captured the imaginations of health care executives around the country because the organization was trying to solve a problem insurers and hospitals all had. How do you help people whose lives are so complicated by things like poverty and hunger that simple conditions like diabetes and asthma regularly turn into $10,000 hospital visits?
Gorenstein: Nobody knew how to care for these patients, but everybody had a name for them. Not nice ones, frequent flyers, super utilizers.
Brenner: Behind the scenes, nurses, doctors roll their eyes. They get angry at people that keep coming back. The worst term is people are called gomers and it stands for Get out of my emergency Room. That’s horrible.
Nikpay: These patients are part of a group called the 5/50s. The 5% of people responsible for 50% of U.S. health spending. Brenner was one of the first people in the country to use data to track these patients as they came in and out of the hospital. He called it hotspotting.
Gorenstein: Brenner was transforming anonymous blips in financial reports into real people like a guy Gawande called Frank Hendricks.
Gawande clip: He was 560 pounds. He had an alcohol and a cocaine addiction. He had congestive heart failure. He was spending basically more than six months out of the year in the hospital.
Gorenstein: After Hendricks got discharged, Brenner got to know the man. He learned that he’d been a line cook and urged him to start cooking for himself again and rejoin his old church. This simple investment of time and a little medical knowhow produced big returns.
Gawande clip: I spoke to the patient. He has lost 220 pounds. When he falls down, he does not have to call 911 to get up. He is off of cocaine for three years, alcohol for two years, smoking for a year. Sometimes because of his heart failure he does go back to the hospital, but it’ll be a day or two at a time instead of weeks and weeks. And his costs have dropped dramatically.
Gorenstein: Stories like this made it seem like the coalition was cranking out miracles left and right, and they had some early promising data. Brenner had taken a seemingly impossible problem and boiled it down to tangible, even simple steps, like making sure every patient had a ride to the doctor, power to refrigerate their meds and a caring person to talk to. And if you did all that, he said, you could reduce sky high hospitalizations, achieving two really important things at once…
Brenner: Better care, lower cost.
Nikpay: Better care, lower cost.
Gorenstein: All that helped explain why Gawande called the work revolutionary and why health care executives were excited.
Allison Hamblin: The idea was really attractive that you could focus on a pretty small group of people, improve their health and save a lot of money for the health care system.
Nikpay: Allison Hamblin runs the Center for Health Care Strategies, a nonprofit policy center that focuses on health for low income Americans. Hamblin says the idea really came just at the right time. Economic incentives were starting to shift. Hospitals and doctors started to see pay bumps for keeping people like Hendricks out of the hospital, and they could get paid for sending community health workers into people’s homes.
Hamblin: So all of a sudden, a lot more health systems were paying attention around the country.
Gorenstein: And the coalition started to make headlines. Pretty crazy ones like Jeff Brenner, Health Care’s Best Hope. And could the Camden Coalition save U.S. health care?
Nikpay: At the same time, some health care folks worried this idea was too good to be true. Whenever Brenner hit the health conference circuit, he’d get peppered with the same questions.
Amy Finkelstein: I don’t mean to sound like the, you know, total empirical economist nerd that I am, but how would we know if we’re succeeding?
Gorenstein: That’s Amy Finkelstein, an economist at MIT.
Finkelstein: I mean, I’m a New Yorker junkie. There were some very compelling anecdotes which you always want to, you know, move from a few anecdotes to many anecdotes, otherwise known as data.
Brenner: I didn’t want this to just be a flash in the pan. I want 100 years from now this problem to be gone.
Nikpay: Brenner wanted the most robust evaluation he could get – a randomized controlled trial, also known as an RCT.
Gorenstein: A quick pause here. Why do economists like you love these RCTs so much?
Nikpay: Well, they really allow you to isolate an intervention’s impact because they let you compare a group of people receiving that intervention – in this case, support from nurses and social workers – to a nearly identical group of people who are not receiving it. And when you think of all the tools we have for measuring the effects of programs, pills or any other treatment you can think of, it’s really the best we’ve got. So in 2014, Brenner and Finkelstein agreed to run an RCT on the Coalition’s program.
Brenner: The field of population health is a mess right now because we have a lot of unproven things that we’re spending money on, and we haven’t done enough high quality research.
Gorenstein: The main question Brenner wanted to answer: Could the Coalition keep people out of the hospital? Not only were hospital stays expensive, but they were a sign of poor health. Preventing them was vital to Brenner, achieving his dual goals.
Brenner: Better care and lower costs.
Nikpay: The two hammered out the details, and Brenner invited Finkelstein to a staff meeting to kick off the trial.
Finkelstein: Jeff stood up and he said, “We think it’s a wonderful program, but we need to rigorously evaluate it. And if it’s not working, we need to try something else.” And I thought to say that to the staff who are out there administering this program took an amazing amount of courage, vision and conviction.
Nikpay: Finkelstein had reasons to be optimistic that the Coalition’s gamble might pay off. Several other RCTs had been conducted on similar models and had shown drops of hospital readmissions as big as 45%. But at the same time, Finkelstein knew the Coalition was working with a much more complicated and diverse group of patients. This was hardly a sure bet.
Gorenstein: In June of 2014, the Coalition began enrolling 800 patients into their trial. Nurse Janeen Skinner remembers one of the first.
Janeen Skinner: I remember it being warm outside. We knocked on the door. We knocked on the window. There was no doorbell. And we were standing there.
Gorenstein: On the other side of the door was the patient, Larry Moore.
Larry Moore: I didn’t actually know what to think.
Skinner: He opens the door and he picks his head through and he said, “Who are you?”
Moore: I didn’t want to let them in the house because I had beer bottles all over the place and everything.
Skinner: And I said, “Oh, my name is Janeen. I’m the nurse from the Camden Coalition. This is our community health worker. We’re your team.” And he said, “What are you going to do for me?”
Gorenstein: Janeen explained the coalition’s protocol> over the next 90 days or so this pair, plus a social worker, would work with him on a plan to improve his health. They’d meet with him every week to address whatever medical and social needs came up.
Skinner: And we told him: Anything that you stand in need of, we will support you through it. And I think it was at that moment that Mr. Moore decided to come outside and have a seat and talk to us.
Moore: Janeen attracted me and she wanted me to come outside. And I said, “Well, hell, I can go out there and sit and talk to her.” And that’s what I did. Even though I looked a mess, I didn’t care. I was drinking.
Gorenstein: Moore stepping outside gave Skinner a chance to size up her new patient.
Skinner: He was tall. He was slim, framed, living with a seizure disorder, hypertension, gait instability.
Moore: I didn’t have no teeth. I had a big thing full of hair, nappy. I had a big beard.
Gorenstein: Together on the stoop at his rooming house they agreed on some health care goals. For about four years, Skinner and other Coalition team members fanned out across the city meeting with patients like Larry Moore, who they had enrolled in the trial. To be eligible, patients had to have been admitted to the hospital at least twice in the last six months, have two chronic conditions and have at least two other problems, like being homeless or actively using drugs.
Nikpay: Patients were split into two groups. One worked with the coalition team after leaving the hospital. The other, known as the control group, received the usual care. Hospitals give patients a discharge, typically just written instructions.
Brenner: Our key thought at that point was that we would connect the dots for sick and complicated people to navigate them to all the different kinds of care that they needed, whether that’s behavioral health, addictions, social services, medical care, and that they would stop going to the hospital.
Nikpay: The whole point of the trial was to put those two groups head to head and measure whether the Coalition’s approach kept more patients out of the hospital.
Gorenstein: And that approach, it seemed to be working for Larry Moore.
Skinner: There was a lot of coordination between neurology, primary care and Social Security for benefits. So that’s what the intervention looked like for Mr. Moore. Medical and social hand in hand.
Gorenstein: Coalition teams knew how to navigate the most byzantine bureaucracies, the craziest clinic calendars, and that action often turned into trust, making it easier for patients to open up.
Skinner: I think the second visit he disclosed that he was drinking. His exact words were “I drink 100 ounces a day.”
Nikpay: Skinner came to understand how deeply drinking had damaged Larry.
Moore: I lost very many good jobs. I had good opportunities. I worked at Pepsi-Cola. I worked at Quikrete Concrete. I worked for Georgia Pacific. I had great jobs, and I lost them because of my disease.
Nikpay: Moore couldn’t function without a drink.
Moore: You couldn’t keep mouthwash. You couldn’t keep deodorant, cologne, anything with alcohol in it. I used to be in Cooper Hospital. I would go up to the nurses station with my wheelchair and wait for the nurse to turn her back and Nikpayatch the hand sanitizer off it and took it in my wheelchair and rolled in the bathroom and drank it. That’s addiction.
Skinner: When someone trusts you with their secrets and you say, “Yes, you told me this, but I’m still going to help you.” I think that is what makes people receptive to care.
Nikpay: Over the summer and into the fall, Skinner and the team met with Moore every week.
Gorenstein: Connection, growing momentum building and then…it stopped.
Skinner: We didn’t see Mr. Moore after November. We went to the house. We sent text messages. We sent phone calls.
Moore: I got kicked out and then I became homeless. I was just going from place to place to place to place. I could go sleep on the bench or sleep on a rock until the next day when the liquor store opens. And that was my daily routine.
Gorenstein: This is the reality the Coalition faced and why it’s so hard to be successful. Poverty and poor health combined to keep patients’ lives constantly on the edge. A small hiccup in one part of life can wreak havoc on the rest.
Nikpay: For Moore it was a missed rent payment.
Gorenstein: He spent the next two and a half years barely keeping it together, and when he couldn’t, he wound up in the emergency room 70 times. Larry Moore landed in the E.R. 70 times over those two and a half years. Six times he got admitted to the hospital.
Nikpay: That Coalition hypothesis…
Brenner: We would connect the dots for sick and complicated people and navigate them to all the different kinds of care that they needed and they would stop going to the hospital.
Nikpay: That hypothesis didn’t pan out, at least with Larry.
Gorenstein: The question was how many Larry Moores were there out there?
Nikpay: The answer was still a ways off because the trial wasn’t over.
Gorenstein: In 2017, two surprising things happened. First, Jeff Brenner, the face of the Camden Coalition, the MacArthur Genius Award winner, the guy responsible for this randomized controlled trial, left. He took a job with insurance giant UnitedHealthcare.
Brenner: The real pitch was could I take some of the learning that we had in Camden and have a much larger platform to scale that work at the largest insurer in the world?
Nikpay: That left the Coalition in a tough spot looking for a new leader in the middle of their high stakes trial. At least one person saw it as an opportunity.
Kathleen Noonan: When I took the job, I didn’t know the results of the RCT and I was excited to come here and work with them because of who they were and what they were committed to.
Nikpay: That’s Kathleen Noonan, who succeeded Brenner.
Gorenstein: And the second surprise that summer: The Coalition reconnected with Moore after his sixth hospitalization.
Skinner: When he was first enrolled, he was using a cane. Now he was using a walker.
Nikpay: Moore wanted help from the Coalition for a second time with one obvious priority.
Skinner: Housing was his goal.
Nikpay: Skinner started in straight away, but wait lists slowed her down. There just waNikpay’t a lot of housing out there. By the end of 2017, Moore was still spending nights outside.
Skinner: We would just ride up and down the street until we saw him. We couldn’t miss him, you know, he would always have his walker with him. And he said, “Where’s my housing?” And he was frustrated with us. He was frustrated because it was really getting cold outside and he didn’t want to be outside.
Gorenstein: One night, Skinner tried to convince him he’d be better off in a shelter.
Skinner: I’ll never forget it. It was December and it was so cold.
Moore: And I said, no, I’m alright. I’m alright.
Gorenstein: Moore instead decided to ride out the night at one of his drinking spots.
Skinner: I came back to the office and I said, “I’m so concerned. Oh, my God, if he went into the hospital, I would be happy.”
Moore: I was on Chestnut on a little step there next to this building. And I was drinking there and I fell out and somebody called the ambulance for me. That’s the last thing I remember. And I woke up in the hospital.
Gorenstein: He had hypothermia, a body temperature of 82.
Moore: Well, I was in the hospital shivering, and they said, man, you aMooreost froze to death.
Skinner: And we came into work the next day and he was admitted to the hospital. And I was like, yes!
Gorenstein: In early 2019, Amy Finkelstein contacted the Coalition. The study results were in.
Noonan: And we were ready for the news.
Nikpay: Positive findings would mean winning the health policy lottery. Their model could spread across the country, turning around the lives of lots of other Larry Moores.
Gorenstein: Kathleen Noonan and a few lieutenants, including longtime staffer Kelly Craig, had joined a conference call with Finkelstein.
Craig: It was at the end of the day…
Noonan: A few of us were huddled around a conference table in my office.
Craig: Jeff was also on the phone, which was nice.
Noonan: We wanted to make sure that we kept our voices low because at that point we were the only ones getting the information.
Nikpay: Negative results could throw the Camden Coalition’s future into doubt. Would funders jump ship? Would insurance and hospital partners abandon the work? Would staff feel like they were doing all of this for nothing?
Gorenstein: Finkelstein, not beating around the bush, told the Coalition what effect their work had on hospital readmissions.
Finkelstein: It had no impact.
Gorenstein: It had no impact. People getting help from a nurse, a social worker and a community health worker were just as likely to end up in the hospital within 180 days as people who didn’t get that help.
Noonan: When she first gave us the news, there was a bit of a breath. A bit of a, you know, my team all looking at each other.
Finkelstein: I mean, obviously, it was not, you know, we wished we had better news. And I thought they were incredibly both gracious and realistic about hearing these results.
Brenner: It’s my life’s work. So of course you’re upset and sad, but this is the messy thing about science. Sometimes things work the way you want them to do, and sometimes they don’t.
Noonan: I mean, who doesn’t want to be able to say to the world that a 90 day intervention that, in the scheme of things, doesn’t cost that much, for the most complex patients could actually result in reduced hospitalizations? We really wanted to be able to say that, but we are not able to say that.
Gorenstein: The Camden Coalition of Healthcare Providers and Dr. Jeff Brenner had failed to deliver on the vision described in Gawande’s Hot Spotters article nearly a decade ago.
Nikpay: With a little time to digest the findings, the Coalition sees slivers of hope in the weeds of the paper. The study did find that people working with the Coalition were more likely to get signed up with SNAP, the federal food stamp program. They also collected lots of other data on other metrics, like emergency room visits that have yet to be analyzed. But nobody in the organization is kidding themselves. Overall, the program didn’t work.
Gorenstein: And while, of course, people are disappointed, nobody is surprised. Kathleen Noonan explains, when you’re on the front lines, if your eyes are open, you learn things. And as the study unfolded, Noonan says her staff saw some clear distress signals.
Noonan: It was pretty obvious to me that a year into the RCT that the care team knew that they were hitting barriers that were impossible to fix within 90 days.
Nikpay: Two patterns in particular seem to be slowing down the work. One: Even when people seemed stable, some kind of life event often swept in and knocked them off their feet, pushing their health down the priority list.
Gorenstein: Like Larry Moore losing his housing.
Nikpay: Exactly. And two: The social safety net that’s supposed to catch people in a moment just like that, it had lots of holes.
Brenner: You know, I’d say the bottom line is we built a brilliant intervention to navigate people to nowhere.
Nikpay: Jeff Brenner says staff often knew the help someone needed, but the resources just weren’t there or they weren’t very good. And so as the trial wound down, the Coalition started trying something new. They launched experiments going even further beyond the four walls of the health care system.
Gorenstein: One of their most ambitious projects: housing.
Moore: Look at my closet, though. I could put a bed in here.
Gorenstein: Larry Moore is giving Janeen and another staffer, Brian, a tour of his place.
Moore: Hey, Brian, come check this out. Brian ain’t even been in here. I want him to see this. Look, Jeneen, this is what I accumulated in two years.
Skinner: This is amazing.
Gorenstein: Larry’s lived here since February 2018, thanks to the Coalition’s housing program that provides housing and support as needed from staff like Jeneen. Sunlight warms the apartment. A tall viney plant stands in front of his living room window. A fluorescent stuffed animal sits on his bed.
Moore: When I first moved in here, it took me about a month to even sleep in my bed. I slept on the couch.
Moore: Because I wasn’t used to having no bed.
Gorenstein: When Moore first moved here, he was still drinking. Jeneen and his doctor suggested he think about taking the drug Naltrexone, a long acting injection that treats alcohol addiction. And he’d stare at that bed and he’d worry.
Moore: Because I really didn’t want to take that shot. I didn’t want to suffer going through the shakes. That’s horrible. If you’ve got to go through the tremors and you get to see stuff jumping out the walls, I mean, it’s horrible.
Gorenstein: The encouragement from Jeneen and Brian nudged him to try anyway.
Moore: I was laying in my bed in my house. I had a can of Earthquake and I said, “Lord, if I can get up out of this bed without falling over and shaking before I get to the bathroom, I’m going to throw this shit away.” And I went to the bathroom. I still had the bed over on the side of my bed in my apartment. And I took a sip and I said, “The hell with this.” And I walked in the kitchen and poured that one out, took the one out of the refrigerator and poured that out. And I never drank again.
Gorenstein: Larry meets with the support group at the Coalition on Wednesdays. Now he’s becoming a deacon at his church. This spring, he’ll be two years sober, and his hospital trips and E.R. visits, they’ve plummeted to one each since he moved in. Of course, he’s still one drink away from returning to that precarious life. But he’s the man he long predicted he’d become if he ever got that stable place to live.
Skinner: And I kid you not, when I saw Mr. Moore, probably a month ago, I was standing next to him and did not recognize him. And he looked at me, he said, Janine, it’s me. And I was like, “My God, you look amazing.”
Gorenstein: Larry Moore’s story is just that – one story. But to the coalition, it’s a sign of what’s next.
Noonan: So that is our karaoke machine.
Gorenstein: Kathleen Noonan is walking us through the coalition’s office in an old Camden social club.
Noonan: There are remnants of a sort of gilded age, and that is one of them.
Gorenstein: She’s talking about an ornate stone carved water fountain topped with peacocks. But she could just as easily be talking about the 2011 New Yorker cover that hangs just outside her office. The wood frame is separating the clipping yellowed by time.
Noonan: We have never rested on the reputation and privilege that came from one article in The New Yorker. While we actually believe that at the time of this article, we had figured out how to identify the most complex patients. I think what is eight years ago is our theory and understanding of how to best help them. So I think that is the past.
Gorenstein: Really over the final year or two of the RCT, the coalition underwent a bit of a metamorphosis.
Noonan: In 2014, we were called the Camden Coalition of Healthcare Providers. We think of ourselves now as the Camden Coalition.
Gorenstein: In addition to their housing program, the Coalition launched programs for people getting out of jail, help for people with legal issues, evidence-based treatment for addiction. They’ve even helped change some laws in New Jersey.
Nikpay: And it isn’t just the Coalition. In the last few years, health care executives across the country have a better sense of how deeply rooted social problems impact health, poverty, violence, hunger and make it hard for people to care for conditions that medically are straightforward. Last year, 14 major hospitals committed $700 million to investments like affordable housing and child care. Insurance giant UnitedHealthcare, under Jeff Brenner’s guidance, has launched a housing program and the federal government has made it easier for Medicare and Medicaid to spend on social needs.
Gorenstein: What they’re all chasing and have been from the start is success that looks like what Larry more experienced. The amazing thing, the seductive thing about working with complicated people is the Larry Moores, economist Amy Finkelstein says, may be the biggest lesson from all this. A program can have great stories and common sense on its side and still fail in the face of rigorous scientific scrutiny.
Finkelstein: I think a lot of well-intentioned people can’t handle the truth. They don’t have the courage to say, let’s do a gut check on ourselves. Let’s do the rigorous evaluation, figure out what’s working and what’s not, and move forward from there.
Gorenstein: Eighteen years ago, Dr. Jeffrey Brenner hypothesized that nurses and social workers could guide the most complicated patients towards better health and cut a bunch of expensive hospital admissions along the way.
Nikpay: Thanks to his courage to do this RCT, we now know that’s not enough.
Gorenstein: And that, says Kathleen Noonan, is progress – even if it’s not the progress she and so many others had wanted.
Noonan: People like stories about success and they like stories about failure. They just love extremes. And I’m really hoping that this is a story about complexity and about courage.
Gorenstein: I’m Dan Gorenstein.
Nikpay: I’m Sayeh Nikpay.
Gorenstein: This is Tradeoffs.
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Brenner and The Camden Coalition
Health Care Hotspotting — A Randomized, Controlled Trial (Amy Finkelstein, Annetta Zhou, Sarah Taubman and Joseph Doyle; New England Journal of Medicine; 2020)
“The Hot Spotters” (Atul Gawande, The New Yorker, 2011)
“America’s Largest Health Insurer Is Giving Apartments to Homeless People” (John Tozzi, Bloomberg, 2019)
Additional Research and Information on Social Determinants of Health
Housing And Health: An Overview of the Literature (Lauren Taylor, Health Affairs, 2018)
Drivers of Health (Robert Wood Johnson Foundation)
Overview of Medicaid Spending on Social Determinants of Health (Center for Health Care Strategies, 2018)
Investing in Interventions That Address Non-Medical, Health-Related Social Needs (The National Academies of Sciences, Engineering and Medicine, 2019)
Evaluations of Other Complex Care Interventions
Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial (Donna M. Zulman, Christine Pal Chee, Stephen C. Ezeji-Okoye, et al, JAMA Internal Medicine, 2017)
Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Controlled Trial (Coburn et al, PLOS Medicine, 2012)
Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials (Deborah Peikes, Arnold Chen, Jennifer Schore, et al, JAMA, 2009)
Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial (Naylor et al, JAMA, 1999)
A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure (Rich et al, New England Journal of Medicine, 1995)
Jeff Brenner, Senior Vice President, UnitedHealth Group
Kelly Craig, MSW, Senior Director, Camden Coalition
Amy Finkelstein, PhD, Professor of Economics, MIT
Larry Moore, Camden Coalition client
Kathleen Noonan, JD, President and CEO, Camden Coalition
Jeneen Skinner, Senior Clinical Manager, Camden Coalition
Original music composed by Ty Citerman; additional music by Bacon and Whitewolf.
Thanks also to Fresh Air with Terry Gross and the WHYY Archive.
This episode was reported by Dan Gorenstein and Leslie Walker and mixed by Andrew Parrella. It was produced for the web by Ryan Levi.
Additional thanks to:
Kaitlan Baston, Sharon Bean, Bertha Carmichael, Bechara Choucair, Ken Coburn, Natasha Dravid, Tim Ferris, Austin Frakt, Jesse Gubb, Mark Humowiecki, Teagan Kuruna, Jake Lowary, Bill Nice, Pam Nicolls, Brian Smokler, Jeremy Spiegel, Sarah Taubman, Aaron Truchil, Sara Vinson, Diane Webber, Katie Wood, the Tradeoffs Advisory Board…
…and our stellar staff!