LUMINA Podcasts

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. A couple weeks ago, I had the opportunity to attend a leadership conference, called Lead from Identity Summit. And if anybody knows me, you probably know I don't attend too many conferences as a participant. I mostly attend these conferences as a speaker, which I really enjoy doing, but a couple of my colleagues said, you know, you really need to come to this. It's, something that's quite powerful. It's actually the second year that they've run this. I thought, you know what, I'm going to give it… I'm going to give it a shot. Well, it was incredible. I do have to say. The, the summit was run by Dr. Doug McKinley. And any of our long-term listeners probably recognize that name. Dr. McKinley has been on this program before, and has talked about leadership before, and so forth. And this is the second time he's run this… his summit, his conference, and the summit was based up in Silverton, Colorado. We flew into Durango, we took the train ride up to Silverton, and the surroundings were just beautiful, and it sort of created a structure of really allowing all the participants to create some reflection on really what leadership is to them. And what I found fascinating around this type of discussion… I've been to a few, a number of different leadership conferences, and most of the time, they, you know, they educate you on the tools that you need, and maybe some tips on how to communicate with people, on how to work through conflict, and that sort of thing. Well, this one was different. This talked about how to create leadership, what leadership means to you based on your identity. And what I found particularly insightful about this was the approach on leadership from your identity is a direct reflection on how you react to the challenges that you're confronted with within our own work, within our daily lives. And all of us that are in healthcare, we're always challenged with all of these pressures to meet the budget, or to change, or to work with, you know, their different constituents, the physicians, and so forth. And the approach of thinking through leadership from your own personal identity on what your strengths are. was, to me, I thought quite powerful. Well, I want to dive into that a little bit today on the program, and I'm really excited to have two wonderful guests. They both attended the summit. Lucy Zielinski, which is obviously a colleague of mine. She's been on the program many, many times and Michelle Williams, a senior nursing executive, CNO, worked with numerous organizations, particularly on the West Coast. Lucy, Michelle, welcome to the program. 

Lucy Zielinski:  

Thanks for having me, Dan! 

Michelle Y. Williams, PhD, RN, FAAN:  

Thanks, Dan, I'm happy to be here. 

Daniel Marino:  

So, Lucy, maybe we can start with you. You know, the… again, the conference was powerful. There was a lot of great information that was shared, but it was an interesting concept when you think about leading from identity, right? Most people don't even really, don't think about that. You know, as Doug said when we were in the meeting, you know, everybody kind of thinks about what their identity is, and they relate their identity to what they do within their job, but that's not really your identity? Talk about what this concept is, leading from identity. 

Lucy Zielinski:  

Yeah, sure, Dan. You know, as you know, I've been a consultant working in the healthcare space for many, many years, but have been fascinated with the whole idea of leadership and personal development. So I had the opportunity to be on the team to put this conference on with Doug, and this whole notion around identity is a little bit different, because to your point, we all learn leadership skills, right? How to communicate, how to listen, how to solve conflict, that sort of thing. But this leading from identity, from a place of identity, really means leading from the inside out. Like, who you are, not just what you do. And the way I think of it is that your leadership identity is unique to you. It can't be learned, it can't be copied, but it's sort of, It's sort of like this… Source code, or internal compass, right? The source code that runs deep beneath your service, and it really helps shape you how you think, how you decide, and how you connect. 

Daniel Marino: 

What I found interesting about that was it was really a paradigm shift in my own mind, because I developed my own leadership skills around my mentors, around what I've read. You know, I went to, as well as MHA school, I went to MBA school, right? And that's what they teach you, right? Leadership is a big part of that. So, it was definitely a paradigm shift in my mind in terms of how to approach leadership different. 

Lucy Zielinski:  

There's no copycatting here. 

Daniel Marino: 

No, there isn't. It's unique to each individual. Michelle, you know, you've gone through two of these, right? You know, this is the second time that you went, and I particularly enjoyed hearing you share your experiences. How has leading  from Identity influenced you personally, and certainly within your career as… I mean, you've held some pretty formidable executive positions. 

Michelle Y. Williams, PhD, RN, FAAN:  

Yeah, thanks, Dan. That's a great question, and Lucy, I really appreciate your insights. For me, as Lucy mentioned, leading by identity means it comes from inside. So it starts with who we are. What we value, and how that guides how we show up, in our work, in our personal lives. You know, as you mentioned, I've had many positions, high-level positions in healthcare and in nursing, but one thing that I am very grounded in is the fact that it's not about the title. But about staying true to your core, even when things get tough. When your leadership reflects your values, people feel it, and it builds trust and belonging. Just a little anecdote, for me, this really comes, really came to life early in my career when I was asked to lead a team through a difficult transition. I realized people didn't need me to have all the answers. They needed me to show up as myself, to listen, to be real. That's when I understood that leadership isn't about performance. It's about reflection of who you are. 

Daniel Marino: 

Wow, what a great point. I mean, you are… you are spot on, and when you can bring your true self to that… to that leadership structure, leadership skill, I think it just becomes more real for the people that you're working with, right? I mean, it's more real for those that are… that are… that are surrounding you. You know, Lucy, when, kind of building on what Michelle said, you know, as you've developed your leadership skills over the years, how has that kind of formed your approaches, your way of interacting with people? 

Lucy Zielinski:  

Well, like… like Michelle even said, in times of uncertainty, it almost creates this stability inside of you, and then you can forge trust with others. And so for me, I'll tell you, Dan, you know me well. I kind of move fast, I'm about performance, about results, about really getting things done. Well, that tends to be pretty busy and exhausting. And so, for me, what I've learned, is that, to really think through things and slow down and ask some questions. Does this choice really align with who I am and what matters most? And then, how does that impact my environment or the people that I work with? So it's, like, a few questions that I ask myself before I make any decisions or go about solving problems. 

Daniel Marino:  

Yeah. You know, one of the things that was a takeaway for me, I'm… you know, if there was, you know, if there's a… if there's a picture of a Type… a Type A personality that's out there, I mean, you know, my face would probably be right there. And one of the things that I saw, which was interesting coming out of this, was that thinking about slowing down and understanding how my personal identity influenced what my own activities were, and being prescribed on that approach around how to interact, was kind of a… was an aha moment, right? Because with all of us that are used to working in healthcare, that are working in a fast-paced environment, you know, we just go, go, go, go, go, right? And we develop those skills along the way. And it led me to believe, or led me to question if that approach… was I really effective in the past on doing that, or by thinking about how… what my true identity was, my true value, my true purpose, how that came into play, I mean, frankly, I think I could even be a more effective leader going forward. I don't know if either of you had the same… same perspective of it, but that was certainly a takeaway that I had. 

Lucy Zielinski:  

Well, Dan, I think we could… I mean, I can agree, and if you think about not only us and how we operate and move fast and try to get things done, but think about the healthcare environment, and I'm sure Michelle has a few comments, too. But think about the burnout that happens with staff, because we are overworked, we're working too hard, and trying just to get too much done that we sometimes can't even handle. So, I mean, I know you even said sleep is overrated sometimes. And I don't know if that's true. 

Daniel Marino:  

Yeah, that was… that's my mantra, right? Sleep is overrated, it interferes with my productivity, which isn't necessarily good, and I don't think that necessarily aligns with what my identity is, but it's something I've grown into, right? Just because that's been that… that level of. If you're just joining us, you're listening to Value-Based Care Insights. I am your host, Daniel Marino, and we're having a great discussion on leading from identity. It was a summit that we all participated in. I'm here with Lucy Zielinski and Michelle Williams. Michelle, let me turn to you, though. You know, from a nursing standpoint, nurses are… and particularly if you're working in the hospital, if you're working in perioperative services, you're working on the floor, it's a very stressful environment, especially for charge nurses, for nurse leaders. You've got to do a lot, right? And you're, you know, you're serving the administrators, you're serving the physicians, you're, of course, serving the patients. How, through leading from identity, how does it help you sort of remain focused? In your experience, how have you been able to kind of use that as kind of a mechanism to keep yourself grounded, and even to make yourself a little even more productive and more of a formidable leader. 

Michelle Y. Williams, PhD, RN, FAAN:  

Those are really good questions, and you're right. Nursing and healthcare, they move at an incredibly fast pace, but even more so than that. it's very complex, you know, and can be very chaotic. I think, for me, one of the things that I, have always sort of stayed focused on is that, you know, in healthcare, as a registered nurse, the goal is to help, to solve problems. and to be keen with assessing, the care needs of your patients, the needs of the team members that you're working with. So it's almost anticipating that there will be something, that you'll need to address, for me, keeps me focused. You know, we've gone through an incredible 5-plus years with the pandemic, with so many changes across, you know, healthcare needs of, communities across the globe, and I think knowing your identity is what keeps you centered with everything… when everything around you is changing. It helps you make decisions when clarity, with clarity and respond instead of react. It also gives meaning to the work beyond the chaos of the day-to-day. I believe nurses show up, and physicians and other clinicians show up, knowing that, through their expertise and their experience, that they are there to help to calm patients and families and be really focused on who they are as professionals and what it means to deliver care, even in those circumstances. And then finally, when you know who you are as a leader. Your words and actions align, and that consistency builds trust across the teams that you work with. In healthcare, as you mentioned, trust is the foundation of everything that we do. 

Daniel Marino:  

Absolutely. 

Michelle Y. Williams, PhD, RN, FAAN:  

It shapes how teams collaborate, how people communicate, and how patients experience care. So I think keeping that at the center of why am I here, what do I bring to this work, and how is this so important to the healthcare system and my role as a professional nurse? 

Lucy Zielinski:  

Yeah, I would almost wonder… Could knowing your identity change patient outcomes? I mean, is there a link there? 

Michelle Y. Williams, PhD, RN, FAAN: 

I think you're onto something there, Lucy. I think knowing your identity also, I think, helps you to stay, sort of grounded in your purpose. 

Daniel Marino:  

It does. I would agree with you, and as you were saying that, one of the things that I kind of thought about when you were running through that is after the pandemic, a lot of healthcare professionals, physicians, nurses, and so forth, questioned their passion for healthcare again, really questioning why they got into it. And I think, getting back to your point. By understanding your own identity, and from your identity, creating or ensuring that that passion is there, defining the purpose, all sort of connects the dots, right? As opposed to just being on this wheel and just working through the wheel. And I think, to your point, Lucy, I would love to explore this more. I really feel like there could be some performance outcomes, some value outcomes coming out of this, if you're… some correlation between a leader understanding their identity and identifying components to it, and tracking the right level of outcome. 

Lucy Zielinski: 

Yeah, that would be interesting. 

Daniel Marino: 

Yeah, absolutely. So, when you think about the conference, though, you know, and again, Michelle, we can start with you. When you were working through this, and you know, again, you've been there for a couple of years, what was a couple of your big takeaways? What was your big aha moments that you can reflect on? 

Michelle Y. Williams, PhD, RN, FAAN:  

That's a great question. I did have, the opportunity to attend two of the summits. And I would say some of the big takeaways, included, just being present. There was a lot of emphasis on sort of shutting out the external world and being present in the work and the activities that we were doing. And then also trying to really think through, who we were, who we are as individuals, and what our identity was. So there were a lot of exercises that we did. One that sticks out for me, and actually both times were pivotal in helping me to, I think grow in so many ways were the sessions that Hendre provided. 

Daniel Marino:  

Yeah, one of those… one of the leaders there?  

Michelle Y. Williams, PhD, RN, FAAN: 

He's one of the leaders there, yeah, and he described himself as the person who was bringing the heat. And what he meant by that was, you know, he was gonna talk about things that might make us a little uncomfortable. 

Daniel Marino: 

I know our attendees can't… or our listeners can't… can't see my… but my hand's raising up. He certainly put me in that uncomfortable role, but, you know, clearly that was something that… that created a lot of… a lot of good purpose and a lot of good… good responses for me coming out of it. 

Michelle Y. Williams, PhD, RN, FAAN:  

Yeah, you know, Dan, I think that was the case for many of the attendees in both of the summits that I attended. People talked about, and I certainly talked about, how, you know, we hide behind these masks in the work we do, and even in our personal lives, and being sort of true to yourself, and pushing to understand what your identity is as a leader  I experienced, two major epiphanies and have grown from them since, the summit. So, my big takeaway is It changed me, and it changed me for the better. 

Daniel Marino:  

That's great. That is… that is fantastic. Well, Lucy, I know this… the, Identity Summit, Leading from Identity, and… and… and what was created there was really the brainchild of… of… of Dr. Doug McKinley. Doug has been working on this for quite some time, and, you know, again, it was quite impactful, and I would encourage any of our listeners, you know, at the end of the program, we'll share some information. But what is kind of the next step? You know, as we think about that leading from identity. And spending the time on understanding the identity, kind of talking about where to go from there, how to incorporate that into, you know, continued reflection on leadership. Any thoughts on, on, on, you know, again, how you take that and incorporate that into the leadership style, or kind of where to go with it? 

Lucy Zielinski:  

Yeah, so I think, like, leadership identity, it's really not something that you can learn or pick up really quick. I think, like Michelle said, it's that tension, that resistance, going into hard spaces and asking some hard questions. That's really what creates transformation. So, as Doug says, here's one of his quotes, is, leadership isn't about being in charge. It's about taking care of those in your charge, starting with yourself. So, to answer your question, Dan, I think leaders have to start with themselves. 

Daniel Marino:  

Yeah, yeah, I think you're absolutely right. They have to start from… within yourself, and do… and create some reflection there, so you kind of understand, you know, what the it is. I mean, that was… that was kind of my big… my big takeaway. The other thing that I thought was interesting, too, when I was talking to some of the other participants. People who are placed in roles, you kind of grow into these roles, because of opportunities that you're presented with, right? I mean, you may be doing a good job in a particular position, and then you get promoted to the next position, or you're getting promoted to the next position. But it may not necessarily… those positions may not necessarily be what really is what you want to do, right? Or may not align with your identity, or may not even be something that you're passionate about. You may be good at it, right? You know, as you and I talked about, Michelle, you know, operational improvements. There's a lot of people who are good at it, but it doesn't mean you necessarily like it. It doesn't necessarily mean it aligns with your identity. It doesn't necessarily mean that you're passionate about it. So how does leading from identity help to better align, I guess, what that passion is with what the role is? I mean, should this be, you know, a mechanism where you're, you know, obviously you don't want to disrupt everything and go out and look for a new job tomorrow, but… 

Lucy Zielinski:  

Or maybe… 

Daniel Marino:  

Or maybe it is, maybe it is, but how do you make that connection, right? How do you make that connection to say, look, this is really what my passion is? Any thoughts?  

Michelle Y. Williams, PhD, RN, FAAN:  

Yeah, no, definitely, and actually, you're speaking to me because, that is the sort of epicenter of my growth, during the first summit that I went to 2 years ago. As I learned more about leading, from identity at the first summit, I realized that the work I was doing, I loved. I love healthcare, I love operational leadership, but there was an aspect of it that I was really good at. I've been good at it for a very, very long time, and it's turnarounds. It's building new infrastructure and designing new systems. The core of that is solving problems. Major problems that, may not necessarily be problems that I want to deal with. But over the years, I've been called upon to address these major, complex organizational problems, and I realized at the summit that I didn't want to do that anymore. 

Daniel Marino:

Yeah. So you made a… I mean, you came out of this then with really a… a… a new purpose, right? New purpose… a new direction, right? That you kind of wanted to go, or at least something else that you wanted to investigate? Is that… was that kind of your takeaway? 

Michelle Y. Williams, PhD, RN, FAAN:  

Definitely, I came out of that first summit reflecting on the work I was doing, the focus, and sort of how I even defined myself over the decades of my work in operational leadership. And I've sort of rediscovered, areas that I have great passion for, that I'm in the process of pursuing, so the summit really helped me to sse that. 

Daniel Marino:  

Yeah, that's great. Lucy, you know, how about folks that are interested in learning a little bit more? Maybe can you align them with Doug McKinley and, you know, maybe there's a website or something. I would encourage our listeners to really tune in and to find out a little bit more about Leading from Identity, because I do feel like it's something that could be quite interesting for a lot of our… for a lot of all of us that are in healthcare. Anything that you can share? 

Lucy Zielinski:  

Sure, so we have a great partnership with Doug McKinley. As a matter of fact, we've done a lot of work together between strategy and leadership. But you can check out Doug's website at https://www.dougmckinley.com/, but I'll encourage everybody to listen to his podcast. There's some great podcasts he has, even on leadership identity, and that's Leadership Currency. So they're available on all streaming platforms. 

Daniel Marino:  

That's great. Michelle, any closing remarks? Anything that you can share with our audience as to kind of sum up, you know, your thoughts on Leading from Identity? 

Michelle Y. Williams, PhD, RN, FAAN: 

Certainly. I would say at the end of the day, leadership is about showing up as yourself, with honesty, empathy, and purpose. We don't have to be perfect, and I think that's a critical piece that I think we need to understand. We just have to be present. 

Daniel Marino:  

You're absolutely right. Well, thank you, ladies, for tuning in and sharing your thoughts with me. Like I said, I thought it was quite impactful from my perspective, and clearly both of you kind of felt the same things. Maybe, Michelle, if any of our listeners want to connect with you, how can they connect with you? 

Michelle Y. Williams, PhD, RN, FAAN: 

I would say the best way to connect with me is to look me up on LinkedIn. I'm Michelle Y. Williams. If you put comma RN, you'll find me, because that name is pretty common. And you can also email me at, Michelle.ywilliams@yahoo.com. 

Daniel Marino:  

Oh, that's great. Well, thank you for that. And Lucy, you're on, Lumina. You want to share your email real quick?

Lucy Zielinski:

Sure, it's Lzielinski@LuminaHP.com, or check out our website, luminaHP.com. 

Daniel Marino:  

Right. Well, thank you again, ladies, for joining. Really appreciate it. Keep up the good work, and, you know, as we move forward with kind of helping each other through this challenges that we have within healthcare, leadership, obviously, is a key to all of our success. So, thank you again, really appreciate it. And if any of our listeners are interested in learning about this topic, or any of the topics we talk about on Value-Based Care Insights. Please feel free to go to luminaHP.com slash insights, or feel free to connect with me, dmarino@luminaHP.com. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

Daniel Marino:  

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. The U.S. healthcare system continues to experience significant shortage of anesthesia providers, and in particular, anesthesiologists. At the same time we're seeing surgical and procedural services continue to grow. Especially when you think about the need for procedural services done in an ASC. The number of anesthesiologists, just can't keep up with the demand. And it is placing a lot of pressure on hospitals. It has for the last number of years. Over the last few years, we've seen the cost of anesthesia services go up dramatically. And that cost hasn't just occurred with the… around the increase in compensation, but the reimbursement for anesthesia services is certainly not keeping up with the rising cost. So many hospitals are looking at what we would call these diverse anesthesia care models. And many hospitals over the last number of years have started to integrate CRNAs, Certified Registered Nurse anesthetists into the care models. And although CRNAs have been involved in the care models for some time there now is a growing reliance on CRNAs to expand their scope of practice. Anesthesiologists are moving into a role of supervising CRNAs, while others are creating more of a medical direction for CRNAs. And in some states, particularly rural or opt-out states, CRNAs are allowed to practice independently. And while this appears to be a nice opportunity to cover some of the shortage and keep up with some of the demand, it's not come without its own challenges. And many of these challenges are around how physicians, how hospital leaders are being asked to incorporate CRNAs into the coverage model, and really to make sure that we are fully leveraged, taking advantage of the opportunities around their scope of practice. Well, I'm really excited today to have one of the leading national experts in CRNAs, scope of practice, and so forth, Dr. Thomas Pallaria. Dr. Pallaria is a respected leader in educating nurse anesthetists, or nurse… I'm sorry, anesthesiologists, CRNAs. He is assistant professor and the director of a nurse anesthesiology program at Rutgers School of Nursing. Dr. Pallaria has also, with his extensive experience, have helped numerous hospitals introduce the CRNA practice model into their overall anesthesia scope of practice. Wealth of experience and knowledge. Tom, welcome to the program. 

Thomas Pallaria, DNP, APN, CRNA:  

Thank you, Daniel. How are you? 

Daniel Marino:  

Doing great, doing great. Let's jump into this. In your experience, and in working many of the hospitals, obviously you're a CRNA yourself, and leading the program here at Rutgers, how are you seeing the CRNA role changing, and especially in being able to cover some of the shortage or the growing demand that we're seeing in procedural services? 

Thomas Pallaria, DNP, APN, CRNA:  

Well, Dan, I can tell you that, I mean, I've been… I've been a CRNA for 25 years. This is actually my… my 25th anniversary, so I… 

Daniel Marino:

Oh, congratulations! Oh my goodness. 

Thomas Pallaria, DNP, APN, CRNA:  

Thank you, yeah, It's been quite a journey. When I started back in 2000, the use of CRNAs was very limited, certainly in my neck of the woods. Where you would maybe see 3 or 4 hospitals, in an area, utilizing CRNA services. As far as coverage models, it was usually a 2 to 1 ratio to CRNAs to a physician anesthesiologist. And even back then, that was in my area, and many areas across the country. However, rural America, even back then, it was CRNA, mostly solo CRNAs, and of course, with the military, that it's been that way before, it's still that way, where CRNAs are independent providers. But now, fast forward 25 years, we're everywhere. And in my neck of the woods, it's, we actually hit a huge milestone for the CRNA profession, and one of the last remaining major medical centers, in the area, in the state, has now converted to a care team model, finally bringing in CRNA practice. And as you said, I have a lot of experience in integrating CRNAs into historically physician-only models. It comes with a huge set of challenges, but, every single one, whether it was introduction or expansion, has been wildly successful to where, as you just said in your introduction, we're no longer, an add-on, we are… we're essential, or we're closing operating rooms.  

Daniel Marino:  

Yeah, p laying a major role on really being able to cover procedural services, and not only, you know, I don't mean to interrupt you, but not only playing a major role, but, you know, and I'd love to hear your opinion on this, but the expertise that, you know, many of the CRNAs are bringing to the overall procedural services or surgical services point of care has really been good, and I think as we start to think about further leveraging it, you know, that potentially is going to help cover some of the shortage. 

Thomas Pallaria, DNP, APN, CRNA:  

Right, and I mean, just as a numbers game, Dan, you know, right now there's somewhere over 60 to 62,000 CRNAs in the country, where our physician anesthesiologist, colleagues, they're around 52,000 or more, so we are… we are outnumbering them, which I think as a… I mean, it taking politics out of it, I think it's a great thing. Sure. Certainly, if you're focused on a care team model, you know, you don't need as many physician anesthesiologists. If you're following medical direction, it would be a 1 to 4 ratio. If you're following supervision, it can be anywhere as, you know, 7 to 1, 8 to 1, depending on comfort level, facility, bylaws and, and skills. So I think it's just a natural progression in serving our population. I mean, the boomers are just continuing to get healthier, and, you know, surgical services are going to continue to expand, so this is… it's a perfect way to provide some coverage. 

Daniel Marino:  

Sure, sure. Let's talk about scope of service for a second, and practice expertise. You know, I've worked with… we do quite a number of assessments of surgical services, perioperative services, you know, of what the anesthesia coverage model needs to look like, and as… and I'm a huge proponent of bringing in CRNAs to the practice model, because I think, you know, again, with the right level of expertise, there could be a tremendous value that we can provide to patients and to overall surgical services. But… but many anesthesiologists don't think the same way. Many of them are concerned with maybe their training or the level of knowledge. What are you seeing? How are you overcoming that stigma with CRNAs? 

Thomas Pallaria, DNP, APN, CRNA:  

Great question, and I think that I'm going to answer this based upon my own experience, of course, because, let me be very clear, I have colleagues all across the country, and we do keep in pretty consistent contact. So, you're going to find sections of the country that are wildly different. Sure. But in the Northeast, the Northeast is traditionally and historically a very physician-anesthesiologist-centric mindset. So for my own career and my various leadership roles it has been a challenge, and I've been very fortunate to have my academic career to offer, as part of the conversation of how a CRNA is trained. And I can tell you, down into the granular detail, that for Rutgers, and for all of the neighboring programs in my area, we're taught by CRNAs and physician anesthesiologists. For example, you know, one of my residents will be on a regional rotation, and they're learning how to do, you know, a popliteal block, whatever, from the physician anesthesiologist. And that… that really holds a lot of weight, because if that… if that resident completes the program and decides to work with that group or that company, the comfort level's already built in. And that's really how, in my experience, we've expanded the, the service delivery that everyone is comfortable with. We really don't have a lot of situations where the physician anesthesiologist will say something like, no, you're not qualified to do that, because they were right there with them training them. So that's a big advantage. Now, is there always a political aspect? There is. Because of my career in academia, I have always… try to turn away from anything that was politically based. You know, there's a lot of battles to fight, and I've chosen mine to be scope of practice and education. But I have a lot of colleagues who are on the other political side, and, you know, they give me their opinion, but I try to stay neutral, because at the end of the day, we're really all here to provide care for our patients. 

Daniel Marino:  

We are, absolutely, and I think the training has a lot to do with it. I think the integration and the collaboration with the anesthesiologist is probably the biggest factor, right? 

Thomas Pallaria, DNP, APN, CRNA:  

100%. 

Daniel Marino:

If you're able to really create strong alignment between the anesthesiologists and CRNA, that's what really gets you past the discomfort, if you will, and really the growing comfort and reliance that the anesthesiologists are going to have with the CRNAs. If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm here talking with Tom Pallaria, and we are talking about the evolving role of CRNAs within the anesthesia care model, in particular, supporting surgical and procedural services. Tom, I want to talk a little bit, about governance. And, you know, one of the things that we push, or we talk a lot about, is having good communication in the operating room, within the ambulatory surgery center. Governance is really key, where you integrate anesthesia services with surgical services. And we're seeing the CRNAs starting to play a larger role. In your opinion, how is governance… how should it be coordinated? What should the role of the CRNAs be within anesthesia governance? 

Thomas Pallaria, DNP, APN, CRNA:  

Great, great point, Dan, and unfortunately not discussed a lot, so I'm glad that you're turning in that direction. It is so… it's critical, in my experience. Depending on where you are, what facility, how long CRNAs have been, providing services there. All the successful, practices had leadership roles for the CRNAs. It's actually not complicated. You have a department, you have a chairperson, you have a private group, maybe not so many anymore, but you have a president of the group. You know, and that chair is a representative of everyone in the department. But to have a chief who also… who governs the CRNA portion of that department is so important. In fact, right before we started this conversation. I had a call from a CRNA that works on my team who had some significant concerns about going forward with a procedure in a space that, frankly, was not going to meet standard of care. And I'm the touchpoint, touchpoint for her, to make sure that she feels comfortable in saying, you know, I don't think that we should do this. It's critical. They need to feel supported. By they, I mean every provider, and certainly a physician anesthesiologist has their section chiefs, or their chairperson. And a CRNA has their chief, and of course, the chairperson. You know, I'm also an ex-military man, so everything is about the reporting structure. And it's fantastic. And in addition, you know, I've had roles in large anesthesia management companies, and representation on the CRNA side from a CRNA leader, only, only provides the opportunity to build a culture in which you are valued equally. It's very important. If you feel marginalized, you're not gonna stay. 

Daniel Marino:  

Absolutely. And not only will that governance model or incorporating CRNAs into anesthesia governance, not only is it going to help the communication, but I think it would also help you work through some of the scope of practice concerns. 

Thomas Pallaria, DNP, APN, CRNA:  

Yes. 

Daniel Marino:  

Some of the… a lot of the CRNAs that, that have been in the field for, you know, like yourself, 15, 20, 25 years, feel very confident in their skills, but they also know what they can do and what they can't do, what they should be doing and what they shouldn't be doing, and frankly, the more experience that they get, their autonomy does come into play. So I would think without having governance, you're really doing the whole anesthesia coverage model, even procedure service, really a disservice. As you're thinking about taking care of patients and really meeting the needs of a lot of the community and surgical services that are out there. 

Thomas Pallaria, DNP, APN, CRNA:  

Agree 100%, Dan, without that type of culture, where you have an equal voice, or frankly, any voice at all, you know, you do become kind of a disenfranchised member of the team, you don't even feel like you're on a team. And, you know, when you develop a provider into someone who shows up, does their job, and goes home, and that's it, that's not sustainable. And just like physician anesthesiologists, you know, you want to feel like you're doing something… I mean, let's face it, Dan, we're…Compensation is very, very important. But I've been in this game a long time. People also want to feel valued and feel like they are making a difference. It may sound a little kumbaya, but it's true. You know, they want to feel like they added some value, and, you know, they want to feel like, you know what, if something needs to be changed, they have a voice and that they are at the table to discuss it. So, it's just so important. 

Daniel Marino:  

Yeah, you need to feel good about your role, right? And especially if you're investing in roles as CRNA, and you're, you know, you've got that, you know, good skills, you know, you definitely want to feel valued. Let me turn the attention to the hospitals. Recently, I was working with a hospital, and we were doing an evaluation of their perioperative services, and they pretty much have a predominant anesthesia coverage model, or anesthesiologists. Very few CRNAs. And the hospital, is new leadership there, and the leadership coming in was really pushing the envelope a little bit with the anesthesiologists, saying, okay, hey, let's think about the coverage model differently, let's start to think about adding CRNAs. When you've worked with hospitals and hospital leaders. How have you changed that paradigm? How have you started to kind of, work with either leadership or anesthesiologists to say, hey, look, we need to do something different here. There's not enough anesthesiologists to cover, we're doing a disservice to our community. Any advice, or what are the things that you've been able to do to kind of change that mindset? 

Thomas Pallaria, DNP, APN, CRNA:  

Dan, it all starts with strong leadership. If you don't have the right players in place during the planning sessions for this huge change, it will fail. I've been directly involved, and I've also been indirectly involved in a consulting manner for this type of change, and I've seen a lot of success, and I have seen some failure. You have to have strong leadership on the CRNA side, and of course, the physician-anesthesiologist side. The physician-anesthesiology side must, must, must support the integration of that CRNA practice, or the expansion of that CRNA scope of practice. You have to have a leader on the CRNA side that has thick skin, frankly. 

Daniel Marino:  

Right. 

Thomas Pallaria, DNP, APN, CRNA:

And can take all of the really negative narrative, soak it all in, and let it go, and make sure that it doesn't make it to the staff, because if it does, it's over. And I think the other component, specifically for the hospital side, is you absolutely have to have, again, strong leadership in the form of, you know, whatever the structure is. The AVP or the director of perioperative services, they have to be right in alignment. And they have to, very importantly, also, because this is new for them, support that leadership role for… of the CRNA so they can be there when a physician goes to them and says, this person can't be in my room. And by a physician, you know who I'm talking about, Dan. Our lovely surgeons who may not feel comfortable. I don't know who this person is. What is this person? Why don't I have Sam? Sam's been here for 35 years. Well, Sam's retiring. And this is our new model, and we need strong leadership on the perioperative leadership side. It's usually nursing, which is great for us, because that's where we come from, is nursing. So we usually do have kind of a built-in partner, but we all have to speak the same language. And if we don't, and there's one little crack, someone will find it exploited, and it will fail. 

Daniel Marino:  

Wow, I absolutely agree with you, and I've sort of referred to it as the triad model of anesthesia services, where you have the anesthesiologist, obviously, working closely with the lead CRNA, but the third leg of that stool has to be the hospital leadership, right? 

Thomas Pallaria, DNP, APN, CRNA:  

It has to be. 

Daniel Marino:  

And to be able to coordinate that in any anesthesia services coverage model, development plan, whatever you want to call it, those three individuals have to work close together, because most of the time, it's a culture change, right? Okay, there's some operational things, there's some clinical things that we need to kind of work through, but at the end of the day, it's how we communicate and how we integrate that new model into procedure services. 

Thomas Pallaria, DNP, APN, CRNA:  

Yes. And I mean, and again, I know, you know, you and I have had this conversation before, but, you know, it's getting… this is gonna sound funny… it's actually getting simpler to look at a plan and integrate it. 

Daniel Marino:  

Yeah. 

Thomas Pallaria, DNP, APN, CRNA:  

Like, what does the CRNA look for? And that… we've really gotten really good across the industry in saying, okay, here's what the CRNA is looking for. Now, maybe not me, Dan, because I'm 25 years in, but now, you have to build a team. It's usually a younger provider. And, you know, we can talk a whole other podcast about generational differences, but they want their comp, they want their life balance, you know, in the form of flexible scheduling, PTO, they want a full scope of practice, how they were trained, they don't want to now say, oh, now I'm a CRNA, I can't do this, I'm not allowed to do that, and they want a role in governance. And that sounds like a nod, but really, it's 4 simple concepts. 

Daniel Marino:  

Yeah, I agree, and I'll tell you, it's… for the new CRNAs coming out of school, and starting to really integrate now with the practice model, it does allow a lot of flexibility for anesthesia services. I had the opportunity to work with, you know, a couple young CRNAs, and it was interesting because a couple of them wanted to become employed, right? And they liked the security being unemployed. A couple of them wanted to remain 1099, and they were interested in having a lot of flexibility there. And I'll tell you, for the hospitals, that model was great, because having that flexibility allowed for stronger recruitment of CRNAs, and let's face it, right? CRNAs coming out, especially for hospitals that are embracing, you know, a more varied coverage model and so forth. Everybody's recruiting for CRNAs, right? So you need to have a differentiator there. That flexibility in being able to offer different type of structures of CRNA was really a game changer for the hospitals. 

Thomas Pallaria, DNP, APN, CRNA:  

Yes, I see the same thing. The only thing I would add to that is I love the flexibility of a per diem. The 1099, the 1099 price tag is really… it's already, out of control. I mean, I want to say the last thing I read was there's probably 5% of the CRNA workforce is 1099, and, like, 10% of the physician workforce. 

Daniel Marino:  

Yeah. 

Thomas Pallaria, DNP, APN, CRNA:  

I know from my experience, you know, facilities, they would rather not. They don't really have choice right now, so they're definitely leaning a little bit more on the recruitment for W-2, which I understand. But to your point, yeah, I want W-2s, but I would like a few per diems, if they have to be 1099, fine, because then, you know what, if you have a situation in which, you know, you have a light day, you can flex them down, although that's a whole other topic of, do you actually want to use that? Because if you flex someone down more than once, they may say, yeah, you know, I'm gonna go somewhere else. So, that gets a little tricky, too. 

Daniel Marino:  

It certainly does. Well, I'll tell you, I agree with you, Tom. I think the role of the CRNAs, they're just playing a much more important role in supporting surgical services, and I think when you really look at what that coverage model is, both in terms of patient care, economically, providing, you know, overcoming some of the access challenges, if we don't think about incorporating CRNAs, you know, in a very predominant way, I think we're going to continue to be challenged, because you know, as I said in my comments, you know, the shortage of anesthesiologists isn't going to change anytime soon. 

Thomas Pallaria, DNP, APN, CRNA:  

No. It's only gonna get worse. I mean, I think the average age of an anesthesiologist is somewhere in the 50s. 

Daniel Marino:  

Yeah, definitely. 

Thomas Pallaria, DNP, APN, CRNA: 

The CRNAs, I think it's, like, the late 40s, so it's… yeah, I…This is not gonna get better. 

Daniel Marino:  

Yeah, that's for sure. Well, Tom, thanks for coming on the program. This was a great discussion. You know, I know many of our hospital leaders, our physician leaders are working through a lot of these same challenges, and very interested in expanding the role of CRNA, so I really appreciate your time. If any of our listeners are interested in maybe connecting with you, can you maybe share your LinkedIn address, or how can they get ahold of you? 

Thomas Pallaria, DNP, APN, CRNA:  

Absolutely, I mean, I'm on LinkedIn, it's Thomas Pallaria. I'm the guy that also says Rutgers on it, so… I think I'm actually the only Thomas Pallaria. So, yeah, feel free to reach out on LinkedIn. 

Daniel Marino:  

Well, that's great. Well, thanks, Tom, for your time. This has been wonderful, and, you know, again, good luck to you with the program, and keep on, you know, bringing forth a lot of great CRNAs. Really appreciate it. 

Thomas Pallaria, DNP, APN, CRNA:  

Thank you, Dan, it was my pleasure. 

Daniel Marino:  

And I want to thank all of our listeners for tuning in. If you're interested in learning a little bit more about this topic, or any of our other topics that we discuss on Value-Based Care Insights. Please go to luminaHP.com/insights, or feel free to message me directly at dmarino@luminahp.com. I want to thank all of our listeners for tuning in. Until the next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As many of our listeners know, CMS has released, over the years, numerous value-based care programs. They range from the early pioneer ACOs to the ongoing ACO REACH and some of the other ACO performance projects. There's a great program that is being released as of January 1st of 2026. It's around TEAM, which looks at the top 5 episodes, and CMS is mandating, for around 700 and 4,750 hospitals, set reimbursement around the high-volume, high-cost episodes. But there's been one program that CMS has announced and has initiated that I've been watching really close. I find it really fascinating, extremely value-added for patients and for caregivers, and that's the GUIDE model. The guide model, focuses on providing support to patients and their caregivers who have dementia and have Alzheimer's. So the CMS GUIDE program… GUIDE stands for Guiding an Improved Dementia Experience, and it's really geared towards the caregivers, and providing the right level of support to caregivers, of those that their loved ones or folks are caring for that have dementia and Alzheimer. I feel like it's just a great program, and one that from a caregiver perspective, could provide a lot of support and a lot of benefit.

Well, I'm excited to have a returning guest, Seth Hyman, who is with JVS Health, he's one of the co-founders and partners. Seth and his colleague, Vanessa Guzman, were on our program about a year and a half ago or so, and talking about GUIDE, and very excited to have him back. Seth, welcome to the program. 

Seth Hyman:  

Hey, thanks for having me back. It's great to be here. 

Daniel Marino:  

So, Seth, you've come a long way with the program. I think the first time that we had talked, you had just gotten approved as one of the administrators of the program, and you were starting to just kind of pull this together. It is a freshly launched program, and really, as of July 1st of this year, it really officially kicked off, although I know you've been doing work on this for about the last year. How's it been going? 

Seth Hyman: 

Yeah, it feels way more than a year, I'll tell you that, but it is going great. You know, we are enrolling patients now, we have our first cohort of patients in, we're serving the family members, so it's kind of surreal to be talking about it now that we are up and running and are taking care of patients, but it has been… it's been a great experience. Just kind of getting to know these families, and seeing what they're going through, and being able to help them, because, as you know, and as a lot of your listeners probably know. It's a disease that not only affects the patients, it really also is terrible for the families, and it really is so isolating and difficult for them. So, to be able to provide some level of support for them is really been rewarding for us, and we're very excited to see where, you know, where we are right now. 

Daniel Marino:  

Oh, absolutely, and I agree with you. I think the support to be able to provide to caregivers of patients who have dementia, you know, this just has a tremendous amount of value. For our listeners, why don't you take a step back. Talk a little bit about just the aspects of the program. Give a quick overview, if you can. 

Seth Hyman:  

Yeah, absolutely. So, there's two main components of the program. The first is a true care navigation, where we will assign each patient, each family caregiver, a navigator, is what we call them. And that person will think of them as a trusted advisor, as a real resource for the family. They're there to help them coordinate all the different benefits, to help guide them, no pun intended, through this journey, and really, as I said, just be a trusted advisor and a shoulder to lean on. So, we'll do things like coordinate doctor's visits, we will have trainings that we could schedule live and recorded for the families to help them with basic housekeeping needs and things like that. So, really just there to connect them to all the available resources that they… that they have. The second component of the program is the respite. So, through this program, CMS has, for the first time, allocated money to us to distribute on behalf of these families for one of three areas of respite. The first is a in-home situation where you could we will find someone to bring into the home as a home attendant. They could do… or if they have someone that they're already working with, we could, work with that individual. So, the home… in-home respite is the most popular that we've been seeing. They also have, adult day centers, so if you want to take your loved one somewhere for the day where they could participate in different sort of programs at a senior center or something like that, we have that available. And then the last is a short-term stay in a memory care facility. So, you know, if you have to go out of town, or anything that you're unable to take care of your loved one for a couple of days, this is an opportunity for you to bring them there and have them stay overnight. So, those are the three areas of respite that they are able to choose from.

Daniel Marino:  

Well, and the rest of it's just so much value for some of these caregivers, right? Because, you know, a lot of times, and historically, they're on their own. They may get help from their family members, but there's really no outside support, and as well, there's no funding for this. So I would imagine that the level of respite or the level of support, would be dependent on, let's say, how advanced the patient is, or their loved one is with dementia and or Alzheimer's. How do you go about determining that? 

Seth Hyman:  

Yeah, so the way that the program works is that, based off of our intake process, we have a series of questionnaires that we have to administer to the patient before we can admit them. They get placed in a tier. Just kind of as you alluded to, it's a low, moderate, and complex tier based on the severity of the Alzheimer's and the progression of the disease. Now, that is… we have to do a reassessment every year on these patients, so just because you start in one doesn't mean that you might not progress as the disease progresses, but anyway, based off the low, moderate, and complex tiers, that determines whether or not the patient is eligible for the respite. So, the folks that are in the moderate to complex tier are the only ones that qualify for the respite. And then each of those patients is allocated nationally $2,500 per year. So, again, we're not going to cover the entire bit of respite, but it is definitely something to get started with the process, and it is sometimes very beneficial just to get started with some amount of money. 

Daniel Marino:  

Yeah, yeah, absolutely. And, you know, I think, I've been watching very closely what CMS is doing, what Dr. Oz is doing, and, you know, he's pulled back on some of the programs, but this is one that still, has pretty much the attention, from a bipartisan perspective, frankly, in continuing to provide this level of support. You had mentioned the financial piece and some of the reimbursement that comes in. Are you able to see a difference between, maybe for some of these more complicated, more advanced patients, they frankly may need a little bit more support. Is that $2,500 that you had mentioned, are you finding it enough to cover? Is it just the tip of the iceberg when it comes into that level of support? And, you know, how can you possibly, or is there ways to maybe put in exceptions for additional funding. 

Seth Hyman:  

Yeah, right now, that's the total amount of money that we get for each patient for respite. I think, you know, there's… they've already kind of upped the rates a little bit, so I think as time goes on, that might go… we're hopefully hopeful that that might increase a little bit, but, you know, CMS has been very responsive to our, feedback, and they have made some other changes, so we'll see. Listen, as I said, it's definitely not enough to cover everything, but every little bit does count. It does count. And kind of, you know, from personal experience, you know, a family member of ours was struggling as a caregiver, and didn't really want t Didn't really want to give in to, you know, bring someone into the home. They were just like, you know, I'm not doing it, I'm not spending the money, I'm not spending the money, and really delayed getting that help for a long time. So, I know from our experience that we would have had this money to say, hey, listen, let's just try it out. It's free, it doesn't cost you anything. Let's get the… let's get you in the door, let's get started. I think it would have made a big difference. I think it would have, you know, really made him more receptive to doing it, so that's something that we are seeing, that, you know, if you do have, you know, a spouse that's kind of on the fence about it, this is a good way to get started. But, as you know, every little bit does have, does… 

Daniel Marino:  

Good way to get started, no doubt about that, and just to get the caregivers and really everybody familiar with this. If you're just joining us, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I am here today talking to Seth Hyman, who is administering one of the GUIDE model programs as part of JVS Health. And Seth, let's dive into one other area there, and that's kind of the alignment with the primary care physician or geriatric providers, specialty providers. They're the ones, historically, and currently and historically, have really been involved directly in the care of these patients, and have provided that level of support, you know, to the caregivers and so forth. How are you interacting with the primary care physicians? I would assume they're the ones that are for the most part, really providing a number of the referrals for you into the program. 

Seth Hyman:  

Yeah, no, it's been… it's been great. We have a number of primary care partners that we're working with, and geriatricians, and neurologists, and social workers as well, that we're working with that are referring directly to us. We, right off the bat, tell them that, you know, this is a social service program, we're not practicing medicine, we're not, changing medications or prescribing anything, ordering tests or changing any regimens. We're here to help them, we're an extension of the program, and a lot… and the feedback has been tremendous. Because a lot of primary care doctors don't have the resources or the time to really engage in some of these programs, and they don't know where to turn, so we were able to come in and say, hey, Send them to us, we'll take care of them. We'll be an extension of your practice, we'll be an extension of you as a social worker. So they've been just tremendous. As soon as we tell them, they're like, how do we… how do we send more? 

Daniel Marino:  

I would think these primary care physicians have to love this, right? Because this is an avenue where they can begin to offer some support for these patients and the caregivers. What's been the collaboration mechanism, though? Do you… are you… you know, because I would think that through some of these discussions, I mean, you're right there with the caregiver and, to a certain extent, with the patient. If you… are you… if you identify some challenges with the patients, or maybe with the home environment, that sort of thing, what's the level of collaboration that your team is having with the primary cares? 

Seth Hyman: 

So, yeah, it's a great question. That's really up to the individual provider, how involved they want to be, and what their workflow is, and what their, you know, desire to be involved is. So we share our notes, obviously, all of our care plans directly with the providers on a monthly basis and let them know if there's any escalations, right? You know, you know, any rapid deteriorations that our care navigators are noticing, we quickly communicate that to the PCP.  As I said, though, it really does depend. Some want to be more… way more involved, and would actually like to have monthly care conferences, which we're happy to do. But others that don't really have the time. You know, as you know, primary care providers are already way too busy and don't have enough time as it is, so that might not be feasible. We could just, you know, fax or send the care plans however they want to the offices, and we're always available if they need to reach us. So it's very, you know, we work very closely with these PCPs, and t's a real collaboration. 

Daniel Marino:  

Yeah, and I mean, that's the benefit, right? Because you're right there on the ground floor, especially if you're starting to see some changes with the patient, or maybe get out ahead of some potential challenges that would occur, and oftentimes what we see is it's all on the shoulders of the caregivers, and caregivers don't often know what to do, they can't get ahold of their primary care physician, so what do they do? They bring the patient to the emergency room. 

Seth Hyman:  

Exactly, and that's what we're trying to… well, at least the goal of the program one from CMS's perspective, is really to kind of alleviate that and keep these folks in their home as much as possible. Because, as you said, your first reaction is take them to the emergency room. If you're burnt out, don't know what to do, a lot of times, take them to the emergency room. We actually have a 24-hour hotline, so if, you know… again, we're not practicing medicine, so if there's a medical emergency, call 911, of course. But having that resource as someone, you know, you don't know what to do, you're feeling stressed out, having someone to call and talk to, you'd be surprised how far that goes, and we've already seen it a couple of times. 

Daniel Marino:  

Well, that is… that's fantastic, no doubt, especially having that hotline just being that level of support. You know, as you've… as you've been launching the program July 1st, and, you know, again, we're probably a good couple months into the program now. What have been some of the challenges that you've seen with the program? 

Seth Hyman:  

That's a good question. I would say the… for us, number one is getting the… developing the relationships with the respite providers. Really finding that, because finding those relationships, and then building on those relationships, and making sure that we have reliable coverage in all the areas that we go into, I would say that would be our biggest challenge because, you know, when we go into a new area, we want to make sure that we have that… that built out. So I would say finding the respite is probably our number… number one challenge. 

Daniel Marino:  

Yeah, just to kind of connect with folks. So, are most of your patients… I know you, you know, your organization is really based in the Northeast and then around the New York area. Is that kind of your primary catchment area, or are you, expanding beyond that, even across the country in some of the other markets? 

Seth Hyman:  

Yeah, right now, I'd say we are focused on the tri-state area up here in New York, New Jersey, Connecticut areas, but we are definitely exploring other areas. Like I said, we don't want to go into a new market until we're able to really make sure that we could serve those folks. But we do have partnerships with some organizations, like in Colorado, where we're partnering with a primary care provider in that state, and we could actually sign a contract with them where they could do the comprehensive assessments for us. So, definitely open to… always open to those types of partnerships where we can work with an organization, let's say anywhere in the country, that has a good network of patients and wants to get involved. They can contact us, we'll kind of arrange where they could do those comprehensive assessments for us, and kind of act as the front door to getting these folks into… into the GUIDE model. 

Daniel Marino:  

Yeah, that's great. Well, and like I said, the partnership is really what's gonna… it's gonna be key here. I mean, it really does take a village as you start to think about providing that level of care. 

Seth Hyman:  

Absolutely. 

Daniel Marino:  

Any, I was interested in the stories. Any positive stories, any, interesting lessons learned that's come out of, the last couple of months? 

Seth Hyman:

Boy, there, there, there's so many, just, like I said, I think just having… Being able to provide that support to these, to these patients. You know, we get it all the time, where we hear. I just need someone to talk to. You know, a lot of times we would think, oh, you know, all these benefits that we have are great, but sometimes they just need someone to talk to we all… we all really, sympathize. You know, we could all sympathize, but, you know, for us, it's personal. We've had a personal story with, with dementia, so just being able to, 

Daniel Marino:  

Yeah. 

Seth Hyman:  

To be able to be that shoulder to lean on, and it really is helpful. 

Daniel Marino:  

Yeah, just to provide that level of support. 

Daniel Marino:  

You know, one of the things that… I had a personal experience as well, too. A very close friend of mine, had developed Alzheimer's, and he was in his mid-80s. The wife was taking care of it, and she was clearly overwhelmed. One of the… as we had offered, I mean, this was before the GUIDE model, obviously, but before, we had offered a lot of support and tried to get some social worker in there, and even to the point where we paid for some concierge-type care management. One of the things that we found was just getting past… just getting the caregiver or getting his wife comfortable with having somebody come in, they're resistant from our experience. you know, and building that trust was something that it took a while to overcome. How have you been working through that? I would assume you're sort of having those same challenges. 

Seth Hyman:  

Yeah, I think the way that we kind of address this is that we insist and we make sure that all of our care navigators it's a one-on-one relationship, right? So you're not getting a different person every time. So they… we spent a… we spent a lot of time when we were building this program, ensuring that our care navigators are people that can form those bonds and those relationships. So when you pick up the phone, you know you're who you're getting, right? You know you're getting Lily, or Stacy, or whomever, that's going to be your person. It's not going to constantly be changing someone that doesn't know your situation. Because a lot of times what happens is these folks get passed around from one organization to the next, and they just don't know… they just feel… they feel kind of, like, cheap. So, these are real relationships. We're trying to develop these bonds that are going to last for years, right? And they're going to be here to navigate them through this… through this journey. 

Daniel Marino:  

Well, and I give you a lot of credit for that. Building that personal relationship, that's really where the comfort level starts, right? 

Seth Hyman:  

Yeah, yeah, absolutely. 

Daniel Marino: 

And then they know that, hey, there's somebody there that they can call. Given that this is kind of an introductory program, CMS is sort of watching it, and you know, these types of programs, always beholden to, Congress and, and budget passages and requirements and so forth. Where do you think the GUIDE model's going to go? Do you think this is something that's going to continue to evolve? And clearly, I think it has a tremendous amount of value. Where do you think it's going to go? 

Seth Hyman:  

Yeah, I think, well, it's an 8-year program, so it's been re-upped for 8 years. It's, as you mentioned, bipartisan. It was initially a Democratic initiative that was introduced by a Democratic administration, but then survived into the next administration. They did a deep dive, and they said, this looks great, we want to continue. So we're fully committed for the next 8 years. I'm not… I don't pretend to know what's going on in Washington, or pretend to want to know we can't control that. All we know is that we're good to go for these next 8 years, and I do think that the people see the benefit here. So, it's a need, it's such a need, and it's just such a no-brainer once you kind of lay it out there, so as far as we're concerned, I think it's going to continue to grow. I don't know if they're going to expand the program or not, add more participants. That could definitely be something that happens, especially in certain parts of the country. We welcome that, you know, we want to just take care of as many patients as possible, so that's… that's where we're at, where all systems go for the next 8 years. 

Daniel Marino:  

That's great. Well, it's great to hear that it is an 8-year program, because that does give you time to invest in the program, to really track the outcomes, and, you know, as we talked about, you know, continue to provide that value to the caregivers and to the patients. So, we have a lot of, providers, a lot of, physicians, healthcare leaders that, that tune into the program from, within Value-Based Care Insights. If folks are interested in learning more, or even referring to you in the program, how do they go about doing that? 

Seth Hyman: 

Absolutely. I would just think I would refer everyone to our website, www.jvshealth.com. And right there on the front page, there's a providers, there's a big button that says, refer here, that you could click on. Patients can also self-refer So that's something I definitely want to stress here. It does not have to be a primary care doctor or any type of doctor referring this program. Patients can come to our website, go right there on our… and click, self-refer. And it'll bring them right to our page that they could go ahead and fill out the forms. We do everything online, so all these forms can be done online. Then we do just a quick 20-minute visit, or 10-minute visit with one of our nurses. That will kind of get the process going, and, you know, hopefully within 3 to 4 weeks, they'll be approved by CMS. So we try to streamline it, make it as simple, as easy as possible. They could also email us at info@jvshealth.com. 

Daniel Marino:  

That's great. You know, the nice thing about that is not only the physicians could refer, but patients could self-refer. 

Seth Hyman:  

Absolutely. 

Daniel Marino:  

Which is unusual in a program, typically. A lot of times, if there's dollar attached to it, you'd have to have a referral from the physicians, but that, boy, that's a nice feature. 

Seth Hyman:  

Yeah, once we… we will… we actually go and reach out to the physicians. We'll need to get a medical record from, you know, a copy of the medical record, the diagnosis, but we handle all that for the patient, so they don't have to go worry about that. So, you know, we're not cutting the provider out of the… out of it, we're just kind of taking it off their plate and making it, you know, streamlining it, making it easier for them. 

Daniel Marino:  

Well, making it easier for the physicians, which, again, makes it, you know, the streamlines that process all the way along, but, you know, I would think then there has to be some outreach to the physician, like you said, just to get some of the background and just some general information, so when the nurses do call and evaluate, you know, they have something to go on, which, frankly, helps the process all the way along. 

Seth Hyman:  

Absolutely, yes, absolutely. 

Daniel Marino:  

Well, Seth, thanks for coming on. Again, this is a program that I've been watching for quite some time. I think we all know somebody who, either within our family or friends, who've had Alzheimer's or dementia, and we see the struggles, right? So this program, I think, has a lot of value. Can you give your email address, or maybe the website, one more time? 

Seth Hyman:  

Yeah, absolutely. It's www.jvshealth.com. 

Seth Hyman:  

Also, email me, Seth, S-E-T-H, at jvshealth.com. I'm always available. 

Daniel Marino:  

Great. Well, thanks again, Seth. Again, I'd love to have you back sometime down the road. Of course. Maybe some of your outcomes, you know, as you're starting to see this. I'm sure you're tracking quite a few. 

Seth Hyman:  

Yeah, absolutely. Well, I appreciate it. Thanks for having me. It's been great.  

Daniel Marino:  

Thanks, I appreciate it, Seth, thank you. And to our listeners, if you're interested in, again, finding out a little bit more about the GUIDE model, or any of our topics that we discuss on Value-Based Care Insights. Don't hesitate to, join luminaHP.com/insights, or contact me directly at dmarino@luminaHP.com. Until our next insights, this is Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

Daniel Marino:  

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. Well, I think we've all been aware of the newly signed One Big Beautiful Bill Act, that was signed into law in around July 4th. And many of the healthcare leaders that I talk to around the country are spending a considerable amount of time. Trying to, work through aspects of the law, trying to understand how it's going to not only impact their organization, but impact the community that they serve. And when you dive into kind of the specifics of the bill, there are quite a few Impacts or implications to our industry, frankly, and to the providers, and really, I think when I look at the bill, and I've spent a considerable amount of time reading it, I really have focused on 4 key areas that I think, as a healthcare community, we do have to focus on. One is really the impact to Medicaid. And according to the CBO, the projections are that 10 to 12 million Americans could lose Medicaid coverage over the next number of years. And again, it's a phased-in process, so things can change, but that's a considerable number. Second is the funding that's going to occur, through Medicare, through Medicaid, through the states, and that impact to hospitals, and particularly rural healthcare. I think rural healthcare, in my opinion, could potentially be really challenged over these next number of years from the bill. Third is insurance access, and there's going to be some stricter rules around the ACA. CMMI is continuing to put forth and really focused on value-based contracts, pushing a lot of that risk down to the providers, and used to be where you can opt in on the risk, now they're making a lot of these programs mandatory. Which is increasing the risk. And then the fourth area there is really the fiscal and political fallout. And I think we're gonna see tremendous amount of fiscal pressure, as well as political implications, depending upon your state, as a result of the bill. 

So, I'm really excited today to have one of the top industry leaders, join us today, Ben Sparks. Ben is the president of Bryan HealthConnect. That's part of Bryan Health in Lincoln, Nebraska. Large health system, but Bryan HealthConnect, in particular, is a physician hospital organization, PHO, that has gradually moved into a strong clinically integrated network. They also have an accountable care organization and have been involved in the value-based care space for quite some time. One of the things that's really impressed me about Bryan HealthConnect is their ability to not only connect with their local providers within the Lincoln area. But they really have extended to, across the state of Nebraska, to many of the rural healthcare providers. Ben, very excited to have you on the program today. Welcome. 

Ben Sparks: 

 Thank you, Dan. Really excited to be here. Appreciate the opportunity. 

Daniel Marino:  

So, Ben, let's, let's jump right into this. Give me your initial thoughts on the One Big Beautiful Bill. 

Ben Sparks:  

Oh, that is a great and very loaded question. 

Daniel Marino: 

 It is. 

Ben Sparks:  

Fundamentally, I think, and you touched on this, there are a lot of things we don't know. I think a lot of opportunities, you know, the Medicaid cuts, you know, who and when and how is a big question we have. The rural transformation funding is a huge hot topic now, and, you know, I think a lot of rural facilities view that as a lifeline, or a chance to maybe make some big changes that they've lacked funding for in the past, so there's a lot of excitement around that. And then, you know, I think just generally, and you touched on this, this movement towards risk, which is bigger than the big, beautiful bill, but kind of fits that same frame. A lot of rural providers, I think, are really nervous what that means for their communities. So, you know, as you very well know, rural facilities tend to have, depending where they are, much larger government payer mixes. So, you know, the changes that happen to Medicare and Medicaid really impact them usually earlier and more aggressively. You know, cuts to Medicaid, when you're on a razor-thin margin, you know, the small changes there can have huge impacts on the viability of your facility, so there's a lot of anxiety, but also maybe, you know, a lot of hope that some of these changes might give these facilities and these providers a chance to do things differently in the future as well. 

Daniel Marino:  

Well, when you look at this, you know, I think the one thing that stands out is, government is definitely trying to put more accountability on the states, right? And changing a lot of the funding, as to how they're going to support Medicaid, and it seems like, you know, they're shifting a lot of those,a lot of those dollars and responsibilities. But for rural healthcare, I think it's a particular challenge, because you don't have a lot of large health systems, you have a lot of rural health community providers, you have a lot of critical access providers, and many of the critical access hospitals, for instance, probably, you know, they only provide maybe around 25 or 30% of, really, the care needed within the community, right? Patients and the population have to travel, and in some cases, maybe they won't even travel. They may not even be able to focus on getting the care that they need. As a large health system, how are you responding to that? You don't want to create a healthcare desert, but how do you respond to that challenge and that level of support? 

Ben Sparks:  

Yeah, that's a great question, and this is something I think, you know, isn't necessarily unique to Bryan Health, because I've seen other providers do this as well, but something that Bryan Health really focuses on is providing outreach. And a lot of our specialists that are part of our network provide outreach to dozens, upon dozens of small communities across the state, and even in neighboring states. You know, so we really try to provide access to specialties that would otherwise be unavailable in these communities. You know, that doesn't necessarily mean that you want, you know, an open-heart procedure done at a 10-bed hospital when there's one per year. But, it prevents those patients who would use that hospital as kind of their care nexus within their community from having to travel for checkup appointments or monitoring, because what we've also seen, is in those deserts where specialty care specifically is unavailable, the reality is people just don't get their screenings, they don't go to their phone visits, and you end up with worse outcomes. And what we really try to avoid at Bryan Health broadly is the disparity between, you know, we have communities, up to about 350,000, you know, down to probably 50, you know, unincorporated communities that we serve. And we, we really focus on removing as many of the disparities in health access, as well as other social determinants, but certainly access is a big priority of ours. 

Daniel Marino:  

Well, I tell you, I've been following Bright Health for many, many years, and I've been very impressed with the mission and the values of the organization. And one of the areas that I've always been impressed with is just the focus on outreach and serving the community. And one of the things that I know, and we touched on it kind of in my opening, one of the things that the organization has been focused on is the physician-hospital organization, but really moving into more of a clinically integrated structure of care. How are you leveraging the CIN to support, let's say, the providers that are in some of these rural communities or critical access hospitals and so forth? 

Ben Sparks:  

Yeah, great question. I think the story kind of goes back, 10 years or so at this point to, you know, ACO. Bryan Health, Bryan Health Connect have been involved in value-based care for a long time. 

Daniel Marino: 

 Right. 

Ben Sparks:  

You've had a lot of success on commercial agreements, government payer agreements. And so the next logical step for an ACO is to start to meld that world between value-based and fee-for-service, so it's a bit more full continuum, full spectrum. And so, the reason we're driving towards CIN is to bring those two parts of our organization together in a more formal type of arrangement. Informally, there's a lot of self-support that happens today. But, a big driver has been payers. You know, payers want to work with a self-enclosed network that is at risk. You know, we talk about, and you brought this up about moving to risk. Well, it's hard for providers who are outside of an ACO to take on risk. And so within the CIN, we can do that. But the other big, kind of, behind-the-scenes actors here that are really driving this are employers. So employers are, you know, facing a ton of stress, you know, you've seen commercial trends at very high single digits, low double digits for a while now. And it's a bit like playing whack-a-mole, where you make a little progress here, and we lose a little there. But employers are really looking for systems to partner with to help them manage their population.And so, in order for us to do that effectively, we have to be a CIN. You know, to bring the most tools we have to the table. 

Daniel Marino:  

So, it sounds like to me, Ben, you really have an integrated partnership strategy, right? Where you're trying to focus on bringing together, obviously, the payers, right? And the commercial payers are going to have to step up and really support the providers, particularly in rural health, but I think in all areas, to ensure that economically, we're still able to provide the care we need. But along with the payers, partnering with the employers, as well as the different providers, do you feel it's giving a lot of support to the providers in the community? Do they see this as a lifeline? Is this helping them get over some of the anxiety or the challenges that they're feeling with the One Big Beautiful Bill and the potential reduction in reimbursement? 

Ben Sparks:  

Yeah, you know, I've often said to a couple groups is that I fully understand why individuals are skeptical about value-based care, specifically specialists, because it's hard. A lot of the models, almost all of the models, historically have been focused on primary care. But, if you can find a way to bring specialists in, if you can find a way to engage them in the same activities. I'll use an example. Ambulary care sensitive conditions. It's a little bit of primary care, a little bit of specialty care. If you can bring those groups together. Our ACO, you know, transparently, that's a huge opportunity for us. Because we have a very rural population that, you know, struggles with access. And so, there's such a large opportunity there that by lowering the cost of care, there's plenty of shared savings, there's plenty of value-based incentives to pass around. And I have found that providers who are skeptical, you know, when they enter into the work, as long as they're engaged in the work and doing what they need to do, that first shared savings payment changes their mentality overnight. 

Daniel Marino:  

Oh my goodness, yes. I mean, you want to talk about the change of focus, you know, they see this, because a lot of times they hear all of this, but they don't necessarily believe it. You send them that first check, and it's like, oof. The light bulb has gone on, and then some. 

Ben Sparks: 

Yes, absolutely. 

Daniel Marino:  

If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm talking today with Ben Sparks, and we are reviewing the One Big Beautiful Bill, and the impact on rural healthcare. So Ben, let me dive into this a little bit further, and I'd love to talk a little bit about some of the rural transformation funding. You mentioned in some of your comments that, potentially this is a lifeline. I think when I look at it, I think there's somewhere in the range of about $50 billion that, are included in the fund, but it's a $10 billion release, I believe, that's going to occur over, say, the next, you know, 5 years or so. When you think about it, and you think about rural healthcare across the whole United States, it's not really a lot of money, right? So how does this figure into your strategy? I mean, obviously, you can't be just relying on this to support, all of the services and make up for, kind of, the lost support for the Medicaid population and so forth. How is this fitting into your strategy? Have you given that much thought? 

Ben Sparks:  

Yeah, and, you know, the first thing I'll say is, very thankful, so I would say within Nebraska, the hospital systems, you know, the state government, the hospital association, you know, and several other organizations that support rural providers work very well together, and I think there's a lot of there's a great spirit of partnership, about how to maybe invest these dollars in a way that has the maximum benefit. I mean, the risk here is these getting all parsed out, because you're 100% right that, you know, it seems like a lot of money on the surface, but as soon as this gets divided, you know, 100 different ways, you're talking a bunch of really small payments that, you know, if there's a facility today that's on the verge of closing, these dollars might help them limp along for a few years. But 5 years from now to be in the exact same crisis we're in today. So a lot of what we're talking about is how do  you know, infrastructure funding for, you know, clinical integration, or, social determinants work, or, you know, telehealth. Like, we're looking at some big solutions. You know, we're a big believer if we can make some critical investments in the infrastructure to provide care more easily, and make it more accessible for communities, I think you'll get a bit of a revitalization for some of these critical access hospitals and these rural health clinics, who are today facing small, you know, shrinking populations, aging populations. It's all about care sustainability. Yeah. So, how do you get the most bang for your buck in the sustainability realm? So, 10 years, 15 years from now, the return on investment for these dollars is very clear. 

Daniel Marino: 

Well, it sounds like, to me, you're putting in place kind of a multi-pronged strategy, right? To kind of build what I would sort of call it an organized system of clinically integrated care. But it sounds like, to me, that you're providing the care support that providers need, and that may be actual providers going out to the community, but it also sounds like you're leveraging technology as well, too. To really be able to drive that care. Do you see as an impact or an outcome of the one big beautiful bill and some of the things that are going to occur. Do you feel like there's going to be a lot of consolidation, or continued consolidation, or maybe these smaller providers are going to look for maybe joining the systems? Or do you think that they're still going to try to remain somewhat independent? And at least to be able to, you know, do what they can do to make things work? 

Ben Sparks:  

Yeah, that's a great question. I think, you know, this is specific to Nebraska, because I think every market's a little bit different here. I think it depends on the provider, right? So, I mean, you there are certainly critical access hospitals within Nebraska that are exceptional facilities with excellent finances and really well-established, built systems of care. There are some that are barely getting by. There are a lot that are in between. You know, for some of those it might make more sense, you know, specifically when you look at patient populations or the cost of infrastructure administration to affiliate with, another system or another hospital. You know, back to clinical integration, however, you know, I think that when you do a CIN the right way, and this is important, when you bring providers across the system of care, you brought up a point earlier around 25 to 30% of the care being actually done at the critical access hospitals, and a larger chunk being done, you know, hour, two hours away in a larger system or a specialist office. Bringing those providers together, I mean, if you think from the patient's perspective, what a patient wants, you know, I want to send my parents, is I want them to know that the physician they're seeing in their small town is coordinated and connected with whoever they have to go in the city, whatever specialist or facility they need to go to. And so you know, I think you can create this big tent, highly integrated care experience without having to go through all of the mergers and affiliations and kind of, you know, what has to go where, you know, the loss of identity that can come with some of that. And so, you know, CIN, I think, allows you to do a lot of the things and get a lot of the benefits you would have in consolidation without having to go through the formal step of consolidation. 

Daniel Marino:  

And that is just such a great point, Ben, and I couldn't agree with you more. I think if you're really able to leverage the elements of the CIN, you know, and had you invested in this for years, I agree with you. I think this is the point where you're gonna start to see the return on the investment, both in terms of financial dollars, but really return around clinical support, right? That we've been waiting for for years, because it does not allow an opportunity to create efficiency. It does allow an opportunity to support providers in communities where they may not have all that support. It is going to provide a lot of opportunity to be able to provide technology and analytics and just information insights that these small hospitals won't be able to do. Or to be able to provide on their own. So, I absolutely agree with you. Do you feel like the payers are gonna step up? When you're having these conversations with the payers, are they recognizing this kind of this burning platform to change?  Or do you feel like it's still going to be a big challenge in the negotiations for them to understand, you know, to really think about, or for them to take their own economic focus. Where do you think that partnership discussion with the payers is going to occur? 

Ben Sparks:  

Yeah, that's a great question, and I will even rope in the brokers and producers here as well, because I think, you know, when we talk about sitting across the table, I think all parties need to be engaged and supportive when it comes to employers. I think a lot of the payers, and certainly all of the brokers we're working with, are very engaged. There's a general understanding that the current process isn't working. You can only lean out deductibles so far. You can only, you know, restrict access to the network so far that you have to come up with innovative solutions. And to their credit, I think you have these progressive employers that are really pushing that to the payout. 

Daniel Marino: 

Yeah, they are. 

Ben Sparks:  

And so, you know, we're finding a lot of payers are working with us, I would say, collaboratively, to make this work. We're looking at some innovative value-based care models with some payers in our state right now that wouldn't work without their engagement. So, I'm excited. I think the stress of the current healthcare finance landscape is creating maybe some space for innovation that hasn't been there historically. Yeah. So I think we have, you know, the next one to five years, I'm hoping we're going to see some really rapid innovation in how we manage and control risk, and share the costs and benefits of care with providers and with payers, along with the employers. And they're brokers as well. 

Daniel Marino:  

Yeah, I agree with you, and  and I, and I do think that it is a multi-pronged strategy, right? You do need to have these conversations and partner with the payers, but having this direct conversation with the employers and engaging them, as well as the brokers, right? Because obviously they're they influence a lot of that, and they're kind of the go-between between the payers and the employers. But to engage the employers in these levels of conversation so we're all clear what the costs are, how do we both how do we best serve the employers and or the employees and their families in a coordinated clinical partnership model, I think is really important. I also feel like there's gonna be some new, innovative programs that are gonna come out, or that are gonna continue to evolve with the direct-to-employer model as a result of the one big beautiful bill. I think it has to, right? We have to create that level of innovation in order to ensure that the financials and the support. And patients are able to be served within their communities. Are there specific things that, right now, as you start to engage your employers, are there certain things or questions that they're asking, or certain things that you need to respond to to ensure that you're providing that right level of support to them? 

Ben Sparks: 

Yeah, I mean, I would say generally, so, you know, a little bit of background on me. I actually started my healthcare career on the insurance side. 

Daniel Marino:  

You've seen both sides. 

Ben Sparks:

Yeah, I have, and a ton has changed. I mean, it's crazy to me. You know, if you go back 15, definitely 15 years, certainly, you know, 20 or 25, this push from we're seeing this push from large you know, I would say poorly controlled networks. Access being and, you know, number of providers in your network being the most critical thing, the most critical value proposition, and it's coming back around where, you know, not that we're going back to the old HMO model, but you're seeing, you know, a much larger attraction towards not necessarily narrow, but maybe slimmer, more highly coordinated networks.  And I think what we're finding is those networks are actually leading to better responses from patients. Patients are more satisfied because their care is more coordinated. They feel they have fewer obstacles to access. And so, I think a lot of the fear around our employees, our beneficiaries are going to hate a narrow network is starting to dissolve, because once they experience it. Or maybe a tiered network is a better way of saying it. Once they experience it, they actually prefer those care pathways more than kind of the wild west of, you know, you pick here and you pick here, and they may or may not talk to each other kind of experience that we've had for a while. 

Daniel Marino:  

Well, I agree with you. I think if you do it right, these narrow networks and the services that can be provided within the networks, can be really designed specific to what the needs are of a certain population. They're not for everybody, but I think as you begin to design those, you're really meeting the needs of the patient and the population, and frankly, I think bringing it back to the one big beautiful bill, I think that is a component of the partnership is really what's going to allow organizations, particularly rural health providers really excel, right? Because it's that community outreach. Well, Ben, I want to thank you. This has been a great discussion. I feel like we've just barely scratched the surface on what's going to occur with, with the bill, how it's going to impact healthcare, how it's going to impact rural health providers, but the one thing I am excited about is how Bryan HealthConnect has positioned itself, to really continue to provide that outreach to the rural health providers. You’ve done a great job, and I wish you a lot of luck. 

Ben Sparks:  

Appreciate that. Yeah, we are excited, you know, our 2,400 plus providers in our network are… are excited for this as well. I think while we're gonna have some short-term anxiety, you know, as part of maybe some longer-term challenges, we do have a few years where we have an opportunity to reinvent things in ways that are more sustainable, and hopefully better for patients, providers, employers, brokers, and everyone else. 

Daniel Marino:  

If any of our listeners today are interested in maybe contacting you, or at least connecting with you, networking with you at some point, can you share any of your information? 

Ben Sparks:  

Absolutely. You're certainly welcome to go to the Bryan Health Connect website. If you want my email, my email is just ben.sparks@bryanhealth.org. Feel free to reach out. 

Daniel Marino:  

Wonderful. Well, thanks again, Ben, and  I'll be watching a lot of the great work that Bryan HealthConnect is doing, and wish you a tremendous amount of luck, as you're working through this. So, thanks again. 

Ben Sparks:  

Thank you, Dan, for the opportunity to be here. 

Daniel Marino:  

And I want to thank all of you, all of our listeners, for tuning in. If you're interested in learning a little more about this topic and others, please reach out to me directly at dmarino@luminaHP.com, or feel free to, go to LuminaHP.com. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

Daniel Marino:  

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. Working with many practices around the country, there's been this growing trend of physicians to explore shifting into concierge medical practice. We've been approached by a number of physicians over, really, the last year or so. Really exploring their interest and trying to understand, is this a good alternative for them as they think about continuing to practice medicine and delivering care to their patients while being able to limit some of the business challenges that they're having. Particularly for primary care, we've talked many times on the program that, the stress level of primary care physicians is just really through the roof, and everything from the all the business challenges that they have, to pressures on economics, to being able to support patients and so forth, you know, continue to be a challenge for primary care. So what we're seeing is a lot of primary care physicians, are thinking about shifting to concierge, as an alternative. But I'll tell you, in a lot of the work that we've been doing, it's not just easy as flipping a switch and saying, hey, we're going to go from traditional practice to a concierge practice. There's a lot of components that need to be taken into consideration. We've had the opportunity to create quite a few business plans for physicians who have thought about making that shift, and in some cases it's worked, and in some cases it hasn't. When we think about concierge medicine, there's really two approaches. There's full concierge, where physicians, don't accept any insurance, they opt out of Medicare, and they create a structure with patients where it's a membership fee, and they provide a number of services to patients. Patients pay for services within that membership fee, and potentially for additional a la carte services. The second one, though, is the hybrid concierge model, which is a little more complicated. So the hybrid concierge model looks at being able to accept insurance, with either some or all the plans that the physician's practice historically has been involved in, as well as potentially accepting Medicare and being able to process payments through Medicare and so forth. And as I mentioned, that is a little bit more complicated. There's a lot of new regulations, a lot of new requirements. Medicare has changed some of the coding rules recently. So, as I mentioned, it's complicated for the physician, but it's also complicated for the patient. 

Well, I'm excited to have with me today an attorney who is a national expert in concierge requirements and regulatory aspects of medicine. Christina Kuta, she is a partner with Roetzel and Andress. Her practice focuses on corporate transition, regulatory support for physicians and medical groups, and has done a lot of work speaking around the country, working with practices around the country, on setting up hybrid or really concierge medical practices. Christina, welcome to the program! 

Christina Kuta:  

Thank you for having me, Dan. 

Daniel Marino:  

So, Christina, let's kind of start from the top, if we can. You know, I mentioned a little bit the differences between the full concierge practice versus a hybrid practice. In your opinion, what's really that difference? 

Christina Kuta:  

So, I'll tell you from a legal perspective, the big difference is there's a lot more legal considerations and implications when you have a hybrid practice. So, full concierge practice, as you indicated, is really where the provider accepts no insurance, has opted out of Medicare. It's an entirely cash-based only practice. With an exception of a few states that do have some regulatory framework for those types of practices, there really aren't a lot of legal implications. The provider opens their practice, takes no insurance can't bill Medicare, and they charge cash for services. That's sort of the what I call the pure, full concierge model. The hybrid model, however, is different in that often the practice itself does still accept insurance, is enrolled as an insurance provider, is an enrolled non-opted-out Medicare provider. And because of that, they are very limited in what they can charge patients for. How they can charge patients, and how they can have a practice that does take cash for certain services. And, you know, certain perks for the practice, and still remain compliant with their insurance contracts, and with, you know, various laws and Regulatory frameworks that might implicate that type of practice, because they are still billing for services. 

Daniel Marino:  

Sure. Well, let's dive into that a little bit. You know, we've worked with a number of practices who are in these different Medicare value-based programs the advanced primary care model is one, ACOs, and, and so forth, and Medicare has, has changed a lot of the coding rules this past year, and things that, under some of these programs that they didn't historically allow or reimburse for, they are reimbursing for. You know, some areas around screenings and wellness and so forth. How does that fit into the hybrid model, particularly if physicians want to continue to accept Medicare for their patients? 

Christina Kuta:  

Yeah, so it has been trickier. I mean, Medicare's evolving a little bit, which is fantastic for practices. But it is a little bit of a hiccup when you have a hybrid-type model practice. So, the general rule for Medicare, and I know, you know, today we'll talk a little bit more about the Medicare opt-out process, but generally a provider is not allowed to charge cash to a patient for a service that Medicare otherwise covers. So, a Medicare patient can't walk into a physician office if that physician's enrolled in Medicare and say, hey, I don't want you to bill Medicare for this visit for what I think is my strep throat that Medicare otherwise covers, I just want to pay cash for it. They're not allowed to do that. The provider's not allowed to charge cash for that. That is a violation of Medicare regulations. So, traditionally, some of these hybrid practices have charged for things like certain wellness evaluations, or having a dedicated office staff member 24-7 being available, or having a coordination of care, things that Medicare clearly wasn't charging for, or, pardon me, wasn't reimbursing for. So, if Medicare doesn't pay for something then you can charge a patient cash. There's no restriction. Medicare is now starting to pay for some of those services, pay for certain wellness services, pay for certain coordination of care services, paying for the ability to have, you know, a direct access to the practice on a 24-7 basis. Now, certainly, you still have to meet certain requirements for these CPT codes and, actually be eligible for reimbursement, but they are starting to inch away at things that used to be very clearly in the category of Medicare doesn't cover for this, now it's in a grayer area, so practices need to be very careful in a hybrid model. If that's something that they're providing, and they're providing it in a way that would meet a Medicare billable code, they can't charge cash for it, so it can't be part of the fee they're charging for a concierge practice. 

Daniel Marino:  

But what about if we have a physician who only accepts traditional Medicare, and let's say is not involved in the advanced primary care model, or has not historically charged for CCM, or any of that? Are they still are they allowed to charge the patient for wellness exams if it isn't part of the traditional Medicare program? 

Christina Kuta:  

So it's a grayer area right now, because while Medicare's evolving in some ways, the Medicare regulations haven't really kept up with the juxtaposition between the concierge-type practice and these, you know, other payment models that Medicare has developed. So, you know, in general, if you want to be safe as possible, what I tell clients is. If it's a service that otherwise is covered by Medicare, but you can't bill for it because you're not in that particular model, but you're a Medicare-enrolled provider, not opted out, err on the side of caution and don't charge cash for it. The patient can go to somebody who does participate in that model and can be otherwise, receiving reimbursement for it. Because we are still in a very gray area, and one thing you. Most of the people I work with are somewhat risk-averse, and they don't want to get on Medicare's bad side, and you don't want to get in a situation where Medicare comes back and says, yeah, this is something Medicare pays for. They may not pay you for it, but Medicare does cover it, and your patient should have been told to go somewhere that covers it. And now you've got to pay the patient back, and there can be fines and penalties, potentially, for billing patients for things that you should not have billed them for. So it can be a it can be a little bit of a hassle, so erring on the side of the caution would be don't do it. 

Daniel Marino:  

Yeah, I would agree with you, and it is a gray area, because I'll tell you, and this is one of the conversations I had with one of our physicians, because they weren't participating in advanced primary care, you know, just accepting traditional Medicare, and so we had a little debate, and I might My advice to him was the same as yours. Err on the side of caution, right? You really want to get yourself in a predicament with Medicare. Let's shift a little bit to the commercials. We do quite a bit of contract negotiations on behalf of many physicians or medical groups and so forth, and I've seen in the contracts from a lot of the commercials, there's added language in there that, you know, again, it's not directly addressing concierge services, but what it is doing is it's basically saying the same as, you know, as we just talked about for Medicare, that if there are services that are being provided the physician or the group is not allowed to bill the patient for those services. And there's also language in there that's basically saying, hey, we have the option of amending this and changing it and saying what's billable and not billable, and we don't even have to notify you. 

Christina Kuta:  

Exactly, and if we do have to notify you, we're gonna give you maybe 30 days back, and that's it. 

Daniel Marino:  

Right, right. So it puts these practices in a really tough predicament. How are you working through that on understanding, kind of, the commercial angle with the practices? 

Christina Kuta:  

Yeah, so we're being very cautious with commercial contracts, and telling all the providers we work with, you've got to read your contracts in detail. And that's because the commercial insurers are getting a little wise to the hybrid concierge practice, and they really are trying, to some extent. to minimize impact. And, you know, there's the most obvious where we cover this code, so you can't bill for this code cash. However, there's a little bit more subtle contract language we've seen. So we have seen language that says you can't treat our patients any different than any other patient for purposes of scheduling or priority appointments. So, when you read that language, okay, well, if I offer a concierge component to my practice, and patient A says, yeah, I'm gonna pay this, and I'm gonna take it, and one of the perks of it is you get priority appointments. Well, you've just violated, potentially, your insurance contract if, you know, the patient is  beneficiary of that insurance doesn't want to be a concierge practice. We've also seen language called, no access fee language, where it will say, you cannot charge our patients an access fee to receive services. So, I can give you a real-world example. We work with a practice, in the Chicago area that specifically was telling all patients, look, we're instituting this concierge component to the practice, you're going to pay X amount of dollars per month, and to do that, we're going to make sure the practice is limited in we're going to give you a 24-7 hour access line. There were some administrative-type perks, nothing related to the actual provision of services. But you had to agree to this to stay with the practice. Well, one of the patients called their insurance and complained. The insurance called the next day and said, we're terminating your contract, because your contract says You can't charge an access fee. 

Daniel Marino:

Right. 

Christina Kuta:  

You agree to be our provider, you agree to see our patients, you can't charge them money just to be able to be part of your practice.  

Daniel Marino:  

Then the practice came back and probably said, hey, you know, we're providing even more services around access than would even be allowed under the contract, but the payer probably came back and said, we don't care an excess fee. 

Christina Kuta:  

That's exactly what happened. We were able to smooth it over and say, okay, we'll make it voluntary, and they agreed not to drop the provider, but this was the provider's 70% of their patient beneficiaries had this insurance. So it would have been devastating to their practice. You know, another thing that we've seen is, I'm sure a lot of your audience is familiar with, physician hospital organizations, where the PHO negotiates insurance contracts for PHO participants. I actually saw a PHO, a very large PHO, actually. I saw their contract, and they added language that says, if any participant has any concierge practice component or charges anything extra for services, they can't be part of the PHO. 

Daniel Marino: 

Oh, wow. 

Christina Kuta:  

I know. 

Daniel Marino:  

Restricting, yeah. So is that did that come from the PHO, or did it come from the payer through the PHO? 

Christina Kuta:  

The PHO. The PHO said, you can't even participate with us, even before we get to the insurance contracts you can't participate with us if you're going to have a concierge practice component at all. And I'll tell you, a lot of providers don't read their PHO contracts fully, and if they do, they read them one time, and then it goes in a drawer somewhere, and it never gets looked at again. And this particular provider had really sort of established already a concierge to my practice, and I said, give me all your contracts. I got to take a look at them, I looked at it, and right there, and they have to be part of that PHO, there's no way they can survive otherwise. So, he had to unwind. And it's already spent a lot of time and money on this, setting up this practice, had to really unwind everything to be able to stay in the PHO. So, really important, when you have a commercial insurance contract, you are signing a contractual commitment to something. Doesn't matter what the law says, doesn't matter anything else. If you make a contractual commitment, you have to abide by that commitment. 

Daniel Marino:  

You have to abide by what's in the contract. If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm here today with Christina Kuda from Rotel and Andrews. She's a partner, with the law firm. We are having a fascinating discussion on requirements on concierge medicine and, and really the hybrid practices. So, Christina, let me dive into that a little bit further, and let's talk about the membership agreements. It seems to me that, you know, as these as the practices are thinking about what they can and can't do around Medicare, if they choose to continue to accept Medicare, what they can and can't do with regards to the commercials, if they choose to stay in those programs. Makes it very difficult. For to be able to outline those in the membership agreement. So, how do you balance that in terms of being able to clearly state the services that you want to provide to the patients but not have it so complicated within a 15-page agreement that it scares the patient. Where's the balance? 

Christina Kuta:  

Yeah, it's tough, I will say. Because you're right, no patient's going to look at a 15-page agreement and say, I'm going to read this and sign it. You know, as a lawyer, I'm used to 15-page agreements. Not the case for most people. So, you have to be succinct. but clear. So I always say, look, you need to make sure whatever you are going to provide for the fee you are charging, focus on that clearly in the agreement. State it out in bullet point form, say this is what you're getting. And this is what I'm charging for that. So patients understand, because, one of the best ways to prevent a dispute later is to try to not have a miscommunication at the beginning. True. Yeah, if it's very clear, I always tell people who practice, like, in litigation areas, if I do my job as a contract lawyer right, maybe I'll never need you, because there won't be a dispute, because it will be so clear. It'll be very clear. No one can challenge it. So you want to be very clear, and you want to make sure, when you're talking about the fee. The fee is very clear. What it is, what is covered, what is expected to be a pain. If you're offering discounts, what are the discounts for? You know, sometimes people will say, if we have people living in the same home that are going to sign up for this, we'll do a contractual discount. Make that all very clear up front for patients, so they understand what they're getting and what's expected of them in that agreement. 

Daniel Marino:  

Yeah, yeah, and again, I think that's just such great advice. I think the clearer you could be on the front end, it just makes it all the way, makes it easier, right? In terms of what the patient to expect, and in the event that this came back for a review and audit, you know, it's clearly stated. For hybrid practices, for physicians that are thinking about this, you know, I guess it depends upon what the payer mix looks like. Are you seeing more and more of the physicians opting out of Medicare? And if so, I mean, is that you know, I know the opt-out process could be quite cumbersome. Are you seeing more of that a trend, or are they trying to manage both? 

Christina Kuta:  

So I think the majority of our providers still are trying to manage both. And a lot of that is because, when people start a concierge-type practice, particularly a hybrid practice, oftentimes they may have other jobs or other commitments, they're not sure exactly how this is going to work out. Is it going to financially make sense? Are they going to get enough patients? So they usually work somewhere else, or maybe do something a few times a week somewhere else that requires them to be in Medicare. And one of the things to consider is, if you opt out of Medicare, you opt out of Medicare entirely. You can't just opt out for Practice A and opt in for Practice B. And a lot of providers are not aware of this. They think they can say, oh, well, for this practice, I just won't enroll in Medicare. You're in Medicare, you're in Medicare for everything. So, we still see a lot of providers trying to manage, and what they may do is, for Medicare patients, they offer a smaller package of services, because they know there are things that aren't covered by Medicare. Some will just say they don't open their, you know, they're not opening that practice to Medicare patients. Because they can't really do what they want to do and charge what they want to charge unless they're opt-out. But we are seeing more providers over the last year or so that are choosing to opt out, that are saying, we're just going to get out of Medicare entirely, we'll do the opt-out process, and once you've opted out, you have no restrictions on charging cash to a Medicare patient for any service, even if Medicare colors it. 

Daniel Marino:  

It's a lot cleaner if you opt out, but to your point, there's a lot of implications there, and I do think you have to really give it a lot of thought and consideration, because it could potentially impact other areas of your practice, or other, maybe, places that you are choosing to practice. 

Christina Kuta:  

Yeah, and once you're opted out, with a very limited exception, once you're opted out, you're opted out for 2 years. So it's not like you can say, I'll try this for 6 months, if it doesn't work, I'll jump right back in. So you have to really if you opt out, you really got to commit to that and understand what that means for your practice and your profession in general. 

Daniel Marino:  

Yeah, no, I agree. So, when maybe we could talk a little bit about some advice for some of our some of our physician listeners and folks that are thinking about this. When we've been approached by many physicians, as I mentioned earlier, you know, we start with the business plan, and we kind of, you know, and it's really a way to both educate physicians. On the different aspects of concierge medicine, but it's also to help them to make some decisions around what they want to do and what they don't want to do. Where do you start with physicians? What's the place that you would recommend them going as they start to think about how do they structure this, and is a concierge practice really right for them? 

Christina Kuta:  

Sure. So one of the first things we always do is sort of discuss what they're thinking of doing from a perspective of a full concierge, a true, or a hybrid model. They may have reasons they have to stay in insurance or have to stay in Medicare, so the hybrid's the only thing that works for them. So, we talk through the pros and cons of that, and sort of try to set a little bit on what their expectation is. Then we always discuss with them, have they run numbers? Have they had a financial analysis? Because, you know, going into a true concierge model can be a little scary if you don't know how many patients you can really expect to get. Do you live in an area where people have means to be able to pay out of pocket? You know, that really can depend on what patient population is available to you. Are you in a current practice that you know your patients are going to come with you to a new practice. So, those are considerations. I mean, you want to start this new venture, you want to have this concierge practice, but you also need to be able to pay your bills, right? And have it make sense. 

Daniel Marino:  

Well, and you're spot on. The economic model is critical, and kind of getting back to what we were talking about before, it all sort of comes together, right? Because the economic model has to be based on the services you want to provide. The services you want to provide has to be, has to be really based on your structure of either accepting some insurance or not accepting insurance. So, all of those elements sort of build on one another. 

Christina Kuta:  

Exactly, and you know, I find that a lot of providers, when they do that financial analysis, that's when they sort of realize, okay, I have to stay hybrid. Like, at least for a while. I have to see how this is going to shake out and then I can transition to maybe a full concierge. And, you know, once they've done that, and they've got a model set, they've got a good financial indication, then we talk about making sure they have appropriate legal advice. Looking at state laws, there are some states that impact. California, for example, has an impact on certain types of concierge practices. Making sure you've met the laws, and making sure you have proper and good patient documentation. Explaining the process, explaining your fees, explaining your policy for collecting payments, you know, how payments can be refunded, all the things that you want to think of in a business component of a practice. Once you've got your model and you've got your number set, then you move towards, really, the black and white drafting aspect of the practice. 

Daniel Marino:  

Yeah, absolutely, absolutely. Well, along with, you know, having some good business support, you have to have good legal support, and I want to thank you, Christina, for coming on. This has been this has been great. If any of our listeners are interested in talking with you, finding out a little bit more, can you share your information? How can they get ahold of you? 

Christina Kuta:  

Yeah, absolutely. So you can email me anytime at CKUTA, that's ckuta@ralaw.com, or you can go to our website for Roetzel and Andress at ralaw.com, and, look me up there. 

Daniel Marino:  

Wonderful. Well, thank you again for coming on. This has been a this has been a great discussion, a lot of a lot of great information. I really appreciate your time, and good luck to you in your practice. 

Christina Kuta:  

Thanks, and thanks for having me! 

Daniel Marino:  

And I want to thank our listeners for tuning in. If any of our listeners are interested in learning a little bit more about concierge medicine, this topic, or maybe other topics that we've talked about on Value-Based Care Insights, please, go to luminaHP.com. You can also contact me at dmarino@LuminaHP.com. Again, I want to thank everyone for listening until our next Insight. I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

In this episode of Value-Based Care Insights, host Daniel Marino explores the potential impact of new federal legislation, including One Big Beautiful Bill Act of 2025, which is set to reshape healthcare delivery and payment models. He is joined by Natalie Davis, a nationally recognized health policy leader who has spent nearly two decades shaping and implementing initiatives to improve access to affordable, high-quality care for all. In 2018, Natalie co-founded United States of Care, an organization dedicated to advancing health equity and ensuring care is accessible regardless of health status, social needs, or income. She also played a key role in launching Town Hall Ventures and The Medicaid Transformation Project. 

Together, they examine the implications of the legislation for hospitals across the country, highlighting both the opportunities to advance value-based care and the challenges of adapting to new funding and operational requirements. Tune in to gain insights into how hospitals can proactively prepare for change, navigate evolving financial pressures, and sustain access and quality of care particularly in resource-limited settings. Strategies are explored to help organizations achieve success while maintaining strong community impact.

LISTEN TO THE EPISODE:

Daniel Marino:  

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Very excited about today's episode. There's been a lot of discussion around the newly signed Big Beautiful Bill. It's officially called the Legislation, H.R.1. It was enacted on July 4, th of 2025. After passing the House and Senate about a month earlier. And there's a lot of discussion, a lot of chatter around what the impact is of the bill on hospitals, rural health in particular, but also our Medicaid population. There is a lot of reduction in Medicare funding that is supposed to be occurring at some point down the road. Some of that may not go into effect until 2027. But nonetheless, there's a lot of interest as to what that impact of the bill is right now on hospitals and in healthcare in general. And how do we continue to fund a lot of the activities and the programs and health care in general for our populations, especially if some of that funding is going to be decreasing.  

Well, to help me kind of work through all the specifics of the bill I'm excited to have Natalie Davis join me. Natalie is a healthcare leader, healthcare policy leader. She launched in 2018 an organization called the United States of Care, and the goal of that is to ensure that everyone in the country focuses on health equity, access to care, affordable healthcare, and so forth. Natalie has done quite a bit of work even around the Medicare Transformation Project that focuses on bringing innovation and care delivery to diverse communities. Natalie, very excited to have you, welcome. 

Natalie Davis:  

Great. Thank you so much for having me. I'm glad to be here. 

Daniel Marino:  

Before we jump into the bill, maybe you could shed a little light. What's the United States of Care? 

Natalie Davis:

Yeah, great. I love talking about our amazing organization. We are an advocacy organization that works on behalf of people across this country. We advocate for policy changes at the State level and the Federal level. So working with Congress and the Administration and State legislatures all across the aisle really to bring forward the healthcare change that people want, and the way we know people want it is that we go out and talk to them. We've engaged over 30,000 people across the country. Yeah, over 5,000 hours. We now have a data warehouse that's really mapping the human experience in the American healthcare system. And we're able to show really where commonalities are. When we launched the organization, we really wanted to prove that people want the same thing out of the healthcare system, and that often politics can get in the way of seeing those similarities. And so we launched the organization and had a really big job to show that there are commonalities across political parties, race, ethnicity, income, geography, etc. And I'm thankful to say that there are a lot of similarities, both within what people want, within what they love, what they hate, the language they use. And we really use all of that to drive our organization and working with all those policymakers across the country. 

Daniel Marino:  

Oh, that's great. Well, obviously from the work that you're doing within United States of Care, you're obviously watching impact of the bill quite closely. I'm assuming. 

Natalie Davis:  

Yeah. 

Daniel Marino:  

Let’s jump into that really quick. Give me your impression of it. Where do you see some of the biggest impact happening? Is it, you know, obviously, there's a lot of impact with regards to the hospitals, but also with patients. But from your perspective, what do you see as kind of that greatest impact? 

Natalie Davis:  

Yeah, I mean, when we talk to people across the country, and we are looking for the shared values and goals that people have, I can tell you that the 1st one that people have is that they want the certainty they can afford their health care. Number 2 is, they want dependable coverage as their life changes. Number 3 is, they want personalized healthcare, which means what, when, and how they want it for their bodies. And number 4 is a healthcare system that's easy to understand and navigate. And when I put those 4 values that people have across political party, race, ethnicity, all sorts of demographics, I'd say this is a really big step backwards towards what people tell us they want that they want health insurance that they can rely on, and that they can afford, that they can understand a system they can get through. And I think we're taking an enormous step backwards in giving people what they want through this. We know there are changes to limiting their ability to access and keep coverage, whether that's through Medicaid or the marketplace. Making it harder to seek and renew coverage. And you know, on top of that really shifts a big burden to States who are going to have a big maze in front of them figuring out how to work within their budgets and give people health care that they need. So we are concerned, very concerned. And I say that on behalf of people that we hear from all across the political party and other demographics, on what this bill will mean for their lives. 

Daniel Marino:  

So absolutely. And you know, one of the big focuses, sort of the personal mission that I have, you know, being in healthcare for almost 30 years is one helping make healthcare more accessible to really everyone, regardless of your demographic or socioeconomic makeup. But I think second is to make it affordable. So when I when I look at different aspects of the bill, I think some of the Medicaid reforms certainly has some concerns with it. I think even some of the funding to rural health care, I think, has some major challenges, and you know, when you, when we think about where CMS is going, I think you know that's sort of the 3rd area there that I think does have some concerns, at least from my perspective. Let's talk a little bit about some of those Medicaid reforms, though. 

You know it's clear that the bill is reducing a lot of the funding. A lot of that isn't supposed to come into effect until 2027. But according to some of the CBO projections they're talking about anywhere between 10 to 12 million Americans could lose Medicaid coverage. What do you feel like the impact's going to be on our healthcare industry and the ecosystem? Because, frankly, the patients still are going to need care. 

Natalie Davis:

That's right. That's right. And you know, we as we think about like you said just the about 10 million that are going to have impacts from these Medicaid and marketplace cuts and changes. We also know that if there's not this extension of the earned tax credit to the EPTC Extension that is in front of Congress. That's another 4.2 million that will lose affordable insurance. The marketplace rule of the Trump administration just finalized is just shy of impacting another 1 million people. So that's roughly 15 million people that will just in the last couple of months will be impacted in their coverage over the years to come. As we think specifically about Medicaid, you know, there are a lot of things that are in place that are going to really hinder people's access to get coverage and retain it. I think the biggest one that we that people I'm sure, have heard about are the work requirements, the work reporting requirements where there's more paperwork and red tape between people and the coverage that they need. This will lead to more coverage losses among people, more churn, more limited access. 

Daniel Marino:  

Oh, yeah. 

Natalie Davis:  

It really, it really just puts in that that red tape and paperwork requirements. 

Daniel Marino:  

And when I think about where the Medicaid, the dollars are spent delivering health care to the Medicaid population. Obviously, medical services is really big right? And that's been growing. And you know there's and we've had many conversations on this program on how to begin to address that. And community outreach is, is a great way of being able to do that and to you know, provide that care, take care of patients with chronic diseases, and then focus on a lot of those social determinant aspects. But the other area that really impacts Medicaid the Medicaid population is behavioral health. So these areas are starting to get cut. You know I can't help but think that it's going to put tremendous pressure on these healthcare providers to continue to provide a level of service that, you know, is frankly so needed. 

Natalie Davis:  

Yeah, I think that's exactly right. I mean, one thing is, we know that when people feel like, even if they can afford their health care. People avoid it if they feel like there's going to be extra costs. Let alone people know that they cannot afford it, they do not have insurance. We know that people are going to avoid going to the doctor. This prolongs, of course, serious illnesses, including mental health, like you just said that have a real impact on themselves, their families, their communities. It has then, of course, when they do show up, they cost more. The more uncompensated care that hospitals and health centers will take on our entire healthcare system, like you just said, is going to be really reeling from these cuts on coverage, because people like you said, still will need health care. That doesn't go away. 

Daniel Marino:

Yeah. It doesn't go away. 

Natalie Davis:  

Right, exactly. 

Daniel Marino:  

So let's talk a little bit about some of the impact on the rural health care setting. Because I you know, I think that a lot of these rural health care facilities, the critical access hospitals. Some of these community hospitals that are in small rural communities. They've been struggling all the way along right even without this. I mean, when you look at what the margins are on some of these hospitals, I mean, they're lucky if they're breaking even or making 1 or 2%. A lot of them are certainly in the red and being subsidized by the state or by other types of programs. What do you feel? The impact is on rural health care as a result of the bill. 

Natalie Davis:  

Yeah, I mean, I think people living in rural America are going to continue to be even more disadvantaged. Now with this bill, we already know, like you said that it's really hard to get access. It's really hard to access care. We have done a lot of work in rural South Carolina and talking to communities there. And one person said, you know, the biggest one of the jobs of our pastor is, if somebody has an emergency he takes them across the state line, or across the county line, I'm sorry where there's a better hospital, and so they can get picked up by the ambulance and brought into that hospital. And so we have pastors who are taking on the role of making sure people get to a hospital. 

Daniel Marino:  

It’s a care manager. Right? Almost care navigator, if you will. 

Natalie Davis:  

That's right, exactly. And it's a real sad state, you know, for rural America. And I think this is going to like you said, only have a bigger impact on that care and the health outcomes for people there, and no doubt that the providers and the health systems are going to feel that in terms of uncompensated care. There's an interesting part of the bill if you're okay with us moving into the Rural Health Transformation Fund. 

Daniel Marino:  

 Yeah, please. 

Natalie Davis:  

Which is specifically about aimed at rural health. So the OBBBA, as it's now called, has set aside 50 billion dollars fund for States to apply and receive funding from CMS to help support health centers and rural communities. I will say that this 50 billion is so small in the grand scheme of the impacts of this and the hole that rural hospitals have already been in. But the bill does set aside that 50 billion. 50% of that will be doled out to States through an application process. And 50% of that is through the discretion of this administrator. And in this case, that's Administrator Oz. And so we're still waiting to hear more information from CMS on what that looks like, both processes. And, but I think it's a real opportunity for CMS to be thinking strategically about, how can this money that'll flow through states? How can that not Band-aid over problems and not Band-aid over rural health problems that really infuse some cash to have some real transformative you know, care and care delivery. And hopefully, you know, I think there's a world in which that will point to more value-based care more, you know, incentives for hospitals and other providers to be really thinking differently about the way that they give, they give care there.  

Daniel Marino:  

If you’re just tuning in I'm Daniel Marino. You're listening to Value-Based Care Insights. I am here with Natalie Davis, and we are talking about the impact of the newly signed legislation, the Big Beautiful Bill, and its impact on hospitals and patients and rural healthcare in particular. So, Natalie, let's dive into that a little bit. When is some of the transformation, when is that supposed to the transformation fund? When is that supposed to take effect? And is it similar to the cost reporting that rural hospitals, critical access hospitals are doing? Or is this a separate fund? That would be maybe more value based as a program? Can you elaborate on it a little bit. 

Natalie Davis:

Yeah. So there's still a lot to know for sure. CMS has said that in September we will likely start hearing some of how they're thinking about this. 10 billion dollars is appropriated every year, 2026 to 2030. So 50 billion total. States must submit an application for that part, the 50% that's going to go out. And we're really hoping that, you know, this is an opportunity where you know, rural communities might catalyze payment reform or way, working better with, you know, hospitals that are in more urban areas really kind of rethinking the way, you know, less of a Band-aid approach. It'll be really up to the Administration, and how they're doing that. But it is a silver lining, we believe, of the of the bill. 

Daniel Marino:

Well, a lot of rural healthcare facilities have come together into some type of collaborative networks, whether they're clinically integrated networks or value-based networks, or something of that nature where they've started to really leverage different services and different support. Because I think, especially for a lot of the critical access hospitals. They certainly can't provide all the services that the patients need. So patients do have to have to begin to travel, which, you know, makes it a little burdensome for patients, but in the same respect there are community outreach programs that are essential to rural health, and I think if those are not properly funded and they go away, it's going to exacerbate a lot of the issues that we're seeing within rural healthcare and make it even more and more difficult. Almost to have these healthcare deserts, if you will, more and more difficult for patients to get the care that they need. 

Natalie Davis:  

Yeah, absolutely. And that's where these you know, these cuts on coverage and red tape and confusion. You know, people hate when their healthcare is a political football. 

Daniel Marino:

Yeah. 

Natalie Davis:

And unfortunately, I think that just happened. And so there's a lot of work that the party in power needs to be thinking about if they were serious about some of the changes they want to make now that the bill is passed. And you know, I think all eyes are to the States. The States are going to be impacted by this differently depending on if they expanded Medicaid, if they did not. What their budgets look like, you know, States can't run at a budget deficit like the government can or households can, they have to break even. And so how they're going to piece together, or cut different services, or cut other parts of their budget to shore this up will look really different. And as we've talked to legislatures and advocates across the country, they have a huge mountain in front of them that they're trying to figure out what to do in order to really make sure that the healthcare economy stays in place, and even more importantly, that patients can get the care that they need. 

Daniel Marino:  

We can continue to provide the services. No doubt about it. Let's talk a little bit about CMS, though. There is some aspects and impacts to CMS here. I've been watching it very close, because obviously, there's a lot of programs that CMS drives a lot of the value-based programs around the ACO, ACO reach. You know, the TEAM program just got enacted, and that looks like that's going forward. But you know, there's a number of others that are out there, particularly around Medicare. Advantage. Right? Where do you see CMS going? Where do you see, how do you see the role of Dr. Oz influencing 

some of these programs, or maybe even the future appropriation of a lot of these dollars in support of some of these healthcare additional healthcare programs or additional healthcare needs that undoubtedly we're going to need. 

Natalie Davis:  

Yeah. So I think you know, taking a big step back. And perhaps this is not new to your listeners, but the make America healthy again. The MAHA movement very clearly is driving everything in the healthcare space that's coming out of this administration, starting, of course, with RFK. And moving down through the different agencies. And the CMS team has taken that to heart for very clearly. And what does it look like for the levers they have, which basically is coverage. It is the largest insurer in the country. But you know there's other aspects, of course, to it, but really, mostly about coverage. How can they use their levers of coverage and payment reform to make Americans healthy is really their goal. And so, just as in the last administration we can think of equity was the big kind of lens that they had over all of their decisions. In this case MAHA and health is the big lens that they have over the decisions and will be really interesting to see how they use the coverage levers to do that. 

Daniel Marino:

Yeah and well, it definitely has been a big focus. 

Natalie Davis:  

Yeah. 

Daniel Marino:  

With RFK Junior. I mean, it's all around trying to make folks healthy, and I think the thought is, if you know, if they are, if they're thinking on being more healthy, that's gonna drive down some costs and make things a little more efficient. So I guess we will, we will see. So when you when you think about the bill and you think about the impacts of the bill and some of the things that we've discussed, what should hospital or healthcare leaders, or even physician leaders what should they be doing now? What should they be thinking about? Strategically, as they focus on continuing to provide the service and sort of managing their way through this unknown, of resourcing. That undoubtedly is going to happen. 

Natalie Davis:  

Yeah, I think the most important thing that they can do right now is be the voice of their patients and going to Congress, going to state legislatures and really making it clear how important coverage is not just to their bottom line, but to patients and to patient health, and to the health of this country and to the promise of making Americans healthy. So the biggest role I think hospitals and providers can play is really pounding the pavement and making sure that it's clear that there are fixes that need to be made, and states need to be thoughtful about how they implement this and doing such with as little burden as possible on the individuals and on our families. So that's the number one message I have for sure for the health care system. 

Daniel Marino:  

I wonder if we're going to see more collaboration and maybe more consolidation? You know we've already seen quite a bit of that in healthcare with a lot of the hospitals merging and private equity getting involved in that sort of thing. You know, I would think, possibly in the rural health care space, we might continue to see even more of that. And maybe there's more alignment with community health systems. Or I'm sorry, community health centers in order to maybe share resources in a way that we're able to continue to provide these services to patients. 

Natalie Davis: 

Yeah, I think there's a sharing of resources, I think is, you know, we should be looking at a lot of things. I will say that, you know, I think there are a lot of states that are looking very critically at consolidation when it doesn't actually help patient care and provide better quality. So you know, it'll be interesting. There are states that are really taking on this issue. There is an interest in Congress to be thinking more critically about who's investing in these hospitals? How is consolidation impacting communities? But no doubt we should be thinking innovatively about how to bring more resources and more services into rural America, into other urban areas where there are deserts as well. 

Daniel Marino:  

Well, you can only reduce costs so much right, and we've done quite a bit of work with hospitals all across the country, rural as well as large metropolitan health systems on financial enhancements. And I'll tell you my lesson learned over the years is you can only reduce, trim the fat so long, so much to the point where, you know there's nothing else to cut. There's nothing else to trim. The next thing you're going to cut is services. And my concern is that, especially with some of the budgetary challenges that some of the States have, if a lot of this Medicaid in particular funding goes away then they're going to be forced to cut services. And that's where I think we're going to see a lot of the uninsured population begin to even grow. 

Natalie Davis:  

Yeah, I think that's right. 

Daniel Marino:  

So if folks are interested in learning a little bit more about you, or maybe the United States of Care, where would they turn to, any thoughts? 

Natalie Davis:

Yeah, United statesofcare.org, you can come to our website and check out our resources. Whether that's information on how what we hear from patients across the country, including, hot tip, they hate the word value. When we talk to them about value-based care. But you could see all the research there on why, that's the case as well as the work that we do in Federal and State level. We have a newsletter that comes out every 2 weeks that I like to call it award winning, even though we haven't won an award. It actually really is a very useful, bi-weekly newsletter. And you can find me on LinkedIn, where I do talk a lot about the healthcare system and the work that we do. 

Daniel Marino:  

Well, I would love to hear some of the survey results that you have with patients and with the communities. Certainly, as it relates to some of the impacts of this. And it sounds like you focus a lot on education and just making sure that care is being delivered where it needs to be delivered. So I commend you on the work that you and your organizations are doing. 

Natalie Davis:  

Thank you so much. And thanks for having me on today. It's a really important topic. I'm glad we were able to talk about it. 

Daniel Marino:  

Alright, my pleasure! Do you want to give your email address, or how can folks kind of get back in touch. 

Natalie Davis:  

Yeah, you can find me on Linkedin, Natalie, Natalie Davis. 

Daniel Marino:  

Okay, wonderful. Well, thanks again, Natalie. Really appreciate you coming on board. And you know, coming on the program and sharing your insights with us. This has been great. 

Natalie Davis:  

This has been great. Thank you so much. 

Daniel Marino:  

And to our listeners. I want to thank you all for tuning in. If anyone is interested in learning a little bit more about this topic, a little bit more about the bill, or even some different aspects related to the bill. Certainly around some of the programs, theT EAM program, or any of the others. Please look up luminahp.com. Or feel free to contact me at dmarino@luminahp.com. But again, I want to thank all the listeners for tuning in special thanks to Natalie Davis. Until the next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

In this episode of Value-Based Care Insights, host Daniel Marino tackles one of healthcare’s most persistent challenges: physician burnout. Joining him are two experts who bring both clinical and research perspectives to the conversation. First, Dr. Stephen Hippler, a retired Chief Clinical Officer at OSF HealthCare, oversaw more than 1,500 physicians and advanced practice providers and has led initiatives to support provider well-being and a thriving work culture. Second, Dr. Laurence Weinzimmer, an endowed research professor at Bradley University, is a nationally recognized healthcare researcher and advisor to Fortune 100 companies.  

Together, they share insights from their latest study on “physician fortitude” examining the deeper, human roots of burnout, the organizational and cultural factors at play, and the strategies needed to drive meaningful change. Listeners will gain an understanding of why burnout persists, and what leaders can do to better support clinicians, build resilience, and improve workforce well-being over the long term. 

LISTEN TO THE EPISODE:

Daniel Marino:  

Welcome to value-based care insights. I am your host, Daniel Marino. Over the last number of years, we've talked on this program a few times about physician, burnout, physician, well-being, if you will, and kind of balancing all the stresses and the challenges that physicians have within their practice. In both in seeing patients in the hospital as well as seeing patients within the clinic. And I have to tell you, through a lot of my recent conversations that I've had with physicians and with healthcare leaders, I don't see it really improving. As a matter of fact, I see it getting a little bit worse. I recently had a conversation with an internal medicine physician, and she was just totally up in arms because of the continuous challenges that she's having. Just even with her epic system, and answering all of the messages and the challenges related to that. And it really got me wondering, is it more about the individual physician and the stressors of the industry that are forcing a lot of these issues around burnout? Is it the culture of the organization, or is it is it just you know, the norm of our of our industry. Well, recently, as part of the work that I'm doing as a board member of the Illinois MGMA, we have a fantastic conference coming up on November 7th and as part of that, there are 2 great gentlemen who are going to be presenting at that conference, and I'll share more of the details at that at the end of our program. 

But here to talk with me about physician burnout, physician well-being is Dr. Steven Hippler. Dr. Hippler is a retired practicing physician and former chief clinical officer at OSF Healthcare, and then Dr. Larry Weinzimer, he is a business advisor to numerous fortune 100 companies, author of 4 books, including 2 national bestsellers, and has done a lot of research on Physician burnout. Larry, Stephen, welcome to the program. 

Steve Hippler:  

Thank you, Dan. 

Larry Weinzimmer:  

Glad to be here today. 

Daniel Marino:  

So, Steve, maybe we could start with you. As a former chief clinical officer, you know you worked with with a large health system for a number of years. You've seen ebbs and flows with Physician Burnout. In your opinion, what's been some of the big drivers of Physician Burnout? And why hasn't, why haven't we seen this really making a turn? 

Steve Hippler:  

Well, Dan, when I was in my previous role, I thought burnout among physician, and really, among all of our staff was one of the biggest problems facing healthcare today. And truly, as you mentioned, if you look at the AMA triennial surveys, the incidence of burnout has not really gone down in these triennial surveys over the past 12 years. So I set out on a search to understand better what was causing, what were the drivers of burnout, and honestly to look for programs that would help the well-being of those that we employed. 

And at the time I was really left underwhelmed, I thought the explanations for what causes burnout were somewhat incomplete, and the solution seemed one size fits all. In our experience we see people who love the EMR, who don't have problems with prior authorization, and it wasn't the busiest people who were always burning out. So the explanations were somewhat incomplete. 

That's when I partnered with Dr. Weinzimmer to start to explore this a little bit further. And one of the things Larry and I hit upon is so much of the literature today talks about it's the work environment causing burnout. Yet why is it, then, that 50% of physicians in similar work environments, working in the same culture do not get burned out? So we spent a lot of time. Larry had done a lot of work on burnout resilience, so we partnered up 5 or 6 years ago to try to get a deeper understanding of the causes of burnout, so that we could come up with more effective solutions. And we've hit upon the topic or the fortitude as one of the key pieces that we think has been missing in this conversation, that we're having globally in physicians and all other people and workers in regard to burnout. 

Daniel Marino:  

Yeah, well, and I agree with you. I have not, you know we've done a lot of work with physicians over the years. The I think the burnout factor really came to a head right after Covid, and it just doesn't seem like it's gotten any better. So Larry, talk a little bit about some of the research that that you've done when you think about those core drivers of burnout. 

Larry Weinzimmer:  

Yeah. So when we really initiated the research on this Dan, we tried to take a holistic approach. As Steve mentioned the majority of interventions that try to reduce burnout focus on the organization. And there was a recent meta analysis published, actually 2 recent meta-analyses published that both showed organizational interventions aren't moving the needle in terms of mitigating or reducing burnout. And there's also a set of literature out there that looks at the individual. And is it, is it the individual or the organization that really helps to reduce burnout? And so what we did was we took a look at both of those literatures simultaneously. And it's not the organization or the individual that helps predict burnout. It's the individual and the organization. And so that's really what the the primary focus of our research has been, and previous to our research there were numerous attempts to understand, is it resilience? Do you have the ability to bounce back after a setback, or is it grit, or hardiness, or mental toughness, or hope, or optimism? There are all these different literatures out there that try to understand burnout better from multiple industries. And this isn't just healthcare. But many of these areas of research have looked at other industries and Steve can get into that in a little while. But we thought that it was actually an interaction or combination of these individual of these attempts to understand burnout at an individual level that could give us new insights, and as Steve mentioned, we landed on this concept we define as fortitude. And where fortitude is different than the others is. Fortitude is proactive rather than reactive. With fortitude rather than bouncing back after a challenge. How do you avoid the challenge? In the 1st place. 

And so we spent Steve. What probably about 3 years developing this, a measure of fortitude? We really wanted to make sure that the measure that we were going to move forward with on our research was statistically valid and reliable. So many measures out there aren't. And so we really we, we spend a lot of time to make sure that our measure of fortitude measures the psychometric properties we set out to measure.  

Daniel Marino:  

Lets dive into that a little bit, because I'll tell you, you know I've worked with numerous organizations who've done their physician provider surveys right and burnout always comes out as number one. And then undoubtedly what leadership does is they go out and they find a consulting company who has a program right? And they purchase this program to address Physician Burnout to improve physician well-being, and they just measure the satisfaction of it. And what always, really, what strikes me about that approach is they're not addressing the root cause of burnout. It's a general program addressing what they believe those causes are, but not really driving into the true root cause for that individual or for that organization. So maybe you know, Steve, dive into a little bit about your concept of fortitude. I think it's an interesting approach as you start to think about how to really redirect the or address these issues of burnout with physicians. 

Steve Hippler:  

Yeah. Well, back to your last comment, you know we do, we give seminars. We'll ask people what's causing you the most distress, frustration, and burnout now. And we create a word cloud. And it's fascinating, Dan, when we look at that, it's all different. 

Daniel Marino:  

Yeah. 

Steve Hippler:  

And that's probably why the one size fits all approaches have never really worked right? 

Daniel Marino: 

They never work. 

Steve Hippler: 

Because what one person's biggest frustrater is today, might not be it for the other person. So we looked at, how do people build the skills and attributes to be, have more fortitude in the face of work, stress, and pressure. And this, Dan, we believe, is applicable to all people. It's not just physicians. Burnout is prevalent now in all industries and even in non-working people. So we looked at all the literature out there on burnout, across all industries and all people. You know, in healthcare we talk a lot about resilience or bouncing back. But when I used to talk to physicians they'd get a little bit angry talking about resilience. It's almost thought or received as that they're not tough enough, or they're not strong enough. And so resilience had sort of a negative connotation. So we looked outside of healthcare and looked at the literature in academia. There's a tremendous amount of literature on how grit helps people improve performance, and to succeed, and a little bit on preventing burnout, especially in healthcare. We then looked at self-efficacy and skills. You know, we don't talk a lot about skills in healthcare a lot. But if you look at the teacher literature, you know, not being able to control your classroom is a big cause of burnout. And now, after Covid, having poor telecommunication, remote teaching skills is a big cause of teachers burning out and leaving the literature. So when you look into healthcare, poor EMR skills, poor communication skills, diagnostic uncertainty, have all been linked to burnout, yet we don't talk about that enough. So grit, self efficacy. If you look at the literature on athletes and performers, hardiness and mental toughness are key skills and attributes that they need to build in order to succeed when under high stress situations, when the chips are on the table, and the stakes are high. Which, although it's talked about in athletes, you know think about our surgeons and our doctors and the ER docs and the nurses. They need mental toughness and hardiness as well. Resilience is always always important as well as well as hope and optimism, because a career is long. So we looked at all these individual attributes and looked at them in the literature across multiple professions. And they all argue that they're different from each other. But what Larry and I did is looked at them and pulled them, pulled them all together, found some similarities, and then created a scale of fortitude based on all these. Our premise was that people needed all of these to really be able to overcome the stress and do better in spite of the stress. So it's not one or the other, but it's all of these. So, Larry, I'll let you speak to how we developed the tool. 

Daniel Marino:  

If you're just tuning in, I'm Daniel Marino. You're listening to value based care insights. I'm talking today with Dr. Larry Weinzimmer and Dr. Stephen Hippler, relating to physician, physician, burnout. And Larry, absolutely, I want to dive into that a little bit. But I would also like for you to really define fortitude. Right? You keep on talking about fortitude. And Steve went into a little bit of detail on that. But in our setting of physician burnout, how is fortitude defined as an activity of measurement and improvement for physician burnout. 

Larry Weinzimmer:  

Yeah, great question, Dan. So fortitude is defined as the courage to withstand setbacks and challenges in the workplace. And as we talked about before. It's really a proactive approach. How do we have the courage to not only overcome them, but avoid having them happen in the 1st place. And the focus on fortitude is really attitudinal. It's a perspective. And what's exciting about that, Dan, that means it's malleable, or it can be coached. It can be learned, it can be changed. 

Daniel Marino:  

Is it organization driven when you're building fortitude, or is it individually driven. 

Larry Weinzimmer:  

Yes! 

Daniel Marino:  

Both. 

Larry Weinzimmer:  

Yeah. So what we found Dan is again, there's some great efforts on trying to reduce burnout at the organizational level, trying to improve organizational support. There's been a plethora of research looking at individuals trying to build, you know, build self-improvement self-help. And it's really the interaction of the 2 and one fascinating thing we found with our research, Dan, was that when an organization attempts to reduce burnout, let's say, for example, they're trying to improve organizational support for their people. If somebody has a threshold level of fortitude, as the organization introduces that intervention, we see a significant decrease in burnout. However, if a person doesn't have that threshold of fortitude, the organizational intervention has no statistically significant impact on reducing fortitude. And so it's really the interaction of the 2. 

Daniel Marino:  

That's an interesting, that's an interesting perspective. I want to dive on that a little bit. So it seems to me, as you're thinking about addressing from an organization perspective, addressing issues with burnout and improving physician well-being if you will, you really do have to measure the individual's level of fortitude. And how then, you know, they're going to adapt to some of those changes, because to your point, you probably can put in all of these initiatives which we often see, and yet burnout never really improves. 

Larry Weinzimmer:  

Absolutely. And that's what we found in those 2 meta analyses is so much effort is being made to try to manage and mitigate burnout in organizations. Yet it's actually increasing in some industries rather than decreasing, even though we have all this effort. So are we focusing on the wrong thing? Not necessarily. But we're there are other things we need to focus on as well. 

Daniel Marino:  

Yeah. So let me dive into a couple of things that that I hear often in working with physicians, 2 things come to mind. One is obviously the stressors around EHR. I think the second is around patient access. And you know, what we saw was, we sort of created our, we exacerbated the problem of burnout with access certainly around Covid, because, as more and more physicians got frustrated, they retired early. Which then created less physicians, less providers in the industry access didn't change right. The patient demand didn't change, and yet there were less providers, right? And so the supply went down, which put more pressure on it. So those were 2 areas there that in my mind were really drivers of burnout. But what does the research show? How does that then align with fortitude, and then, as you start to address those things, to improve burnout, both with the physician and with the culture, how do you take that into consideration because those are tough challenges. 

Steve Hippler:  

Yeah, you know, Dan, the literature on EHR. Shows that if you train people how to be more facile with the EHR burnout goes down. I know there are a lot of individuals who have different EHR skills. That training, And again we talked about self-efficacy can be an important tool to help people. You know, I grew up in, started my career in the paper chart world. And I look back and there were these similar issues with paper charts. Nobody likes to document. And I'll be honest, I think it's those coding and documentation rules. 

Daniel Marino:  

Right. 

Steve Hippler:  

That are almost a bigger driver than the EHR, which is the vehicle to implement those that sort of caused a deprofessionalization of the medical profession. But learning how to use the EMR better, taking time out of the day. To sit with a trainer, do short, learn shortcuts, smart phrases, and whatever really has been shown to be a strategy to reduce burnout in some. Scribes this AI enabled dictation, I think all those are great tools for it to help with Burnout related to the EHR. 

Daniel Marino:  

So when you, when you then think about putting in programs in place. When we think about addressing this, speak to, you know, maybe, Larry, you can jump in here. Speak to how you align the research with the programs I mean is this, should this be very individually focused? Or can you create a program that is organizational based? That's addressing a lot of these issues. Or maybe it's both. I don't know. 

Larry Weinzimmer:  

Yeah. And Dan, it absolutely is both. And so with the work Steve and I do we, when we work with organizations, we 1st of all spend time educating people on fortitude and on, as you mentioned earlier, Dan, on drivers of burnout, what's causing burnout to help them really understand what the problem is. And then what we'll do is typically is facilitated group coaching where we work with them to develop, where each person develops their own individualized strategy. Then we create accountability to make sure that they're really focusing and committing to the change. And one thing that's pretty exciting a paper we're about to submit for publication shows that we took a group of 31 physicians and APPs and put them through the training for what we call our fortitude training and develop their individual strategies. And we also measured a control group, people that they worked with in the same environment that didn't receive the training. After 4 months we remeasured both the experimental group, those that received the training and the control group, those that didn't receive the training. We saw a significant increase in fortitude, and, more interestingly, a significant decrease in burnout for those that receive training. And for the control group we actually saw a slight increase in burnout over those 4 months.  

Daniel Marino: 

Oh, really? That’s interesting. 

Larry Weinzimmer: 

Yeah, so yeah, so we're really excited about that. And as I said, Steve, this week, we're submitting that for publication. 

Daniel Marino:  

Yeah. 

Steve Hippler:  

So the organizations, Dan really need to create the environment and individualized training programs and support their people, to help them improve their own well-being. One of the things we want to do with this work is to shift the conversation a little bit from it being all about the workplace and leadership's job to prevent burnout, to it is about the workplace and the leadership job. But individuals also bear some responsibility to have insight into what their greatest driver burnout is for them individually, and to be able to develop their own individual, unique strategies and build the skills they need, and build the fortitude they need to help overcome that. 

Daniel Marino:  

Well and a lot of times, it's easier said than done right? Because what you're talking about is creating self awareness of leadership of individuals. And having them understand that or become aware that, hey If we're going to address this, we need to really, we need to change, right? We need to create a paradigm shift within the organization that both is addressing the individual and to your point, which I love different levels of fortitude. Because what's important and how one person is going to address or react to it is different than another. But also then, understanding how the organization needs to react to it. 

Larry Weinzimmer:  

Yeah. 

Steve Hippler:  

Right and an understanding that individuals need to be coached to help build their own unique strategy skills and well-being. As part of this culture within the healthcare system. 

Daniel Marino:  

Yeah. Well, gentlemen, this is this has been a great discussion, and I'll tell you a topic that is definitely near and dear to my heart. You know, as I mentioned early on, youboth are presenting at an upcoming Illinois MGMA Conference. The conference is on November 7th at Soldier field. So you're going to be presenting, you know where the Bears play, and I think Larry, to your point earlier, maybe on the 50 yard line. Who knows? Right? 

Larry Weinzimmer:  

We're hoping. Yeah. 

Steve Hippler:  

We're looking forward to it, Dan. 

Daniel Marino:  

That's great. Talk a little bit about, maybe share with our audience for those that are interested in learning more, maybe, about the research that you're doing, or you know, the concepts that we've addressed here, I think, are somewhat new concepts. How can they get a hold of you? How can they share some of the, or how can you share some of the information with them? 

Larry Weinzimmer:  

Yeah. And so they have a couple of different ways to learn more about the topic. We are publishing quite a bit in the area. We have a paper forthcoming in the Journal of Healthcare Management that should be out in the next couple of months. If they want to take a look at our recent research, a great source would be our website. It's nexusinsights.com, where we post all of our research. Where our speaking engagements are. So they can get some of the leading research that we haveor leading edge publications that we're putting out right now. And additionally, we're both on LinkedIn as well. 

Daniel Marino:  

Yeah. And Steve, how about for you any things you could share about your contact? 

Steve Hippler:  

Yeah, likewise. And people, we have a contact us link on our webpage, on our website. So for people who want more information, who want to contact us. Please just go to our website and fill out the Contact Us form, and we'll get right back to them. 

Larry Weinzimmer:  

Yeah. 

Daniel Marino:  

Great well, and as I mentioned you, gentlemen, both will be presenting at the Illinois MGMA Conference on November 7th so anybody's, particularly in the Illinois market or in and around that, please plan to attend, because it will be a great conference. Well, gentlemen, I want to thank you for coming on the program. You know again, an important topic, one that absolutely, you know, we need to address, and we can only address this together. I really appreciate your time. 

Larry Weinzimmer:  

And thank you so much for the opportunity. We are passionate about this, and excited about the future, with the research. 

Steve Hippler:  

Yeah, thank you. And remember, we want to continue to focus on the fact that it's not just the organization or the individual. But it's a combination of the 2 that, based on our research, we believe will help people improve their well-being and reduce burnout. 

Daniel Marino:  

Great point. Great point. Well, Steve, thanks again. And, Larry, thanks to you, And to our listeners, if you're interested in finding out a little bit more about this topic, or additional information related to our conversation with Steve and Larry please reach out to me at dmarino@luminahp.com, or visit luminahp.com for more information. 

I want to thank everybody for tuning in, and until our next insight I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

In this episode of Value-Based Care Insights, host Daniel Marino explores the evolving role of operating room (OR) nurse leaders within the perioperative service line. As perioperative services become an increasingly important strategic and financial focus for hospitals and health systems, the demand is growing for leaders who can combine clinical expertise with business and operational acumen. 

Joining the conversation is Cheryl Barratt, a seasoned healthcare consultant with over 30 years of experience in surgical services operations, system integration, and performance improvement. Cheryl discusses how perioperative nurse leaders, while strong clinically, frequently lack the training needed to manage the broader responsibilities of these roles. She shares practical insights into how organizations can support their development with leadership, financial, and strategic competencies that enable them to lead more effectively and drive long-term performance. 

LISTEN TO THE EPISODE:

Daniel Marino:  

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Many hospitals, of course, are focused on trying to increase their revenue, trying to increase their efficiencies. All of them have been focusing for a long time on reducing costs, and a big area that impacts certainly hospital financial performance is the activities that are done in the operating room. And whether it's the main operating room or it's the ASCs, the number of cases, the volume of cases being performed within a day, the efficiencies of that case, and everything from the pre-evaluation or preoperative services to post-operative care, all of that affects the financial performance of the hospital or the health system. And what we're seeing is because there's such a focus on that, and rightly so, many hospitals have expanded their strategic focus on the OR, and expanded that to really include it as a service line. Perioperative medicine service line is what we are beginning to see. Which is really kind of exciting for the hospitals, because again, it's a focus on how you think about it from a continuum of care perspective. 

But also, if you're going to do it well, you need to partner with your surgeons. So surgeons in particular are excited about this because it allows them an opportunity to potentially do more cases or improve their own efficiencies and so forth. 

But while doing this, even though the strategic focus is there, the infrastructure is something that remains a challenge for hospitals today as they start to expand their focus. And what I mean by that is the leadership, the organizational structure that's important to drive the success of a perioperative service line if you will. 

 Well, someone here to talk about this, I'm really excited today to have Cheryl Barrett join us. Cheryl is an RN and a seasoned healthcare executive. She's been in consulting for over 30 years, helped numerous hundreds of organizations across the country with improving their or and perioperative service line. As mentioned, she's an RN, and she also has acted as a vice president of perioperative services. So welcome to the program Cheryl. 

Cheryl Barratt:  

Thank you, Dan. Nice to be here. 

Daniel Marino:  

So, Cheryl, as we see these hospitals expand their service line focus, what are you seeing as the major gaps in the leadership particularly, say the OR managers? 

Cheryl Barratt:  

Well, where I see the gaps is basically, you know, learning to work in a new environment and basically not having some of the skill sets that make it more of a service line direction rather than kind of a siloed OR or periop direction. Basically the operative support areas. So I see that as an opportunity for nurses to learn more about business and have kind of a business acumen skill set that they bring to the table. That is not something that's easy to pick up. Right? I mean, it takes some dedicated work, and often involves going back to school, and you may be in a master's program in nursing that offers some of those courses. But I have found that actually concentrating in business, administration or hospital administration, really going kind of outside of nursing to get that additional education is really helpful. 

Daniel Marino:  

Well, absolutely, I mean, and you see it, because you know a good OR director is very clinical, right? He or she knows the clinical side of surgical services, knows, you know, maybe the efficiencies of the OR knows how to support their surgeon, their surgeons, and so forth. But the part that is meeting that's missing. And you touched on this, is taking a business perspective of what's current, not only in the OR but across that continuum of perioperative services, and many of the nurses have not been trained to do this right. So to build, to develop that business acumen, I think, to a certain extent is a challenge. But also it's an opportunity that's out there. 

Cheryl Barratt:  

Absolutely, absolutely. So. I remember when I made that decision a long time ago to go back to school, I knew I was going to be in classes with people who had never been in an operating room, and possibly would never be in an operating room until their old age. Right? So I was surrounded by people who were like business school candidates, right? And it was really different, really, really different in terms of the schooling, the education, the camaraderie with your fellow students and the expectations. There was no clinical part.  

Daniel Marino:  

No, it's all the business. 

Cheryl Barratt:  

Right? Yeah, yeah. And you know the challenges of accounting and finance, were definitely big hurdles for me to overcome. But has served me very, very well over the years to have that basic background and then be able to go toe, to toe with finance and really understand what they're trying to do and what you're trying to do, and collaborate together to meet the business objectives of the organization. Even to the point of trying to learn a little bit about coding. Coding is pretty important, right? 

Daniel Marino:  

It is. 

Cheryl Barratt:  

And you have to understand some of those basics to be able to be effective as a leader. You also, I think, another thing that's really changed within the surgical services is the whole idea of a dyad or a triad. So it's not just on the back of the OR director. Right? You're now in a dyad or a triad, either with your chief of surgery and chief of anesthesia, or one of the other right? It depends if you have a dyad or a triad. And working collaboratively to really help and steer the organization towards the goals of the organization. So no longer is the nurse taking a back seat as an administrator, but really is in the forefront with those two other really clinical people, and the nurse may bring more business acumen relative to the operating room to the table than the surgeons. But I can say that there is a huge push these days with both the surgeon and the anesthesiologist, who are in that active role as chiefs and as triad members, to also get some of that business education. 

Daniel Marino:  

Absolutely. Well there's such a right now as organizations are focusing on really enhancing a lot of their financial performance of the OR there's a major push to upscale all of the business acumen related to perioperative services. Right? So you can see that as the organization starts to evolve, that business focus has to come into play, you know. A couple of months ago we were doing an assessment at a hospital where we were looking at O services, and you know we had talked with them about what a high performing perioperative service line would look like. And one oof the questions that came down is, well, you know talk about the structure. Well, the 1st thing I talked about was the dyad model, as you said right, having, say, a vice President of perioperative services that works closely with a you know the chief of surgery or the anesthesiologist, or in some cases both. But it's also important to have a strong business manager there, because the perioperative, the vice president perioperative services is really a strategic role, right? I mean, he or she needs to know operations, and they need to do it well. But they also strategically have to think about how to grow the service line, how to grow the performance of the OR. And in order to do that, you need to have a strong business partner or somebody there that basically knows the ins and outs of the numbers. 

Cheryl Barratt:  

Right, right. So you know, I always advocate that the OR director have a strong sense of those numbers, really know what they are, but you know you don't want to spend your life doing Power Point Excel spreadsheets. Right? That's not your role. Right? So you're more of an executive. So you have to have that business manager. But, as I said, you have to know the data also because you do not want egg on your face relative to the data when it comes up, because it's going to be discussed. You have to be transparent. You have to know it. And if someone asks you what the formula for this is, what's the algorithm, you absolutely have to know. And not only do you have to know that, but you have to know within your own system what are the inclusion and exclusion criteria. So that you are, when a physician asks you well, let's say, for turnover time, you know, if it goes past 60 min is that included or excluded? You need to know that. 

Daniel Marino:  

Yeah, yeah, absolutely. Well, if you're just tuning in, I'm Daniel Marino, you’re listening to Value-Based Care Insights. We're having a fascinating discussion on enhancing the OR and perioperative services, and in particular, you know, upscaling the OR director to more of a service line, Vice President of Perioperative services leader. So Cheryll, one of the questions as you were talking, I thought about is, it's got to be a pretty difficult paradigm shift for many of the nurses who've just been used to managing clinical operations, serving the physicians and so forth. 

And a lot of times the ones that do a good job, you know they take care of their surgeons. But when you're moving into more of a vice president or a service line leader, you really need to do what's best with the organization. So there's a bit of a you know, maybe a battle there, right? I mean serving the physician or serving the organization through advancing the perioperative service line when you were working in the OR, and you clearly made that leap. How did you manage through that. 

Cheryl Barratt:  

Well, one of the things I did was really work very closely with my CEO. So I found out what the needs were from their perspective and then translated those and involved my chief of surgery and chief of anesthesia. We didn't always agree. 

Daniel Marino: 

Sure.  

Cheryl Barratt:  

You know, that's the, actually, that's the best part of an organization is to have collaboration between these 3 people and serve the organization. And you know you win some. You lose some. You don't always win right? You don't always get your way, but it's not about getting your way. It's about advancing perioperative services within the organization and giving the best product to your client. The patient. 

Daniel Marino:  

Right? And yeah, serving the patients. And it's got such a huge opportunity around it, right? 

Because if you know, these leaders in perioperative services now have a real opportunity to make a difference within the organization. They can make a difference by reducing costs, and probably have the ability to work directly with the purchasing folks, or certainly with the surgeons, to streamline some of the supplies, and so forth, which they probably couldn't otherwise do as the OR director.  

I think there's also an opportunity to think about growth. Right? How do you really bring in additional surgeons that's going to expand the financial performance of the OR is what. As well as then, you know, all of those things that are important around say block utilization, or the things that really drive the efficiencies of the OR so I think it's I mean, it's a great role, as you know, on paper. I think the challenge is how we get, or how we get the leader to kind of upscale themselves and take advantage of those opportunities. 

Cheryl Barratt:  

Absolutely, and the key is education, and the key is experience right? The more you do it the better you get at it right. And the more you're surrounded by great partners in your chief of anesthesia and your chief of surgery, the better you all progress together towards meeting the goals of the organization and serving the clients. And that's exactly what every nurse, every anesthesiologist and every surgeon wants to do, is serve the client and the patient and their families and support them through. You know, surgery is traumatic, right, no matter what it's traumatic, and we need to have that empathy as well as that knowledge base to provide what is necessary for the patient at a cost that is reasonable. 

Daniel Marino:  

Right? Right? Absolutely. So. You know, when, when we're working with organizations, one of the philosophies that we put in place is, you need to have a strong governance model, right? So the governance model should include the senior say, surgical leaders, clinical leaders, operational leaders that could drive a lot of the performance of the OR right, and that governance becomes really important. How does the role of the perioperative service line leader change as you start to evolve that governance model. 

Cheryl Barratt:  

Well, I think one of the ways it changes is, you don't just follow a script of what the policy says. Right? So let's say. For example, 10 years ago, the policy said “We are going to have a 1 day release time.” Well, a 1 day release time may have worked for everyone back then, or possibly didn't. And you had a lot of disagreement about it. But today you have to look at it kind of globally. What does it mean for every single service? 

Daniel Marino:  

Yeah. 

Cheryl Barratt:  

It means something different if you have all of your patients basically scheduling within a 2 week period of you doing the surgery versus months out like, if you're an ophthalmologist, right? So you have to take into account all those needs and tailor, the governance and the policies to meet the needs of those surgeons and their patients. 

Daniel Marino:  

Yeah, I think you're right. I mean, you know, the service line leader, the Vice President of Perioperative services does really need to think more at the 10,000 or 20,000 foot level, right, as opposed to in the weeds. When he or she was running the operations of the OR they were in the weeds. Right? And it was all about, how do we create direct efficiencies, room by room, or, you know, for the supplies or for the individuals. But when you're placed in this leadership role, when you're thinking about it at a higher level. You really do need to think more strategically. 

Cheryl Barratt: 

Yes. 

Daniel Marino:  

I keep going back to the fact that it's a real paradigm shift for folks. It has to be. 

Cheryl Barratt:  

Yeah. And I think the thing, the challenge is keeping up. So keeping up with the literature, keeping up with what's going on at conferences. You have to stay engaged. You absolutely have to stay engaged. You don't want a new service coming in, or a service line coming in, specialty, and you don't know anything about it. So trying to keep up, even if you don't have that service at your hospital right? You have to keep up, and it means not only going to conference, you have to read the literature, you absolutely have to see what is best practice out there, or leading practice and work towards that leading practice. You know. One of the things that I really took to heart in my nursing education was the difference between when a best practice is introduced, and when it's implemented widely, and you know it can be a 13 to 15 year gap. We don't have 13 or 15 years anymore to get to best practice right? So keeping up with the literature and then doing performance improvement to reach those levels with the collaboration of your surgeons and anesthesiologists and leveraging your surgeon and anesthesia partners to help you in that endeavor. 

Daniel Marino:  

So when, when hospitals are thinking about upscaling their surgical services, their or services into more of a perioperative service line, should there be a very focused strategic initiative around developing that OR leader into a perioperative service leader? Or in your experience? Is it better to maybe go out into to recruit a seasoned individual that could really drive it. I mean, I guess it comes down to do you build it within, or do you go out and sort of buy it. 

Cheryl Barratt:  

I think it really depends on the organization as well as who's in place at the time. Right? And if you don't have somebody who has business acumen. What resources do you have within the organization? Some places have really great management training within their organizations. I would say, that's probably lesser what I see than more right. There may be some, but there's typically not. It's not like going to school, right? It just like isn't like going back to school, and that can be kind of an intro. But I do see more and more organizations recruiting for the best talent. But the best talent is hard to come by. And you know the typical OR director position is open for a very long time. If you're recruiting from the outside, so there's always at least 100 positions open across the country always. So you have to come up with the money right, to pay them well, and if you don't have the internal talent, perhaps giving them a mentor is helpful, and some education, or really encouraging that they get that education. Not every place can have, you know, somebody with experience. So we have to grow our own also. 

Daniel Marino:  

We have to grow our own, I mean, especially in rural areas. I mean, it's, you know, the need for human capital is probably the biggest challenge that they have. But I think for all organizations, as you're starting to really create this position, groom this position for success, having the right education in place. And you know I totally agree with your perspective on having a mentor. I think that's the best way for folks to be able to learn. But you have to invest in your people right? You have to be able to grow it. So as we're thinking about this and the value of the perioperative service line. Do the typical or do the evolving role, he vice President of perioperative services? Are their roles typically just confined to what occurs in the OR or do you see this role also expanding to say the ambulatory surgery center, or even having some influence in the surgeon's offices? Right? Because what happens is the surgeon's office with consults directly impacts what occurs in filling their block schedules and their block utilization. Thoughts on that? 

Cheryl Barratt:  

Yeah. So actually, I've seen kind of two different ways to approach this. One is to really kind of have. Or actually, there's three. One is still kind of very periop oriented, pre-op you know, ambulatory surgery, the OR, pacu and phase two recovery. That's kind of old school, right? Because the continuum starts well before that. The continuum starts all the way back in the physician's office. So I see some organizations linking the office management with the periop director. So that's 1 movement. I also see other organizations linking the post-op on the floor to the periop manager. So it really depends on kind of the philosophy within the organization. But I've seen both of those and I personally favor the pre-op because there's so much that can be done from a prehabilitation perspective with the patient, so that we truly do impact the length of stay and outcomes. 

Daniel Marino:  

Yeah, I agree with you. I think the you know, the Vice President peroperative services, you know. If preoperative services, preoperative valuation is not reporting to him or her frankly, I think that's a bit of a mistake. I think they have to have an influence, because what they do preoperatively directly impacts what happens post-operatively right. And when you look at readmissions, when you look at even influences in length of stay or transitions of care, you know it all goes back. It's really not what happens in the operating room. It's what happens prior to that. So I think that influence really becomes key. But I find it fascinating with the evolving reach and responsibilities that these roles are going to start to undertake. And I think to your point, I could see a lot of these roles, maybe not directly responsible for, say the surgeon, the ambulatory clinic, surgical offices, but influencing what goes on there because there is such a strong connection. 

Cheryl Barratt:  

Absolutely, absolutely. As I said, especially with the whole concept of prehabilitation, right? Not putting the patient on the schedule until they're in shape for the surgery. Right? So that's a paradigm shift that's definitely a paradigm shift. And to learn more about that in periop medicine is imperative. So even if you're not responsible for that as the director, knowing about what should be happening relative to prehabilitation is really powerful information that you can work with your chief of surgery and chief of anesthesia, and have a risk stratification model in place, so that you're putting patients on the schedule when they're ready to go to surgery. 

Daniel Marino:  

Yeah, absolutely, absolutely. Well, Cheryl, this has been great, and I know, you know, for many of our listeners who have given a lot of thought in expanding their surgical services to more of a perioperative service line having the right individual in place to drive this, I mean, is is absolutely. critical for success. And I really appreciate you know, you coming on and talking about this. For any of our listeners who may want more resources or have some questions, are there any sites or any resources out there that you can direct them to? And if you're comfortable, I would even love for you to share your contact information. 

Cheryl Barratt:  

Sure. So I think if you're thinking about expanding your skill, set to really do a good in-depth, look at if you're a nurse right? Not everybody that runs an operating room is a nurse. But if you're a nurse to look at programs within your area, either online or you know traditional schools to expand your knowledge within nursing. There are schools that concentrate on both the business aspects as well as the nursing aspects in master's programs. So that would be one resource to look at. But also explore joining organizations outside of nursing like ACHE, HFMA. And there's one organization that I really love because it's truly collaborative. It's nurses, it's physicians, it's surgeons, it's anesthesiologists who get together every year the American College of Perioperative Medicine. Anybody who is clinical or non-clinical, would really benefit from joining that organization and going to their annual conference. 

Daniel Marino:  

Yeah, I couldn't agree with you more. And I think if folks can begin to look at that, even those that are outside the clinical focus. You know that that support the business acumen would be great. Real quick, any of our listeners want to get a hold of you, any thoughts on how they can connect? 

Cheryl Barratt:  

Yeah, Cherylbarratt@cbarrattassociates.com.   

Daniel Marino:  

Wonderful. Well, Cheryl, thanks for coming on. Wonderful, you have a clearly, a huge breadth of experience. Really appreciate your insights. Thank you very much. 

Cheryl Barratt:  

Thank you. 

Daniel Marino:  

And for our listeners, of you want to learn more about this topic or any of the resources that Lumina Health Partners has related to perioperative services, service line development, OR efficiencies, or any of our topics we cover on Value-Based Care Insights. Please reach out to dmarino@luminahp.com or visit luminahp.com. And want to thank all of our listeners today for tuning in until our next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

In this episode of Value-Based Care Insights, host Daniel Marino continues the conversation on CMS’s mandatory TEAM Model (Transforming Episode Accountability Model) — a five-year episode-based pricing initiative impacting 741 hospitals across the country. 

Joining the discussion is Dr. Christian Pean, a board-certified orthopedic trauma and reconstruction surgeon at Duke University School of Medicine, executive director of AI and Innovation for Duke Orthopedic Surgery, and co-founder/CEO of Revel Ai Health. Together, they unpack the clinical and operational impacts of TEAM, with a focus on five key surgical procedures. Dr. Penn highlights how emerging technologies, including conversational AI platforms, are enhancing episode management and streamlining outreach, triage, and documentation to help providers improve care coordination and succeed under TEAM. 

LISTEN TO THE EPISODE:

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. In today's discussion, we're going to start or have another conversation around the TEAM model. For those of you that were listening at the last episode, my colleague and I, Lucy Zielinski, took a deep dive into what TEAM is, the impact to the hospitals, the 741 that are mandated. And we felt like coming out of that, there were still a number of questions really around providers, how they needed to manage the success related to the 5 surgical procedures and in particular, how they need to structure their data, their organizations, even the care with their patients in order to drive the right level of performance. And again, just by way of background TEAM stands for transforming episode accountability model. It's a mandated or mandatory 5-year episode, based pricing model that, you know, is coming through from CMS. There's 5 different episodes that are included in here, and these are the high volume, high cost procedures, and they're low extremity, joint replacement, surgical hip, femur, fracture, treatment, spinal fusion, CAGB, coronary artery bypass graft, and the major bowel procedures. And as I mentioned, there's 741 hospitals across the country that are included within TEAM. And, interestingly enough, as we're having conversations with different hospitals and even some of the conversations I'm having with our listeners, many hospital leaders, many providers don't even realize that they're involved or within TEAM, or they're one of the mandated hospitals. 

 Well, I'm really excited today to have a great guest, someone who I've had a number of conversations with Dr. Christian Pean, a Board-certified orthopedic trauma and Reconstruction Surgeon at Duke University School of Medicine. Dr. Pean also is executive director of AI and it Innovation for Duke orthopedic surgery and core faculty member of the Duke Margolis Institute of Health Policy. As well as his role within Duke, Dr. Pean is also the co-founder and CEO of Revel AI Health. And really excited about Revel AI, Dr. Pean and I have had a number of conversations related to the platform, and some of the work that he's been able to do, and some of the value that he's added to a lot of providers so excited to dive into that as well. Dr. Pean, welcome to the program. 

Christian Pean:

Thank you. Thank you so much for having me. I'm really excited to be on the show, and I'm really glad that this model is being emphasized, especially as an orthopedic surgeon. I think that the awareness of this model is just lacking, and, as you know, there's so many orthopedic episodes that are included in this model. So yeah, just very happy to be on the show and speaking about this today. 

Daniel Marino:

Yeah, I agree with you. You know, the mandated joint replacement and bundle program, like, you said has been around for a while, this is kind of the next evolution of that. And you know the interesting thing about this, and I mentioned this in my opening comments, many of the providers, many of the hospitals, don't even realize they're part of that. So from your perspective with your work that you're involved in at Duke, and obviously your role is an orthopedic surgeon, talk from your perspective of what TEAM is and how you see it impacting a lot of the work that you're doing at Duke as well as done with your patients. 

Christian Pean: 

Absolutely like you said, this is really a continuation of previous models that we've seen. The comprehensive joint replacement bundle, BPCI. But this is different because it's mandatory. So there's no option to not participate in this bundle. And I think another contrast to what we've seen in the past is we're used to 90 day bundles. We see that CMS has moved that window to 30 days. The nature of the care episodes that are included in this model. You mentioned them. CABG, lower extremity joint replacement, which is total hip replacement, total knee replacement, total ankle replacement, major bowel procedure, surgical hip and femur fracture, treatment and then spinal fusion. 3 of those are orthopedic. I really want to call attention to the hip and femur fracture bundle. We are not used to managing that a lot of the care that's focused on these patients is about upstream risk optimization, modifying risk factors, making sure that your patients are well indicated for surgery. Those hip and femur fracture patients, we don't have the luxury of any of that. That's going to be very different. There's a lot more in this model that I think is going to impact health systems that are selected. Something else right in this model consistent with the pro Pm Mandate, you have to collect patient reported outcome measures on your hip and knee replacement patients and your ability to collect 50% of those measures is going to factor into the risk adjustment. 

Daniel Marino:

Yeah, you're absolutely right. And you know, one of the things that really caught my attention. As I've dove into the economic structure of this. And you touched on this previous bundles were basically, you know, few days before the episode. And then 30 days after. For the TEAM model, you need to manage that patient 30 days prior to the episode and 90 days post episode, right? And the cost structure is predicated on how you're managing patients recovery. Recovery in the home. We're going to be evaluated by the readmission activity that's occurring. As you mentioned, a lot of the quality patient reported outcomes, as well as in patient safety factors. So it's going to be critical that providers do the work with the patient upfront on really capturing all of those elements that are going to drive or identify the risk factors, but really drive the recovery and have that recovery plan post episode. Without that I think providers are really going to be challenged with the success of this program. 

Christian Pean:  

Absolutely, absolutely. And I think that traditionally in value-based care. We kind of think that we need a few things to happen for systems to participate. You need alignment and incentives. You need access to the data, and you need care transformation. The data is going to be made available. The alignment is not an option anymore. So it's really about operationalizing that care, transformation and the challenges that I see here, like you said, this is care that needs to be coordinated upstream. We do not do a very good job of systematically risk stratifying these patients. The levers that you can pull to contain costs in these orthopedic patients side of service shift. So if you want to have less patients in the inpatient setting and just opt out of the bundle in that way you can move them to the outpatient setting. But that means being very proactive about the care coordination way upstream, and maybe shifting people that otherwise would have had surgery in the hospital to an ambulatory surgery center that takes a lot of care coordination. 

Daniel Marino:  

Yeah, you're absolutely right. And it's being able to identify those patients who are would be good candidates for that in the surgery center. Because, you know, if you've got a patient who, let's say, you know, has a high BMI, or maybe doesn't have the right home setting to do rehabilitation in the home, or you're not able to coordinate with a rehab facility post episode that's going to factor into all of this. So it's really a very comprehensive approach that providers need to start to take, to risk, stratify that patient. But to really understand what's the best care plan post episode for that patient, so you could really manage that recovery as efficient as possible. 

Christian Pean:  

Absolutely a hundred percent. And I think that one thing that we haven't really thought about as we're operationalizing these bundles. This is going to be the 1st time that these hospitals need to put infrastructure in place to follow these patients in this manner. Another sort of nugget that's hidden in this mandate is, we have to be getting primary care follow up for these patients within that 30 days after surgery. That's another tremendous amount of care coordination you need to do. So you talked about identifying the risks upstream. I think that actually, social drivers of health and social support are really important to screen. For in this model, in order to identify patients that need care, navigation support, you've got to figure out not just how to avoid the post-acute care utilization in the emergency room and readmissions. You've also got to get that patient back to the primary care physician. That's not something we're used to, but it is completely consistent with CMS’s approach to value-based care, bringing the accountable care organizations and specialists more closely together. This is going to be really hard work. 

Daniel Marino:  

Yeah, well, and like you said historically, particularly orthopedic specialists. But I think you know a number of specialists, when a pay in the fee for service world, when the patient is referred the physician or the surgeon does their work. They finished, you know, the surgery, and then they're done transition. So you know, I guess from an orthopedic surgeon perspective that's a paradigm shift. 

Christian Pean:  

100 Percent. 

Daniel Marino:  

So how do we get our surgeons, our physicians, our providers, thinking about that differently in such a way that they do need to collaborate, and they do need to integrate with primary care better. 

Christian Pean:  

100%, I mean, surgeons are not used to having to deliver this sort of longitudinal care, and it is completely a frame of mind shift. We're going to need surgeons to champion the resources and the infrastructure that are going to help them succeed. We are being asked to do more with less every day. We're seeing surgeons trying to do more cases in order to combat shrinking reimbursements, and then to try to ask us on top of all of this to collect this information is going to be really challenging, which is why I think surgeons need to be the ones leading the charge asking for care coordination resources, and yes, technology enablement. I don't think that you can perform well in these models without knowing your own data very well. Your performance as you stand the benchmarks and putting technology in place to automate some of this process. Because I think in a lot of these models, we're going to be wanting to throw people at the problem. But we're in an environment where the turnover of staff, the margins that hospitals have are not going to be able to accommodate the kind of coordination that will help them to succeed in this model. And then you're gonna get hit twice. You're gonna get hit with labor costs. You're gonna get hit with financial penalties for Medicare in October of each year of this bundle, which, by the way, there are 3 tracks in this bundle you start on the optional Downside risk or upside in year 2- 5 of this bundle you are mandated to do downsided risk. Unless you have a special provision in place as a safety net hospital. But that's that is, that is a really precarious place to be in without operational logistics in place. 

Daniel Marino:  

Oh, you're absolutely right. I mean, there's no doubt about it. CMS wants to hold providers accountable right? They want to have a risk component. That's all part of this. If you're just tuning in, I'm Daniel Marino, and you're listening to value-based care insights. I'm here today talking with Dr. Christian Pean, and we're taking a deep dive into the TEAM model, talking about it from a orthopedic or from a provider standpoint, and really talking about all those elements of success. Dr. Pean, I want to talk about the care management activities you just mentioned that the data becomes really important. And this is really hard for many organizations to start to think about what data they should look for as they start to not just risk stratify the patient, but to do something with that risk, stratification with that risk score, and then how to build that into one care management but 2. The recovery plan. So talk a little bit about the data, and then I'd like to dive into a little bit of Revel AI, because you've got a solution right now that's helping to kind of aggregate that. But talk a little bit about the data. What are you seeing on the front end, that becomes really important that providers should really be focusing on. 

Christian Pean:  

So the benefit of this model is, it's being distributed by the Government, and they are sharing the benchmarks. Regional benchmarks that hospitals are being held accountable for. By the way, those benchmarks are showing that the average hospital in this bundle is slated to lose between $700-$1200 per care episode. The average hospital in these bundles is doing over 300 cases. So that's a lot of money on the table to lose the data you need. You need provider performance information. You need risk stratification information. You need to be able to follow that information prospectively so that you can make adjustments in the care that you're delivering to these patients. And unfortunately, a lot of systems don't have workable dashboards in place or tools that can help them in real time, operationalize this data, and act on it right? 

Daniel Marino:  

Yeah, you're absolutely right, but you know. But I think it becomes really then then tough. Because if you're thinking about all of the elements that go into risk stratification. There's the internal data factors that are important, right? Those are sort of the clinical outcomes where you should be measuring, let's say, you know, if a patient is a diabetic what the Aa level is, you should be measuring other aspects of their chronic diseases or comorbidities, that kind of figure into that. But then you have the external data. You have the you, you have those social, determinant factor, those factors that are important for that that will drive, say, care, or rehab in the home that sort of thing, and it does become overwhelming for providers to think about how to aggregate all that data and then how to make sense of it. Right? So you incorporate it into a care plan. How should care manager start to think about that? One of the things that we talk a lot about is in the pre surgical evaluation, the things that need to occur with the patient prior to surgery. That's where you capture that. 

Christian Pean:

Yes. 

Daniel Marino:  

Talk a little bit about your experience on how that that information should really fit into that pre-surgical evaluation. 

Christian Pean:  

Yeah. And we have experience with this, both with my academic hat on and my Revel AI hat on, you have to embed care management into the workflows. There's a lot of opportunity. At the time of surgical indication. If you have a standard risk assessment, you need to be collecting that right then and there. You need a failsafe. The preoperative assessment that call even that happens the night before. Surgery is an opportunity to capture more information from that patient, and then you need to be able to have patients on different pathways of care management. And, by the way, I mean CMS has definitely been leaving breadcrumbs on the trail here, trying to encourage. I mean, we've got transitional care management, principal care management, chronic care management programs. All of these have been designed to incentivize us to take care of these patients longitudinally. 

Daniel Marino:  

You're absolutely right. I kind of think about it as a balance between the fee for service activities, because you can bill for CC. 

Christian Pean:  

Yep. 

Daniel Marino:  

As well as then positioning you for success within value-based care. And this is the perfect example on how, if organizations would have kind of put those components in place prior to this, they could be positioned really well, going forward. Now, you know, with the new episode, talk a little bit about Revel AI. 

Christian Pean:

Absolutely. Yeah. 

Daniel Marino:  

There's a lot of technology solutions which are starting to emerge to help make sense of a lot of the data. Artificial intelligence is sort of the new buzzword, right? I went to HIMSS all over the place. I think you know you know of the of the 5,000 vendors that were there. 4999 of them had AI in their title. Talk a little bit about Revel AI, though what do you see as the technology solution, how it could support some of what we've been talking about, particularly around the care management. 

Christian Pean:

100%.  

Yeah. And I'm an AI enthusiast. I really believe I think this is kind of like the call to action. If you don't know about generative artificial intelligence, and you're not using it in your day to day productivity in your day-to-day care activities. It's time to catch up. This is everywhere. It's going to transform the way that care gets delivered. At Revel AI. What we've done is we've really tried to combine clinical subject matter expertise the policy mandates and really well vetted, responsible, artificial intelligence models to coordinate and automate a lot of this care. We like to use an acronym. In value-based care you're stepping into the arena. Right? So this is, you know, you're going to battle sometimes it feels like in these models. So we use that to our advantage. You need to assess, risk, stratify, engage, navigate, automate. Our platform is doing all of those things. We're collecting those assessments preoperatively that can help clinicians risk stratify their patients. All right. That's that assessment and risk stratification piece. We're engaging with the patient. So we've got text and voice based engagement that reaches out to the patient to further coordinate care, and all of that is done by a voice and text based conversational AI agent that's been trained on the clinicians protocols. It can make a huge impact just on de-burdening the staff effort that you have to put into this right? And then we're navigating patients to those resources. We have a really great partnership with find help. So when patients have social drivers of health, we're helping surface those social risk factors to the clinician as well as resources they might be eligible for. And we're navigating patients also into those buckets. We're trying to help care management here. We want care navigators to not be on the phone all day, by the way, between 8 Am. And 5 Pm. When patients might not be answering, but instead have a personal AI copilot that's helping do proactive, outbound, outreach, collecting that information and summarizing it smartly so that they can act on it, and then helping with some of that collaborative navigation for those patients, so that you can really succeed in these models. 

Daniel Marino: 

So we've done quite a bit of work with different provider organizations, helping them to optimize their care management. And I'll tell you in a lot of the work that we see when we 1st go into an organization the care management activity, the performance of care, management, activity is is upside down. Care managers end up spending 60, 70%, sometimes of their time aggregating the data, and only about 30 to 40% of the time actually working with working with their patients, actually doing the care management that has to be flipped. If we're going to be successful. 

Christian Pean:  

Yep. 

Daniel Marino:  

So how is Revel AI changing that paradigm? 

Christian Pean:  

I love that. You know you are, you're absolutely right. In care management you really want to be able to focus your attention on the patients that need your direct care the most. We're helping to automate a lot of those touch points and that outbound outreach. So the care managers aren't spending all day on the phones playing phone tag, trying to, you know. Play whack-a-mole here. We outfit them with an AI dashboard and their own personal voice agent. It's going to be able to accept inbound calls from patients. Categorize those calls, risk, stratify those calls as they're coming in. And then, by the way, we're also flagging those patients so that if they are in a special bundle or program, you've got that immediately visualized for you. And I think that's going to make a huge difference. 

Daniel Marino:  

Huge difference. It's going to totally streamline, streamline, the workflow, I think, all the way all the way along. So when you started to work with the providers, particularly within the musculoskeletal areas. What's been some of the outcomes? How have you seen Revel AI make a difference?  

Christian Pean:  

We're saying we're seeing tremendous success. 

Daniel Marino:

Have you? 

Christian Pean:  

Yeah. Yeah. And I think that this is really speaking to the way that we've approached and partnered with the entities that we're working with. We're seeing an upwards of 80% collection of patient reported outcome measures. 

Daniel Marino: 

Oh, that's wonderful.  

Christian Pean:  

Yeah we're seeing on average, 91% of patients actually get risk stratified when they sign up for our care pathways. And we're seeing that our AI agent is handling on average 9 h of calls per provider, and that, I think, is just something that you can really quantify as a return on investment. This is really something that I think is going to change the way the care gets delivered, but also deliver on the promise of generating a return on investment for using this technology. 

Daniel Marino:  

Yeah, absolutely. You know, we've started to work with the different hospitals that are under the under the mandated program. And we have a, we have a readiness assessment. We have a checklist right? And if we've gone through that, the feedback that we've seen so far is the number one standout is the aggregation of the data. How do you actually, in your pre-surgical process? Right? How do you transform PAT the pre-anesthesia testing that all the hospitals do? How do you actually transition that to more pre surgical evaluation and aggregating the data, this is the biggest problem that some of these hospitals are solving for. And we're identifying that within the checklist. So I would imagine, as Revel AI comes in, you know. That's a big solution, you know, a big solution opportunity for you. 

Christian Pean:  

100%. You know, you're right. I mean, we have seen people literally using pen and paper to keep track of these patients, you know, excel sheets in various folders. There's no need for that. You plug something like this in at that preoperative assessment at the time of surgical booking, and then you let the system help surface the patients that need help. Risk stratify those patients, and then really start to change the way that care gets delivered in a measurable and impactful way. 

Daniel Marino:  

Yeah, well, this is great, and I'll tell you. You know I'm a big proponent of TEAM. I think it's got a lot of nice opportunities, but you know providers need to, they need to be proactive. 

Christian Pean: 

 Yes. 

Daniel Marino:  

And be able to manage this. If any of our listeners are interested in learning a little bit more about Revel AI, can you share the website, or maybe your contact information? 

Christian Pean:  

Absolutely, absolutely. I mean, you know, 1st off, anyone is welcome to reach out to me on LinkedIn. I love furthering these conversations just one on one wearing both my academic hat and my Revel AI hat on. Anyone who's interested in the platform can reach us at hello@revelaihealth.com. That's hello@revelaihealth.com. Our website is revelaihealth.com. I'm going to put a personal plug in here. I think that it's so important for surgeons to get more involved in value-based care and understand artificial intelligence. We're starting a site techie surgeon. There's going to be more information about that. We're going to try to help educate people on how to implement AI to really change care and move the needle on value-based care in particular. 

Daniel Marino:  

Well, congratulations to a lot of the great work that you're doing here. I really I agree with you. I think surgeons, now is the time for surgeons to get more involved in this, and it's just, It's a great opportunity, but they can't do it on their own right. 

Christian Pean:  

Absolutely, absolutely. 

Daniel Marino:  

Well, Dr. Pean, thank you for coming on the program. Really appreciate it, and good luck to you as Revel starts to really move forward and love to have you back. I want to hear some of these outcomes, especially as we move into closer to the launch date of January 1st. 

Christian Pean:  

100%. I think we've only scratched the surface. You know. I didn't even get to talk about how important bone health optimization is for these patients. Huge missed opportunity. I really appreciate being on the show, and would be excited to come back again. 

Daniel Marino:  

Well, thank you. I appreciate that. And for any of our listeners, if you're interested in finding out more around TEAM and even can connect you with Revel AI. As I mentioned, we have a lot of information on our website. We have a readiness assessment as well as a TEAM checklist that we're happy to share, and we're sending it out for free. So please take advantage of that. And again to all of our listeners. I want to thank everyone for tuning in until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care. 

In this episode of Value-Based Care Insights, host Daniel Marino explores the evolving role of artificial intelligence (AI) in population health. As AI continues to dominate industry conversations and drive vendor offerings,  healthcare leaders are faced with questions: What is real, what is hype, and where does the value lie? 

Dr. David Nash, Founding Dean Emeritus of  Jefferson College of Population Health and a nationally recognized thought leader in value-based care and population health, joins the conversation. Additionally,  Rick Howard, a seasoned Chief Data Officer and AI Strategist contributes to the conversation with his deep expertise in leading data-driven innovation across healthcare organizations. 

Together, they break down common misconceptions, highlight the most promising AI applications in care delivery, and offer practical insights into how health systems, providers, and payers can responsibly integrate AI to drive meaningful outcomes and return on investment (ROI). 

LISTEN TO THE EPISODE:

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As we think about the evolution of value-based care and population health, boy, there's a lot of activity that's going on. I've been doing population health now for probably around 15/20 years, and with now the increase in new technologies and in particular artificial intelligence, boy, there's just a lot of activity that's occurring. And along with that activity, I think there's a lot of misnomers as to what artificial intelligence is, how we believe it can support some of our business services, manage our population, all of that.  

I had the opportunity to go to the HIMSS Conference, oh, I believe in March, and again spoke to many of the vendors. And I think 90% of the vendors that were there had AI within their name. It's certainly the new, the new buzzword. So many of the questions I often get asked as I'm having conversations with leaders around the country is help in separating fact from fiction. Right? What can AI do for us? How do we make sure that the artificial intelligence that we're starting to incorporate within our processes is real, can support our outcomes, is worth it, is going to create some type of ROI on it if you will. 

 Well, I'm really excited today to have 2 wonderful guests, certainly experts in this area. 1st is Dr. Nash, Dr. David Nash. Dr. Nash is a board certified internal medicine physician. He's the founding Dean Emeritus of Jefferson College of Population Health. He's worked in the population health space for 25 years. Certainly, you know the expert when it comes to population health.  

My other guest today is Rick Howard and Rick is a senior leader, Chief Data Officer and has worked with a number of different organizations, and if there is any expert out there on artificial intelligence, it certainly is, Rick. So Dr. Nash, Rick, welcome to the program. 

David B. Nash MD MBA:

Thanks! Great o be here. Great to have Rick with me, for sure. 

Rick Howard:

Thank you, Dan, and same, and likewise great to be here, and great to be sharing the stage with Dr. Nash. 

Daniel Marino:

So, Dr. Nash, maybe we could start with you. When you think about where population health is going right now, you know one of the big challenges that we've seen is, it really falls on a couple in a couple of areas. One, how do we aggregate all of this data to make sense of it. There's always a challenge in having providers, physicians, care managers react to activities instead of proactively managing the care. And I think just performing to the right level of outcomes. You know, when you think about where we're going with technology, how do you feel like it's going to influence what we're doing on some of those areas that I mentioned? 

David B. Nash MD MBA:

Well, great question, Dan, and wonderful to be on a program talking about the future of population health, since I had the privilege of helping to start the 1st college in America called Population Health, edit the textbook, and edit the journal. So, now it's part of our everyday lexicon. Let me reassure you that 15 years ago, even on our own campus here in the great city of Philadelphia, nobody knew what we were even talking about. So, what a hoot and a half. Right? Okay?  

So now to try to answer your question. Well, look, you can't improve quality and safety. You can't improve anything unless you're measuring it. So even the measures are a mess right now. And then, you can't improve anything unless you have the right data in a timely severity adjusted non-punitive way. And the current electronic medical records, not to mention any names, but the outfit in Madison, Wisconsin, doesn't give you the data that you need. 

Daniel Marino:

Right. 

David B. Nash MD MBA:

It's basically a billing system, no matter what they say. So I'm involved with a host of fantastic companies around the country that are trying to do exactly what you described. For example, an outfit like Innovaccer in San Francisco, California, which sits on top of all of these medical records and literally sucks the data out of the EMR, out of the lab, out of the outpatient arena, out of billing, out of clinical details, and puts it all in one place for the clinician, and there are competitors for sure to Innovaccer. 

But we're only going to be able to improve care by giving clinicians timely non-punitive data about their own performance relative to a peer group. And then we have to teach them how to use the data to improve by standardizing care by reducing variation. 

Daniel Marino:

Yeah, and integrating it into their process, right?  

David B. Nash MD MBA:

Right. 

Daniel Marino:

It has become more of the norm than the exception. 

David B. Nash MD MBA:

And then we'll get to it, I'm sure. But we've got to then build the newer clinical decision support tools into the workflow, because I can't open more than 2 screens at a time. It's impossible, and most especially for the folks who are busy clinically still, not me anymore after 25 years. But you can't have the time and energy it takes away from the doctor-patient relationship. So, I'm really excited about all the new technology coming our way that will give us patient level data and population health level data. My only concern, Dan is, I hope I'm around to see it because, you know, we've been talking about this at HIMSS for 10 years, and I'm on the other side of the mountain. So, I really hope we get to see this technology. But the short answer is, you're right. We've got to pull the data from multiple places. 

 I would add one other thing at the patient level, we have to really harness those predictive analytics we've been talking about for 10 years, too, to prove that you're sicker than me. And you're going to need extra resources, and you might need a discharge planning, and you might need a social worker, and you might need, God forbid, a nursing home, and we ought to be able to know all that just as soon as possible. Let's remember the World Champion, Philadelphia Eagles had great predictive analytics on the field against those lowly Kansas City Chiefs, probably better than most hospitals. 

Daniel Marino:

Right, right? And it clearly worked for you so that. 

David B. Nash MD MBA:

And it clearly worked. That, that and the tush push clearly worked. 

Daniel Marino:

Clearly worked! 

So, Rick, let me turn this over to you. A couple of weeks ago you were on the program, and you made a couple of really interesting points. Right? You talked about the data. You talked about the opportunities that we have using artificial intelligence to really aggregate and make sense of that data. And one of the questions that I asked was, how do you know it's real? Right? So how do you know how to take this information, and you know, sort of I don't know, filter out the bias and really ensure that the information that we're getting out of our intelligence is something that can be then integrated within that workflow. Speak to that a little bit. 

Rick Howard:

 Would be happy to, and again great to be on, and certainly great to be here sharing the stage with Dr. Nash. But Dr. Nash is absolutely right. We've got a significant amount of data, even at the per-patient level that's out there. Any system is going to have to have clean data going into that system to make any sense out of it. So, data normalization is pretty much the step one. And it's not necessarily the easiest step when you're talking about data coming off of an EHR. 

But once you get past the normalization layer, then you start to really get into the exciting components. So AI can help with the ability to build a clinical model supporting a specific chronic condition and giving you those prescriptive and even predictive measures that need to be taken, or that you can start to anticipate, and how you're managing that patient, that specific patient. I'm not talking about all patients with a chronic condition. I'm talking about a specific patient. 

AI has the ability to do that by bringing the patterns together, understanding those patterns and then applying some of those patterns with additional information to a specific patient and their condition to be able to manage appropriately. 

That's the exciting area of AI, but it gets better. You start to think about that application of AI. Well, now, you've got digital assistants out there that can sit and communicate with a patient, have a dialogue with the patient. And there's been a number of studies that state, the digital assistants may actually get a more transparent data set from the patient than an individual would, because the patients are going to be concerned about being judged, or having bias against them for their behaviors, their habits, their specific norms. 

The more transparent that data is, the more rich that data becomes to be combined with the clinical data. And now you're having a legitimate conversation about not only clinical,  but behavioral activities for that patient that will better manage their specific chronic condition. 

Daniel Marino:

So that so that key, as I hear you describe this, right, is to take this data and to use it in such a way that we're much better informed about the patient. Right?  

Rick Howard:

Right. 

Daniel Marino:

So, Dr. Nash, as I'm hearing Rick speak to this, then it really becomes,you know, the role then, of the primary care physician, and in particular the specialist. Because I think the specialist is the one that's really been challenged here to use this to really provide more proactive care, right to think about that within their care model, and then frankly wrap around that care management service to help them drive with the patient what the potential servicing, the clinical service should be, and particularly the post-care outcome, should be. 

David B. Nash MD MBA:

Well, I think that's partially right, quite frankly. But I see the interface of technology and specialists, maybe in a different way. Let me answer your question first, and then I'll give you my sense.  

Daniel Marino:

Sure. 

David B. Nash MD MBA:

So sure, in ACO reach, which is largely, you know, ambulatory and then team, TEAM, which is mostly inpatient. Better data is going to mean more efficient care, less waste, better outcome, lower cost. 

Daniel Marino:

Sure. 

David B. Nash MD MBA:

But the data requirements are formidable. Now for Part 2, as it relates to the primary care doctor and the specialist, here's what makes me excited as a primary care internist. I want to have good data on the performance of the specialists in my network. And I wanna pick and choose who's gonna be in my network. Because, look the way we currently do this is the primary care doctors are in the network, and we might own one or 2 specialists, but most of them are out there doing what they've always done. Private practice fee for service. And we largely have very little idea about their performance.  

So, what I'd like to see Dan is incoming data on the performance of specialists. And then we decide who's in the network and who isn't with the ultimate goal of creating a high value, clinically integrated network, not a narrow network. I hate that term, but a high value network that can really deliver population, health.  

So I think, you know, that's where the data flow, the incoming information back to primary care on specialist performance which we could do today. We got to have the moral authority and the economic incentives to make it happen. 

Daniel Marino:

So if you're just tuning in, I'm Daniel Marino. You're listening to Value-Based Care Insights. I'm having a great conversation with Dr. David Nash and Rick Howard, talking about population, health and AI, and kind of the next generation of value-based care.  

So what I'm hearing you say, Dr. Nash, one of the things that you see as a real opportunity here is to aggregate this new, you know, this set of data. These new opportunities, using AI to help to inform us about what's happening with our network. 

David B. Nash MD MBA:

Exactly. 

Daniel Marino:

To drive that awareness with our specialists in the hopes of making some type of behavior change. 

David B. Nash MD MBA:

Right. So let's look around the marketplace right now, right, in the middle of 2025. There are organizations that are stealthily committed to doing this right now. We had 3 of them on stage at our 24th annual Population Health Colloquium here on our campus at Jefferson, Philadelphia, just a month ago.  

So for example, Risant right? So Geisinger, Cone Health. These are outfits that know what they're doing. They're going to benchmark. They're going to compare data. Then, when they take additional delivery systems under the Risant umbrella, somewhere around one per year for the next 4 or 5 years. Imagine the data capabilities, of 4 or 5 places under the Risant umbrella. That's 1 great example.  

How about Craig Samitt leading longitude health with the 5 amazing, gigantic delivery systems? Imagine being poor Craig with 5 big bosses, but beside that they'll be able to benchmark, too. Depending on how level the playing field is. 

And then how about Populance? You know. Henry Ford thinks that it's got the secret sauce, and is so convinced of that that they're going to let Chris Stanley go out and sell it and deliver data and tools and care coordination and guidelines and care processes to other places. So look, this is happening. 

Daniel Marino:

Right. 

David B. Nash MD MBA:

I think, you know the folks out there who don't track these kinds of things. And, after all, you know, this is what Rick and I do for a living in part. I think folks are going to wake up one day and say, Holy Mackerel, I'm behind the times, let's get with it, and we're not talking about just an EMR. Let's just once again. That's, that's old hat. 

Daniel Marino:

Going beyond EMR, absolutely. 

David B. Nash MD MBA:

And then the final piece for me, which is really exciting, especially because I have forgotten more medicine than I ever learned. 

I'm excited about all the clinical decision support tools that are being developed that could be embedded into the workflow, and tools like OpenEvidence. Tools that folks like Walters Kluwer are working on combining stuff like Avid and UpToDate. I mean, it's just super exciting. 

Daniel Marino:

It is. It’s super exciting and just tremendous amount of momentum from some of those organizations that you mentioned.  

So, Rick, let me turn this over to you, though, you know. So Dr. Nash just went through a whole host of different organizations. And you know, embedded functionality. 

When you look, and you're seeing the landscape of where artificial intelligence is going, now. I sort of put it into 2 categories right? There's the advancements of the business services, and how we can do more with less and create greater performance. But there's also a lot of clinical support services out there that AI has a big opportunity to really provide some advancement, solve some problems. 

Where do you see both of those at? Is one further along than the other? 

Rick Howard:

Well, I think maybe the administrative side might be a little further than the clinical side. But Dr. Nash just made an important alignment around how you support a clinical workflow. 

We need to look at things in the form of, “How does a physician get an instruction inside of their sourcing system so that they're following a best practice”? The industry calls that a computerized clinical practice guideline. AI driven computerized practice guidelines that are already interfaced, or, more importantly, interoperable with an EMR can slide that instruction into the EMR, even to the point of a change. Think about making a change as simple as going from a IV based antibiotic to a tablet based antibiotic. Most people don't understand. There's a significant cost alignment between those 2 particular distribution points of an antibiotic. 

If we can trigger that decision inside the EMR to say it's time to move, based on all of the data that the AI engine has now formulated and understands where the patient is at that particular point in time. You can now make that switch between the IV based antibiotic and the tablet based antibiotic. 

That is a simple example of a very much of a much broader application of these capabilities to drive these best practices. And the beauty of AI is, it's continuously pulling in data. So those best practices are changing continuously based on the fact that it's pulling data through. 

Daniel Marino:

So then, Dr. Nash and I know this is your area of specialty here. It just leads me to believe that you're hearing a lot in the media about the advancement of greater diagnosing, of, say, cancer and other illnesses that are really impacting our population. From a clinical perspective, what are you seeing in terms of that advancement of a lot of that clinical support, a lot of the clinical servicing. 

David B. Nash MD MBA:

Well, I think we're seeing a quiet revolution. I think our listeners are super sophisticated, and they know in fields like radiology and pathology, where machine learning has been in play now for 7, 8 years, we're getting better diagnostic accuracy. We're improving our efficient approach. We're reducing waste. We're reducing error when it comes to making diagnoses. And I'm excited about what the future potential is when we can put all of this stuff together. 

Yeah, on my phone I've got, I alluded to OpenEvidence. I mean, these are incredibly sophisticated. It's ChatGPT 4.0, almost, on the clinical side. If I had a tool like this, when I was a intern and resident, would have been the most fantastic thing. 

Daniel Marino:

Oh, my! Gosh! 

David B. Nash MD MBA:

Saved me a lot of time. I would have slept a lot longer, so I can just imagine what my, you know, 38 year old Doctor daughter is going to have in her fingertips in the next 5 years at the bedside. So I'm excited about all of this, but I also think, you know, it's still culture change and and getting physicians to implement this into the workflow. We're only gonna do it, if it doesn't disrupt what we do every day, and if we believe in our heart that it will enable us to do a better job. And so all the technology in the world, we know culture eats technology before breakfast. So while it's great, I think we have to also think about the human machine interface and the workflow. 

Daniel Marino:

How about some of these companies out there, you know, and I'll bring up one. You know. We had talked about early on Artera. 

David B. Nash MD MBA:

Yeah. 

Daniel Marino:

Really allows for just a vast number of aggregation of data as they begin to look at different clinical outcomes and so forth, to create diagnosis and probability of diagnosis, and probably probability of treatment. 

David B. Nash MD MBA:

Yeah. 

Daniel Marino:

Speak a little bit about that. 

David B. Nash MD MBA:

Sure. 

Daniel Marino:

Because I think that’s really a game changer as we see it. 

David B. Nash MD MBA:

Sure! 

Daniel Marino:

And that revolution that you mentioned. 

David B. Nash MD MBA:

Yes, and again, you know, I'm excited about Artera and many other clinical databases which use AI enhanced capabilities. Artera is on the West Coast, and they have a 250,000 person data set of, you know, believe it or not, prostate biopsies. 

And so for guys like me, who have had a prostate biopsy, and I got it read by an academic great person at Jefferson. But then I said, hmm, 250,000 patients versus 10,000. I'd love to have my slides read by that outfit, and so I managed with my academic urologist as my great doctor, send my slides off to Artera. Of course there's Jefferson graduates at Artera to help put all this technology together. How exciting! And look! It's not the end, all or the be all, but it's certainly as from a patient perspective, I found it very reassuring to learn that, yeah, I'm in a super low risk category, based on tens of thousands of men my age with my diagnosis. 

And let's extrapolate that to pancreatic biopsies, lung liver, kidney. I mean, we're going to be able to do all of this and do it efficiently and effectively at a pretty low unit cost. 

So these technologies are amazing. And I believe that companies like Artera and many other GRAIL being another great example, you know right now, the gallery test is, I think, something north of 40 potential cancers. Well, you know that they're going to add 40, 50, it'll be 60 cancers, both, you know, liquid biopsy for solid tumors and others. This is going to be continued to be super sophisticated. 

Daniel Marino:

And I think just building off of that. It just creates another information point where it allows providers, specialists, even patients, to be much more informed. 

David B. Nash MD MBA:

Yes. 

Daniel Marino:

Going back to that, that overall philosophy and population health. If you're really going to make the change, you need to be proactive. 

David B. Nash MD MBA:

You need to be proactive. 

Daniel Marino:

Totally supports it. Right? Totally supports that drive. 

David B. Nash MD MBA:

I would say. The last thing that I'm really excited about is what AI is gonna do for clinical trials. Right? So I mean, that's a topic we could have another hour on, that. We ought to be able to reduce the number of folks in trials we could do n of one trials do them, you know, so quickly, so efficiently. Get people of color, get women get all kinds of diversity. I mean, this is gonna blow apart the sort of, current CRO structure. 

Daniel Marino:

Oh, it's gonna allow us to move so much faster. So, Rick, you know a lot of listeners from the provider community, right? We've got you know IT leaders on here, CEOs, CMOs, many hospital leaders. You know, it's challenging right? In my earlier comments I said “It's hard to figure out fact from fiction”. Right? What advice would you give to some of these senior leaders, the CMOs of the world, who are who are excited about this, and to be careful not to get wowed by the technology, but to really focus on those things that are going to create a lot of good value. Any suggestions come to mind? 

Rick Howard:

Yeah, and I actually understand where you're coming from, Dan. There's a lot of noise in the signal out there, and so we've got to separate the signal from the noise. And I think, though there are some areas where there has been some very tried and true AI based solutions. Ambient listening is one of those. What a game changer from the perspective of allowing the doctor to actually be face to face with the patient and have a conversation about the problem instead of being face to face with the computer. 

Dan Marino:

Sure.  

Rick Howard:

So I think ambient listening is one of those. I think digital physician tools, and I think Dr. Nash just spoke to one of those. Digital tools that allow the mass of information that's being created quite frankly, hourly, on the healthcare front, to be at the physician's fingertips so that they now have the information to make the right decisions. And then I'll go back to the digital assistants, giving a doctor a digital assistant so that they can not necessarily even type a question, Ask a question. And get that answer coming back to them.  

So I think there are tools out there that are going to make the doctor's life easier. And I'm sure Dr. Nash will agree with me. I'm excited, because not only does it allow the doctor to focus on the patient, it's also optimizing the doctor's visit timeframe to where we can start to eliminate some of the burnout that's being caused by pajama time, as I call it, with all of the work that has to happen after they leave the clinics, or after they leave the hospitals. 

Daniel Marino:

I think we're gonna see, we're gonna see this technology moving fast and furious. I think I think at the end of the day it's gonna come down to what makes sense for the organization, and how you could truly incorporate that change, those opportunities into your population health strategy.  

Well, gentlemen, I mean I appreciate your time. Boy! Quick half hour! We could have talked about this for another hour, hour and a half at least. I'm so excited to see where this is going, and I'll tell you I'd love to have you back on. And particularly you, Dr. Nash, as you start to kind of work through some of these organizations and seeing some real results of what AI can do. I mean to tell those stories is just so exciting.  

David B. Nash MD MBA:

Super. Well, I look forward to it. Hope you have us both back. 

Daniel Marino:

Absolutely! Absolutely, Rick, thank you as well, too. Appreciate it! 

Rick Howard:

My pleasure! 

Daniel Marino:

And I want to thank all of our listeners for tuning in. Without you, Value-Based Insights would not be as successful as it is. Until the next Insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.