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As healthcare organizations move from AI curiosity to real-world implementation, many leaders are asking the same question: where do we actually begin? As the industry heads into 2026, providers are under pressure to move beyond experimentation and apply artificial intelligence in ways that deliver meaningful, workflow-driven impact without adding technology overload. 

In this episode of Value-Based Care Insights, host Daniel Marino is joined by Don Woodlock, President of InterSystems, to explore how healthcare organizations can take a more strategic and disciplined approach to AI adoption. Drawing on InterSystems’ deep expertise in interoperability, data platforms, and AI-enabled solutions, the conversation focuses on where AI can truly enhance clinical workflows, reduce administrative burden, improve revenue cycle performance, and support better decision-making. 

From ambient clinical documentation to smarter data connectivity and actionable AI insights, this discussion cuts through the hype to highlight how healthcare leaders can build an AI foundation that drives real value for clinicians, patients, and health systems, all while advancing the goals of value-based care. 

LISTEN TO THE EPISODE:

 

 

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Reflecting back on 2025, an issue that many of the healthcare leaders worked through was, of course, how to really make sense of artificial intelligence, and really the practical approach related to AI. And we've spent quite a bit of time talking about different solutions on the program, but, you know, as we start to think about moving into 2026, many IT leaders, many healthcare leaders are still thinking about what that practical approach is on incorporating artificial intelligence into both their business workflow and their clinical workflow. And it's created some real challenges. And the challenge is really around the potential distraction that artificial intelligence can create within the organization. So when I… when I've talked to many leaders within hospitals and with health systems across the country, they're asking quite a few questions around how do they begin to really evaluate what is that practical approach around artificial intelligence, and frankly, where do they start as they think about integrating it into their clinical operations, into their workflows, and so forth. And some of it has just been incorporated, right, into the technology that they have, you know, incorporated in their organization. For instance, EHRs have started to introduce ambient technology that has started to create some nice value for many of our physicians and our providers. Also, on the billing side, we've also seen a lot of opportunities around appeals and pre-authorizations and things that have been integrated into the practice management solution and have helped, really, our revenue cycle. But I think we've got a lot… a lot more… a farther place to go, a lot more to really consider as we think about how to practically integrate AI into our operations.

 

Well, I am really excited today to have a guest that has a lot of experience with artificial intelligence. Don Woodlock is president of InterSystems. InterSystems, as many of you have known, it's a long-standing technology solution. It's been involved in many hospitals and health systems over the years. We've had the experience of working with InterSystems as well as some other solutions, and InterSystems has always done a nice job of creating interoperability between disparate systems and creating that connection of data and technology. Don, welcome to the program.

 

Don Woodlock:

Daniel, great to be here. Looking forward to this.

 

Daniel Marino:

So, Don, maybe we could start a little bit with, where InterSystems is at right now. As we talk a little bit about the practical approach of integrating artificial intelligence as a solution, both into clinical operations, into business operations, into thinking about what that… that value is. Talk a little bit around where InterSystems is with… Trying to provide some of those solutions.

 

Don Woodlock:

Sure. If you don't mind, let me just start just with a few minutes on what InterSystems is before I kind of layer AI into that equation. I appreciate the kind words, we've been in the market for a long time. One of the centerpieces of what we do is interoperability solutions in healthcare and beyond, so making sure data can move around, can come together, can be reformatted, and that an organization can really have the data be where it's needed for decision-making and all that, good stuff. So we've been a long-standing interoperability player. We're also a data platform where people build applications on top of us. You know, most famously, Epic is built on our technology, so many… we have many customers, indirectly that use our technology in that way. And then we also have health solutions, most notably an outside the U.S. electronic health record, which has been a great, great area for us to introduce AI as well, but a number of solutions inside, inside the U.S. as well, targeted at kind of interoperability use cases, Master Patient Index, or ePrior authorization solutions, you know, things like… things like that.

 

Daniel Marino:

Yeah, so you're really touching all areas of the technology and integrated with the different technology, which puts you in a fantastic position to really start to take advantage of artificial intelligence and probably provide a lot of that value to the hospitals and health systems.

 

Don Woodlock:

Yeah, it's actually kind of an amazing time, because. Gen AI, in particular, can have a very positive impact on a lot of the areas that we work, so we've been quite enthusiastic adopters of the technology throughout our products.

 

Daniel Marino:

So, when you're… when you're working with some of these hospitals and some of the health systems right now, given the platforming, given the integration of your platform with the different technologies, where are you seeing most of the practical value or the practical, let's say, implementation, realization of AI coming from?

 

Don Woodlock:

Sure. So, I think we all, are enjoying our first win in Gen AI for providers, and that is ambient. As well, which you… which you mentioned. I was at… you might have been there as well. I was at the CHIME conference a few months ago, and it was really just a high-fiving each other around… around Ambient. Everybody was feeling good. about what we've collectively done as an industry. And this is lots of vendors, you know, in that, in that frame, but it's a great use case of Gen AI, it's a great kind of burden, or a large burden on physicians and clinicians, the documentation of what occurred, and people have done a great job, you know, of putting in place solutions, both building them and adopting them in health systems. And we have our own ambient solution that we built natively in our own EHR, and that's been a huge, huge hit.

 

Daniel Marino:

That is a quick win. And I… and I agree with you, you know, I've had some opportunities to talk with, many, many physician leaders who've taken the lead on really driving a lot of that, both designing it for their clinical workflows, but then also experiencing it in real time in terms of how it's impacted their delivery of care. And all of them said the same thing. I mean, it's saving them time, the information that they're getting is much more robust. And it's like the wow effect, right?

 

Don Woodlock:

Yeah, yeah.

 

Daniel Marino:

To experience it, we're seeing this value, and now folks are saying, okay, well, what's next?

 

Don Woodlock:

Yeah, sure, sure. And I think that, in terms of questions about what next, the other… what's next? The other area that we're doing a lot of work on is around, kind of, clinical summarization and a chat experience for a clinician to learn about the patient. Okay? So, you know, tell me about this patient. Have they been in here before for this? Do they have any history of cardiac disease? Is there anything from any other health system, you know, that I need to know? Sort of check the national networks, bring in relevant data? You know, that whole process of learning about the patient, do they have any risk factors for the surgery that I'm thinking of giving, to them. I mean, it just saves an enormous amount of time hunting and pecking their way through the chart, you know, for information that may, may be relevant for that.

 

Daniel Marino:

And I would even imagine, building on that. And this is where I think InterSystems has such value. Being able to aggregate all that data, but really synthesizing the data into critical information that could drive performance, right? Really help with diagnoses, help with the prognosis, help with the care plan in such a way that, you know, in such a way that we've never had that level of synthesized information like we've had now. I can only imagine that's just got to be a huge value driver for a lot of our physicians.

 

Don Woodlock:

I mean, absolutely. So, let me give an example. So, we, last year launched a product called our Health Gateway, Inter Systems Health Gateway, and it allows a provider to connect to national networks and bring that data in. So we keep track of a lot of stats, including our largest patient. So our largest patient, somebody asked for the patient record, and 4,800 documents came back. 4,859 documents. Now, what are you going to do with that.

 

Daniel Marino:

Exactly. Nothing. Yes. Nothing.

 

Don Woodlock:

I mean, nothing by itself. So our technology, of course, parses it all, so we can kind of, you know, have a single problem list, med list, allergy list, so that's good… that's good, too. But then Gen AI… Gen AI's happy to look through 4,800 documents, you know, synthesize it for you, or kind of answer, you know, dig through to find a question like, you know, is this a veteran that's had burn pit exposure, and just kind of find that and answer your questions. So, sometimes I think about it as… as the more success we have with interoperability, like bringing data together, like… like that, the more we create these giant charts. In a sense, and the more we create more information that can be digested easily through the old-fashioned user experience of clicking around.

 

Daniel Marino:

Yeah, absolutely.

 

Don Woodlock:

Gen AI is a really great… I mean, it's a well-timed solution. As we get better with interoperability, applying GenAI from a user experience point of view is really necessary, actually, for the Commission to get value from all this data that we brought together.

 

Daniel Marino:

Well, absolutely. I think it just helps define the path, right? Helps really define how we can provide more robust care plans and more, let's say, focused care delivery to patients who may have some challenging cases. Let me ask a little bit, though, around workflow. Are you seeing a lot of the clinical workflows, even the business workflows having to change because of the new AI technology and the information that we're getting? Or are you seeing that the workflows are actually pretty good, the information that we're giving right now is just allowing us to move faster through the workflows?

 

Don Woodlock:

Well, I would say that when the workflow doesn't need to change too much, it's gonna help with your AI adoption. So I think some of the early cases are partially because the workflow doesn't need to change too much. So let me… let me just… let me just, elaborate on Ambient a little bit part of the reason it's successful is just the wow of the technology, like you mentioned. It's just kind of amazing. It takes an audio and now gives me a nice soap note and what have you. But part of it, the reason that it's been adopted, is we already had a workflow a long time ago, you know, using dictation firms, and then using voice recognition, and then using scribes. You know, we've had, you know, Gen AI Ambient kind of fits into Kind of a multi-decade process that we've had of helping physicians with this task. You know, so we kind of slotted it into a workflow that people understood. There's a good human in the loop, right?

 

Daniel Marino:

Right, absolutely.

 

Don Woodlock:

It's the human that was just there with the patient. So it's the right human, they remember what happened, they sign the note, it's all good from a human-in-the-loop point of view, and everything's been worked out because of these prior things like scribes and dictation firms around the legal risks, who's responsible for inaccuracies, all that stuff's been worked out with prior versions of the technology, so Ambient really, in addition to having a lot of technical merits, it had a lot of workflow and legal things going for it. It was a familiar territory that it kind of slotted into.

 

Daniel Marino:

Slotted right in, because there was a lot of, to your point, there was a lot of pre-work and foundational elements that were in place that helped to guide it. If you're just tuning in, I'm Daniel Marino, and I'm here today talking with Don Woodlock, president of InterSystems, and we're talking about the practical deployment of artificial intelligence within hospitals, within the provider community. Don, I want to touch on an important topic that I think is guiding a lot of the decisions right now of many of the hospitals and healthcare leaders. Are you seeing the technology being deployed as a next generation of the technology, or is governance of AI within hospitals and health systems informing the decisions on what technology… what AI technology or AI-attributed technology should be implemented. Is it the technology, or is it the governance that's guiding it, or should govern… should guide it?

 

Don Woodlock:

I mean, well, it's… I think the governance should guide it, and since it's cost money, you know, some of these, solutions, I think it's getting…you know, visibility at the top. I do think having a really good governance process that you're happy with, that works, is an important part of AI adoption.

 

Daniel Marino:

Yeah, because I'll tell you, this is new, this is… this is new area for many hospitals and health systems. A lot of them do not have AI governance, and, you know, we've… a lot of them don't even under, you know, they have data governance, they have governance in, you know, managing, you know, medical groups, you know, they have different levels of governance, board governance, all that. But AI governance has not been something that they've tackled right now, and many of them are trying to figure out, well. What does it mean? How does it work? How do we start to integrate it?

 

Don Woodlock:

Yeah, and some of our earliest AI projects, which predated Gen AI, but just doing, you know, old-fashioned machine learning type of things, they would get slowed down for months while the health system figured out, well, who needs to approve what, and who do I need to involve, and, you know, without… you think of governance as slowing you down, but it's not correct, actually. Yeah. You know, getting governance in place, having it work, having a process, having the right stakeholders involved, having the right subject matter expertise on AI, that kind of… that kind of thing. It allows everything to move fast once you…to get that set up. And until you get that set up, you're gonna move slowly. And so I would really encourage every organization to sort of get their act together on that front.

 

Daniel Marino:

Yeah, I agree with you. I think having strong governance, you know, it's sort of, you know, it helps you define the North Star, right? Where you want to go, and to your point, it helps you move faster. So, you know, one of the vendors that I've been working with, technology vendors that we've been working with is doing a lot of work with aggregating data and putting some probability models together. That is informing both, the let's say, probability of a patient having an issue that would be exacerbated versus also defining what the right course of treatment should be. We're seeing a lot of that within cancer, right? So cancer, through a lot of these trials, are starting to aggregate all this information and put some of these models together. I guess two questions for you there. You know, how do you see some of that integrating with generative AI and also with the care models? And then second to that, how should hospitals and health systems start to take advantage of that as an opportunity.

 

Don Woodlock:

Yeah. Well, on the… on the sort of probability of an event happening, kind of the prediction aspect of models, you know, I… I… I personally, in our company, we were a big fan of… of this. Re-admission, you know, no-show appointment, you know, length of stay, you know, calculate, you know, those kinds of things, and I feel like none of that… that… none of it, but it really didn't take off in healthcare. I mean, Gen AI…was really the, I think, the eye-opener for AI in, in healthcare, and these predictive models only had, you know, so much impact. I think they'll actually be used now more, that sort of the AI door is open, the governance groups are there, people are more comfortable with it, and get a feel for how it how it might work, and so… so I think it'll actually, grow to some extent now. They can go together, which is kind of the essence of your… of your question, where you could have specialized models that you kind of fine-tune on your own data, your own situation. That sort of thing, but plug them into a larger agentic, you know, and Gen AI.

 

Daniel Marino:

Yeah, and I think, you know, you bring up a good point. I think first is trying to really understand the capabilities of Gen AI, right? And how do we… you know, and for hospitals and health systems to really start taking advantage of that, obviously the ambient technology. But there's so much more that it can begin to do, and especially if you start to incorporate that into your predictive probability modeling. And, you know, we talk a lot on the program about value-based care, and to move into more prospective monitoring of patients and using generative AI using some of these probability models to identify, more focused approaches to that high-risk cohort, or the rising risk cohort, for instance. The value drivers coming out of that, I mean, to me, just seems like it's enormous.

 

Don Woodlock:

Yeah, and just let me riff off what you're saying. You can imagine the following combination of technologies. Like, you use a predictive model to sort of have your highest risk patients bubble to the top. Whatever that might mean. Assigning case managers, putting them on the top of work list, whatever. And then you use Gen AI and, like, Agentic frameworks to help you get your work done. What's going on with this patient? What would some good next steps be? Can you arrange this? Can you help me arrange that? That kind of… that kind of thing, where Gen AI can really help, and Agentic AI can really help get… get some of the work done. But you can use some of your more experienced models to sort of bubble up those highest risk cases to the top.

 

Daniel Marino:

Well, I tell you, that's such an important point. So, really, what you drew out here is two value props that really should be measured, right? It's how you're using generative AI to identify, you know, that real high-risk cohort, or what have you. In your example, but also then creating the right level of information to increase efficiency of your team. So it really, if you're doing this the right way and focusing on both, those two value propositions are really what's going to drive a lot of phenomenal outcomes for you, and probably wrap into your ROI, I would assume.

 

Don Woodlock:

Yeah, I mean, to be very generic about what you just said, the first is a use case around where to focus. Right? Which patients should I focus on, or which claims are about to get rejected, and I should focus… you know, whatever. So where to focus is a good use of AI in a general way, and then speeding up your work tasks. Right. Some of your work tasks is, like, what's going on in this… with this patient, or this patient situation, and… and GenAI, like I said, they're happy to read those 4,800 documents, give you a summary, that's all… that's all great to a computer, not… not so friendly to a human. So, kind of helping you understand what's going on, and then get some of your work done.

 

Daniel Marino:

Yeah, yeah, I agree. So, Don, given where we're at right now, and, you know, you kind of touched on this earlier, right? The governance is important because these technologies, you know, they're not free, there's a cost to it. Are we starting to see the ROI come through, or are we still a little ways away from that?

 

 

Don Woodlock:

I think generally speaking, we're a little a ways from that, and part of it is our first, like I said, our first home run, we…many health systems did not focus on a hard ROI for ambient. They focused on physician, burnout, wellness, satisfaction and I applaud them for that. I mean, you know, it reminds… it reminds us, it reminds me that healthcare is not strictly a dollars and cents business. It's about something more important, and I think we've demonstrated that with AI so far. I think it… I think it's gonna be hard to ROI soon enough, you know, when we get to the impacting the billing, when we speed up work, and get more productive, those kinds of things. I think it's gonna be, easier to measure the ROI, and we're gonna demand it. And I think it's… I think it needs to be part of the conversation, so I'm not just a, let's just use AI, it's a great tool, it's a lot of fun, you know, I'm not that kind of… I wouldn't say that that's a good idea, but I think it's… I think it can be hard to measure the ROI in the early days of something.

 

Daniel Marino:

Yeah, I agree with you. I think there's that intrinsic value component, but I do feel like, you know, given where the continued strain on margins are, we have to keep our focus on the investment, and then what the potential opportunity is gonna… going to come out of that. Well, Don, this has been… this has been great, and I know, you know, a lot of our listeners valued a lot of your comments and your advice, and thoughts around generative AI, and certainly that practical approach. Any piece of advice that you might give to some of our listeners, those that are really thinking about advancing their AI strategy, or even integrating a lot of the capabilities that they're starting to come across?

 

Don Woodlock:

Yeah, I would, I'd say two things, maybe. One is, I think it's a good practice to align with your major vendors. So, they're gonna be rolling, and I'm thinking of the EHR vendors, maybe.

 

Daniel Marino:

Sure.

 

 

Don Woodlock:

They're going to be rolling out AI capabilities, you're going to be part of a community of other systems that are using it as well. I think that's a nice, good place to start. And a good center of gravity for your AI initiatives is to do it that way. And the second thing I'd say is we, you know, as you deploy AI, there's an impact… there's an impact of the data and the connection to your other systems that make AI really work. So if your data foundation is not so good, it's scattered, your data's kind of messy, your AI is going to be equally, you know, inaccurate, not as,you know, not as capable. And I would say, from an interoperability point, you know, Agentic AI is all about connecting… allowing AI to connect to the systems that you have and get some things done. And so having an interoperability framework that makes sense, that brings your organization together, is also going to empower your AI to really work well for your employees.

 

Daniel Marino:

Oh, great points. I agree, Don. I really appreciate that. Well, I want to thank you for coming on. This has been a great conversation, very enlightening for me. You obviously, you know, have had some great success, and I wish you and InterSystems a lot of success as you go forward, and work with a lot of hospitals and health systems. I mean, you are at the forefront of change. Frankly, we all are, and it's quite exciting.

 

Don Woodlock:

Great, thank you, Dan.

 

Daniel Marino:

If any of our listeners are interested in connecting with you, or maybe learning a little bit more about what the solutions are that InterSystems brings to the table, can you share your, contact information, or maybe direct them to your website or something?

 

Don Woodlock:

Yeah, two things. I mean, come to our website. We have all of our intersystems.com, we have all of our solutions outlined there, and certainly contact us if you're interested in any of that. And then feel free to connect with me directly on LinkedIn. I also have a video series called Code to Care, which is on LinkedIn and associated places where I explain these AI concepts. I love teaching, so it's a bit of a side job, but… Yeah, that's great. If you'd like to learn more about AI, you can connect with me on LinkedIn.

 

Daniel Marino:

Well, that's wonderful. Well, thanks again, Don. I really appreciate your time. Great conversation. And if any of our listeners are learning a little bit, are interested in learning more about this topic or any of our topics that we talk about on Value-Based Care Insights, please contact me at dmarino@luminaHP.com, or feel free to visit our website at luminaHP.com. I want to thank everyone for tuning in and listening. Until our next Insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

Artificial intelligence (AI) is rapidly reshaping healthcare, yet many provider organizations still struggle to move from interest to practical application particularly when it comes to value-based care contracts. While AI promises efficiency and insight, turning it into measurable performance and financial advantage remains a challenge. 

In this episode of Value-Based Care Insights, host Daniel Marino explores how AI can be used to address one of healthcare’s most complex challenges: evaluating and managing value-based contracts. Drawing on real-world experience, Daniel explores how AI can be used to build performance models that connect contract design with operational outcomes across clinically integrated networks, ACOs, and other value-based arrangements.

Joined by Eddie Diaz, a data scientist with more than 15 years of experience in value-based care analytics, the discussion highlights how AI can bring clarity to attribution, risk, quality, and financial performance to help CFOs, CMOs, and managed care leaders better understand contract opportunities, risks, and results. Together, they explore how AI can move beyond hype to deliver real, actionable value in value-based care contracts.  

LISTEN TO THE EPISODE:

 

 

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Like the rest of the world, all of us are trying to figure out what artificial intelligence means. And, for many of our listeners, if you've been tuning in, we've had a number of episodes, a number of conversations with guests talking about, the impact of artificial intelligence, AI, on healthcare. Everything from business operations to the impact on clinical diagnoses, how we can incorporate that in clinical workflow, and so forth. So, within our consulting firm, within Lumina Health Partners, we as well have been trying to figure out how to incorporate artificial intelligence and I've thought for a while that as we start to incorporate this into a lot of the work that we're doing, it could certainly create a lot of efficiencies, but like with everybody else, we were trying to figure out where. And for years, with a lot of the work that we've been doing, one of the areas that I've constantly been challenged in is coming up with a contract management tool, contract evaluation tool, that is really geared towards value-based contracts, And a tool that could really help CFOs, chief medical officers, managed care officers, a tool that could help them evaluate value-based contract. And how to really see the opportunities and the performance outcomes, that would come out of a contract. And a value-based contract is challenging, right? Because you have a lot of other variables that aren't in a fee-for-service contract. You have attribution, you have, you know, different definitions of risk. You know, you're thinking about the different programs, and oh, by the way, quality is also an important component. So it's been very difficult to create a contract management tool, and frankly, I've worked with a number of analytic companies to try to create one.

Well, I'm really excited to share with you today the work that we are doing around artificial intelligence, and how we've created our own performance model, that is driving, or let's say, correlating a value-based contract with actual operational performance outcomes within a clinically integrated network, an ACO or some type of operational value-based performance. It's quite exciting. And here to help me talk through this is my colleague, Eddie Diaz, and Eddie is phenomenal. He's a data scientist by nature. He's got 15, over 15 years of experience within value-based care, and has worked with numerous organizations on creating different analytic products, and is just really a super, super knowledgeable in artificial intelligence capabilities. Eddie, welcome to the program!

 

Eddie Diaz:

Thanks, Dan. Appreciate it. Excited to talk to you.

 

Daniel Marino:

So, Eddie, let's talk a little bit about the performance model. You know, we've worked on this with a few clients and have been refining this. For our listeners, talk a little bit about the robustness of the model, and maybe you can start a little bit with the data ingestion.

 

Eddie Diaz:

Sure, sure. So, the model fundamentally looks at a variety of different data formats, right? So, if we work with healthcare data, we have a lot of data in image files, or native versus you know, image PDFs. There's also a lot of documents that exist in terms of, PowerPoints. And then there's a lot of flat file data, like Excel-based data. All that kind of is disjointed. And the beauty of what we've done and what we've accomplished is that we've been able to extract all of that with extremely high fidelity, unify it to make it understandable, so from the contract, whether it's a PDF, from the payer reports, whether they're in PDF or Excel-based versions, we can unify all that and give it a semantically representational layer that can start to put intelligence in connecting all the dots.

 

Daniel Marino:

Well, and I'll tell you, one of the things that impressed me about what we've been able to do is that for one particular client, for one particular health system that we worked with, we ingested a tremendous amount of data, right? If I… if memory serves, it was something like, you know.

 

Eddie Diaz:

I think it was about 100 billion, right? So 100 gigabytes of data.

 

Daniel Marino:

Yeah, claims data, plus the documents that came back from the payers, plus the contracts, right? And we did this, you did this, in a relatively short amount of time. I think it was 7 or 8 weeks, which was unheard of before AI. I could recall a couple years ago working with a large analytics vendor, one of the top analytics vendors, and, you know, I think we've ingested probably a quarter of this data, and it took, at the minimum, 3 months. And to semantic align this data still was a bit of a challenge. I mean, it was really impressive what you all were able to do.

 

Eddie Diaz:

Yeah, one of the things we can highlight is how even just a year ago, with the advancements of these models, they're becoming more and more robust with increasing efficiency and productivity, that a year ago, we would have needed probably 2 or 3 other resources. And today, and maybe 6 months of time, whereas today we have weeks, and we need less resources. So it's an incredible achievement, and it's incredible how we could pass that on to the clients.

 

Daniel Marino:

So, a lot of times in these contracts, where I see the breakdown occurring is you've got the managed care team negotiating what they feel is a pretty strong value-based contract with the payers. And, you know, again, the value-based contract could include an MLR target, or a total cost of care target, maybe a RAF score, some quality components, and that sort of thing. And, you know, so that exists in the contract. And where I see the real gap occurring is the alignment with how that information then is either supported by clinical operations, or how clinical operations could support the performance of the contract, right? So one of the things that, you know, I'd love for you to talk a little bit about is how the performance model helped to close that gap. What did you see? And let's start with maybe MLR, because I think that's… this is a big area of focus. What did you see as an output of the model that helped to close the gap around the medical loss ratio, in terms of what's in the contract and the performance. By the, you know, by clinical operations.

 

Eddie Diaz:

Yeah, so one of the things that we were… that we were seeing is, because we can extract the key terms and the key drivers of the contract performance directly from the contract. Measure that up against the financial and quality outcomes. We can have a very clear line of sight on terms… in terms of what are the performance levers that these individual providers need to achieve. So, we could discover that if there's a gap, like we've seen in certain clients, of 5-10% between their MR and their actual performance, there are certain key utilization areas that we can highlight where they're significantly underperforming. Right? As well as quality gaps. So, in terms of utilization, we could identify, you know, high specialty to, to, high specialty per 1,000 performance, right? Right. Or, you know, or conversely, low PCP access, you know, as measured by PCP visits per 1,000. So those are some of the key levers that we were highlighting to say these are where your areas are. If you start to kind of change that juxtaposition, we can improve that baseline and get your MLR to where it needs to be.

 

Daniel Marino:

Well, and I'll tell you, that's a big challenge for a lot of organizations, because especially when, you know, you're thinking about the performance of these Medicare Advantage contracts, a lot of times, and what we've been seeing is that some of the… some of these… the healthcare organizations, you know, they'll have an MRR… MLR of 88%, 90%, 95%, and yet the target, you know, has to be 85, right? I mean, they've got to get it down, and frankly, if you're going to make money, you actually need to get it close to 80%. But what they struggle with is where to focus the attention on bringing down the medical loss ratio. And what's that blueprint? So, how did the model help create that path? That knowledge base in terms of where to put resources, how to really be able to manage the care. How did the model support that?

 

Eddie Diaz:

So, one of the things that I did, Dan, that we worked on was essentially helping the clients understand the relationship between the MLR and all of the downstream metrics, when we talk about inpatient utilization. ER utilization, physician services, like we were talking about before, pharmacy utilization. So, there is… there is a very clear line of sight in terms of the impact that each one of these specific measures has on the MLR. And based on their operational, competencies, right, and their most effective use of operations. We might be able to help them pinpoint, if you focus on these key areas, on avoidable ED visits per 1,000, on your physician PMPM rates, on your generic, you know, pharmacy prescription rates. They need to have the blueprint that works the best, that's complementary to their existing operations, in addition to understanding the roadmap to enhance their future operational performance.

 

Daniel Marino:

Yeah, you're absolutely right. And, you know, when you think about utilization, obviously utilization does impact the MLR, right? Because it's all driving around cost, but there's certain utilization categories that have a greater cost impact than others, right? Particularly, like, inpatient utilization. If you have a strong transitional care program that helps. But it's not just having the transitional care program. It's focusing on the right cohort of the patients, right? The high-risk patients, or those, let's say, high… those DRGs that are creating an additional, say length of stay, an additional day in the hospital that you can focus on to really bring down some of the costs. And the exciting thing about the model is you were able to identify that. I mean, almost down to that specific profile of a cohort of a patient that we needed to focus on.

 

Eddie Diaz:

Yes, that's the… that's the beauty of the overlay and the integration between the claims data, because we are allowed to double-click into different cohorts by disease care management programs, or by disease category and disease state. That there will be a high impact. In the entire population, right? And like we're talking about with risk, there's… there's always the… the fact that most of these organizations, especially, primarily fee-for-service health systems that… that are… that are not intentionally, but they're overlooking their rising risk populations. Sometimes accidentally. And that is an area that we've identified in particular that can really start driving some really good performance down the line by giving them those tactical insights.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm talking with my colleague, Eddie Diaz, and we're discussing the performance model that we've used to help organizations close the gap between their value-based care contract with payers and their operational performance. Eddie, I'm gonna turn the attention, or the discussion a little bit around, the risk adjustment factor, the RAF indicator, that is oftentimes used within the contracts to identify risk, and certainly within Medicare Advantage, it's an important component. And I'll tell you, in my experience. It's often difficult for maybe the clinical leaders or physicians or, you know, even some of the finance folks to understand what really influences the RAF, what the impact is on the RAF related to the contract, and what we need to do in order to properly have the RAF reflect our population. And just, you know, by way of explaining that, the risk adjustment factor is a way that you're able to quantify what the, what the risk is, or how sick your population is that you are managing. Most of the time, the RAF score is underrepresented of the… let's say, the sickness of the population, or the acuity of the population. So, Eddie, talk a little bit about how the model identified a gap with what was identified as the RAF score, but then also the acuity of the population.

 

Eddie Diaz:

Absolutely. So, we could think of RAF, as being calculated in multiple different, segments or entities that are essentially stakeholders of that same patient. You have the government, which is CMS, you have the provider, and you have the payer, right? So each one of them are kind of responsible, the provider being responsible for the activities that are necessary to enable a proper risk adjustment factor, and then that recognition when, through billing processes, gets recognized by the payer, and ultimately the government. But there's often wide gaps, and what those gaps… what we can do with the claims data, as well as with the benchmarking data that is provided by the payer, is see what that gap is by using claims data. So I could create, essentially a RAF score based on the population, and find a delta of where that underfunding potential might be.

 

Daniel Marino:

And the government, if I could just jump in for a second, you know, this past year, the government changed a lot of the regulations moving into V28, which changed a lot of the HCC coding, which obviously influenced the RAF. So, you know, I would assume as you're looking at the model, the model took all that into consideration.

 

Eddie Diaz:

100%, because over the last few years that there was a blended model between V24 and V28, and now we're going into the full-blown V28. And we're seeing, you've seen this, like I have across all clients across the country, is a downward pressure. Which makes it very challenging. It means you have to be increasingly efficient. And it's becoming very challenging to be… to perform well. Our… the model is allowing our clients to be able to understand where those gaps are, whether it's at a cohort level, or it's an operational level, or it's a documentation level, right?

 

Daniel Marino:

Yeah, absolutely. And, you know, one of the things that I was impressed with, that I think, you know, our client was particularly impressed with, was the model not only showed, how the coding needed to be improved and optimized within HCC, and where the gaps were. But it was done in a compliance format, because, you know, that's a concern, right? You don't want to overcode, and I think V28 is helping with that. But it also showed what the financial impact would be. And I think that's the other thing that's an important takeaway for our audience listening to this, is, you know, again. Anybody can point to a number, but it all is dependent upon what the acceptance is and how well, say, your physicians and the coders, actually activate improved coding, right? So, you end up having a low probability, moderate probability, high probability with different dollar figures in there, and the model almost moves it from a retrospective review to really a prospective analysis of working through what that coding is and plotting the path and measuring the path in order to achieve those values.

 

Eddie Diaz:

100%, Dan, and to add on to that, what the model can do is move beyond just traditional natural language processing, or NLP for short, which creates a lot of false positives, right? Which ends up becoming a manually intensive validation process. And we really want to move away from that because it allows these providers to not have to redo work. They can quickly get to where they need to be, and move on to the next patient, right?

 

Daniel Marino:

Yeah, absolutely, absolutely. The last area that I want to talk a little bit about is quality. You know, as we know, I mean, if you know, you can do as well as you want on, cost and managing the population, but if you don't hit the quality targets and the quality thresholds, then, you know, then you're going to be challenged in really maximizing your potential under these contracts. So the quality piece becomes really important. I touched a little bit of this on a couple of my comments, but how were you able to use the performance model to help the organizations think about looking at quality and sort of care management from a retrospective perspective, if you will, to more of a prospective way of thinking through working with these patients, getting out in front of these patients. How did the model help in that regard?

 

Eddie Diaz:

So, one of the things I wanted to highlight first, before we jump into that topic, is how… what really stood out to me, once I overlaid all this information is some of these targets that they were setting up, or had negotiated for, were actually unachievable, right? And then there's… they're also the inverse, where if they're outperforming a low target, they should raise that target, because they can make more of a bonus, right? So I thought that that was really interesting, and giving that insight to the client, because oftentimes, the quality data is sitting in one kind of department, and it's never being married back to what kind of contract terms that we negotiate, right? So, but in terms of the actual operational implementation of quality programs, I think what's… what is quite, what stands out, especially if we… if we look at not only just a single client, but them in relation to other clients that are performing, that are working with similar contracts, is what targets are they working on that are the most competitively advantageous based on their operational footprint? Similar to what we discussed earlier, right?

 

Daniel Marino:

Yeah, I mean, it's that contract harmonization, right? I think that's a critical point that you just brought up, because a lot of times, you either have something in the contract that isn't aligned with operations, or vice versa. They may be doing really well, and yet it may not be reflected in the contract. So that contract harmonization is important, but I think you bring up another good point, too, because the robustness of the model not only took into consideration what the current state was, but also looked at what the market activity was.

 

Eddie Diaz:

Correct. Correct. And seeing what their competitors, so to speak, were doing in terms of their target benchmarks, but also which measures they were using to measure themselves, in terms of their targets. So that combination of targets that they had set up, whether it be on specific HEDIS outcomes or a more truncated version, was, I think, eye-opening to a client. Whereas they could see that they can either improve or get rid of certain measures to be more optimal that's consistent with their operational expertise.

 

Daniel Marino:

Right, so we were able to actually get some recommendations that would go to the managed care folks in terms of how to incorporate in their next round of negotiations, which,

 

Eddie Diaz:

Correct.

 

Daniel Marino:

Some of these contracts are negotiated annually, so that's an important point. So, with the quality piece, though, let's talk a little bit about that, because, you know, again, I think, obviously, quality is critical. You know, when we think about quality, you know, some of the quality outcomes, some of these are more, let's say, operational performance-led versus clinically led. How did the model help to kind of close that gap? You know, when we think about, let's say, measurement of the chronic disease, or you mentioned some of the HEDIS measures, how did the model align that with some of the performance and, let's say, the performance dollars?

 

Eddie Diaz:

So, so yeah, absolutely, right? When we think about the HCCs, or the chronic conditions, there's a kind of a dual aspect of that. If I'm capturing appropriate coding based on the appropriate risk of my patient population. I'm also seeing them, so I'm also meeting certain HEDIS criteria, right? I'm doing those FOBT tests, I'm doing breast cancer screenings. because I'm engaging with them, right? So there's this kind of dual… Process of access constraints. And limited access creates a deleterious effect across a myriad of outcomes, not only just MLR, but also quality. But inversely, if you focus on quality, because you're getting those folks into being seen, it starts to have positive impacts from a quality perspective, but also on the MLR perspective, as well as the RAF lift. And this kind of symbiotic nature is very interesting to our business, right? And it's interesting for our clients, and it's what they have to focus on, right?

 

Daniel Marino:

Absolutely right, and I'll tell you, just to kind of bring this together, one of the things that was exciting to me was when we were working through this, was identifying access, right? And the question really became, this particular client knew that they did not have enough PCP access, so the question really was, well, what's the right level of access, and what should it be when you think about the number of visits per 1,000, and the model was able to create that, is what as well as then balance that with what the specialty access visits were. Really powerful, and I think, again, it plotted the course, which I think was something that we… I personally, having been doing this for contracting and working with organizations for over 20 years in value-based care, I've never seen this before. It was quite exciting.

 

 

Eddie Diaz:

Being able to tell them, if I point… if I… if I show you what your PCP visits per 1,000 could be, and what that downstream impact on everything else, it's really hard to bring that to life, and that's what we've achieved, which I think is extremely helpful for our clients.

 

Daniel Marino:

Absolutely. Well, Eddie, you know, we just barely scratched the surface on this. I'm excited about what this direction is. You know, again, I think this is the first time that I've actually seen and realized the powerful nature of artificial intelligence. We've been able to, again, do this in, I think, 7, 8 weeks' time compared to months and months and months prior to this, and the costs were considerably less. Certainly an incredibly realized value coming out of artificial intelligence. Eddie, if any of our listeners today are interested in learning a little bit more, or maybe connecting with you, can you share your contact information?

 

Eddie Diaz:

Yeah, absolutely, Dan. I'm on LinkedIn, and that is, you can look me up on… on… as… as Eduardo Diaz, or healthcare, or Eduardo Diaz Healthcare, and then you can also reach out to me by email, ediaz@LuminaHP.com.

 

Daniel Marino:

Well, thanks, Eddie. I really appreciate it. Nice job with all of your work. You and the team have done a great job with this. Really appreciate it. If any of our listeners are interested in learning a little bit more about this, we're going to be doing quite a bit of write-up, and we have white paper and some other things. It's quite exciting. If you are interested in learning about this, please feel free to contact Eddie or reach out to me at dmarino@luminaHP.com. You could also visit luminaHP.com. for, additional information. But want to thank everyone for tuning in. Until our next Insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

As healthcare leaders look ahead to 2026, the pace of change shows no signs of slowing. From the rapid acceleration of artificial intelligence and evolving site-of-service regulations to new federal policy signals and leadership shifts in Washington, the strategic pressures facing providers, including hospitals and medical groups, are intensifying. 

In this episode of Value-Based Care Insights, host Daniel Marino sits down with Chris Collins, President and CEO of ECG Management Consultants, to reflect on the defining forces of 2025 and explore what healthcare leaders must be prepared for in 2026. Drawing on more than 25 years of advising health systems, academic medical centers, and physician enterprises nationwide, Chris offers perspective on emerging trends, strategic risks, and the leadership priorities that will matter most in the year ahead. 

Together, they unpack how provider organizations can navigate regulatory uncertainty, harness innovation responsibly, and position themselves for long-term success in an increasingly complex healthcare landscape. 

LISTEN TO THE EPISODE:

 

 

Daniel Marino:

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. Well, this is one of the episodes that I enjoy the most, and thinking through all of our episodes throughout the year. I always enjoy reflecting on the past year's activities and influences, that have occurred within our industry. And then thinking about what we need to pay attention to as we move into this next year, and obviously 2026, is going to be an interesting year for healthcare. So when we think about 2025, in my mind, there were a couple of really key influences. Obviously, artificial intelligence really ramped up. We saw a lot of activities, a lot of influences around business operations as well as clinical operations. We saw some new regulation that came down. Particularly around site of service changes, and of course, we can't forget the one big, beautiful bill with the new administration coming in, with Dr. Oz and Robert F. Kennedy Jr, we're only starting to kind of see some of the changes that they're going to put in place. And as we think about, you know, wrapping up for 2025 and heading into now 2026. All of these changes, as well as others, are going to continue to place pressures on, the healthcare community, on hospitals, on medical groups, and really create some new strategic challenges for many of our leaders. 

Well, I'm very excited today to have a great guest, somebody who has been a extremely strong strategic advisor, partner to many hospitals, large health systems, academic medical groups around the country. Chris Collins is president and CEO of ECG Management Consultants, bringing over 25 years of experience in strategy and so forth to a lot of large systems around the country. Chris, welcome to the program. 

 

Chris Collins:  

Thanks for having me, Dan. 

 

Daniel Marino:  

So, Chris, when you think about 2025, what were some of your big takeaways? 

 

Chris Collins:  

Well, it went by quickly. I would say, and not to be a downer, I would say the word that comes to mind is unsettling. 

 

Daniel Marino:  

Yeah, that's great, yeah, you're right. 

 

Chris Collins:  

On many fronts. We could spin the wheel and say, you know, the government and policies, but also just in the trenches, in the health systems. It's just unsettling. I think that's the word that sums it up best. 

 

Daniel Marino:  

Yeah, I agree with you, and especially, I think, a lot of the health system leaders, they were just trying to figure out what it all means, right? Not only what it… how it's going to influence their organization, but what does it mean for them going forward? So when you think about 2026, what are the things that you're keeping, you know, you're keeping your eye on? 

 

Chris Collins:  

Well, AI is creeping into every conversation, and I think we're all gonna be fatigued by it by the end of 2026. How many times we say AI? And my biggest fear, when I listen to our clients, and the industry, is that if we don't play this right, it's gonna be a distraction more than a helper. And what I mean by that is, I think, if you look at healthcare, the providers, the services sector. I think we can all agree, we still have a lot of work to do on the fundamentals. And so, when this shiny new object comes along in AI, and it's coming up in every cocktail party, everyone's racing to say, well, how do I adopt it? How do I use it on the business front, on the clinical front? And I would say, pump the brakes.Because I think we still have a lot of work to do on the fundamentals. Maybe we're not even optimizing how we use basic analytics today before chat GPT got us all talking about AI, even though it's been around since the 70s. 

 

Daniel Marino:  

Yeah, I agree. You know, right before the holidays, I had a conversation with the CFO, and he brought up the same issue, right? It's the new shiny object, every vendor, every technology firm has artificial intelligence in their conversation and in their mantra, so to speak. And as we were talking about this, he brought up a good point, that the success, the adoption of artificial intelligence isn't really going to come down to, the functionality so much as it's going to come down to how we use it, right? The governance around it. So I think, getting back to your point, really thinking about what it means for the organization going forward, and how to best incorporate it into your processes, whether it's business processes or clinical processes is gonna be critical. If not, it's just going to be a major distraction for organizations. 

 

Chris Collins:  

Yeah, and you know, later on, I'm sure in this segment, we'll talk… we'll get into the payer space and value-based care, of course. What's ironic is I see a lot of parallels. So, AI, if you do your research, it goes back, it dates back in healthcare, in the 70s and 80s, Mass General Brigo. Others adopted it. Pitt adopted it. Really, truly. And so, in the payer space, we had managed care. And so we rebranded, and we get excited about value-based care and other alternative payments. And now AI, because it's come into everyone's home. We're now all talking about it again. And yes, it's much more advanced, but I think it could be a distraction a little bit. And I don't mean… I think it's here to stay. It's gonna be… it's already impacting healthcare, but I think we gotta be careful and be cautious. 

 

Daniel Marino:  

When you think about artificial intelligence, and again, I sort of put it into these two categories, right? Influences around business and business processes and operations, and then the clinical workflow, the influences around clinical outcomes. In your mind, is there an area that you feel that artificial intelligence in 2026 will make a big impact? Is it more on the clinical side, or do you think it's more on the business side, or is it still too early to tell? 

 

Chris Collins:  

You know, I think it's a two-part question, right? One would be, if you could wave a wand, where would you place its focus? And two would be. What do you think systems are going to use it for, mostly? And then a cautionary note is, remember, things are expensive, right? And these systems don't have a lot of extra dollars lying around. They're still trying to replace their fleets of equipment, they're trying to retain talent, and so I feel for them, because…they have very little room for error, right? So back to your question, I… I would hope that, where it's a natural fit in the space of…of imaging and pathology, I think that should continue. I think if you get too acute with it in the next 12 months, I think that's… I don't think it's gonna pay dividends. I think, back at the ranch, in terms of business operations, predictive analytics. revenue cycle, transcription, all those things, I think would be, you know, full throttle. Because you can gain efficiency, you can do really, really amazing analytics with it, but, you know, here's the thing. The prerequisite to all of this, before you get to enjoy talking about AI, you need to have data governance, you've got to scrub the data, it's got to have integrity, you've got to have the foundation, and that's where I think many of our clients and systems might miss that step and race too quickly to AI and not realize that AI is only as good as the data that it gobbles up. 

 

Daniel Marino:  

Yeah, you're absolutely right. I think, you know, organizations can't be wowed by the shiny object. They have to really figure out what that value is, and how to use it, and what it's going to mean for them. Let's shift to the next topic. We've seen, continued change in 2025 with shifts in site of service. I think some of the specialties that we continue to see impacted are certainly, orthopedics. You know, in a lot of the work we've done with clients, I mean close to 80, 85% of procedures are done on an outpatient basis. Cardiovascular service is another one that's really shifted from inpatient to outpatient. When you look into 2026, what are you seeing as the big impact, or how should hospitals start to really consider some of the changes that are going to impact their revenues related to site of service? 

 

Chris Collins:  

Well, look, we can tie it back to the previous topic. 2026, or go back to 2024, if you took all of your inpatient data and outpatient data, and zoomed out, and did some analysis and said, hypothetically, where could this care be provided? I think, most leaders would admit that a lot of it could be provided in an outpatient setting, right? Lower cost setting, everyone wins. Patient wins, system wins if they're careful with reimbursement. And so, I… we can say 2026, but the reality is more of this care needs to shift to an outpatient care setting. And yes, certain states, it's restricted in terms of CON for ASCs, etc, but just at a macro view. It's gotta go to outpatient care. We've got to stop going into the bowels of a hospital for routine care. Low acuity care, that can be done in an outpatient setting. Backfill it with high acuity. We're all short of beds. So, we all are in agreement, and now we just need to get it done. So, I hope this trend continues. It's obviously… you said orthopedics, that was probably the leader on the shift to ASCs. I think you'll see that continue. All the data is telling us that that's the case. So I think that would be… that's actually an example of returning to the fundamentals, right? Right, sure. Focusing on that, and not getting distracted by 3 meetings about AI. 

 

Daniel Marino:  

Yeah, about the other things that are occurring. If you're just tuning in, I'm Daniel Marino, you're listening to Value-Based Care Insights. I'm here today talking with Chris Collins, President and CEO of ECG, and we're talking about the trends that we're going to be faced with as we move into 2026. Chris, I want to build off of one thing that you had said, and it's around the ASCs. What we saw in 2025 is this continued move to establishing joint ventures. With independent providers, and in some cases, even the employed providers, as they've restructured, in a joint venture type of a role, hospitals with their physician partners. Are you seeing a lot of that continue? Is that… is that, as we move into this shift into more of the ambulatory arena with ASC, do you see that as a continued initiative that's really going to drive change? 

 

Chris Collins:  

No question, no question. I mean, the short story is many years ago, when ASC started popping up, and physicians would stand them up, hospitals, said, well, that's not…We're not gonna do that. We need to figure out how to prevent them from doing that. They're going across the street, they're taking our patients, etc. And then fast forward, you know, if you can't beat them, join them. And so, it's a good ending. Now they're teaming up. And they're establishing joint ventures. And guess what? Patients win, right? And so now you have systems working with physicians and physician leaders who are also business… very business savvy, standing up ASCs. So it's a good outcome, and it's going to continue, there's no question about it. 

 

Daniel Marino: 

Yeah, I agree with you. I do think it creates a bit of a challenge for some of the hospital leaders. They have to be, I think, open and willing to bring in physicians as their true partner on driving a lot of the business activities, but from what I've been able to see, and I think you captured this in your comments, if it's done well. It creates a lot of value for the patients, a lot of value for the communities, and frankly, you can really tie it into some of your payer negotiations. 

 

Chris Collins:  

No question, but it does be… these all begin with relationships. And again, I'm gonna keep saying it's on the list of fundamentals, is embrace physician leaders. Right? There should be no daylight between the hospital administrative teams and those physician leaders. I mean, that's where some of the best ideas are. If we're going to improve access. If we're gonna sustain or enhance quality of care, adopt AI, whatever it is, you're gonna need that partnership. And we're not there yet. You know, so we've got work to do. 

 

Daniel Marino:  

Yeah, you gotta… you gotta continue that relationship, you're absolutely right. Right, right. Let's build it. So… I'm gonna kind of move to another topic, and that's really around the payer community. We saw in 2025, it seems like COVID and the reimbursement really caught up with a lot of the payers. They… in a lot of the payer contracting and new negotiations, we saw the payers having to make some concessions and probably offering a little bit more increases than they have in previous years. And it's put some of the payers in a little bit of a predicament, you know, with some of the…reporting with UnitedHealthcare, and even with Cigna and Aetna, we saw the MLRs increase quite a bit. Where do you see the payer landscaping moving into 2026? Is it going to be a continued battle around fee-for-service? Do you feel like value-based care could maybe gain a little bit more speed? Any thoughts on where you see the payer activity occurring? 

 

Chris Collins:  

I think you're gonna see it go back to, kind of, pre-COVID, more around fee-for-service, back to the negotiations, and… and look, I… if you do a look back, and I know you're well-versed in this, Dan, if you go back and look at the data for 10 years. I think… I think we get, you know, a D- on adopting value-based care. And, we rebranded it. Go back to managed care of the 90s. Yes, it's different, different approach. But the reality is, it's still a fee-for-service dominated market, and I don't blame the payers, I don't blame the providers. We're skating around the biggest issue, which probably will never be solved, which is this antiquated reimbursement system. Whether it's DRGs or in the outpatient space, it's disconnected from cost. So all we're doing is we're doing all this patchwork, and we're trying to come up with risk models. And it's a huge administrative burden for these health systems and providers every time we roll out another program. 

 

Daniel Marino:  

Yeah. 

 

Chris Collins:  

We celebrate as a country that we're saving a few shekels, and we're making… I mean, we are putting a dent in it. The philosophy of value-based care, obviously, is something we all agree on. How we're doing it is very sluggish, and very slow, and no other sector would adopt it so slowly. I don't think we're getting to the root cause of it. 

 

Daniel Marino:  

Yeah, I agree. I think in order for us to really pick up the momentum. I think two things have to happen, and you touched on this. I think, one, we have to get a better idea of our costs, both internal costs and what we're spending on care, you know, the total cost of care. But I think the other key piece that's going to be important is we need to continue to focus on the outcomes and differentiate reimbursement based on the outcomes that we are providing to our patients. And if we can do that, that's where I really feel like value-based care will pick up some strong momentum. If we can't do that, it's going to be a continued fee-for-service game for now until who knows when. 

 

Chris Collins:  

Yeah, I agree. But when I say cost, and this is probably for another segment, I'm saying something more provocative, which is the Medicare fee schedule, you know, that was launched a long time ago. That's just been adjusted for inflation, so those…the reimbursement itself, and everything's indexed off of Medicare. They do not reflect the actual cost if you add up what the cost of care is to deliver. 

 

Daniel Marino:  

Oh, sure, yeah. Reimbursement isn't covering the cost, yeah. 

 

Chris Collins:  

Right, right, right. So that's broken. So then when we talk about cost or reimbursement, we're negotiating almost these false reimbursement rates. Yeah. And that's not going to be solved, you know, probably, maybe even in our lifetime, sadly. But, that's what I'm saying. I think that's the… that's the disappointing, point to all of this. 

 

Daniel Marino:  

Well, and I'll tell you, that couldn't be more true than within the Medicare Advantage segment. Because if you think about how Medicare Advantage is really structured, you know, again, the reimbursement isn't enough to even cover the cost, and then because of all of the challenges that some of the commercial carriers have placed on providers around managing denials and the appeal process, I mean, their costs have gone up, it's not gone down. So…when you think about that, where do you feel like Medicare Advantage is going to be in 2026? 

 

Chris Collins:  

Well, it's a tale of two stories. Medicare Advantage is unstoppable, right? I think most CEOs agree, it's here to stay, and it's putting… it's making a dent. But most are also not pleased with it, because the denials have been a struggle, the administrative burden and the administrative requirements are daunting. So I… I think it's going to slowly make progress. I think it's a step in the right direction. I hate to say it, I think it is. I just… I just fundamentally get frustrated when I think about…When you peel back the curtain, the actual reimbursement system, the backbone itself is entirely broken. I mean, we're… we're creating a new reimbursement system in Dubai, and you can learn from the failed system of the U.S, and I don't think… it's not politics. I mean, I don't think there's any U.S. president in our lifetime or Congress that'll have the backbone to kind of rebase the entire thing, which is what is needed. 

 

Daniel Marino: 

Yeah, yeah, I agree. So, one of the other challenges that we've seen in 2025, and actually it started shortly after COVID, is the challenges around patient access especially in the specialty areas, you know, it's… in some markets, I mean, it's, you know, 3 months to get an appointment to see an orthopedic surgeon, and so forth. Looking into 2026, do you see that changing at all? Do you see patient access improving? 

 

Chris Collins: 

 It has to. It has to, because it's burning from both ends. Consumerism continues to seep in, and patients are not going to tolerate it, including younger patients, right? Young adults. That's why concierge medicine is increasing. So, it's gonna burn from that end. And then health systems are realizing that we have to do more with less, and they have excess capacity in pockets. So, yes, it depends on the specialty, but it's not… don't buy the cover story. It's not always the shortage of specialists. It's the mismanagement of capacity. So, if you look at a clinic's schedule, and you look at the rooms available by day of week, and you look at who's trying to get into the system, there's a disconnect, which takes you back to the fundamentals, right? Even with Excel, or Power BI, you can solve that, right? Yeah. You don't need AI to solve that. 

 

Daniel Marino: 

I agree. 

 

Chris Collins:  

I think, yeah, access has got to be… we've got to optimize our capacity management of a system and improve access for patients, everyone wins. And that will generate additional revenue for the system, etc. So, I think access improvement. Hopefully, it's not, you know, we don't, postpone it and wait for a shiny AI tool or platform to solve it for us. We have the tools in front of us right now to attack that issue. 

 

Daniel Marino:  

Yeah, I agree, and we're not going to solve access by recruiting. I mean, it's just not going to happen. There's not enough…physicians coming out of med school, and by the way, every health system in the country, every hospital in the country, everybody's competing for the same physicians, and you're just not going to solve it by recruiting. To your point, you have to really think about efficiency, you have to think about the technology there in order to drive it, and that's the only way we're really going to meet the needs of our patients. 

 

Chris Collins:  

Yeah, I agree, agree. 

 

Daniel Marino:  

So, given some of these issues that we see, and, you know, I feel like we've just barely kind of touched all of the issues that we're going to see in 2026. Thoughts on how, health system leaders, on how physician leaders, how should they focus on these issues? How do they, you know, maybe align it with their teams, or align it with their boards, or really just take these into consideration around their strategy moving into 2026? Thoughts? 

 

Chris Collins:  

Well, this will be a blanket statement, because I want to be careful. There are some systems that do it remarkably well. But… but, at a macro level. I still believe that the most underutilized asset in a health system are the physician leaders, and the relationship between those leaders and the C-suite. I really do. You could pick any issue, Dan, and we… and I'm not saying all the physicians, the physician leaders that represent the employed physicians or the very loyal, affiliated physicians, a lot of the solution sets live right there, working together to look at access, look at cost of care. And not just push it down to the physicians as if they're staff, right? If you're gonna make a change… 

 

Daniel Marino:  

Engage them, yes. 

 

Chris Collins:  

Yeah, engage them. Standardizing scheduling templates, some basic fundamental things that need to be done, everyone agrees. The way in which you do it, and building consensus, and coming up with the right model, and doing the right testing, and then allowing those physician leaders to get others on board, will pay huge dividends. And if you… if it's just more directed and implemented, by a bunch of suits like myself, it's not gonna go well. 

 

Daniel Marino:  

Yeah, you're absolutely right. I mean, when we think about these topics that we just talked about, the physician alignment was critical. It's a foundation part of all of it, right? You know, in terms of even you know, how we set up the joint ventures, how we align our support, and even drive some of the clinical change within artificial intelligence. It's all dependent on how well we align with our medical community, with our. 

 

Chris Collins:  
Right, and don't forget, we can tie all these together, because reimbursement drove physician employment of physicians by systems, right? 

 

Daniel Marino:  

Yeah. 

 

Chris Collins:  

Physicians didn't come running into the systems because I can't wait to be employed by health systems. It was because of reimbursement in the market. So now that they're there, they're inside the tent. Treat them like a partner. That's the, I think that's the special sauce going forward, and the systems that do it well have great outcomes, and they're very well run, and others are still a little hesitant, right? 

 

Daniel Marino: 

Yeah, it's a little challenge. 

 

Chris Collins:  

But they don't do it on a day-to-day basis. 

 

Daniel Marino:  

Well, thanks, Chris. This has been a, good conversation, and as I said, you know, I feel like we just scratched the surface. You know, your insight has just been, just fantastic. I really appreciate it. I'd love to have you back again. Maybe we can kind of take a deep dive in a couple of these topics, particularly around maybe the specialty service area. I'd love to get your thoughts on that. 

 

Chris Collins:  

That sounds great, thanks for having me. 

 

Daniel Marino:  

Well, thanks, Chris, I really appreciate it, and for our community and anyone tuning in, if you want to hear more about this topic or any of the trends that we're seeing as we move into 2026. Please connect with us on LuminaHP.com. You can see any of the articles, any of the information on our Insights page. But I want to thank everybody for tuning in. I wish everyone a very happy and healthy and prosperous 2026. Until our next Insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

Orthopedic care is evolving rapidly, driven by shifts in site-of-service, advances in surgical techniques, and growing patient expectations for advanced technology, improved outcomes, and convenience. As procedures, such as joint replacements, move from inpatient settings to same-day outpatient care, orthopedic groups are rethinking how they deliver high-quality, cost-effective care while remaining competitive in this changing market. 

In this episode of Value-Based Care Insights, host Daniel Marino continues the clinical service line series with a deep dive into the orthopedic service line. He is joined by Lori Pagan, CEO of Ortho Northeast, a physician-led orthopedic and spine practice in Indiana known for its entrepreneurial approach and strategic partnerships. 

Together, they explore how orthopedic groups are adapting to industry trends and building stronger physician–hospital partnerships. They highlight strategies for positioning orthopedic groups for long-term growth while enhancing patient outcomes and experience. 

LISTEN TO THE EPISODE:

 

 

 

Daniel Marino:  

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Well, we are continuing our series and our conversations on clinical service lines. I'm really excited about today's program. We are going to dive into orthopedics and the orthopedic service line. Orthopedics continues to, I guess, do well for health systems, but more importantly, it's been really interesting for the independent orthopedic medical groups. Many of the orthopedic medical groups, they just have an inherent entrepreneurial spirit to them, and frankly, if you think about how things have changed over the last even 4 or 5 years, many successful orthopedic groups have really focused on the trends of the industry and have done a pretty good job of responding to those trends. And in particular shifts inside of service, for instance. Five, six years ago, a vast majority of hip and knee replacements were done inpatient, and patients had two to three inpatient days and stays before they were discharged. Now, everything is done same day, and it's amazing, within, you know, a few hours, patients are up and walking around, and many of them are released the same day into their home environment. So I'm excited to have the conversation today about a successful orthopedic group that has done a nice job of creating strategic partnerships, with their hospital partner, but also responding to the market. So I'm really pleased today to have Lori Pagan, she is the CEO of Orthopaedics NorthEast ONE . They are located in Central Indiana, Fort Wayne, Indiana. Lori has had a great history of really driving the success and partnering with her physician orthopedic leaders. Lori, welcome to the program! 

  

Lori Pagan:  

Thanks, Dan, I'm happy to be here. 

  

Daniel Marino:  

So, Lori, you've obviously done a nice job of directing the group and identifying some of the trends. And thinking back, let's say, this past year, and even before that, what have you seen as kind of the key trends that has really… that have influenced the direction of the group that you've been able to respond to. What are a couple of those key trends? 

  

Lori Pagan:  

Sure, I think that there are 3 things that stick out to me over the last few years, and the way things are trending, and I see them continuing into 26. Number one is technology, and the patient-driven interest in technology. So, the vendor manufacturers are advertising more. Partnering more, there's more patient engagement in what technology is being used in my knee replacement, or my hip replacement, my spine surgery. So they're asking those questions, sometimes to the point where they're asking for specific robots and or technology applications in those surgeries. So I think Technology is one big area. Another big area that you mentioned previously is the migration from inpatient to outpatient. Doesn't always mean for us that we're moving it from the hospital to the ASC. But it means that we are discharging same day out of the hospital. We are fortunate enough to have a joint venture partnership in both ASCs as well as an orthopedic hospital, and so we can take care of very high acuity patients. in our orthopedic hospital, and in some cases, be able to discharge them same day. So, the shift from inpatient to outpatient, and having that ability to choose where we deliver that care. And then I think the third thing is really, and it goes a little bit back to my comment about patients talking about technology, but just consumer-centric care, the access points, the speed at which we can get somebody from Whether it's from our orthopedic urgent care, or their initial visit to their hospital, all the way through post-operative care, and then following them through that journey. So those are the three real big areas that we have seen over the last few years that continue to trend into 2026. 

 

Daniel Marino:  

When you think about the technology piece, you said something that's really interesting. Are you seeing consumers being more educated on what they need, or let's say the technology that is being used to support some of their orthopedic care? You know, you had mentioned robots and, you know, maybe some of the devices and so forth that are important in orthopedics. Are you seeing that patients are becoming more educated healthcare consumers regarding orthopedics? 

  

Lori Pagan:  

We are. I think you always have the subset of consumers who have 100% trust in their doctor, and they don't come in overly educated. They've taken some direction, maybe from their primary care, from friends and family, and then they come in, and you have your consult, and you work through things. But there's an emerging group of patients who are really educated to the point where they may have been… they may have seen advertising from a particular robot, or a particular implant device. You know, you've got total knees now that track kinematics and outcomes that then the surgeon and the patient look to afterwards, and what does that look like going backwards? Their gait, everything. And now, with the introduction of AI, of course. Patients are putting some of the products that we may use through AI, comparing them to other ones, and then challenging us and saying, okay, I see you use this, but what about this? So yes, I do think there's definitely a shift to a much more educated patient. 

  

Daniel Marino:  

Wow, that's fascinating. And, you know, it's… you could see that, right? I guess, you know, some patients are really, you know, they dive into it and kind of want to understand what some of that technology is, but to integrate some of the outcomes related to the devices, I think, become really interesting. Do you do a lot of education programs with your patients? You know, you mentioned consults. 

  

Lori Pagan:  

Sure. 

  

Daniel Marino:  

But how are you educating the patients, you know, either before, during, or even after, you know, the procedures? 

  

Lori Pagan:  

I think one thing that we do really well is we have taken over the education of all of our total joint patients, and then are also moving into the spine surgery space in 26. So we actually have our advanced practitioners teach our joint replacement classes. So they walk the patient through from… now, this is after the decision is made to have surgery, right? They walk that patient through exactly what pre-op is going to look like, that preoperative process, and then during the process, and then post-operatively, all the way down to what it's going to look like at home. Of course, that looks different for a patient that's going to go home out of the outpatient setting versus the inpatient.  We have seen a shift away from, sending patients to rehab facilities. There's more in-home rehab. And so the benefit of our advanced practitioners, teaching these classes is they are with the surgeon side-by-side through all of this, right? They are in the OR with the surgeon. The patients can ask the questions, you know, what's it like during surgery? The PA and or the NP can explain that process from start to finish. They work hand-in-hand post-operatively with PT, and so we pride ourselves in our advanced practitioners teaching those courses and preparing our patients, and we've seen better outcomes because of the preparation that's been done. 

  

Daniel Marino:  

Well, I can't help to think the value you're adding to your patients, has to be enormous. And just having that expectation and that awareness, I think, helps post-recovery, right? It helps the planning, and in particularly the caregivers prepare for what that post-recovery's gonna look like. Especially as you think about that transition to the home environment, often what we see a lot of times is surgical providers, or even the hospitals, they don't typically do a good job and evaluating the home environment. So patients are discharged to their home only to find out that the caregiver can't take care of them, or they have all of these stairs, or, you know, it's just not structured appropriately. And if organizations, if individuals knew that ahead of time, you can do a little bit more planning around it. But it sounds like your education program kind of takes that into consideration. 

  

Lori Pagan:  

We do. We work hand-in-hand with our surgical schedulers, slash navigators that help us through that whole process. So, there's a lot of discussion one-on-one with the patient through navigation to understand what their home environment looks like, what their support system looks like. You know, do they have family responsibilities? Do they have work responsibilities? How do we frame all that, and what's the best way to get the patient from their, operative day back to their full life. Whatever those responsibilities. And then these education classes that the advanced practitioners are teaching, they're helping with some of that, I'll call it, occupational discussion. Okay, well, you're going to need a shower chair. Okay, you have stairs. This is the way we need to tackle that. You don't have somebody to help you. Let's work on getting a home health resource for those few days afterwards. Do you have a driver? All of the things, because now that you're not inpatient anymore, you know, your driver needs to be there with you. 

  

Daniel Marino:  

Yeah. 

  

Lori Pagan: There is a 2 to 6 hour, depending on what procedure you're having, all of the things. So all of those discussions have… happen actually at multiple levels. We're having it at the navigation level. Our class sizes, we keep them very small, around 8 patients, sometimes up to 15, so that there's dedicated question and answer with the advanced practitioner, so that all of those questions, again, can be addressed. And or, all of us have been there, right? We've talked to our doctor about something. Oh my gosh, I forgot to ask this question. I talked to my navigator about it, which then spawns more questions. Well, then comes in this education class, where even more questions can be answered. But all of that time, the navigator is kind of that consistency through the whole thing. They are able to always have access to that navigator if they forgot to ask a question in class. That class is attenuated by printed materials, online materials, videos, we try to run the whole gamut there. 

  

Daniel Marino:  

If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm talking with Lori Pagan, CEO of Orthopedic Northeast, and we're talking about successes and trends related to orthopedic service lines, and in particular her orthopedic medical group. So one question I want to dive into a little bit is, we have seen an ongoing trend of increased support around navigation, and you talk a little bit about that. Navigation, for many specialties, for many medical groups really is the key, that link, right, to the patient. It's the link between the patient and the surgeon, but also really guides the care all the way through the, you know, the patient, you know, the continuum of care, if you will. But more importantly, kind of drives a lot of that success, post-recovery. Talk a little bit about your navigation. You had mentioned it in a couple of areas. Do you have one navigator? Do you have multiple navigators that kind of fit into different areas upon, you know, within the continuum? How is that working within your group? 

  

Lori Pagan:  

So, I would say we have multiple layers of navigation that, over years of experience, we've been able to integrate. I've been in environments in past lives where there's one navigator that navigates all the way through. I do think that there can be some benefit in that, but also some drawbacks, because of the expanse of orthopedics. The sub-specialized care that we deliver, and the different departments that you have to bring together, each area has its area of expertise, and they do that best. So to have one navigator, sometimes isn't ideal, so our pieces and parts work together to deliver a navigational experience. If I had to identify one area. We have a centralized navigation that schedules your survey, that goes through everything preoperatively, that has access back to the surgeon if needed, access forward to the educational process that we do. So there is one person that a patient has access to all the way through, but every piece, every layer is integrated. So that we're delivering the highest expertise of care at each level. 

  

Daniel Marino:  

Well, and that makes sense, right? Because especially when you have the different subspecialties there, or the surgical services, whether it's spine, or hip, or knee replacement, and, you know, the therapies and the post-recovery, you know, it's very specific, right? So, to have somebody, have a navigator who knows that inside and out, I think just provides a probably a greater depth of knowledge and support for that patient. So, I would agree with that. I think that, you know, that approach makes a lot of sense. One area I want to shift to is the changes in… the shift in site of service. You know, you mentioned it earlier in your comments that you have seen the shift from inpatient to outpatient, and you're fortunate to have the joint venture with the hospital, so, you know, you're kind of managing it through that. What are you seeing in changes of reimbursement? You know, Medicare's putting a lot of pressure, they announced Teams, which has 3, musculoskeletal episode-based pricing models that are included in it, and, you know, I can't help but think that you're getting, like everybody else, pressure from the commercial carriers. What are you seeing in terms of the reimbursement, the structure, and how is that impacting your thoughts or your trends around shifts in site of service? 

  

Lori Pagan:  

Sure, so we definitely have seen the shift inside of service, like everybody else, from the hospital to the ASC environment. I will say Indiana's a little unique, a little behind in terms of the number of ASCs. Already in other markets, I think they could be… and you may correct me if I'm wrong here, but maybe even 5 years ahead of Indiana in the ASC world, in that their ASCs are not full. So our ASCs are full, so we are… we are definitely choosing the cases that go to the ASC from an acuity in a clinical sense versus being necessarily pushed. 

 

Daniel Marino:  

Right. 

  

Lori Pagan:  

We don't have an overabundance of ASCs which would then, in turn, allow the payers to say, send all of this there. There simply isn't the capacity. There's a nice balance in the state of Indiana. We are certainly developing more ASCs. We just opened one in October, within the region. There was one last year that opened. We have one opening next year. So they are coming online. We will be able to move more and more. But we're still very carefully choosing based on acuity, and just clinical conditions. So we've been fortunate, in that respect. 

  

Daniel Marino:  

Yeah, and I think, you know, when you think about, then, the payers, have the payers… are they restricting any of your… or maybe restricting's the wrong word. Are they, limiting or providing some, you know, direction, or maybe standing in the way of where some of these procedures should occur, you know, through some of your pre-authorization through some of your denials. Sure. How have the commercials responded to some of this? 

  

Lori Pagan:  

So I think… I have not seen quote-unquote restriction. What I have seen is Suggestion through payer contract, meaning. 

  

Daniel Marino:

Yeah. 

  

Lori Pagan:  

Certain implants I can't do at the ASC. I have to do at the hospital, or vice versa, right? So I think that's more the direction that I'm seeing. It's more a suggestion, and of course, we can make the choice. But of course, we want to deliver the best value to the patient in the proper level of acuity, and so that's how we make our choices. We haven't necessarily been restricted. We face the same headwinds that every other, whether they're hospital-employed or independent group in terms of pre-authorization, we have those same headwinds. But in terms of restriction, I don't know that I've necessarily seen that. We're more driven by choices that we make based on the patient, and or, you know, maybe a patient wants a specific implant for whatever reason. An interesting thing about my market is I sit right adjacent to the orthopedic capital of the world, where all the orthopedic manufacturers are, for the most part. And so if I work for one of them, I want that particular implant. 

  

Daniel Marino:  

Sure. 

  

Lori Pagan:  

The payer may not be covering your implant at the ASC, which then we do that outpatient in the hospital. Again, that comes back to us being very fortunate in that we have the ability to place it in either setting. 

  

Daniel Marino:  

Yeah, yeah, well, and that's an interesting perspective there, but, you know, again, I think what you're… you know, you mentioned it, and what many orthopedic groups are seeing is a rise in some of these pre-authorizations. some of the denials associated with it, which is really a bit of a shame, right? Because if you need it, you need it, especially with some of the knee replacements, the hip replacements, and so forth, and the technology is advancing so quick, especially if you're able to track your outcomes associated with some of these devices. I mean, it can be fantastic for the patient and for the surgeon as well, in terms of the continuity of care. But unfortunately, what we're seeing is a lot of these commercial carriers, particularly around the Medicare Advantage world, or within the Medicare Advantage world, they're denying it. 

  

Lori Pagan:  

That's right. Or they put in barriers to pre-authorization of surgery, right? They're requiring X number of PT visits, failure of conservative treatment, and things like that. And that's all well and good. The problem is when you see a large amount of patients who just simply through pain, can't even get through some of the pre-authorization hurdles that those payers are requiring. 

  

Daniel Marino:  

Yeah, yeah, that's… that's… that's amazing. As you, as you sit back and think about, some of your initiatives as you head into 2026, and even beyond. Are there a couple of things, you know, what are a couple of things that you're really focusing on? Are there a few things in terms of, maybe, where your referrals are coming from, or your community outreach? Are there a couple things that you can share that are top of mind for you as you head into 2026? 

  

 

Lori Pagan:  

Sure, I think number one is points of access, right? And a great way for us to accomplish that and serve the needs of either urban or suburban or rural communities are walk-in clinics. So, Ortho Urgent Cares. Ours happens to be called Ortho Now. We have branded it. We've got four in the surrounding area. They are filled to the brim Monday through Friday to the point where we're looking at adding weekend hours. Part of that is pressure from payers, right, to keep people out of the ERs, and quite frankly, we can deliver specialized care in these ortho-urgent clinics, and be able to set some folks in CAS if they then need surgery, we can book directly then into our surgical suites. you know, within a couple of days, without having to… having the patient having to wait hours and hours and hours on end in the ER, where there are much sicker patients. And higher acuity things that need to be handled in the in the ER, we're… we're more equipped to be able to handle those here at the clinic level, and then if they need surgery, get them scheduled for most likely outpatient surgery from there. So, ortho-urgent clinics are a big focal point for us going forward, as they have been, as well as keeping lower acuity and generalized orthopedics close to your home. And so, putting those ASCs next to the clinics, out in the communities that might be more rural, more suburban, and then if you need real high-acuity care with high technology for whatever reason, we can bring those back to our hospital and all of these clinics are connected, all the surgeons are connected, there's a lot of inter-referrals going on. If somebody sees something out in one of those communities and says, you know what, I really think my partner is better suited to do that with this technology at this facility. That goes a long way for the patient. They're very well taken care of, they understand that that is available, and we're able then to navigate that care appropriately for that continuum of care. 

  

Daniel Marino:  

Well, as you're describing that, I'll tell you, one of the things that come to mind, and I love what you're… what you're describing, is you really expanded your orthopedic continuum of care, right? So, not only are you continuing to focus on those high-acuity patients that, of course, you know, needs to happen in the hospital. 

  

Daniel Marino:  

But I love the fact that you are continuing to drive orthopedic care to the community, and that is such a different focus than what a lot of organizations do. A lot of times, especially in orthopedics, they want to be that destination center, which is, you know, for patients to drive to, to kind of go to. And that's important, right? Especially if you're defining a center of excellence. But the key with orthopedics, especially if you start to see this trend, is to deliver care as close to the patient and within the community as possible. And I love the fact that you've created such a strong focus on orthopedic urgent care. I mean, what a value add that has to be for patients and for, frankly, you know, for the mother or the father that has their son or daughter playing sports and something happens to them, not to have to sit in the ER, but to go to the orthopedic urgent care. 

  

Lori Pagan:  

Absolutely, and, you know, I want to give credit where credit's due. Our collaboration and partnership with our health system is stellar. In my career, I've never seen anything like this. It's a joy to work with our partner health system, which happens to be Parkview. And they make it possible for us to bring our sub-specialized care out into the communities. They support that journey. At their hospitals out there with our joint partnership ASCs in those markets, as well as then, as you would describe it, you know, kind of this hub where some of the higher acuity, the more in-depth technologies and things take place, but it's very synergistic and, can't say enough about the partnership and how that enables us to be right next to our patients out in those communities. 

  

Daniel Marino:  

Well, I'm glad you brought that up, because I think an important attribute of certainly orthopedics is that alignment with the hospital partner, and I mean, that, you know, that can't be overlooked, right? The stronger the partnership, the stronger the alignment and the vision and the strategic direction, the more successful the orthopedic group is going to be, but then also the hospital as well, too, so you're absolutely right. Well, Lori, thank you so much for coming on. Boy, you're a wealth of knowledge, and congratulations on where you've taken the group, and I wish you a lot of success as you head into 2026 and beyond. It certainly sounds like, to me, you're positioned extremely well to continue to grow and to continue to navigate some of the challenges that we're going to see. 

  

Lori Pagan:  

Yeah, thank you so much for having me on, I've enjoyed it. 

  

Daniel Marino:  

If any of our listeners are interested in connecting with you, or maybe learning a little bit more about what you've done, or the group, can you share your contact information? 

 

Lori Pagan: 

I sure can. It's Lori Pagan. My email address is lpagan@orthone.com and of course, I'm also available on LinkedIn, and I'd be happy to interact with anyone that's interested. 

  

Daniel Marino:  

Well, that's great, and again, I want to thank you for your time today. Thank you for sharing your knowledge and your information. This has been fantastic. 

  

Lori Pagan: 

Absolutely. Thank you, Dan. 

  

Daniel Marino:  

And a special thanks to all of our listeners for tuning in. If anybody's interested in learning a little bit more about this topic, or any of our topics that we talk about on Value-Based Care Insights, please, go to luminaHP.com/insights, and again, thanks everybody for tuning in. Until our next Insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

As the year comes to a close, we thought you would enjoy a throwback to one of our most popular episodes of 2025. 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, join the conversation. Additionally, Rick Howard, a seasoned Chief Data Officer and AI Strategist contributes to the conversation with his deep expertise in driving 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. 

 

 

Daniel Marino:  

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As I mentioned on previous episodes, we are spending time talking about different service lines that are impacting physicians, hospitals, health systems across the country. And in today's episode, we're going to take a deep dive into cardiovascular services. Cardiovascular services is one of the areas that I've been very familiar with over the course of my career. I had the opportunity early on in my career to manage an internal medicine group, of which we had about a half-dozen cardiology and cardiovascular surgeons that were part of the group. So, I've really spent a lot of time over the course of my career, both helping medical groups, hospitals, and health systems with cardiovascular services. But really watching the change that has impacted the service line, and for the most part, really impacted physicians and patients as we see that evolution occur, particularly around where care is being delivered, inpatient versus outpatient. But also with the increased focus on preventative care that has occurred in cardiovascular services. 

Well, I'm really excited today to have a good friend and an individual I've known for quite some time, Dr. Nihar Desai. Dr. Desai, Associate Professor of Medicine and Vice Chief of Cardiovascular Medicine at Yale School of Medicine. He leads the research, operational initiatives, and focuses on a lot of the outcomes related to improving cardiovascular care, care delivery, and even value-based outcomes for Yale New Haven Health System. Nihar, welcome to the program! 

 

Nihar Desai:  

Thanks so much, Dan. It's great to be with you, and I'm very much looking forward to our discussion.  

 

Daniel Marino: 

So, Nihar, as was mentioned, cardiovascular services has really evolved over the last number of years. I mean, even thinking back 5 years where it's come from, and some of the services that it's evolved to today, you know, related to shifts in where care is being delivered, and, you know, as I mentioned, some of the preventative-type care, some of the therapeutics that are included in here. From your perspective, what are… what have you seen as some of the exciting trends or changes that have occurred over the last number of years within cardiovascular services? 

  

Nihar Desai:  

Yeah, Dan, I think that's a great place to start, and in many ways, we're in the golden age of cardiovascular medicine. I think there's never been a time where we've known more about the pathobiology of cardiovascular disease. We have a rising, you know, sort of prevalence. People really need cardiovascular disease prevention and cardiovascular care. We have an expanding toolkit, more treatments, more pharmacotherapies, more devices, you know, more things that we can do for the patients that we care for. And yet, at the same time, I think we find ourselves, you know, confronted by the more sobering, aspects of cardiovascular medicine and cardiovascular care delivery. We find, you know, quality is suboptimal, that variation, you know, lingers, disparities are too great, and costs continue to spiral. And so we have to confront  sort of these two things that are happening in parallel, that on the one hand, we've got more insights and more treatments and more things we can do. And yet, at the same time, we have some pretty profound challenges in terms of our operations, our care delivery processes, and the financing model that really brings us to much of our discussion, I think, around the push to value, but some of the inherent complexities and challenges that we have to face. I mean, I'll give you one, you know, maybe quick example on that front of you know, again, at the same time that we have all of these great things happening. We have more and more challenges in terms of access. Patients have a harder and harder time accessing, you know, services. Costs continue to spiral. We have very, very high fixed costs. Labor costs, especially on the hospital side of things, have gone up very substantially over the last, you know, 5 years. And revenues obviously have not kept up, and so the math really is starting to be quite, quite difficult when you think about the care model, the traditional care model that we have been, you know, kind of embedded in. And so, I think that really raises the specter of, how do we reimagine the experience of patients? How do we reimagine cardiovascular care delivery? how it's being done, who's doing it, where it's happening, what technology is being brought to bear to kind of facilitate and enable it, and I do think that that is what's required, is a true reimagination. 

  

Daniel Marino:  

Well, and I think we're going to continue to see, as we start to incorporate more and more innovation and AI, and I want to get to that in a second, but you're going to see continued shifts in evolution around cardiovascular medicine, right? And how it's being able to…how we're readjusting or taking care of the patients. But if you just think back. What's happened even over the last 5 years? I mean, I could remember working with a cardiology group and a cardiovascular medicine group, and, you know, there was a vast majority of the care that was being done inpatient, or at least, you know, where, if it wasn't being done inpatient, even some of the procedures and so forth were done in more of a 23-hour observation and so forth. And now you fast forward to where we are now, and it seems like much more is being done in the ambulatory arena. Much more is being done using therapeutics and so forth. How have you seen that shift? Or maybe the better question is, how have you adjusted to that trend and to that shift? 

  

Nihar Desai:  

Yeah, Dan, I think it's a great, you know, theme to touch on. I think we went through this phase, I think we're still in the midst of it, around an incredible amount of consolidation in healthcare, on the delivery side, and I think cardiology was really an important part of that story. 

  

Daniel Marino:  

Yeah. 

  

Nihar Desai:  

I think we had more and more providers that used to be in private, you know, community-based, you know, practices being absorbed into hospitals and health systems, and I think there were obvious, you know, financial reasons why those things happened. And yet at the same time, now we're seeing, in the same regard, that patients actually want care closer to home. 

 

Daniel Marino:

They do. 

  

Nihar Desai: 

That might be more convenient to them. They don't want to spend time, you know, in the hospital if it can be avoided. And now we're also seeing changes on the payment side when it comes to site of service where there might be more neutrality in terms of, you know, how payments are distributed, and so people are having to navigate these things. I will say, the other big, push that's happened in the field is that technology has now enabled things to happen in a fundamentally different way. What used to require a multi-day hospitalization can now be done same day. You know, what used to be a 4- or 5-day hospitalization for an acute coronary syndrome, even. You know, patients are seen in the emergency department, they may go to the cath lab that afternoon, and they might go home the next morning. And so we've seen a kind of a fundamental change in the technology in kind of how services can be rapidly mobilized for care. We see a demand on the side of patients to really have care that's closer to home, that's much more convenient and accessible. And we also have these changes on the payment side that are also sort of saying, hey, what's the right place for this care to happen, where it's most safe and effectively delivered, and most efficiently delivered. And the large, you know, tertiary quaternary care referral center may not be the optimal site of care for everything.  

  

Daniel Marino:  

Yeah, I would agree with you, and, you know, it's an interesting dynamic, as you laid this out, because you're absolutely right. We're seeing shifts in site of service to ambulatory, we're seeing our care being delivered more efficiently, right, with better outcomes, which has been great for the patients, but our costs continue to go up, right? And yet when you look at the level of reimbursement, and the reimbursement pressures that are being placed on cardiovascular services, it's not going up. As a matter of fact, it's going down. And I can't help but wonder, as you think about even your planning and how we begin to think about delivering care where it's needed around all of those areas that drive efficiency. If the revenue doesn't keep up with your expenses, you're gonna have a tough… a continued tough time to be able to hire and to maintain good staff, good physicians, good providers to support the care. 

  

Nihar Desai:  

Yeah, Dan, I think you hit it right on the head. I think, you know, Medicare has certainly, you know, telegraphed this to us. I mean, they're proposing additional cuts, you know, on the subspecialty side of things. There's budget neutrality, so there's obviously a relatively fixed, you know, pool of funds for that, and how those are distributed matters a lot. We've got to sort of think about, you know, the impact on equity and access and what that means for a large academic health system like ours. And I will also say, I think, you know, we're trying to make investments across the board. I mean, we're trying to grow and invest in hospital-based, you know, programs. In procedural and imaging-based, you know, modalities that we think represent the frontier of medicine, the best of what our patients want and deserve. And we also have to invest in the community, and we want to have, you know accessibility and offices, where people are, kind of looking carefully at the geography that we serve, where patients are coming from, to access our system, and if there's an opportunity for us to be in their community to provide, maybe, primary levels of service, and to even provide subspecialty service that's close to home, then we certainly want to be able to do that. Now, you're right that despite the all of these things, and all of the benefits that we see from that, if the revenue doesn't keep up, then that makes the math harder and harder and harder. It makes it difficult to build infrastructure, to make investments, to hire personnel, and at the same time, like we've sort of alluded to all along. We have incredible access challenges, and so if anything, we feel like we need to hire more. 

  

Daniel Marino:

Right. 

  

Nihar Desai:  

Both physicians, advanced practice providers, pharmacists, others members of the care team that can do different things, and that's sort of getting back to that reimagination of who's actually doing the care, but we certainly need more clinicians, you know. 

  

Daniel Marino:  

Yeah, to keep up with all the access challenges, no doubt about it. If you're just tuning in, you're listening to Value-Based Care Insights. I am here with Dr. Nihar Desai, Associate Professor of Medicine and Vice Chief of Cardiovascular Medicine at Yale School of Medicine, and we are talking about the impacts of cardiovascular medicine, and really the changes that have occurred, as well as the future trends. So, Nihar, I want to ask a question. As you were talking and describing the changes and the challenges, certainly with the payments. You know, the natural thing that comes to my mind is, you know, is value-based care now starting to really creep in as a way of being able to help better support the economic structure? In other words, are you tracking a lot of your outcomes? Not just your quality outcomes, but your performance outcomes in such a way that says, you know, hey, payer, you know, we need to share in the results here, right? Because, obviously, it's keeping costs down for them, it's keeping the premiums lower, you know, are you able to incorporate that into a lot of your value-based care agreements? So, it's helping to, I don't want to say subsidize, but create a new revenue stream, if you will, that are really aligned around what those incentives are. 

 

Nihar Desai:  

Yeah, Dan, I think that's a… that's a great point. I think it represents one of the true, kind of, fundamental questions that we're all going to have to confront, which is, we've been tethered mostly to traditional volume-based fee-for-service, and certainly on the hospital and academic health system side, that's where we've primarily been. And, you know, for lots of reasons, including many of the ones that you have said, we realize that the future has to be around population-based payments and value-based care and alternative payment models. And, of course, we've always had that to some degree. I mean, you can rewind the clock, you know, more than 10 years, and say, you know, we had the Affordable Care Act, we had Hospital Readmission Reduction Program, you know, we had payments that were at least, you know, tied to quality and outcomes, but increasingly, I think we're all realizing that the more of the ACO model, more of the population-based, you know, payments are going to be essential if we really can do what patients want, which is prevention, avoiding costly hospitalizations, that we can deliver all the preventative therapies that continue to emerge and can have impact for patients, but then to do so in a way that fiscally rewards, you know, payers. As well as those that are providing care. And obviously, things will continue to blur around that line of, you know, who is the payer and who is the deliverer as systems, you know, continue to take on more and more risk. Yeah, I think one challenge that we have to sort of confront, though, is You know, for many hospitals, we are still heavily tethered and connected to fee-for-service, that the business… 

  

Daniel Marino:  

Many hospitals, I mean, you're not any different. You see that across the country. 

  

Nihar Desai:  

Yeah, and so, you know, that model, you know, where you're really thinking about volume, you're thinking about capacity, you're thinking about throughput, versus a population-based model, where you really think about, you know, prevention and avoidance of, you know, costly utilization. I mean, they are a bit at odds. There's obviously a tension there. Now, I will say, we're quite, you know, eager and interested to see how CMS rolls out, you know, like, the ambulatory specialty model on the outpatient side, where heart failure is, you know, one of the, you know, key focus areas for that, you know, new initiative that's going to launch in, you know, in January. And so, I think we're eager, again, to start using some of our experience in those types of programs to learn to develop some additional muscle memory around how do we use data, how do we use that data to drive, you know, operational improvement to deliver the kind of care that our patients want, and then also to be, you know, fiscally and financially rewarded for delivering, kind of, on that value proposition. 

  

Daniel Marino:  

Right. Well, going all the way back to, you know, the beginning of time of population health, and even thinking about the early days of clinical integration, cardiovascular related comorbidities, or cardiology comorbidities, was always a driver, right? It still is today, right? When you think about managing patients with high blood pressure, or managing patients with CHF, or managing patients with coronary artery disease. You know, we all know that as you start to be… to introduce prevention, monitoring, all of those things could really help a lot of downstream, or save a lot of downstream costs, and not… as well as then really improve a lot of… a lot of the outcomes. So, you know, so when you're thinking about this, let's fast forward a little bit to the future. Artificial intelligence is really giving us a whole new avenue to begin to think about how we want to manage patients. And, you know, we're doing work right now with one organization where we're aggregating data, and not only are we helping them to think about, through this data, what's the right care plan, but probability models based on risk cohorts of different patients. But it's all built on those comorbidities of patients. Where do you see… where do you see cardiovascular services or cardiovascular medicine evolving to with the integration of artificial intelligence to kind of provide that level of knowledge, influence, care model changes, or what have you? 

  

Nihar Desai:  

Yeah, Dan, I think that… I think AI has a lot of promise in the cardiovascular realm for many of the reasons that you've said. I think in the here and now, we are… we're certainly using AI. I mean, we have, you know, communication tools that we're using to you know, kind of reimagine and re-envision our ambulatory practice, that, you know, a physician or a provider is having an outpatient visit, and, you know, when they go into their electronic health record, there's essentially a templated note that's kind of waiting. 

  

Daniel Marino: 

Yeah. 

  

Nihar Desai:  

You know, at the end of that, you know, at the end of that outpatient visit. I think more so to the future, as you kind of say, there's this idea of prediction. Kind of risk protection and early identification of patients that might have rising risk, that, you know, patterns that are invisible to the human eye, if you will, but that are very identifiable to a computer algorithm, or to an AI algorithm.I think will help us better align preventive therapies to rising risk. 

  

Daniel Marino:  

I think it's going to help tremendously. I think it could help tremendously, because what it does, especially when you look at cardiovascular medicine and those issues that impact patients. You know, there's, you know, there's the physical issues that relate to patients, but there's also a lot of social determinant factors. There's also a lot of factors that are lifestyle, influencers that oftentimes aren't necessarily as large of a focus as it should be. I think as you start to think about creating the right care plan, or even the right potential outcomes, I feel like incorporating some of that into an AI model, and certainly a prognostic or a probability-based model, would certainly give, you know, you and your colleagues, I think. Other opportunities to create more focused care plans. 

  

Nihar Desai:  

Yeah, that's right, Dan, because I think what we've learned, and I think as you get back to, sort of, a population health mindset and a value mindset, I mean, one of the things we always say to our team is, you know, doing everything for everyone is not a plan. We've got to be able to sub-segment, you know, population to really tailor interventions and care models to the risk that, you know, these populations have, the specific needs that individuals have. And I think AI has a lot of potential to help us with that. Its ability to refine and to, in a much more sophisticated way. Sub-segment, you know, populations to really help us identify the unique needs or the particularly important interventions or therapies that may be particularly beneficial. I think that's where, you know, some of the power of AI, you know, really can come. And so, yeah. 

 

Daniel Marino:  

I agree. 

  

Nihar Desai:  

I think we're all optimistic. Yeah, I think we're all optimistic that as digital tools continue to come, as we have more and more data streaming in, you know, about patients, that will need some of these adjunctive tools to help us, you know, distill and curate that information into actionable insights. 

  

Daniel Marino:  

Well, I would think… you have to be really looking forward to that, because I know working with you in the past, you love data, you love being able to understand the insights out of the data, and I would think being able to now aggregate it on a much higher level and incorporate that into different treatment plans and have us… having more focused care plans. I mean, I would think that's got to be very exciting to you and to many of your colleagues that you work with. 

  

Nihar Desai:  

Yeah, Dan, I think you're right. I mean, I think for us, we've been very bullish on, you know, trying to you know, stream different streams of data together, that that has to be part of the answer here, that bringing together clinical data with operational data and financial data, that's been part of our recipe for some time. I think, the advent and the ability of AI to even further that to kind of enhance that, to bring it together, and also couple it with much more deeply phenotyped data on individual patients. Like you said, not just about clinical factors, but maybe social determinants and other factors that we know are highly predictive with clinical events and outcomes. I think that really represents the frontier for us, yeah. 

  

Daniel Marino:  

Yeah, I agree. Do you think… you know, you mentioned access being a challenge. Access is a challenge for everybody, right? And I think we're really trying to figure it out, and I've… as I've said before, and I'm a firm believer of this, I don't think we're going to solve the access problem by just recruiting, because, you know. Yale School of Medicine, as well as every other health system in the country, is all vying for the same physicians that are coming out of school, right? But… so, what are your thoughts with access? Do you… do you feel like, you know, from what you're… from what you understand and what you see with AI, do you think AI has an opportunity to help solve the access problem? 

  

Nihar Desai:  

Yeah, I do, Dan, because I think, again, what we do now is, again, you know, we have to sort of appreciate just how stark the contrast is, that on. 

  

Daniel Marino:  

Yes, absolutely. 

  

Nihar Desai:  

On the biology and the pathophysiology and the treatment side, we're innovating so fast, and yet the delivery model for care essentially hasn't really changed. 

  

Daniel Marino:  

No, it's been very antiquated.

 

Nihar Desai:

Absolutely. Like, we still expect people to drive 45 minutes, to pay $8 to park, to sit for 20 minutes in the waiting room for a 15-minute visit with someone, and I think that model has to be fundamentally disrupted. Now, that might be the right care plan and site, and care delivery operation. For a particular profile of patient that has a specific kind of need, and wants and needs, and really deserves and benefits from that kind of care delivery might not be what everybody wants, and so I think we've got to be ready to reimagine what is that care, where is it happening, and who's doing it. A cardiologist obviously brings a lot of expertise and training, but we've got terrific you know, members of our care team, our advanced practice providers, we work side by side, shoulder to shoulder with them on the inpatient side and the outpatient side, in the procedural laboratories. We've got pharmacists and nurses and others that we all have to bring into this. And I think that mindset of a true multidisciplinary team of who's ready and able and willing to kind of help care for our patients in the way that they want and deserve? And I think there's a lot to be gained and a lot to be kind of reimagined, you know, through that work as well. 

  

Daniel Marino:  

That's such a great point. I mean, bringing the care team together in a way that you're really focusing that care to really that specific need of the patient, that's what's going to solve this, right? As well as then some of the innovative approaches that, like you said, we're going to have to figure out how we incorporate that differently than, you know, and moving beyond just the traditional model. Well, Dr. Desai, this has been fantastic. I, I really appreciate it. I love the conversation. You know, you certainly are at the forefront of a lot of the areas of cardiovascular medicine and cardiovascular services. For any of our providers that are listening or tuning in, any piece of advice you might share with them in terms of, you know, maybe what they should look for as they think about working with their physicians? 

  

Nihar Desai:  

Yeah, Dan, I think, you know, this has been a terrific conversation, and obviously one I'm eager to continue on for our, you know, for us and for our audience. You know, I would say, start pulling data together. Data too often is fragmented and isolated. There's sort of groups that use one type of data over here, and others that use different types of data over there. But I think if you bring it together and see it through the lens of the patient, you know, what is the patient's experience? What is their journey? How are they touching the system, and where are all the places where we can make things better for them? In the acute setting, in the longitudinal setting, in all the coordination and continuity of care that we have to provide to them, I think that is really the North Star that's going to get us out of this, is we need data, but we have to get through the patient's lens. 

  

Daniel Marino:  

Yeah, we have to look at data, but we have to use it as insightful insights, right? So we really begin to think about it and what's going to help the patient, so I couldn't agree with you more. Nihar, thank you so much for coming on the program. This has been a fascinating discussion. I think just… just great diving into this with you, and you know, best of luck to you and to your colleagues as you begin to move on, and, you know, we'd love to have you back on at some point down the road to even kind of hear how you've continued to evolve cardiovascular medicine. 

  

Nihar Desai:  

It sounds great. Well, thanks again, Dan, for the opportunity. You know, all best to you and our audience, and yeah, certainly look forward to more discussions like this. 

  

Daniel Marino: 

Great. Well, thank you, thank you again, and special thanks to all of our listeners for tuning in. If you're interested in learning more about this topic, or any of the topics that we've covered on Value-Based Care Insights, please go to luminaHP.com/insights, and you'll find just a vast amount of information there. 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 am your host, Daniel Marino. I'm really excited about this program and some of the future ones that we're going to have in place. We are going to spend the next few episodes talking about a series that we've put together around different service lines, specialty service lines. So over the next couple of episodes, you're gonna hear some great information, great insights, where we'll dive into primary care, other specialty services such as cardiovascular services, gastroenterology, orthopedics, and maybe a few others as well, we'll see. Certainly, as we conclude 2025 and move into 2026, the service line growth and development, is something that is really top of mind for physicians, for healthcare executives, really for the entire industry. So, in today's episode, I'm really excited to dive into primary care. Primary care is an area near and dear to my heart. I started my career in primary care managing, internal medicine practices, managed about, I don't know, I think there was around 20 or 25 internal medicine, and then slowly brought on family medicine as well. And when you think about where primary care has gone over the last, really, 4 or 5 years since COVID, it's changed quite a bit. There's been a lot of pressure on primary care physicians. There's certainly a shortage on primary care physicians or on providers in general. We've seen a lot of burnout, a lot of physicians, primary care physicians, just really getting tired of all of the administrative burdens that are being placed on them, whether it's with the EHR, or assisting with new referrals, or just managing all of the patient concerns and the patient challenges. So, as well as the shortage of primary care providers, it's also forced us to kind of exasperate into these new issues around patient access, and it's extremely difficult for many patients to get into their primary care physician timely, and many of them have looked at different alternatives, and the industry has evolved into expanding access. That would include virtual health, telehealth, and so forth. And then, along with that, in managing primary care services. What we've started to see is that behavioral health has really expanded into, a primary care role, where many primary care physicians now are having to work with patients on a lot of their behavioral health concerns and challenges that they might have. 

 Well, I am really excited today to have two experts in primary care. First is Dr. Sarita Soares. Dr. Soares is the program director for the Yale Primary Care Internal Medicine Residency Program, and is also a Primary Care and Addiction Medicine Physician at Yale. My second guest is Dr. Brad Richards. Dr. Richards is the Executive Director of the Yale Primary Care Internal Medicine residency program, and also an associate professor of medicine at the Yale School of Medicine. Brad, Sarita, welcome to the program. 

Brad Richards:  

Thanks for having us. 

  

Sarita Soares:  

Thanks, Dan. Glad to be here. 

 

Daniel Marino:  

Well as I mentioned, you know, primary care, I just have such a… I value it so much. It's the entry point of care. If really done well, it's the gatekeeper, it provides the oversight, and it's just such a strong component of our overall healthcare system, but we have so many challenges that we're faced with. And really, I think the biggest one is really around the shortage of primary care physicians, and then some of the corresponding issues that we've talked about, access being one of them. Dr. Soares, when you look within your own practice and within your own organization, I'm sure you're experiencing some of those same challenges with shortages. What are you seeing as some of the biggest challenges that are impacting primary care, and in particular, say, physicians or new folks wanting to get into primary care? 

  

Sarita Soares: 

Yeah, thanks, and I think this is something that we've been, we as a country have been dealing with for decades, and, yet the problem is getting worse as we have an aging population. And honestly, as you said, primary care is the gatekeeper, but I like to think of it a little bit more as… ideally, it should be the foundation, right? Like, a strong foundation that is broad-based, and is supportive. And should not be a narrow door. And yet, as you've mentioned, access to primary care has become a really huge challenge. I think part of that is resources, and traditionally, they were primary care physicians that were providing primary care. And we just don't have enough, young doctors who want to do primary care anymore, partially because it's incredibly challenging to be the master of you know, a variety of, medical issues, mental health issues, insurance, navigation, social work, evolving pharmaceutical agents, and, and, you know, there's just, like, a multitude of things that you need to be an expert of to be a primary care doctor. And yet, it's long hours with a lot of administrative burden, and a relatively low reimbursement in terms of pay, compared to, other specialties. And as a medical educator, I'll say, most people want to go into medicine for the right reasons. Most people really want to provide excellent patient care, and so, payment is not really top of mind for those who start their journey, but as we have graduates, who come out of medical school with $250,000 to $500,000 of student loans. Finding a field that's gonna allow them to pay the bills, and pay back those student loans is important. So I think part of the access is, it's a tough job that's undervalued and underpaid, and we have an aging population, and in general, even if we have enough primary care physicians in a practice and such, we just have an older population that's more complicated, and so there's certain patients that just need more of our time. 

  

Daniel Marino:  

Yeah, I agree, I agree. All of those factors, I think, are really contributing to a lot of challenges and burnout, higher burnout in primary care, and the compensation, I think, isn't really keeping up with it, especially when you see all the amount of time that… and the responsibility that primary care physicians have. Brad, let me turn to you. I can't help but think access is a major problem. It's a problem all over the place. In a recent study that we had assisted with, we found that the average time to get into a primary care physician, certainly for a brand new visit, could be… could be 3 to, in some cases, even 6 months for that new visit. Even for return follow-up, unless you have, like, a, you know, a high-acuity visit, or condition, rather, I mean, it could be 4 to 6 weeks before you get into a primary care physician. How are you addressing some of the access concerns within your organization to kind of keep up with the needs of the patients? 

  

Brad Richards:  

Yeah, it's a great question, and one thing that we've implemented is, you know, we have a resident faculty practice, and we have an urgent care clinic as part of our practice where we only see our own patients. And, you know, we call it urgent care. It's really anything goes. We are embedded in a federally qualified health center. We see a majority Medicaid patient population, though we have a lot of people who are both Medicare and Medicaid, dual eligible, and we do have some commercial and also uninsured individuals. But really, if someone needs something, we want to get them in as soon as possible. They're, you know. I will say, from a financial model, we're still very much a volume-driven organization, but usually we fill up all of those, for the most part, those slots. And so that… that does work. And, you know, the… the downside is we don't always have… for folks who are showing up for urgent, we get them into care, but we don't always have continuity of care, which obviously is a core tenet. You know, there's some continuity. It's within our practice. The people they're seeing are doctors of our practice, but it's not you know, their same PCP. So, that's one way. I've seen other places, you know, they'll open up, they'll have slots that will only open up 24 hours in advance. You know, you can do triage via telehealth. I think there's a lot of ways of addressing, kind of, urgent needs and providing access, but I think, to your question, the incentive to do that in a traditional, I think, or traditional fee-for-service model is not always there, because it's more about just making sure you fill up all the slots, as opposed to saying, getting people the access they need. And so you're not necessarily as incentivized as an organization to say, gosh, we gotta make sure we can get someone in within 24 hours, or even a week for their blood pressure follow-up, because we already are filled out, and, you know, operationally, that's… that's what we are mostly concerned about. 

  

Daniel Marino: 

Well, and it's a balancing act, right? So, you know, ideally, what we're seeing a lot is trying to deliver the care to the patient really where the patient needs it. And ideally, if you have patients who are high acuity, higher risk, if you're managing the comorbidities, all the responsibility of primary care, you know, there's different access components, different ways of delivering that care, right? You know, you can do it, obviously the traditional way of having patients come into the office, but I think telehealth and virtual health could also come into play as well. One area, and I would be interested, Sarita, in hearing your thoughts on this. Many large organizations, particularly academic organizations, have adopted a team-based approach of care, where they've included with the physician, potentially advanced practice providers, but really even expanding that to include social workers, diet, dietitians, even care managers and nurse navigators. That allow each of those care team members to really perform at the top of their license, if you will, but really create more of a comprehensive approach to primary care services to the patient. Can you comment a little bit on that? Where do you see the care teams kind of fitting into that whole primary care delivery system? 

  

Sarita Soares: 

I think that's the gold standard. I think that's the right way to provide primary care. I think the, you know, the amount of, really, challenging social determinants of health, barriers to wellness that a lot of our primary care patients have is incredibly overwhelming for that patient, and certainly for a primary care physician. And having a strong team of social workers, patient navigators, pharmacists, the dietitian who's able to translate what we might prescribe in terms of a diabetic diet into what someone can actually afford in the food desert in which they live. That's the secret sauce of success in primary care. And, having, you know, advanced practice providers has been phenomenal. Our practice has a small cohort of them, and they have been the glue that have just been able to have, tremendous, continuity with patients, and also just have their year to the ground, because they are dedicated, embedded in our clinic, as opposed to many of our physicians who are practicing, primary care, but also a number of other… they wear a number of other hats, and so it's a little bit harder to, be able to be that longitudinal continuity of the needs that patients, have. And so, I agree, I think team-based care is amazing, and I think the organizations that have really invested in team-based care are actually seeing much better health outcomes. The team doesn't need to be employed for every patient, but having the flexibility to prescribe the right team member for the right needs of the patient is, I think, the best way to personalize care. 

  

Daniel Marino:  

That's really the key. Right, because you're meeting… you're meeting the needs of the patient, right? Not everybody has those same needs. If you're just joining us, we are talking about primary care, and some of the challenges, and as well as then the changing model of primary care services. I am joined today by Dr. Sarita Soares and Brad Richards, both executives, physician executive at Yale School of Medicine and Primary Care. Brad, let me turn to you, and let's talk a little bit about value-based care and how that is coming into play. Value-based care, obviously, and primary care, is a… is a huge driver. And it's… it's no secret for many organizations primary care contracts and reimbursement is somewhere in the range of 90% of what they… that's embedded within the organizations, and If you're successful in value-based care as an organization, you have to have a robust primary care service line that looks at comorbidities, that's really managing the care, coordinating the care with the other specialties and the other physicians. But you also have to begin to track some of your outcomes. In your opinion, what's been the influence on value-based care, on primary care as you've seen it within your group? 

  

Brad Richards:  

So value-based care is, you know, a pretty wide spectrum of payment models that can be kind of grouped underneath there, all the way from, you know, taking full risk, where you're fully at risk for the total cost of care of a population, including 100% upside and downside, where, you know, you can, get all of the dollars that you might save, compared to a baseline, or you're going to lose a significant amount if you're at If you have downside risk. Versus, you know, you might have a pay-for-performance program, which is really dipping your toe in a value-based payment arrangement. And so, you know, if you're dipping your toe into the value-based pain arrangement, it's hard… you're not going to make a lot of changes, because you're, you know, most of your revenue is still going to be coming in through volume of service delivery, versus if you're really a total cost of care, you're really going to be looking much differently at your population, because your financial risk is really steep. And your volume-based service delivery may be inconsequential or very small in terms of your actual revenue as a practice. And so, really, where you sit in the value-based payment framework makes a huge difference with how you're going to actually, you know, shape your practice and change it. Where we are, there actually is, at least for Medicaid, and then obviously Medicare has the Medicare ACO program, MSSP. We have a Medicaid program that does have a cost of care component, but interestingly, because we're in an FQAC, they actually don't have much capital to make investments to manage the population in a way that you might think, partially because that payment doesn't come until 18 months later, because it's a, you know, you're getting a shared savings payment, much, much down the line. So it's hard to make those investments and capital up front on the care team. 

  

Daniel Marino:  

So are you seeing in that particular program, sorry to interrupt you, but are you seeing in that program, though, are there… is there more pressure being placed on the primary care physician because they don't have the right level of investment and resourcing? 

  

Brad Richards:  

You would think so, but we don't really even talk about the program because it's an upside-only program. So I think this is an interesting example when there's not really any downside risk, so there's no financial risk to the organization for not performing. 

  

Daniel Marino:  

So they're not performing any differently than what they would normally. 

  

Brad Richards:  

And it's a pretty small amount of dollars as a… it's not like a full risk contract where you're getting a lot, it's pretty small, and so most of the revenue is still volume-based, and so no one really even talks about that program, even though all of our patients are actually part of it. So I think it's a really interesting example of, yeah, actually, there is a value-based payment arrangement. We don't really talk about it very much, and we're not really focused on the outcomes that you might expect I think partially because of the undercapitalization that you would… that we don't have in terms of the outcome we would need to do. 

  

Daniel Marino:  

Well, I tell you, the undercapitalization for primary care, I think is a major issue. And I've said for the longest time, if, matter of fact, I recently was talking to another senior leader in an organization, and I said, you know, if value-based care was the car, t he engine to that car is care management. The more you invest in care management the more that it helps to support your physicians, and in particular, primary care. Because without this, and this was kind of the basis of my question, without strong primary care, without having that investment in there, all you're doing is creating more work for the primary care physicians. And their heart's in the right place, right? And they want to do a good job, and getting back to, Sarita, what you said, I think all physicians, I believe, get into medicine because they really want to help patients, they really want to help people and make a difference. But, you know, we all have limits, right? And without having the right support, we can only do… we can only do so much. 

  

Brad Richards:  

When you want to make a difference, you're often limited by the model with which you're working in, and if you're working with a really high-risk population, it's really hard to make the time and effort and investment to make a difference for someone that's really struggling with significant and persistent mental illness, and maybe housing insecurity, or other things. And, you know, and you, like you said, you see this pressure, you know, we work in a large academic system. We often have, you know, patients that we see in the hospital, we work both in the hospital and in the outpatient setting, you know, that transition of care, there's very poor transition, right? And if you talk to folks in the hospital, they're like, well, primary care will help manage this, but you're seeing patients all the time. If someone's going out to live in their car, how, you know, or they don't have a phone, like, we're not going to be able to reach them. We're not resourced. As you said, we are undercapitalized, and unless you actually invest, it's really hard to make an impact, so I always… I always think of, like, the value in primary care is, like, the is that relationship and then that long-term ability to have an impact on people's health and well-being, but you have to have the resources to do it well, and often for underserved patient populations, we don't, because the payment model is really such a volume-based service that is really more for people… it's more of a population that's in the middle, right? It's not for people who have, who don't have housing. Like, we're not going… it's really hard for us to go out to the street and find people there. It's… or homebound populations, we're older populations. Gosh, it's really hard to scale a home-based primary care program that's based on fee-for-service. People do it. It's very hard. It's much easier in a value-based payment arrangement because of that downside, you know, of preventing hospitalizations, ED visits. 

  

Daniel Marino:  

But you have to have the investment that's included in there, otherwise you're going to be really challenged. Sarita, I want to turn to you and get your opinion on a couple things that you mentioned earlier. You know, and as I watch primary care, you know, I've seen it evolve over, you know, my 25 years in healthcare, and as I mentioned, primary care when I was managing my office, primary care physicians and offices are very different than what it looks like today. And one of those big differences is behavioral health as a component of primary care. And I know a lot in your practice, and as the program director, addiction medicine is an area that, you know, you're really focused on. How has behavioral health, how has it changed primary care? How has it impacted primary care? I mean, I can only imagine that it's just putting even more stress on the primary care physicians to take all of those elements into consideration. Thoughts there? 

  

Sarita Soares:  

Yeah, I mean, I think we… we practice a very biopsychosocial model of medicine, so I think we, in primary care, very much feel that we need to take care of the mind, the body, the spirit of the patient. And a lot of times the… we can't take care of the physical body until we're doing a really great job with the mental health care needs of a patient. 

  

Daniel Marino:

Great points, absolutely. 

  

Sarita Soares:  

And, you know, I think, you know, we are… we train our future clinicians to care for mental health, but the amount of time that that takes, and the amount of resources, and the frequency in which, patients need to be seen, can kind of overwhelm them, right? And so that can be one of the other things that blocks up the access. And so I love the fact that we're now seeing more co-located, or ideally even, integrated behavioral health care teams. 

  

Daniel Marino:  

Me too. I think it's a game changer, and I think it's something that's been missing for a long time. I think having that as a component, it's the only way you're really going to really, you know, fully take care of the patient, both in terms of their mental health and their contributing conditions, such as, you know, diabetes and BMI and some of the other factors that are there. 

  

Sarita Soares: 

The other, another thing that is important that we're starting to see more of is a destigmat cessation, of, mental health. I mean, I think, you know, growing up, even, like, a couple decades ago, talking about going to a therapist or, you know, talking at all about depression or anxiety was somewhat taboo, and, and… Yeah. 

  

Daniel Marino:  

Nobody did it. 

 

Sarita Soares:  

And no one did it, right? And so, and there are still some populations where, you know, people would feel a little concerned about saying, I'm going to my psychiatrist's office, but if I'm going to my primary care doctor's office, and I'm having… I'm seeing another team member who's helping me with my overall health, I think that's amazing, right? It's a one-stop shopping, and I think we're caring for our patients the right way. 

  

Daniel Marino:  

Yeah, I absolutely agree. Brad, thoughts? 

  

Brad Richards:  

Yeah, I was just gonna say, I think, tying it back to payment a little bit, so we… we exist, Sarita and I both practice where we have co-located behavioral health, and it's great. I mean, honestly, it's… it is really, really helpful, but, the challenge in tying… again, tying it back to payment is in a fee-for-service or volume-driven, we still often don't communicate that well, right? I, don't often talk to any of the behavioral health providers about our patients all the… as much as I think we should, which comes back to payment. Not all of our patients need that, right? Some people just need to get referred. We can do warm handoffs, and that's great. But some people are really complicated. They have a lot of biopsychosocial complexity, as Sarita alluded to. And it can be hard to communicate, because we're tasked with seeing as many people as we can, and we don't have time to do these touchdowns or touchpoints, and so you're messaging people, you're hoping to catch them. 

  

Daniel Marino: 

Well, and the only way to get ahead of the game is, you know, you have to have, to your point earlier, the right level of investment, the right level of support services, because it is complicated. And what you end up finding is it's… I feel like, and this has been my personal opinion for many for many years, I think the primary care physicians take on too much responsibility, because there's nobody else to really be able to do it. Well, I want to thank you both for coming on. I feel like we just barely scratched the surface in some of these conversations, but I really appreciate your opinions. I'd love to hear your perspectives. Certainly with… with… on value-based care and access and… and the whole behavioral health piece, I think these are just key issues that are… that are so important. Thanks again for coming on the program. 

  

Brad Richards:  

Thanks for having us. 

  

Sarita Soares: 

Yeah, thank you, Dan. 

  

Daniel Marino:  

And to any of our listeners, if you're interested in finding out a little bit more about this topic, or others for that matter, please visit luminaHP.com/insights. I want to thank all of our listeners for tuning in. 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 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.