LUMINA Podcasts

As the CMS Transforming Episode Accountability Model (TEAM) launched on January 1, 2026, healthcare organizations are now facing the realities of implementation and the pressure to perform. In this episode of Value Based Care Insights, host Daniel Marino speaks with healthcare strategist Heather Flynn Kearney about what organizations are experiencing during the early stages of this mandatory model. 

They discuss TEAM’s goals, why CMS targeted specific high-cost procedures, and how hospitals are managing operational, financial, and clinical challenges. From data limitations and coding accuracy to care coordination and post-acute partnerships, the conversation highlights the core capabilities needed for success. 

Whether you're directly involved in TEAM or preparing for future value-based models, this episode offers practical strategies to improve coordination, reduce variation, and drive better outcomes in episode-based care. 

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. In today's episode, we are… it's kind of a follow-up to an episode that we had, probably late summer, early fall, where we dove into the CMS TEAM model, Transforming Episode Accountable model of care. And, you know, at that time, we had talked about the elements that went into TEAM, we talked about the mandated, organizations, and what their responsibilities are, and so forth. Well, the TEAM model launched officially January 1st. And, again, it's a… it's a 5-year program, that would conclude at the end of 2030. So, part of what we wanted to work through are, again, what are some of the key things that we're seeing right now? Through some of the hospitals and the health systems and the organizations that have been participating in it. And especially as we're working through these first couple of months. What are some of the drivers of success? So, you know, it's important as we think about it to continue to focus on how the information that we get, and the understanding related to CMS, and really what their goals are.

Well, I'm really excited today to have one of my colleagues, Heather Flynn, who is a healthcare strategist. She is an industry expert in understanding policy and sort of the CMS regulations and the drivers, and she has a lot of experience helping organizations put these types of programs in place, and really help to drive some of the success. Heather, welcome to the program.

 

Heather Flynn:

Hi, Dan, great to be here, thanks for having me.

 

Daniel Marino:

So, Heather, let's kind of start at the beginning. Let's talk a little bit for some of our listeners who may not be that familiar with TEAM. What are the key elements that are included in that, and probably more important, what are the goals of CMS as they've started to launch TEAM?

 

Heather Flynn:

Yeah, when you look at CMS's goals around value-based care, they've always been trying to increase coordination, decrease spend, help redesign care processes, and incentivizing more efficiency in care. So, when you try and think about what conditions they're going to focus on, TEAM is not that much of a surprise. It is kind of a next generation of BPCI Advanced and CGR that we've seen in the past. Which continue to target a few things. So, CMS is going to look for areas of high spending in Medicare, they're going to look for areas of high volume, but also high variation, and I think that's what a lot of people forget, what all of this is really aiming towards is to increase standardization. CMS wants predictability around cost, so they're going to target conditions where there's a lot of post-acute care spend that could go one way or the other, and episodes could look really different. They want to push the system to align on a care pathway that kind of makes things a little bit more predictable.

 

Daniel Marino:

So, one of the things I find interesting is the 5 high-cost surgical procedures, or the 5 procedures that they have, right? So, it's the lower extremity joint replacement, the surgical hip femur fracture, spinal fusion, CABG, coronary artery bypass graft, and then major bowel procedures. In your opinion, why did they select these procedures? You know, is it because these are the highest volume ones? Has this created the most cost variation? What have you seen, or what are your thoughts behind why CMS maybe selected these?

 

Heather Flynn:

Yeah, I think it's… I think it's a few things. I think it does check the boxes of high spend, high variation, high volume. But also, with cases like this, there's a clear quote-unquote trigger or start to an episode. It's a very definitive… the procedure is where the episode begins, where when you try and target more, like, chronic conditions, for example, or some other things, it gets a little bit harder to define. So these are really easy episodes to where does it start and where does it end? But it's also where CMS sees a lot of fragmentation of care. So these are procedures where there are a lot of providers involved, there's often multiple care settings involved. So it's an opportunity, again, for them to increase that coordination, increase that efficiency, and try and have the system be more coordinated in how they handle these high-volume, really often cases that hospitals are seeing.

 

Daniel Marino:

So the 741 hospitals that were mandated under the program here, were these the ones that maybe had the highest variation, or how were these… how were these hospitals selected?

 

Heather Flynn:

Yeah, CMS uses a pretty, randomized, as they say, sample of statistical areas in the country, so they try not to select specific hospitals based on their, past experience.

 

Daniel Marino:

Right, their performance.

 

Heather Flynn:

Correct, but what I will say is the downside to that, that a lot of people will push back on the models about, is within a statistical area, you're going to have really large health systems, but you're also going to have really small community systems, which are going to experience this model very differently. They're going to have a lot different capabilities, but they're essentially going to be evaluated similarly and based on each other when you consider regional settings of benchmark prices, for example.

 

Daniel Marino:

Yeah, and, you know, when we've looked at it, it's, you know, for some large health systems. You know, one of my clients is 13 hospitals. Only one of the hospitals is included as the mandatory hospital. So, I think, to your point, it's, you know, maybe the algorithm or the statistical analysis they did to select these, possibly wanting to just get a good, I don't know, structured representation of the different hospitals in the different areas that they can begin to test and drive some of the success.

 

Heather Flynn:

Yeah, we see that a lot across models, and, you know, it's never a perfect science, and that's one of the things that CMS has struggled a lot with. Is they're trying to be simple and straightforward in their methodology, such as a random sampling of core statistical areas, but by doing so, then they can't account for nuances, like what you're mentioning, of what if you have one hospital that's included in an area, but then in a neighboring county, that county's not included. Then you're kind of one foot in, one foot out, and that makes it harder for that system to then manage. But then expecting CMS to account for those complexities then makes the model more complex, harder to understand, harder to administer, so it's a little bit of a balancing act.

 

Daniel Marino:

So, I know we're only 2 months into this, maybe 3 months into this. What are you hearing? How are the hospitals, those that are mandated and working through this, how are they doing? What are they struggling with? What are some of the things that you're hearing?

 

Heather Flynn:

Yeah, I don't think it's… there's nothing revolutionary here. I think it's the same challenges that we've seen with all models, especially mandatory models. It's the operational burden, you know, the upfront investment that's required to manage these patients and manage them well and succeed in the model, so how do you track these episodes? How do you get real-time data? That's really tough. To know what's happening on the episode in real time, and be able to intervene if you need to, because you can't wait for the CMS data, right? By the time CMS gives you data on your episodes, it's too late. So not only tracking the patients data-wise, but also making sure you're capturing everything from a coding perspective. There are some adjustments for high acuity and more complex patients, but only if the hospital are capturing those aspects around the patient. So I think the data and the coding and the documentation is one piece. And then you have this other piece of care management. How do they manage care outside of their walls? How do they coordinate with post-acute care? But also, how do they start this up front and kind of do the pre-op evaluation that helps them set the stage? And have a good plan for this patient, kind of, before the episode even begins.

 

Daniel Marino:

Yeah, I want to dive into care management, but before we do that, I want to go back to what you had mentioned on coding and documentation, because the data is so critical here, and what we see… now, we've helped numerous organizations, numerous physicians kind of improve, for instance, their HCC coding, and still, you know, with many organizations across the country. The capture-recapture rate of HCCs is only about 65-70%, and it puts organizations in a really difficult position. And I can't help but think that those that are included in TEAM, if your coding isn't up to, you know, a reasonable level, certainly with the HCC coding of that 90-95% threshold and the documentation isn't accurate, that really has to be eight ball. And I think you can start to extract your own billing data, maybe the pre-adjudicated claims in order to evaluate it, but if it's not good data, you're not going to be able to really act on it, and you're going to miss that opportunity. Is that what you're seeing with a lot of the hospitals right now, as they're starting to move forward with really understanding the population related to team?

 

Heather Flynn:

Yeah, I mean, data is always a consistent challenge. Not only having data real time that you pull, but also understanding the CMS data that comes out later. I think, again, especially this goes back to those smaller hospitals that might not have these robust data systems in place, and all of a sudden this team model's kind of placed in their lap. And they have to figure out how to track these patients, and especially then, not only with data, but then when you think about when the volume comes into play, it's kind of a double whammy, right, of if you don't have the data, you don't have the coding, but then also, maybe you have a small volume of patients. You lose that law of averages, that those big, health systems have on their side. And it becomes a tricky formula to make it work if you don't have the ability to track patients, to look at the data, but also the volume to account for if one or two patients kind of become a high-spend episode.

 

Daniel Marino:

Yeah, kind of, you know, kind of changed the curve, if you will. If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I am today talking with Heather Flynn. Heather is an industry policy expert, and we're talking about the TEAM model and really kind of doing a quick review on the last couple of months as we begin to move forward with kind of really evaluating some of the successes of TEAM. So, Heather, I want to build on one other thing that you mentioned related to the data. Risk stratification of these populations, I think, has to be critically important, right? Because without understanding the risk factors that go into candidates for these procedures. I think it puts you… puts these organizations at a disadvantage related to maybe the pre-surgical evaluation that they need to do, but probably more importantly, planning for the post-surgical recovery. And oftentimes, readmission rates, whether it's through the ED or complications post-surgery aren't as a result of what happens in the OR, it's as a result of other things that are complications to the surgery. So, talk a little bit about some of the challenges, maybe, that organizations have as they're starting to really work through that risk stratification and what they need to do in order to really think about proactively managing these populations.

 

Heather Flynn:

Yeah, I think you make a good point that a lot of the spend, and especially the variability in spend, happens post-discharge. So I think a lot of folks focus on the post-discharge, but to your point, planning for post-discharge is going to happen pre-op. So I think, to your point, it's not only risk stratification in terms of identifying chronic conditions that might come into play, how can you help manage those, but also help promote other healthy behaviors. You know, a lot of times we hear that called prehab, if you will. But also, Setting the patient expectations can be a big factor, too. So not only coding that patient, but talking to the patient and saying, where are you going post-discharge? What will that look like? If you're going home, who will care for you post-discharge? You don't want this to be a surprise that after the procedure, then you're starting to have these discussions about what is post-op going to look like, and where's the best place for that patient to go. So based on that risk stratification, you could either have the conversation about going home and what that home care would look like, or you could start talking about post-acute care, outlining those options, and hopefully having that option selected, again, pre-op. Because the other challenge you see hospitals running into is space with post-acute care providers. You don't want to wait until after the procedure to find out that all of your preferred providers have no space for your patient, and then that results in a longer length of stay, and again, that goes to the quality, scores and impacts that.

 

Daniel Marino:

Well, it fits right into what you had started talking about before, was the whole care management piece of it, right? Because then you become a little bit more prospective on the care that you need to manage with the patient post-recovery, and then where the patient… the best opportunity for the patient to… to recover, whether it's at the home or a post-acute provider. Talk a little bit about the importance of partners, though, to this, because, you know, again, although the hospital, I think, is held primarily accountable to cost and the activities around the episode. You know, the post-acute providers, the SNFs, the rehab facilities, I think have to be critically important to this, because, you know, a large length of stay with a post-acute provider would certainly totally disrupt the whole cost model related to that episode.

 

Heather Flynn:

Yeah, exactly. As I said at the beginning, you know, we're trying to decrease variation here, so you want to standardized your care pathways where you can. So that means working with your post-acute care network to align on care pathways by condition. How are you going to coordinate care? What does data sharing look like? Is that feasible? So you both can be on the same page? That would also enable the hospital to track that patient real time, because once the patient leaves the hospital, you still need to understand where are they in their post-acute care journey. You, you know, the hospital's on the hook for 30 days post-discharge, so that hospital needs to continue following up and have a relationship with their partners to be able to understand is this patient tracking as we would expect, or do we maybe need to reevaluate? And if you don't have those open lines of communication and or the actual data sharing with your post-acute care providers, that becomes a lot more challenging, it becomes a lot more of a manual process of calling the providers and waiting for a callback, and that's when things can easily fall through the cracks.

 

Daniel Marino:

Yeah, that coordination with the post-acute providers and the partners, I think, is critically important, because without that, like I said, then things end up breaking down. Oftentimes, when we work with organizations, the transitions of care really is the difference between success and failure related to achieving some of these readmission goals and so forth, and I think you need to have the partner there that really is aligned around the care plans and the care models. Talk a little bit about quality. How is quality fitting into this? You know, I know It can't just all be about cost, it can't be all about utilization management. You know, certainly efficiency and reducing clinical variation is really important, but quality, obviously the quality of care and making sure that the model and what we put in place has to drive the highest level of quality that we can provide. Where does that fit in on the indicators and the evaluation of TEAM?

 

Heather Flynn:

Yeah, I think quality is… the quality score is overlooked, in my opinion, far too often. I think a lot of people… a lot of folks look at the quality score as, you know, a little adjustment that can, you know, give you a little bit more of a bonus, or perhaps take a little bit away, but especially in TEAM, the quality score is going to be much more impactful than that, and not surprisingly, I think CMS did this on purpose. They are trying to drive quality of care and ensure that while we increase efficiency, we're not compromising quality, we're not increasing readmission rates or hospital-acquired conditions and things like that. So, when you think about the composite quality score that a hospital is going to be assigned in TEAM, it's really powerful. It can sway the reconciliation amount by… Positive or negative 10% in some cases.

 

Daniel Marino:

Wow, yeah, that's quite a bit.

 

Heather Flynn:

When you think about a hospital who might have otherwise had really efficient spending, they might be set to receive a reconciliation bonus or positive payment from CMS, but if they have a negative quality score, or they receive, like, a negative 10% adjustment, for example, on quality, that bonus could now become a repayment amount.

 

Daniel Marino:

Yeah.

 

Heather Flynn:

So you really can't ignore the quality score, and I think that's kind of what comes from the preparation of… we're not only looking right now at what do your readmissions look like? Where are your care pathways? Who are your referral partners? But also, what is your length of stay? What kind of outcomes are you having? If we look at, by condition, what the quality scores are that are included, how are you performing on those currently, and what would we expect that to impact your team participation and success.

 

Daniel Marino:

Well, and that's such a, you know, that's a good point, and sometimes, although, you know, again, quality should always be at the forefront, and I think most of the time it is. It's very easy to get involved in the process of managing the care, instead of thinking about that with how it's going to impact quality, and are we really driving to some of these success indicators? So, you know, we've covered quite a bit. We talked about the data, we talked about care management, we talked about, you know, quality and documentation and coding and so forth. When you think about, you know, there's a lot there, right? So, when you think about the key things that are really important for these… these health systems, you know, the 740 or so that have been mandated, are there two or three recommendations or a couple of things that you would really recommend that the hospitals focus on as they think about moving this forward, really impacting some of their outcomes and their overall performance?

 

Heather Flynn:

Absolutely, and I think some of them we've already talked about, but if we're going to recap, I think where I always recommend health systems begin is know your baseline, know your degree of current risk, or as I call it, your current state assessment. To the extent you can, with the data that you have, understand by condition your volume, your average spend, your variation by surgeon, you know, you can look at this as law of averages, but this differs by surgeon sometimes. Where are your discharge destinations? How are you capturing the data? Are you capturing those comorbidities, or are they often getting missed? And then, as I just mentioned, how would you perform on the quality score today? So let's start by, you know, figuring out where we are right now before we try and change anything. That gives us a sense for what are the highest priority items and the most impactful items that we can… that we can change to be more successful in TEAM. I think a lot of times hospitals can, you know, get bogged down in the details and focus on the small tweaks here and the little upgrades there, but let's figure out what's going to be the most impactful changes that are going to result in the biggest improvement in our performance and TEAM.

 

Daniel Marino:

That's a great point.

 

Heather Flynn:

That would be one, and I would say second would be, again, the data piece. We've tracked on this… talked about this quite a few times, but how are you going to build real-time data visibility? How are you going to track those patients during the episode? But then, take it a step further, and I think part two of this is if you are able to intervene, then how are you going to intervene? So if an episode starts to go off plan, what is your plan B? How are you going to intervene? What tactics are you going to use? And then lastly, we also talked about it, but I can't reiterate enough the importance of your post-acute care network, referral partners, care coordination processes, data sharing to the extent possible. But I think one nuance to this as well that we haven't touched on yet is your post-care network and these care pathways only work if the hospital physicians and surgeons are participating and bought in, and they agree with this. You need their buy-in and their participation to make this whole thing work.

 

Daniel Marino:

Well, and as you were going through this, I mean, that was going to be one of my questions, is where do the surgeons fit in, right? I mean, should, as a best practice, should the hospital think about putting together some type of an integrated governance model that would include hospital and the hospital operators with the surgeons who are driving this, as well as then incorporating maybe some of the post-acute partners.

 

Heather Flynn:

Yeah, I think when hospitals take more of a participatory approach. And everyone is at the table from the start to say, hey, with the surgeons and our post-acute care partners, but also our care management team and our IT folks, what does it… what does the episode look like, and what should this care pathway look like, and how do we all come to the table aligned? I think it's challenging to, behind the scenes, develop a care pathway and try to hand it down. That usually is not as successful.

 

Daniel Marino:

Well, it needs to be physician-led, there's no doubt about that. The physician is really the one that's driving this. Well, Heather, this has been great. Again, it's always fascinating to understand or to kind of dive into a little bit of the drivers and the motives around CMS and doing some of… putting forth some of these programs, and then, you know, again, the hospitals and the health systems are at different places in terms of their capabilities and their infrastructure, so being able to sort of raise those capabilities up to align with the… with what CMS's goals are, I think, always remains the challenge. I appreciate you sharing your insight on this. If any of our listeners are interested in contacting you, maybe learning a little bit more about some of the policies, or maybe just some of your experience that you have in working with some of these hospitals. Can you share your information?

 

Heather Flynn:

Yeah, of course. So on LinkedIn, I'm under Heather Flynn Kearney. You can reach me there, or happy to share my email, which is going to be hmkearney@ecgmc.com. Happy to chat more or share some more insights.

 

Daniel Marino:

Great. Well, thanks again, Heather, for coming on. Really appreciate the conversation, and really appreciate your insights. This is… this was fantastic.

 

Heather Flynn:

Thanks, Dan, it's been great. Great talking to you.

 

Daniel Marino:

And for our listeners, a very special thank you to you all. If you're interested in hearing more about this topic, or maybe some of our other topics, please visit luminaHP.com or ECGMC.com as well. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

As Medicare Advantage enrollment continues to rise, health systems and provider organizations are recognizing that these contracts demand more than traditional care delivery. In this episode of Value-Based Care Insights, host Daniel Marino is joined by value-based care expert Dr. Doug Ardoin to examine what drives performance in Medicare Advantage. 

Together, they discuss why provider organizations often struggle after entering these arrangements and outline the core capabilities required to perform effectively, from accurate risk capture and attribution to utilization and care management. This conversation offers healthcare leaders practical insights on aligning clinical operations with contract expectations to improve financial and clinical outcomes in value-based models. 

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As we all know, Medicare Advantage continues to gain a lot of momentum across the country, certainly being pushed by CMS. year over year, Medicare Advantage continues to grow with many Medicare beneficiaries now shifting into Medicare Advantage. But as we all know, it's still under a lot of pressure. There's a lot of large health systems that have decided to not participate in Medicare Advantage. For a whole host of reasons, most of those reasons are really around the administrative costs and the administrative challenges that Medicare Advantage places on these organizations related to pre-authorizations and increased denials and so forth. I think that's, you know, it's all very relevant. But in today's episode, we want to dive into the… kind of the path to success as organizations that are participating in Medicare Advantage. How can they achieve a level of financial success on performing well and really putting in place some proactive interventions, and understanding the key concepts that really drive the level of performance that's needed to succeed under Medicare Advantage? And then there's a number of elements there. You know, if you're in a straight Medicare Advantage contract, you know, you're going to get reimbursed based on Medicare rates, or maybe a couple percentage points higher, but many of the commercials are commercial carriers that have the Medicare Advantage products are actually including now additional incentives. So you could have a performance incentive if you perform better than the elements that are inherent in the contract, or you may enter into a shared savings component, whereas if you're able to show that you can save money, you're splitting that with the payer. Others are moving into an upside-downside element associated with Medicare Advantage, but at the end of the day, it comes down to how you perform, right? It comes down to how you manage the population, understand the data. You know, driving the care to the patients that really need it based on their acuity level.

 

Well, I'm really excited today to have a colleague who I've known for many years, a true expert in the field, particularly related to value-based care and clinical integration, Dr. Doug Ardoin. Doug, welcome to the program.

 

Doug Ardoin:

Thank you, Dan. It's great to be here.

 

Daniel Marino:

Doug, I know you've done a lot of work around Medicare Advantage. You've, you know, you've built numerous CINs, and you've really helped position many physicians, many provider organizations around success of value-based contracts, as well as Medicare Advantage. In your opinion, why are organizations… why are they struggling so much to perform under the Medicare Advantage contracts?

 

Doug Ardoin:

I think there are a couple of reasons, Dan. I think, first and foremost, I think a lot of them don't really understand what they just got into when they sign a Medicare Advantage contract, especially if it has a lot of value-based elements to it, and performance elements that create, you know, financial incentives, or even financial downside. So I think a lot of times, they get into it just thinking that it's just another way to have a contract with a whole lot of lives that are going to be attributed to them. And that they're going to be successful if they've done what they've always done, in a fee-for-service arrangement, which isn't going to work very well at all in a value-based arrangement, especially with seniors with Medicare lives. So, I think for a lot of these organizations, it really is, have they built and do they understand their own internal capabilities and competencies for this type of a contract, or do they have access to the kinds of resources that are going to make them successful.

 

Daniel Marino:

Yeah, you're absolutely right. So when we think about the elements, or the performance drivers, let's call it, of a Medicare Advantage product. There's 3 or 4 key elements, right? I think the biggest one is medical loss ratio. And, you know, the government sets that standard at 86%, you know, there's some flexibility in the negotiations with that, but the MLR, I think, is an important driver. I think the other drivers that you look at is utilization, good versus bad utilization. The risk stratification that's associated with… with, managing the population, and… and quality. So, when we think about those four performance drivers, maybe we could talk a little bit about the medical… the MLR net loss ratio first. In your opinion, what are organizations struggling with? How come they're not doing a better job of influencing the MLR?

 

Doug Ardoin:

Well, first of all, I think they need to understand… make sure they clearly understand how that MLR is calculated. You know, once again, it is the expenses, you know, divided by the risk-adjusted Medicare revenue, and I think a lot of times, organizations pay a lot of attention to, or they think they know how to pay a lot of attention to the numerator focusing on, utilization. But I think they, a lot of times, forget the denominator, and they forget that, that risk-adjusted Medicare revenue is very important. And it's not particularly difficult to influence if you understand how that works. How you marry up a, you know, really solid documentation, very descriptive about the different illnesses that your patients have. Understand how to get very precise and accurate for diagnosis coding, getting an ICD-10 that's… that's very specific, not one of the ones that's, like, diabetes not otherwise specified, but very specific about, like, diabetes with renal or visual or other manifestations. And knowing how, when that comes together, How that precision helps drive more Medicare revenue into the denominator, because now the plan has a deep understanding of, kind of, how sick the population is you're taking care of. So, the MLRs, it's important to really understand what's driving the numerator, what's driving the denominator. And just quickly on the numerator side, yeah, I mean, you're gonna have all of your typical expenses, you know, office visits, and ER visits, and hospital visits, et cetera, et cetera. But a lot of times, what folks don't focus on also is pharmacy, and pharmacy expense, and really understanding…

 

Daniel Marino:

Pharmacy expense, just to jump in really quick, I mean, that's the biggest challenge. That's been going up higher year after year than the medical costs, right? The pharmacy spend is going up much higher, so you're right. I mean, that's a… that's a significant driver and a real challenge to the performance of some of these utilization costs.

 

Doug Ardoin:

I would agree, and I think that's a great opportunity, to be able to sit down with the payer that you're now in a contract with, and I will say this. The relationship with the payer in an MA contract is a lot different than in a typical fee-for-service contract. You are truly partners now with that payer. You both have the same incentives.

 

Daniel Marino:

Yeah.

 

Doug Ardoin:

Performance within that contract. So, aligning that is critical. And pharmacy spend is an area where you can align very closely with the payer to understand how you're going to manage pre-authorization for specialty drugs and certain oncologic drugs and things like that. Understanding how you're going to implement, say, stepwise therapy, to be sure that you don't jump to the most expensive pharmaceuticals and most expensive therapies at the beginning. And how you're going to manage that with your attributed population, with the patients. But you're right, Dan, pharmacy expenses is something that can quickly get out of control.

 

Daniel Marino:

Yeah, you're absolutely right. So I'm gonna go back to…the risk stratification point that you brought up, because I think it's really a good one. You know, understanding, the risk stratification of the population, and placing the population, different risk cohorts. You know, allows providers to really deliver care really based on the needs of the patient, right? Based on that acuity level. And yet, many organizations struggle with really risk-stratifying their attributed lives, their attributed population. And so I just wonder, is it because they don't understand, they don't have the means to be able to calculate risk stratification? They don't understand the scoring mechanism? Maybe they just don't get all of the data? Many of them just seem to be beholden to the payers and just… you know, take their risk score for face value. What are your thoughts there? What's really holding the providers back from calculating risk?

 

Doug Ardoin:

I think two things. I think…Number one is making sure they're getting the data for their attributed population, and I think… I think understanding attribution is… is a pretext to then knowing how to risk stratify, and we can… we can maybe get into that discussion a little bit. But on the risk stratification part, it's making sure that you've got the data for the… for your population that you can… you could…As simple as just dropping it into a spreadsheet, and maybe using some predictive analytics to help you sort through to figure out who has certain diseases, who has certain diseases with comorbidities, and start to create that list of maybe kind of more healthy to, you know, to rising risk, to chronic with high risk, and maybe those that are even frail and at the end of life, and being able to using your diagnosis codes, maybe even what you understand about what the pharmacy spend is for individuals, so that you can put them into these different risk categories. And then at that point, start to think about precision ambulatory care management, how you're gonna do… how you're going to manage these corridors, because you're not gonna manage them all the same. I think you gotta know how to analyze the data, put, you know, parse it and put it where it belongs, and then make that… then make that information actionable.

 

Daniel Marino:

If you're just tuning in, I'm Danny Marino, you're listening to Value-Based Care Insights. I'm here with Doug Ardoin, and we're talking about the performance drivers of Medicare Advantage. So Doug, just building on that really quick, you know, as we were working with one organization, and many of them, I think this is the case, they really under-represent the risk of their population. And as an example, you know, the average risk for a Medicare Advantage population, let's say, you know, the RAF score is 1.0. For this particular organization, they came in at a 1.03 as their calculation, but when we looked at the… we did the analysis of the community and Medicare and really getting in and looking at the claims data, they should have been closer to a 1.15, compared to a 1.03. Which, getting back to your point earlier on the calculation of the denominator of the MLR, that really under-represents the acuity factor and the cost threshold of this population. So, how much… you know, I guess I'm gonna put you out there on this question. How much is that really underrepresenting, then, the financial opportunity that the organizations have to really appropriately drive the right level of care? I think… no, I think it's extremely important, and I think… I think the impact is… is… is extraordinary, quite frankly. I believe for a lot of, organizations, provider groups that initially get into Medicare Advantage and have this type of an opportunity around the MLR, I think they're going to have to do a deep dive into how their physicians and advanced providers, how they diagnoses code. If they're noticing that there are a lot of not otherwise specified codes, they're going to have to address that almost individually with every one of their providers. I know of organizations that will not allow NOS or not otherwise specified ICD-10 codes anymore. They tell them, there's no such thing as diabetes not otherwise specified. You have to use one of the very specific codes, which could be diabetes with renal manifestations. There's no such thing as a heart failure, COPD, or CKD code that's not otherwise specified. Because those codes, they don't map to the correct risk adjustment, or the correct HCC, code that Medicare uses, then, to calculate RAF, or Risk Adjustment.

 

Daniel Marino:

Well, as I've heard… as I've heard you say time and time again, coding and documentation accuracy is critical, right? And it's just so underrepresented within organizations, but it has so much value attached to it, and being able to make sure you're accurately representing the risk of your population.

 

Doug Ardoin:

And receiving the proper amount of revenue, Medicare risk-adjusted revenue.

 

Daniel Marino:

Yeah, absolutely. So let's… let me shift, Doug, to utilization, because utilization is a big driver of cost, right? And in my mind, there's good utilization and there's bad utilization. The good utilization, is making sure that patients are seeing their PCPs. You've got your annual wellness visits coming in, you're managing your chronic diseases, within your primary care network, and so forth. The bad utilization is the over-reliance on the emergency department or the, you know, higher admissions through the ED, that sort of thing. How… when you think about performance drivers, how is… how is managing that bad utilization, how does that… how can organizations really begin to think through influencing that, so you're steering from that challenge of bad utilization to good utilization? Patients still need the care, and they're not getting it, right? So, how do organizations make that shift?

 

Doug Ardoin:

I think the best organizations do this through a multi-pronged approach to access. They begin to think of access differently and in different ways. Certainly, the traditional access point of a patient makes an appointment and sees their physician or APP is just one way of managing access, which then begins to manage utilization and prevent unnecessary ED visits or avoidable admissions to the hospital. That's just one way. And how you use that access point is important, that you definitely want to use it for your higher risk chronic patients that you may want to see once a month just to make sure that they're staying on their medications, they're doing what you're asking them to do, that their caregivers, their family members are engaged, and that they've got a tight connection with your ambulatory care management. But then from there, I believe you also have to use, you know, virtual visits, you have to use all the other access tools that you have available to you, you know, televisits, and I think you have to rely on your ambulatory care management team. And I stated earlier, and to use precision care management, you may want to have individuals on your team that are very interested in and are highly skilled at ambulatory care management for heart failure populations. You may want to use, wearables, you know, and other types of instruments, you know, out there to be able to do monitoring, right, of your patients. But I think you have to think about access and management and monitoring differently. And then. Lastly, maybe develop a really good relationship with the emergency room, so that when your patients do show up, they call you first, and explain…

 

Daniel Marino:

There's an advanced triage component.

 

Doug Ardoin:

Exactly. So there are lots of different ways, but you have to think about access differently.

 

Daniel Marino:

So, you know, kind of bringing this all together, right? Because, you know, if you think about access, the patients need the care, right? So they're going to go wherever they can go in order to get the care that they need, and I think for organizations to be proactive, reaching out to those patients and making sure that you're directing them to the care that they should be getting, and really where they should be getting the care. I mean, it does come down to risk stratification, right? We talked about that. But it also comes down to care management, and I love what you said around precision care management, because I don't think many organizations think about it that way.

 

Doug Ardoin:

No, I would agree. I don't think many of them do at all. Organizations that I've been in in the past, I… I believe that they had to… they had to grow into that model as they began to understand, as they took on more and more Medicare Advantage lives that were value-based or risk-based, and they realized that just kind of having a generalized blanket structure to care management wasn't doing enough to look at those individuals with certain diseases and very specific needs, that, that you could then tailor care management to. One area in particular, is behavioral health, and that's another area where you really need to have very specific, very precise care management for patients who struggle with behavioral illnesses.

 

Daniel Marino:

You know, for… I'll share a quick story. For one…client we were doing some work on, or work with, rather, they wanted us to come in and evaluate their care management program, and they were spending a lot of money on care management. When we benchmarked them against the market, they were actually coming in and spending about 10-15% higher on… both in terms of FTEs and cost than what would, you know, typically be with the amount of covered lives that… that they would have. And what we found was that it wasn't that they didn't have the programs. And it wasn't certainly that they didn't have the resources or the staff, but the folks were not deployed, and the programs were not focused on the right areas of the population to really drive the right level of performance. And it just gets back to what you said. You know. If organizations are really going to proactively manage the population, you have to understand, really, where you're driving the care, where to put the resources, right? And I just feel like so many organizations either don't really think about it that way, or maybe they just don't have the data and the insights to really understand where those level of programs need to occur.

 

Doug Ardoin:

I would agree with that. I do think it has a lot to do with the organization. I think a lot of organizations, if doing value-based care in an MA contract is a little bit of kind of playing around the fringes, and they really are truly more of a fee-for-service shop when it comes to everything else than they may not give the attention and time necessary to deeply understand how to utilize resources, like care management, and how to accentuate the competencies within. So that's… that's what I've seen a lot of, out there. Which is, you know, very different from, you know, some of the larger groups, whether they're mostly, you know, large primary care groups around the country, or even some of the health systems that have gone much more deep into value-based care, begin to understand the value of the focus needed to make sure that this works in a way that drives the level of precision that you need.

 

Daniel Marino:

Well, as I've said time and time again, if a value-based contract is the car, the engine's care management, right? And, you know, the more robust your care management, the more successful you're going to be with these contracts. Let's shift to the last component. I want to get your thoughts on quality, right? Because, and many of the contracts, you know, there's stipulations of the quality indicators, there's quality of performance in there. It seems to me, with many of the organizations that we've evaluated around the performance of their MA contracts. Quality is the one that is kind of stand out, or stood out, right? I mean, it seems any of the organizations have performed well on quality. Is that what you've seen as well?

 

Doug Ardoin:

I believe so. I think that quality measures have been around now for so many years, and whether it's a Medicare Advantage contract, or even a commercial contract, especially if it's a CIN contract. If you're… if you've been doing a Medicare Shared Savings Plan, ACO, for many, many years, then I believe that most organizations have gotten the message that how you manage and document quality for diabetes and blood pressure control and cancer screenings and all of that. All of that is so very important, and it gets looked at in just basically every contract.

 

Daniel Marino:

Yeah, and like you said, it's been around for a while, and folks have performed well on it. So real quick, Doug, I know we're coming up on time. For organizations that are maybe underperforming on their MA contracts, or really are seeking to perform much better, you know, real quick, any advice you'd give them?

 

Doug Ardoin:

I would say go back to the basics, first and foremost. Do you understand your attribution? Do you know who you have? Do you know how you get them? Is it retrospective, prospective? And we could spend too much time on that, but do you understand… can you put them… put your members, your patients, into risk corridors? So, go to the basics about understand your population. Understand, you know, how you're utilizing care management, and are you… are you driving toward precision, cohort-based, or even disease-specific-based care management? Are you educating your physicians and providers on how to accurately diagnose, you know, and get the right codes for, you know, and document for your patients? And then lastly, I would say, are you… are you meeting with the payer on a regular basis? Are you guys sharing information freely? And do you really feel like you're set up as a partnership for success?

 

Daniel Marino:

Yeah, really, collaborate. I mean, that is just such key, so key. You're absolutely right. Well, Doug, thanks for this. This is fantastic, and, you know, I'd love to have you back again. Maybe we can do a further deep dive on risk, or attribution, or any of those elements. I think they're so critical on the performance of MA. Really appreciate it. Real quick, if any of our listeners want to get in touch with you, do you mind sharing your contact information? Sure, yeah, they can reach me on LinkedIn, or through my Lumina HP email address would be fine. Either one of those would be great.

 

Daniel Marino:

Wonderful. Well, thanks again, Doug. Really appreciate your time. Great conversation. And to any of our listeners out there, thanks for tuning in. Without you, Value-Based Care Insights would never be as successful as it is. We'd love to hear from you. Please keep the comments coming. To learn about this topic or any others, please visit LuminaHP.com or ECGMC.com. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

In this special episode of Value-Based Care Insights, host Daniel Marino announces an exciting new chapter: Lumina Health Partners has joined ECG Management Consultants. Dan is joined by Terri Welter, Partner and Leader of ECG’s Payer Strategy and Contracting Division. 

Together, they explore the evolving dynamics between payers and providers, the growing role of advanced analytics and transparency data in negotiations, and how reimbursement models are shifting in response to mounting market pressures. The conversation dives into key trends in value-based care, physician compensation alignment, clinically integrated networks, and the strategic use of data to drive sustainable performance. 

As healthcare organizations face increasing financial and operational strain, this episode highlights how deeper expertise, stronger analytics, and more collaborative payer-provider strategies can lead to smarter negotiations and stronger outcomes effectively.  

LISTEN TO THE EPISODE:

 

Dan Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. We have a really exciting episode today. I am beyond excited to announce that Lumina Health Partners, the sponsor of Value-Based Care Insights, is joining ECG Management Consultants. Really an exciting opportunity, not only for the folks that are within Lumina, but all of you, all of our listeners. You know, as you recall, as many of you know that listen throughout the years. Value-based Care Insights brings really strong topics insights, if you will, and it's great to hear from a lot of the national thought leaders across the country, and especially a lot of the providers. You know, we've received many inquiries, and have many of you all on our show, and talked a lot about the insights. Well, with now ECG and the alignment of Lumina with ECG, it just brings just a greater wealth of information, a greater knowledge base, and as we start to navigate all of the challenges that we have within healthcare, I'm just excited to bring even stronger solutions to the table. Well, here to talk to us a little bit more about this is now my new colleague, Terri Welter. Terry is a partner with ECG, She leads the Payer Strategy and Contracting Division Terri, welcome to the program.

 

Terri Welter:

Thanks, Dan, it's great to be here, and I echo the welcome of Lumina Health to ECG, and look forward to us working together for many, many years, so it's great to be here.

 

Dan Marino:

Well, thank you, and we are excited as well. You know, as I mentioned, ECG has worked with hundreds, if not thousands, of providers, hospitals, academic medical centers, medical groups. Across the country, and, you know, really strong in payer strategy, medical group operations, hospital performance strategy work, and so forth. I know you lead the payer strategy area. What are some of the things that you're seeing that ECG is really leading as they're starting to have these conversations, or really supporting a lot of the providers with, let's say, payer contracting, if you will?

 

 

Terri Welter:

Yeah, so Dan, we have been developing our payer services practice for many, many years. I started at ECG 20-plus years ago, and we've actually put together a team of 40-plus professionals that all they do is sit between provider and payer relationships. So, we're really at the table, we're doing strategy work, but we're also at the table doing the negotiations. We've done negotiations in all 50 states. So one of the things that we're leaning into is really bringing a lot of data to the discussion, you know, now more than ever. You know, both providers and payers have a lot of stress, right? Financial strain, operational strain, so we need to actually come to a solution that is going to work for both parties, so to do that we bring a lot of data to the table to understand, sort of, market position and what the parties need in order to make things work.

 

Dan Marino:

Well, and the data is key. You know, we've assisted a number of organizations with payer contracting as well, and the understanding the data, understanding the market positioning related to the data, and how you create sort of a win-win with both, you know, the hospital or the provider group and the payer is really key. One of the things that I've been particularly impressed with ECG is the level of transparency data. You've really gone out and built a whole model around the use of transparency data.

 

Terri Welter:

We have, that's right. We believe that the transparency data has been a game changer, right? So, think about it. For many, many years, you know, that information was sort of under lock, because contracts were confidential, you know, you could purchase some of the data.

 

Dan Marino:

Yeah.

 

Terri Welter:

Now, with the new transparency laws, well, it's not always perfect in every market, it's getting very, very good, so we have access to both the payer and provider data across the country, and we… what's different is that we have done negotiations in those markets, so we understand based on our experience, whether that data is valid or not, so we're able to take that data and actually put together a story, you know, in every strategy and every negotiation. So I believe that, ultimately, that transparency data is going to drive down costs. You know, right now, it's actually a bit chaotic because, you know, if you think about it, there's so much variability from market to market, but the data on the transparency side is really, really powerful.

 

Dan Marino:

Yeah, it really is, it really is. You know, one of the things that we've seen around a lot of the payer activities is shifts inside of service, there's different types of reimbursement structures that are coming, that payers are starting to work through with providers, whether it's, you know, hospital-based reimbursement or more ambulatory-focused reimbursement, even value-based care, is really kind of picking up in certain markets. So when you think about the payer strategy for hospitals or health systems, is there a particular approach that you've seen that has really been advantageous to a lot of the providers, or is it really just market-specific? Is it really more so provider-specific.

 

Terri Welter:

It's provider-specific, with some exceptions. So we're seeing… in the past, really, 5 to 10 years, I think there was a push to ambulatory, and there still is a push to the ambulatory side in terms of getting the patient to the right site of service to meet their needs. But if you look at… at what happened was, now we have that information available on rate for the outpatient side. So, we're telling our provider clients that you really need to be very competitive on rate for outpatient services, but what we're finding is that the inpatient side may be underpaid because we have an acuity issue in the inpatient, right? So, patients are sicker that are in the inpatient, so we're seeing a push towards moving, revenue to the inpatient side, believe it or not because the outpatient has been, you know sort of shoppable in terms of, you know, patients have options, but, you know, we need to move dollars to where patients are sicker, and it requires, you know, a higher level of care for those patients.

 

Dan Marino:

Well, and it probably, you know, when you talk about the data, then what really becomes important is to almost measure the acuity of the patients, right? So the higher risk patients are the ones that are really going to the hospital, and we're seeing that, you know, all across, particularly as you start to think about value-based care. I mean, risk stratification of the population becomes really important, but you bring up a really interesting point. As you're… we're starting to measure more of the acuity and seeing the acuity increase on the hospital side. I can see how hospitals now are really getting under-reimbursed based on that level of acuity, right? I mean, if you're really getting measured and building the pay structure, the reimbursement structure around an acuity level that was, say, I don't know, modeled 3 or 4 years ago, the acuity is much higher now.

 

Terri Welter:

That's exactly right, and we're seeing, then the need to put dollars to those high-cost cases. We're also seeing, on the contrary, actually, we're seeing pressure to move dollars away from the drugs, because as you know, you know. Drug reimbursement is you know, a high-cost area, right? And we're trying to figure out a way to make more available to, you know, the community, but in doing so, you know, we're moving dollars to inpatient. So it definitely is sort of a math problem, the high acuity, but then we also have issues with drugs, outpatient imaging, you know, those areas that perhaps we are overpaid on that we need to move to inpatient. So… Solving that problem.

 

Dan Marino:

Right. So I know one area that ECG focuses a lot of work on is, provider compensation. And, you know, physician compensation over the years has continued to evolve. We've had the good fortune of working with numerous organizations, employed medical groups, independent medical groups, on what their compensation structure is. And many of them have shifted to straight salary, to RVU-based, and now are starting to pick up a little bit more of a quality component in there. What are you seeing, or what are your colleagues seeing, in terms of the trends of compensation? And maybe in particular, how is that aligning with some of the payer strategies and the work that you're doing within your own division?

 

Terri Welter:

I mean, we're… my colleagues, we have a division called, you know, the MGO divisions, Medical Group Optimization Division. They actually say that they're getting quite a number of requests to consider, sort of, fixed-based compensation. The Mayo Clinic, the Cleveland Clinic model, and in doing so, you have to have really sort of sophisticated, performance-based organizations. So, setting that aside, when we're looking at value, we are seeing an uptick And the level of incentive-based revenue put in physician compensation and provider compensation, compared to what we did before. You know, it's still highly productivity-based, we have some fixed-based comp, but we are seeing an increase in sort of tying value-based measures to, you know, that tie to the contracts to, you know, provider compensation, and uptick. You know, it's hard to connect all those because, you know, they're differentYou know, streams of revenue, but we are seeing that happen, and particularly when you're working with, you know, a clinically integrated network or an organization that has a lot of primary care, you know, within their network.

 

Dan Marino:

If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I am here today talking with Terry Welter, partner with ECG Management Consultants, and we're talking about the advanced topics, the advanced resourcing from the newly announced Lumina Health Partners joining ECG. Very excited about this, this opportunity. So, Terry, building on that. In some markets, we're seeing value-based care picking up steam. In other markets, it's not. And in particular, with some of the payer contracting, some of it has really created a lot of momentum. Are you seeing a big divergence in the amount of, let's say, increase in the percentage of value-based care revenue related to these compensation models? Is there… is there a variance there, or are you seeing maybe the compensation models, again, starting to evolve as hospitals, health systems are starting to take on more and more value-based contracts, and have a greater percentage of their revenue tied to value-based care.

 

Terri Welter:

We are seeing, Dan, the compensation arrangements evolve as the value-based arrangements evolve within the health systems, but it depends on the organization. I'd say the biggest thing we're seeing is we are seeing a sort of resurgence of value in the arrangements with payers and providers, but we're not seeing an increased level of risk assumption being taken by providers, especially by our health systems.

 

Dan Marino:

That's interesting.

 

Terri Welter:

And I think the reason is, is that, you know, there's a… there's a focus on… well, actually, the reason is in part because of the acuity level of the patient that's gone up, right? So there's a focus on, let's figure out what you're already working on from a quality standpoint, from a value standpoint, and let's sort of build measures around that. So we're seeing an uptick in the amount tied to value. Both in the comp arrangements and in the arrangements between payers, but we're not seeing an uptick in the level of risk-taking in terms of, sort of, full global cap risk, but we're seeing, you know flexibility between payers and providers, and tying, you know, tying dollars to things that actually, you know, make a difference that that provider's working on. Like, an academic health system, for example, is going to do really well on clinical pathways, readmission rates, you know, measures around safety and quality, so we're seeing the programs being built around, you know, those focus areas.

 

Dan Marino:

Right, right, right. Well, I'll tell you, it's really… it's a journey for organizations to move into risk. It really is. And I've said, and in conversations I've had with, you know, numerous leaders across the country, you don't just wake up tomorrow and decide you're going to enter into a risk-based contract, right? I mean, you really do need to build your infrastructure. You know, culture alignment around risk is critically important, but you also have to have the capabilities in place in order to ensure your success as an organization as you enter into these global risk or full risk contracts. One of the areas that ECG… that I'm particularly excited about with ECG is hospital strategy and the strategic growth and development that your colleagues bring to the table in working with both academic medical centers, but these large health systems. And you touched on it a little bit earlier, that, you know, you're seeing these clinically integrated networks becoming an important component of the hospital strategy. Is that a… do you see that as a strong growth trend, or where are the CINs, the integrated networks, coming into play, maybe as you're thinking about that payer strategy?

 

Terri Welter:

Yeah, the clinical integrated networks, they're still a component of the strategy, but I think that's starting to evolve, so we're seeing a continued push towards clinical integration, right? Let's make sure that the care delivery system is connected, right? Primary care to specialty, to hospital, to ambulatory sites. At the same time, some of those clinical integrated networks, were successful and some were not, right? So what we're seeing is that they need to have strong rela… whatever it is, if it's a CIN, it's an ACO, you need to have a strong relationship with a payer partner if you're not a payer yourself, right? So we can't do this in isolation without connecting it to sort of the full data that payers have, and the payment systems that payers have. So what we're seeing it evolve towards is sort of product, joint product development with payers.

 

Dan Marino:

Yeah.

 

Terri Welter:

Developing your own health plan, we have… we do see that happening around Medicare Advantage in particular, but I would say more, you know, finding good payer partners that are willing to work with you on, sort of, that… the evolution of the clinically integrated network.

 

Dan Marino:

But, you know, I would think is, and I've seen this, as hospitals start to really build their networks, and their networks become pretty strong, It changes the whole mode of the conversation with the payers, right? Because when you're fee-for-service negotiating a contract, you know, you're, you know, you're going back and forth, it's hardcore hardcore negotiations, you know, sitting each side of the table. When you're negotiating around a value-based care, particularly for clinical integration, I mean, it's more collaborative, right? I mean, and that, like you said, that ability to create that combined product and integrate the goals and the objectives towards reducing cost of care, all of that, I mean, that's a different type of discussion.

 

Terri Welter:

That's right, and what… that's a key element to, you know, have at the table in those discussions, is what's our value story, right? And that means you know, our physician network, our provider network, you know, not the hospital only. So what we're finding is that, you know, the old school discussions between hospitals and payers, it's very different now. You know, many, many of our hospital systems now have sort of major employed, you know, provider networks. And those discussions at the table are critically important to you know, to the payers. Like, they want to know what they're doing around sort of that network and, you know, how you're integrating care, how you're keeping patients out of the hospital, right, and getting them to the right set. The conversation got switched, that's for sure.

 

Dan Marino:

So your value prop is really different, right? So when you present a value proposition to the payers around a fee-for-service contract, or your negotiation, it's very different for how you do it around a value-based care.

 

Terri Welter:

Absolutely, and it's what's happening in the, you know, do you have ASCs? You know, do you have, you know, freestanding imaging? What's happening around primary care? What are you doing around care management and really chronic disease management? So, much of that is, you know, old school, we used to call it population health, but now it's really care management and what's getting the patients to the right setting, so it's not… we want the system really wants to have the sickest folks in the hospital, right? There's other settings for those that don't need hospital care, right? And that's sort of the discussion that's happening at the table.

 

Dan Marino:

Yeah, that's great. When we think about ECG's presence in healthcare, you know, one of the things that really has impressed me about ECG is it's strictly focused in the healthcare industry. I mean, you all have been around 52 years. I mean, it's a phenomenal history there. Are there particular trends that you're seeing that we're working through now that, you know, whether it's AI, and you mentioned data, you know, is there a particular focus that the firm is really, I guess, focused on with their clients to really drive a lot of the change, or at least kind of help them through some of the challenges and, you know, the tough times that they may be having right now.

 

Terri Welter:

We're really focused right now on, we believe that advanced analytics are sort of table stakes that are necessary in order to be strategic, in order to drive the strategic decision making, so what we're working on, and having, you know, highly evolved programs around, is bringing data to the table, in every client relationship, every client situation, so that we can help them sort of operate at the top of their license, make good decisions around strategic, initiatives. Rather than, you know, having to analyze all that data themselves. So we bring the data, but we actually use it in a way that it's necessary so that we can make very strategic decisions. That does include considering AI, but again. That's… that's an evolving market that we're continuing to follow. I believe that in one year from now, it's… it's gonna… we're gonna have a lot more clarity on, okay, these are the things that are working around AI and where our clients should focus. But advanced analytics is something that helps us drive strategic decision making, so that's really something that we're very focused on.

 

Dan Marino:

Well, I'm really excited to hear that. I think that's just such a value add for a lot of hospitals and health systems, because I'll tell you, just about everyone in the country struggles with getting the right information that is actionable. A lot of these systems have a lot of data. But they don't know how to aggregate the data in such a way that it's really valuable information that helps them make that level of decisions. And I think the ability to bring that advanced analytics as an additional tool, as an additional resource to the table, whatever engagement or however we're helping our clients. Boy, that's just such a big value add.

 

Terri Welter:

Yeah, Dan, and I'll give you an example of that. So, many of our clients have the ability to, you know, model their payer contracts, or to get the transparency data, but it's not connected, right? So, or to get market data, but it's not connected, so we have the ability to do the contract modeling and dashboard it with the transparency data so that you understand where you are in terms of, you know, current state for yourself, but also how you compare to the market. So bringing it together and aggregating it is key. I think you hit on that exactly right. It's… the data's out there, but how do we bring it into a…

 

Dan Marino:

Yeah, and deliver it in such a way where it really becomes a strong tool and even leverage point, right, in being able to really improve your operations and financial performance.

 

Terri Welter:

Exactly.

 

Dan Marino:

Well Terri, this has been… this has been great. I'll tell you, I'm really excited. I know our listeners will be excited in the upcoming episodes as we add some of the national thought leaders that are within ECG, and even some of the clients that's even talked to tell some of these stories, I think it is just going to be fantastic. As we wrap up, can you… would you mind sharing your contact information and maybe just a little bit of information on ECG, if any of our listeners are interested in visiting their website or anything of that nature?

 

Terri Welter:

Sure, I'd be happy to. So, if you want to visit ECG's website, we're at https://www.ecgmc.com/ and we have a whole lot of articles and background information on the type of work that we do. If you want to contact me directly, my email address is twelter@ecgmc.com and would love to hear from you anytime.

 

Dan Marino:

Well, Terri, thank you very much. I can't wait to get in and hear a few more of the stories and some of the successes that we've seen around the country, and be able to share even that more with some of our listeners. I think it's going to be great going forward.

 

Terri Welter:

Thank you so much, Dan.

 

Dan Marino:

And for our listeners, again, we're really excited about our partnership and what we plan to bring to you all. Some of the future topics that we plan to discuss are specifics around medical group operations, and in particular, how we could improve or augment some of the compensation models, what we're seeing in terms of supply chain and workforce. All great things that we know are top-of-mind challenges with our healthcare leaders. As always, if you're interested in learning a little bit more about today's topic, or any of the topics that we've had on Value Based Care Insights. Please feel free to visit luminaHP.com/insights. You'll find all of the topics and all the episodes there, as on-demand downloads, through our podcast portal, as well as https://www.ecgmc.com/ As Terri said, there's a wealth of information. I want to thank you, the listeners, for tuning in. And until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

Emergency departments are under more pressure than ever as they are facing overcrowding, extended wait times, workforce strain, and rising patient demand fueled in part by primary care shortages. In this episode of Value-Based Care Insights, host Daniel Marino examines how these mounting challenges are reshaping the hospital’s front door and what they mean for patient care, operational performance, and long-term sustainability. 

Daniel is joined by Dr. Richard Wolfe, Chief of Emergency Medicine at Beth Israel Deaconess Medical Center and a nationally recognized leader in emergency medicine operations. Together, they explore why emergency departments have become a critical pressure point for hospitals, how overcrowding affects quality, safety, and clinician burnout, and what forward-thinking health systems can do to better support their emergency medicine teams while continuing to serve their communities effectively.  

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. Well, we're continuing our series on looking at different specialty service lines, and I'm excited today to have a conversation around emergency medicine. And in particular, kind of diving into some of the challenges that hospitals are having, with their emergency departments, and just, you know, all the things related to serving the community and just managing through some of those challenges. So, what are some of the things that hospitals have been struggling with? Well, I think the bigger one is overcrowding. In most, if not all, emergency rooms, emergency departments they are faced with overcrowding, patients having long wait times, and, you know, and I see it only getting worse, especially with the challenges that we have with primary care shortage, and patients not being able to get into to see their physicians. And if they need care, they're gonna go somewhere. They're either gonna go to urgent care or if urgent care's closed, they're gonna go to the emergency department. So, again, the whole notion of overcrowding, certainly challenges the whole healthcare system. But as well as then the overcrowding, what we see is a lot of the strain that is being placed on the emergency medicine providers. The physicians, the nursing staff the clerical and administrative staff, that strain again, it's a high-pressured area, and again, the strain really does have impacts in terms of the care that we're providing, and just really serving the needs of our patients. But emergency departments are just… are so critical in serving the community, as well as then, obviously, supporting the hospital and the margin. So, to walk through some of these challenges, I'm really excited today to have with us Dr. Richard Wolfe. Dr. Wolfe is Chief of Emergency Medicine at Beth Israel Deaconess Medical Center. It's a nationally recognized leader in emergency medicine. Dr. Wolfe has spent quite a bit of time not only supporting emergency medicine, but really acting as a national putting in different models, and so forth. Dr. Wolfe, welcome to the program.

 

Richard Wolfe:

Thank you, and thank you for the invitation. There's nothing I like better than talking about the problem I've been wrestling with for the last 25 years.

 

Daniel Marino:

And it is a big problem at that, no doubt. So, maybe we could start here. When you think about some of the challenges that we're facing as an industry, with emergency medicine and emergency department, what are the top things that come to mind?

 

Richard Wolfe:

Well, you began with the problem of crowding, which gets down to the essential problem for the hospital, because on a day-by-day basis, what you see are angry patients and families, errors being made, and problems, ultimately, that can be quite costly as well to the bottom line, as well as damaging to the image. So, there's clearly people feel the problem at the level of hospital administration and on the front line in the emergency department. The problem is there are no really good guardrails, and what I've seen is a slow progression where this thing, the resource gap, which is what it is, to deliver emergency care continues to widen because of economic pressures.

 

Daniel Marino:

Yeah, absolutely. And so what I've seen, and what we've done with a lot of hospitals, is we begin to think about that, and supporting emergency medicine, the urgent care strategy is one that's really been taken off, right? And it's many hospitals have started to incorporate those strategies as a way of being able to provide additional support to patients, both in overcoming some of the patient access issues that we've been having, but also, you know, patients who are let's say, low risk, or don't necessarily need to go to the emergency room, have another alternative. But I don't know if it's actually working, because we're still continuing to see the overcrowding in the emergency room.

 

Richard Wolfe:

So, it really breaks down their three problems, right? Input, which is where will patients go, and if you can get them to go somewhere else, that would help.The throughput, and then the output, how do you get them, once their emergency department stays finished, to the next stage of the care? So, urgent care is part of the input solution. Can we divert patients elsewhere? That's always been the rationale for urgent care. The problem is, there are very different types of urgent care, based on how you staff them, what resources you place, and the vast majority staff with mid-levels, without really high-end imaging or a full scope of labs ends up competing and diverting more from the primary care office than they do from the emergency department. In fact, they tend to refer to the emergency department. We've experimented here in Massachusetts with urgent care staffed with emergency physicians, CT scan imaging, full scope of labs, and we've actually shown that those do divert from the emergency department. And they get only not low acuity, but actually occasionally mid-level acuity, where you're trying to determine, do they need a hospital admission. So it can work, but it has to be designed carefully, and unfortunately, so far, there's not a lot of evidence telling people how to do that.

 

Daniel Marino:

No, and you bring up a good point. You know, most of the urgent care that we're seeing right now is… it is diverting more so from primary care offices and not really… not solving the problem of overcrowding in the emergency departments. There's no doubt about that. But the strain, I think, is another large issue. The strain that is being placed on emergency medicine, physicians in particular. And, you know, I think if you're an inner-city emergency department even versus a rural, you know, that strain is the same. You know, you're seeing a lot of pressures because, you know, you have to support those emergency rooms 24-7. What are you seeing in terms of the challenges for a lot of your colleagues?

 

Richard Wolfe:

Well, the… so, as you said, we've been a little bit victims of our own success, in that we've defined ourselves capable of handling anything at any time, at any place. So what's happened, though, is as the workload has exceeded the resources available, the emergency providers find themselves very often with moral challenges, having to ration care, because you don't have everything that it takes, and having to make choices that are, extremely unpleasant and against their very sore ethical code. Secondly, that effect is not simply at the level of the emergency department, it spills over to all the services that support it. For example, CT scans get overwhelmed, so there can be hours of wait, which hits that second area, the throughput time, and actually ends up making it very difficult to recruit technicians for CT scanners, and really, has had effects on, say, radiologists. The same thing, the services that catch the emergency patients on the inpatient unit at the hospitalist, which now have to actually provide, inpatient care, often in a hallway in the emergency department, have also been adversely affected in terms of morale, and in terms of seeing their ability to deliver the role the way they perceive it should be done.

 

Daniel Marino:

So, are you seeing… because, you know, obviously there's a shortage of providers all over, and I think even in emergency medicine, you don't see as much… as many providers, I think, as we certainly would need, given the amount of schedules and everything else. Are you seeing the compensation and, as well as then the reimbursement keeping up with the economic challenges of a lot of the… in support of the emergency departments?

 

Richard Wolfe:

Yeah, so I think for now, it's held well. In fact, the one type of provider I haven't had trouble staffing in my departments, or most people haven't, have been actually the emergency physicians. If you're able to create an environment it's nursing, techs, literally all the other providers, because after the pandemic, about 20% never showed back.

 

Daniel Marino:

Obviously in the pandemic, a lot of our provider colleagues left the industry, right, with early retirement, and you probably saw that a lot with nursing and some of the other clinical support personnel, I imagine.

 

Richard Wolfe:

Yes, no, no, and that's still true to this day. The cost of nursing, for example, has skyrocketed because of the shortage. And yet we still struggle occasionally to staff the department. Plus, the people we're getting often are recent grads out of nursing school, so don't have the experience and skill sets of the senior nursing staff we had pre-pandemic, which were able to carry, you know, higher loads. And actually were less likely to make, you know, the early errors you see in emergency care.

 

Daniel Marino:

For, you know, for some of the emergency departments and some of the hospitals, they're directly employing some of the emergency physicians and so forth. Others, they contract with them. What are you seeing in terms of the trend of contracting with, external emergency medicine groups. Are they… are they able to fund themselves, or are you seeing subsidies, stipends, and so forth being… becoming more and more part of the financial arrangement with the hospitals?

 

Richard Wolfe:

So, corporate medicine was making emergency medicine profitable through out-of-network billing, without contracts. The no-surprise billing laws really stopped that, and other types of practices are more competitive. Most emergency departments require fairly hefty subsidization from the hospitals on hospital employment, or even occasionally corporate medicine. There is a way to do it if you create practices that are very transparent and give the emergency physicians some degree of ownership. They tend then to actually increase their, you know, the good marker of productivity would be RVU per hour. Once they feel that that workload is aligned with their mission and income. But if they feel those two things are cut off, then they'll tend to focus on, you know, detailed-oriented patient care and not really worrying much about, you know, the throughput issues.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm here today talking to Dr. Richard Wolfe. Dr. Wolfe is the Chief of Emergency Medicine at Beth Israel Deaconess Medical Center, and we are talking about, nationally, the challenges that are placed on emergency medicine, and in particular, emergency departments. Dr. Wolfe, I want to kind of shift our conversation to what you're seeing with potentially some solutions, or some new innovative approaches related to supporting emergency medicine in hospitals. You know, as I think about it, it's Emergency medicine is so critical in supporting communities. It's really, in most cases, the mission of why hospitals are there, right? It's the beginning part of the mission. You have to be able to support patients in the community. But I also feel like, It'll… if done well, it can support the economics of the hospital, it can support market share. If there's a real focus strategy around growth and how you want to begin to really support emergency medicine and all of those things within the department. But it doesn't come without at least being able to incorporate some innovative solutions. What are the things, what are some of the solutions that you are seeing, or the new models that you're seeing that hospitals are starting to undertake as they're thinking about maybe reinventing or re… you know, maybe working through some of these challenges in the emergency department.

 

Richard Wolfe:

Well, there's some oldies but goodies that people haven't really universally implemented. The most classic one is the concept of surgical leveling, that our hospitals function on the elective basis, the patients you want. On a 5-day week, where weekends are really very low in terms of use, and hospital capacity actually is quite ample. And that if you could actually get the ORs to function, and surgery to be done on Saturday and Sunday, and to reuse the full 7-day cycle, you can have remarkable decompression. That was shown in studies by Gene Litvak, initially at Boston Medical Center. It's been done in a number of places, and has had very positive effects in terms of decompressing crowding and also increasing hospital productivity. But curiously, it's still only implemented, on my last check in about 6% of hospitals, because it's hard to get, OR teams to be willing to work on weekends. Our culture doesn't like it. But it's been one very win-win solution when you can get it. The lean process has been talked about a lot, but often doesn't get applied to the emergency department throughput, and it's mainly about putting measures, accountability, benchmarking into the two components that really drive up, emergency department length of stay, notably turnaround time of imaging of, testing, labs, and particularly complex imaging, CTs and MRIs. And then secondly, turnaround time of consultation, because we rely on, other specialties for a number of problems, particularly that require admission or procedural intervention.

 

Daniel Marino:

Right, well, having the consults there, having the surgical consults or the other specialty consults available to come in, I mean, that's, you know, a big area of delay, oftentimes, in a lot of emergency departments.

 

Richard Wolfe:

To come in, and then to understand that they're on the clock, and that they have to reach decisions promptly so you can keep the flow going.

 

Daniel Marino:

Yeah. You know, one of the areas that hospitals, you know, they're… it's really gained more and more attention over the last couple of years, obviously, is the inpatient stays, right? And the length of stays, and it's sort of a double-edged sword, because a lot of emergency departments, when patients come in, in some cases, you know, they have to be admitted. In other cases, depending upon when they were discharged, if they fall within the 30-day readmission, you know, you need to kind of focus that, and then probably third to that is in some hospitals, you know, they may not have beds available. How are you seeing observation units and say, alternative pathways for these patients. Are you seeing any solutions there that hospitals are starting to undertake to kind of balance the inpatient mission versus the patient coming in and just sitting in the emergency room? You know, that throughput?

 

Richard Wolfe:

Yeah, in other words, that is, in some ways, a way to divert the input to the inpatient unit. It's very effective. You can actually allow the emergency physicians to select out patients that, say, have only a 15… 20% need for an inpatient admission after 48 hours, and put them in an observation category. Those are the patients that if you admit them to the floor, you're going to be billing as an observation anyway, but in very expensive, well-staffed space. And in an observation phase, particularly attached to the emergency department and supervised by the emergency physicians, you actually shorten… it's been shown that it shortened lengths of stay. You don't need the same, you know, concentration of nurses or the same level and cost of space. So it's, one, very cost-effective. Two, the emergency physicians actually, can be paid for the clinical work, so you don't need to actually support hospitalists or others to provide that care, so it ends up absolutely being a win-win solution as well.

 

Daniel Marino:

Yeah, I agree with you, and I'm glad you kind of described it that way. We've had the opportunity to work with a few different hospitals, and I'll tell you, it really comes down to the data, right? Understanding the patients, understanding where they've come from as they present to the emergency department. And then, as you start to dive into the patient's condition. I think accurately identifying the patient's risk, so you're able to really drive that care, to the patient that, you know, based on what their need is, right? So you then begin to understand is it more of an observational-based, you know, or do they have to be admitted, and then, you know, you're kind of managing it? And it's really moving into that proactive approach on managing the patients. Are you seeing a lot of emergency departments, emergency medicine physicians, are they starting to incorporate a lot of the patient outcome data as a mechanism, or as a support component of driving a lot of the care plans.

 

Richard Wolfe:

Well, they certainly do track outcome for a number of features. I don't know how many have leveraged that, and they do obviously track the number of observation patients that end up on inpatient units. I don't know how many have translated that into creating the solution of an observation unit. Interestingly, having personally run observation units for a very long time, the one remarkable feature is if you tell an emergency physician, I only want you to put a patient in here if you think there's less than a 15% chance they'll need to be admitted, and they will nail it right on the head, without any other director or instruction. Every time.

 

Daniel Marino:

Really? Yeah, that's interesting.

 

Richard Wolfe:

You know, the issue is they've been tracking, and they build up pattern recognition for their patients, and they have a good gauge of who really is going to kind of stay upstairs for many days, and who might be able to be turned around in a short period of time.

 

Daniel Marino:

Right, right. So, when you're talking to some of your colleagues around the country, and they're coming to you with these challenges of overcrowding, and maybe the pressures that they're being placed on, placed with, with maybe not having enough inpatient beds, and so forth. What do you feel like is kind of that sustainable emergency medicine model? I know it's, you know, it's kind of a very broad question, but where do you see are the high impact points of change?

 

Richard Wolfe:

So, I'd like to frame that in what I think is coming, which is with the changes in healthcare, the defunding, potentially, of Medicaid, the shift from commercial to government payer. Reimbursement for emergency care based on professional fees is going to get harder and harder, and at the same time, the work environment will get more and more difficult. So, it's a key… I'm framing this as a key question, because how are you going to keep them on the farm when it really gets toxic, they can do something else? I would say that the concept of transparency is key. It's getting the physicians themselves involved in the decision-making. Helping them understand what economic forces are driving it, why the hospitals can't just open other beds to solve the problem, why putting patients upstairs in hallways may decompress the emergency department, but creates its own set of problems. So the more you make the physicians partners in the process, rather than employees, and victims in some ways of the process. The more you're going to be able to retain, and the more you're actually going to come up with innovative solutions to be able to fix the problem.

 

Daniel Marino:

Well, and I think that's such an important point. You have to… you have to bring physicians, emergency medicine physicians, into the fold and having those conversations. I really feel like we're going to be faced with just continued challenges, if not more challenges, within the emergency rooms. Many folks believe, and I'm one of them, that over the next few years, if the one big, beautiful bill continues to take shape, you're gonna see a lot more patients, a lot more of our healthcare consumers losing coverage, right? But the care needs don't go away. They still have to… they still have to get care. So, where are they going to get care? They're going to go to the emergency room. So, I don't… I don't see the issues of overcrowding, reducing, frankly. I think you're only going to see it increasing, especially, you know, if patients do lose coverage. So, I think your point is well taken. You have to engage the physicians, but I also feel like we have to put in new innovative care models, new pathways in order to manage the patients. We have to find a way to get out in front of it. Otherwise, we're going to continue to be faced with these issues time and time again.

 

Richard Wolfe:

Oh, I… I agree completely. I mean, I do think the ultimate answer is we are going to need some type of healthcare reform to align the finances with the needs of the population. That said, there's still a lot of ways we can reduce, the burden, try to close that resource gap by innovative uses of space. Certainly telemedicine, as a way to sort of divert patients, potentially, from the emergency department. Observation units, as you suggested. And then looking at the flow on the inpatient unit, because emergency crowding is really hospital crowding and discharge units, care plans, better discharge planning, so that people get out on time, rather than have to have another day in the hospital because of disorganization. There are a host of small, little pieces that are discovered just through lean processes that can actually have a major impact.

 

Daniel Marino:

Yeah. Well, Dr. Wolfe, this has been great. I really appreciate it. You know, you bring a lot of great insight, to, obviously, our conversation and some of the challenges. If any of our listeners today, and, you know, we have many providers, many administrators and physicians who tune in from time to time. If they're challenged within their own organization, facing with many of the things that we've talked about today, any recommendation as to where they should start? Where do they… what should they really think about as a starting point to maybe help to think about delivering care differently in their own emergency room?

 

Richard Wolfe:

I think if they're ready for it, to sit down with the emergency physicians and have an open, frank discussion and sort of hear where the pain points are, where the problems are. And do the same, sort of, with the different pieces of the… of that sort of flow. Hospitalists, radiologists. Technicians, and so on, to really make sure you understand the elephant, so to speak, so that you can then begin to try and really address the core sort of dysfunctions and workarounds while coming up with some innovative solutions that others have tried.

 

Daniel Marino:

Yeah, I agree, and that's a great point. You know, as we've said, I think to collaborate with your emergency medicine physicians and to think about the new innovative approaches, I mean, they're seeing it day in and day out, right? They're the ones that are going to be able to really come up with the ideas and the solutions to drive it forward. Well, Dr. Wolfe, thanks again for coming on. Great discussion. I have a feeling this won't be the last time we're going to be talking about this, and again, I wish you a lot of success. You've done some phenomenal things in your own organization, and truly a leader as we're being able to re-innovate and restructure a lot of emergency medicine and emergency care that's being delivered at the hospitals. So, thanks again for your time today. This has been great.

 

Richard Wolfe:

Well, thanks for the invite, and I really did enjoy the discussion. Thank you.

 

Daniel Marino:

And if you're tuning in and interested in hearing about this topic or other topics we may be talking about on Value-Based Care Insights, please reach out to me at dmarino@luminaHP.com. You also can visit our website at luminaHP.com. I want to thank everyone for listening and tuning in. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day.Take care.

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.