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Dr. Rajaie Batniji, Co-founder and CEO, Waymark, Dr. Sachin Jain, Chief Executive Officer, SCAN Group; SCAN Health Plan, Brent Nicholson, Co-founder and Chief Partner Officer, Carrum Health  Moderator: Chrissy Farr, Second Opinion Media

Brainstorm Health 2024: Technology’s Role in Value-based Care

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Dr. Rajaie Batniji, Waymark, Dr. Sachin Jain, SCAN Group; SCAN Health Plan, Brent Nicholson, Carrum Health, Chrissy Farr, Second Opinion Media

Value based care. So maybe five years ago at a similar conference in another time, we would have been the hot panel, but now it's the A I panels that are the hot panels. So I think I'm going to start with Satin, who's written a lot about this topic of value based care and how much it's real and whether the implementations are actually doing what they say would love to get your sense with where we're at now just on value based care in general. Has it met the promise? I think it's easy to say, no, it has not met the promise. And I think one of the reasons is that I think everybody still has got a split personality about it. Um And when you actually look at what's happening under the hood in most organizations that are so called committed to value based care. Um The commitment is only an inch deep and, you know, a mile wide. Uh And I think a lot of organizations haven't done the hard work to really ask themselves the existential questions about how they're gonna actually evolve to a new business model because they haven't necessarily had to do that. So I think, um, you know, it's largely been an incomplete experiment so far from, from where I sit. I, I wouldn't say that that's uniformly true. I think the future is here in many places where value based care has been implemented at scale. But I would say nationally it's, you know, we're still in the early innings of the value based care story. J do you, do you agree? Do you have a more optimistic view? I mostly actually agree and, and actually, it's a pleasure to agree with that. And you know, I would say that the biggest issue in, you know, way, Mark, we work in Medicaid. The biggest issue we we see in value based care is that there's so much like fake value based care. I wrote a piece on this, um for health affairs called value veneers where I think what we're actually seeing is there are a lot of programs that sort of like check the box on value based care. They, they technically meet the requirements of it so that a health plan and a provider could say yes, you know, C MS, we're doing value based care, but they actually failed to do what value based care was intended to do. And value based care was intended to actually change the nature of care delivery. And so I think my rubric for looking at a value based program is not, you know, is there incentive payment for Xy or Z but has this program changed the nature of care delivery? Um And for us, like that means like, you know, have we created a new health care workforce that can reach patients where they are? Are we able to move responsibility and accountability for care outside of the traditional brick and mortar health care system and directly into the communities that we're serving where those interventions could be most impactful. And so I think unfortunately, so much value based care is kind of operating almost like a loyalty rewards program rather than truly something that can change what's paid for in health care. And that's actually what we have a true shortage of is real value based care. We have an excess of veneers. So one of the things that I think Sarin has also been writing about is just that value based care can focus on a few things like you look at hospitalizations and making sure that people are getting discharged quickly. That can be one way of thinking about value based care. And there are others that we tend to focus on a lot of that based on how the bill works and how we record outcomes Brent for you as you look at what is value based care and what isn't. And through this context of thinking about fake value based care and veneers, what do you think of the true measures or outcomes that we should be looking at so that we don't just get fixated on a few things that may or may not be right for that individual patient. Yeah, sure. I, I think uh what, what we focus on is actually engaging in arrangements with providers that have both upside and downside risk. That's in our version of true value based care. It's engaging with the provider to ensure that they have a shared accountability and actually are invested in the outcomes of the patient. And so, uh you know, what, what we're looking at is uh you know, condition or episodic uh based care in the specialty care area, uh in engaging with providers to have more ownership outside, say the four walls of an operating room uh to extend their accountability to uh not just did we technically perform this procedure correctly, but did it actually get the patient better? Did it actually address what they went into the facility to get the operation for in the first place? And maybe I'll just kind of jump off of that and throw the question out more broadly. But does that kind of work require actually thinking about which physicians are good at what they do and not good at what they do? And I know this is a very uncomfortable topic for a lot of people when we start thinking about how do we rate and rank physicians. But that is essentially part of what you're saying. Right. Absolutely. I mean, we are not believers in the general hospital model that you can have a building that is good at health care across the spectrum. And so when we're looking at, we're zeroing into specific episodic conditions and looking for expertise and top performance down to a very granular level. And you know, we use the power of, you know, massive data sets to help us gain insights into which providers do meet that very high bar of top 10% 10 top 10% performance. Um, and we're looking to engage them in these upside downside risk arrangements, um, so that they can, uh, really do what they do well, and, uh, don't have to be saddled with the administrative burdens of figuring out how do we then figure out how to submit claims and how do we then figure out how to do the authorizations and how do we figure out then handling with the payers to make sure that we get the money in the door. We want to find the best providers, allow them to do what they do well and then make sure that they are rewarded for that. So, so I wanna just say I love this conversation because, um, I think a lot of value based care conversation is actually not about what you're talking about. It's not about getting patients to the best clinicians. It's actually about labor arbitrage is how do we take the work that specialist M DS we're doing to generalist M Ds and then then take work that generalist M DS were doing and take them to nurse practitioners and then take work that nurse practitioners were doing and take them to our ends and take work that RNS were doing and then take them to community health workers and then take the work that community health workers are doing and then give them to people's family members. And I think we have to talk about labor arbitrage and we have to talk about actually what is an excellent health care system actually look like. And I think most of us intuitively get that. You have to actually go to a great clinician who really understands the condition well and knows how to treat it and knows the, you know, boundary conditions of that condition to be able to effectively get the kind of treatment that we need. But that's not the conversation we're having about value based care. For the most part, I totally agree on the labor arbitrage piece. And then, you know, to flip that question, push it further with J how do you see the role of the patient here? Because if they feel like they're just getting pushed into a lower level of care with less of a specialist, wouldn't, wouldn't they? As a patient say, you know, why, why I want to be in the other system? I want to be in the system where I can see the specialist that I want to see. I, I mean, I think to me, we, we center our approach literally around the patient. And so if you think about what's broken in the health care journey, imagine you're you're covered by Medicaid, um which all of our patients are in all the the states that we're in. People have a hard time accessing a physician. They have a hard time navigating the health care system. They need to use social resources that no one has helped them get to. And so to me, the point of value based care is let's actually get the physicians to see them, let's make availability happen. Um Let's wrap those physicians with the expertise that they need to appropriately navigate this member and literally guide them the whole way through their journey. And so to me, it's about complementing the existing system by creating net new resources. I mean, if you look at the data and this is we always start with data, if you look at the data about like what works in health care delivery for a certain population. And I think you need to do this population by population in, in Medicaid, for example, it's like totally clear, right? Like study after study proves that the same models work. The challenge is that those models have been funded either by, you know, a one off grant. Um They've been funded out of like a special budget from a health plan or health system and to actually do these things and do them for a long time so that communities can know that they can rely on these services to exist in the future. You can do them under a value based arrangement so that you can have that kind of permanent source of funding where actually accountability for care can actually move toward these, these new care delivery groups. So just a reminder to the audience that we are taking questions, so I'll slip to all of you next. Um I'm gonna ask you a question about A I because that has been a big topic of this conference. Um We've talked a lot about actually using A I in diagnosis, not just kind of back office, which is where it tends to be more kind of discussed today. Um Sergeant, do you think in a value based world, a true value based world, there is more room for A I in that context because it becomes less about who's going to pay for this. Yeah, the I think yes, a lot of, you know, kind of value based care is in like full delegation of risk to a downstream entity. I think the real challenge of freeing up enough resources to actually invest in A I. Is that how that downstream entity that's taking full risk, actually allocates those dollars to sub entities, how they pay specialists, how they pay primary care doctors, how they pay ancillary care providers. And that is still happening very much in a fee for service way and So then the question becomes like where does the A I get introduced? Does it get introduced at the risk bearing entity level or does it get introduced at the level of, you know, the primary care doctor or the specialists? And is there enough margin in what is actually being delegated, sub capitated to the primary care doctor of the specialist to actually integrate A I in ways that are gonna reduce cost and improve quality of care. And that's, that's a long way of saying, I think we're still figuring it out. Yeah, I would, I would add to that. I mean, I think so much of like the way we talk about A I and health care is about well in the future, you know, humans will be talking to machines, machines will be doing the diagnosis. I I think that's actually totally wrong and you know, our, our approach to A I development is really let's automate the routine tasks so that we can allow our caregivers to spend even more time with patients. Um and second, let's automate the identification of which patients are gonna benefit from certain services so that we can actually spend our time targeting the appropriate patients. And you know, we've been, we've been publishing actually quite, quite a bit on our, on our development in this this realm because I think that is where you have step change, improvement in improving access to care is you're gonna create and enable a net new workforce through A I and actually give them the pattern matching of somebody with years more fair. Yeah, I would offer a slightly alternate perspective uh from scan, which is, you know, our view is that, you know, A I is going to enable humans to become super humans. And so, you know, when you call your health plan member service representative or you're talking to a nurse from, you know, uh a care coordinator department, they're gonna be able to do more and know more about you and, and be able to leverage everything within our system through, you know, advanced decision support to be able to make those interactions more valuable and more meaningful. That's, that's how we're thinking about it. I guess two other um angles, at least from our point of view of Kam is uh agree with Rae what you said about using the power of A I and specifically machine learning to help identify the right patients, get them to the right programs and services at the right time because there's just a sea of information out there. And it can be very hard to understand and navigate for a common patient who just has too many options available to them, too many mouths trying to get their attention. And so being able to do that and say, identifying only a small percentage of the population uh in our instance that we're able to then say we can identi we can correctly identify, say up to 95% of the surgeries that are likely to occur over the coming years. Uh And then uh being able to serve up the appropriate pro program to meet the needs of that patient. And then from the providers point of view, being able to help these providers perform better in value based care arrangements. Um We've seen some tools out there that uh help to uh create these uh personalized care plans that uh you know, harvest all of the information from millions of different patients rather than just a handful of patients that one doctor has seen to be able to do things like optimize variables around, you know, the length of stay the discharge destination, the post operative care protocols so that, you know, they can zero in on a likelihood of readmission and then be able to uh adjust and tailor their follow up and check in protocols uh accordingly to then result in the best outcomes and then perform better under these value based arrangements. I'm gonna flip for a question from the audience who's got a burning question on Vala I RJ does a stats of one inference for the individual. So I love what I'm hearing about, you know, these patient care journeys and how you're really tailoring them. I'd love to know what um what the biggest challenge is to incorporating A I or anything like that into that workflow when well, I I'd say for us. Um you know, one of the considerations is to try and shield the patient from all of the complexities of what we're talking about here up on stage is really to um you know, make it so that the patient doesn't have to uh understand or navigate well, am I in a value based program? Am I not what you know? Uh And so, one of, one of the things that we work on is um ensuring that we are working very tightly with our uh providers on the patient identification um and the and the patient attribution. And so that's one of the things where um we have a, you know, very specific implementation process. We have a very specific pre registration identification process that ensures that uh when the providers that we're working with are seeing a caring patient, they can understand uh that and uh they can uh follow the, you know, the program protocols accordingly. II I think we have a similar challenge for us. The biggest challenge is like, just imagine, right? We, we serve a new market, we're serving 50,000 patients covered by Medicaid there, you know, where do we start? Right? Like how do you know which patients to, to reach out to? And so, you know, our first A I use case was we built this product that, that, that allowed us to bring in all of the historical medical claims, the local zip level social determinants, data information from food banks and housing registries and actually build this composite picture of a patient. And the result of that, which we published earlier this year in nature, the scientific reports was that we had 90% predictive power, positive predictive value in anticipating who's going to use acute care in the coming days and weeks. That means er visits, that means inpatient admissions compared to the next best model that was performing at like 30% right? So that means that now one out of 10 of our outreach is the patients are to a patient that we can't serve versus seven out of 10 if we're using a prior model. And so I think you have to get really efficient at doing that modeling so that you can actually direct your, your resources as effectively as possible. Sergeant. I'm gonna call on you for a last question. We have a few minutes left. Um So one of my, the, you write a lot of pieces, you've written a lot for Forbes. Um And I loved what you said about just the chan problem and having a patient for a single year because obviously, we, we do enrollment annually. How problematic that is. Can you just end us on a note of talking about your idea with a three year? Absolutely. I, you know, so I think one of our biggest challenges in our industry when we actually think about interventions that will actually move health outcomes is that most people are in their health plan for a year. That's the most that we can actually be certain that someone's gonna be in their health plan for a year. So, so, very little right. And the most you can do in a year is maybe you can do an annual wellness visit, maybe you can get them appropriately coded. Um, but as far as actually better managing their chronic disease and then seeing the return for it, it's just not gonna happen. And so, um I believe at least in the Medicare space, we have to get out of single year enrollments, we have to be thinking about 3 to 5 year enrollments, which would then give us the confidence that our investments in year one would have some payback in year 234 and five. I believe that's the foundation of value based care that has been missing in most of the, the so called value based care models because without the reliability that a member is going to be on your books in three or five years, you're unlikely to want to necessarily make the investment in year one to actually, you know, create some health outcome benefit in year, year, year three or year five or you may want to. But it doesn't necessarily pencil from a financial perspective. And I just think um it's these types of structural changes that are gonna actually lead us to true value based care as opposed to the value veneers that uh Rege has written so eloquently about how, how optimistic are you that's gonna happen. So, I think the, the number one objection people have is like, what if somebody finds their way into a plan that, you know, is really bad for them or they're being treated badly by that plan in year one and they really need to get out. Um, you know, I think we have to get comfortable with the trade offs. So, um I think it'll take a while for us to get comfortable with those kinds of trade offs. But I believe that the centers for Medicare and Medicaid Innovation, in addition to all the science projects that they're running right now, should add 11 more science project, which is to really look at what a three or five year enrollment in a plan would do and have it be voluntary. People should wanna enroll and do it. I think people will wanna enroll and do it because it'll be intuitive that a health plan that's, you know, that owns your life for three or five years is going to view your care very differently than a plan that owns it for a single year, time horizon, for risk and a time horizon for, for change. You need to line up. Exactly. Well, you had it here. We love it. Thanks everybody for joining us. Thanks so much.

Dr. Rajaie Batniji, Co-founder and CEO, Waymark
Dr. Farzad Mostashari, Co-founder and CEO, Aledade
Dr. Ria Paul, Clinical Associate Professor and Executive Medical Director, Value-Based Care Program, Stanford Medicine
Moderator: Chrissy Farr, OMERS Ventures 

Brainstorm Health 2023 - Navigating the Shift to Value-Based Care 

Dr. Rajaie Batniji, Waymark
Dr. Farzad Mostashari, Aledade
Dr. Ria Paul, Stanford Medicine
Moderator: Chrissy Farr, OMERS Ventures 

Navigating the Shift to Value-Based Care 

Dr. Rajaie Batniji, Waymark
Dr. Farzad Mostashari, Aledade
Dr. Ria Paul, Stanford Medicine
Moderator: Chrissy Farr, OMERS Ventures

So we've talked a lot about transformations in health care so far today. But there's another vitally important and impactful shift underway that we want to delve into this move from volume to value a system of value based care rather rather than fee for service. It comes down to reward good outcomes instead of paying based on the amount of services provided. These models are meant to drive both patients and providers towards maintaining better health rather than dealing with problems downstream. The hope is to also reduce cost, streamline the process and improve accessibility. Medicare wants every beneficiary to be receiving value based care by 2030. And investors have taken notes according to mckinsey and company private capital inflows to value based care companies quadrupled during the pandemic. So let's talk more about how to make the most of value based care with Dr Raja A N G, co founder and CEO of Way Mark and Dr Farzad Matahari, co founder and Ceo of Alidade and Dr Ria Paul, clinical Associate professor and executive medical director of the Value based Care Program at Stanford Medicine, speaking with Chrissy Fary back on the stage again to lead this conversation. Welcome. Um, so this time I actually do have three doctors. I triple checked. Um, um, so I'm gonna pick on Z over here to kick things off. Um, we are talking today about value based care, which is the topic of discussion that comes up at every single health care conference and rightly it should. Um, but, you know, usually along the lines of it's great. It's, um, where the heck is it? Um So that I wanted you to just catch us up on just, you know, what's the latest, where are we at? What, what are the stats showing? Um And just uh you know, any kind of recent updates from the C MS side that you think we should be aware of. Yeah, so this administration continues the line of previous administrations that say kind of we have to move in this direction of value based care, paying for outcomes, not for volume. I think the difference from the past 10 years is we now have a lot of evidence in terms of what works. And unfortunately, there's a bunch of stuff that didn't work. So what works, what works is giving primary care docs accountability for the total cost of care that works. Um What hasn't worked uh has or has, has had mixed results and, and again, we're still hopeful, we're still looking for models, we're still looking for ways to do it. But what we don't have the evidence for yet is um uh other than for seniors, so commercial is really hard. Uh We heard an talk about that. Uh Medicaid is really hard and I, you know, I have huge respect for the increasing number of groups who are, who are taking that on hospitals is really hard. So, uh you, I, I guess I feel privileged to be doing the easy work here and uh my colleagues on the panel here tackling some of the harder, harder issues. Um Medicaid really hard. You are building a company that's trying to do Medicaid. Um So share with us kind of why you decided to go in that direction, especially having been a collective. You were on the employer side and really made, I would say a bit of a 1 80 shift um into, into this, this Medicaid area with, with way. So um why, why is this need um being so unmet and and why do you think look at first it wasn't really a 1 80? I mean, my clinical work has always been focused on Medicaid, that's where my clinical practice has always been. And my research work had always been on how do we pay for health care and low income settings around the world? And so for me, it was actually a need to say that we had all the creativity and the capital going towards Medicare and employer. And if we were going to do something about health equity, if I wasn't part of the solution then I was part of the problem. And so for me, it was just this mission alignment of, you know, we need to bring some of that same creativity, we need to bring some of that same investment into Medicaid to actually do something about improving outcomes. Um And I think the question is, is it hard? Absolutely. It's hard. It's hard for, for all sorts of reasons. Um You know, there's churn the reimbursement flow. Um probably one of the main reasons that value based care hasn't taken off in Medicaid is that, you know, you actually don't have this arbitrage of, you know, risk adjustment. And so the only way to make a value based model work in Medicaid is to actually improve outcomes and to actually reduce costs. And you know, that's not the same, can't be said for all value based programs. And so that focus is everything for us. And so we have to actually look at far as I talk about evidence, you have to look at the evidence of like, well, what's actually worked and we've seen over and over and study after study in the US and internationally. You know, when you bring care to the community and you've got community health workers, you've got accompaniment for high risk and rising risk patients, you're reducing readmissions by half, you're cutting overall medical costs by a quarter, you're dramatically improving health equity outcomes. And to me, the challenge is everybody says Yeah, but those programs are really hard to pull off, they're hard to implement, like, of course they are and there is no better challenge worth taking on. Yes, go ahead. Um We're not in health care health systems now. Um Well, I was going to direct your question your way. Um So you take care of seniors and um I would say, you know, if we walked down to the streets of, of L A right now, Marina Del Rey and said, you know what's value based care? I don't know that that many people unless you were in this conference would be able to tell you and would know to advocate for it. So how do we actually reach the patients? Do you think that they should know that they're being treated in a value based way or do you think it should just change almost invisibly and suddenly their health care experience is different? Well, I think, you know, first from the health system standpoint, like we are a hospital system and also an Academy Medical Center, which makes it very hard to do value based care. But I think at Stanford, we have taken the bull by the hands. We are, I'm very optimistic about value based care. And though our tripartite mission is to provide innovative care together with education and research, we are focusing on hybrid model where we are providing innovative care but aligning with the value based care principles and as Chrissy alluded to that. What are we doing for the patients? How do the patients know that we are providing value based care? So it's something that happens on the back end, what we are doing with our providers, our providers, we are trying to support them every step of the way in their practice and in their day to day practice because as you know, all primary providers are under the onslaught of various things, right, messages and so forth. So we are supporting them with a care team model where the care managers embedded in the team are reaching out to the high risk patients, the seniors. So then the seniors get a call from the case managers, they feel like they are part of the health system and they are being cared for and that really prevents a lot of er visits and hospitalizations because they don't feel that drop of a hat that they have to go to a hospital or the er and so that is what we are doing and also through COVID, what we saw is like a like a emergence of mental health issues, right? And so we have integrated mental health physicians in our day to day practice to support our primary care provider. Stanford being a very specialist, heavy organization. Many come to Stanford to get specialist care care, has access is impacted and we want to do the value based care model. So what we institute is E consoles where where providers can reach out to specialists just for feedback and particular issues and then get that feedback back. And that is so timely and so convenient. So it kind of encompasses the various strategies of value based care as we practice. And I think the patients slowly begin to feel the benefits. Like one of my patients said, you know, virtual care. I love it now though, he's an elder initially, he didn't like it, but now he says, oh, I love it now. It's so convenient and I think it's cost effective too to the health system. I said you're right, it's cost effective. So I think, I think we are getting there with Valli based care in bits and pieces, small steps. But, but it is a process. I love this patient who wants to save you guys money. That's great. Um OK. So questions from the audience. If anyone has one, you think that's my over there? Hello Ris Bakari. Uh I'm an MD. So uh how sophisticated are we getting in getting providers to accept downside risk as part of BBC contracts versus the kind of current participation awards we kind of handing out today who wants to take this one? So the majority of our lives are now in downside risk contracts and we have downside risk in both um Medicare advantage, but also traditional Medicare and also commercial contracts. Um I personally don't think that it is wise or necessary to put a small practice with like the threat of bankruptcy with a gun to their head to say like, ok, now make good decisions, right? Um I think from an organizational system perspective though, I do think that it's important for organizations taking risk to be facing downside as a uh as a, as a curative to FIFA service incentives. So, Aida, we have 1000 practices last year, 1500 practices this year who work with us, we bear cost risk on the downside, but we don't pass that down to the practices. And we, we take a similar approach at way mark where we take downside risk. My, my view on this is a provider should really take risk on what they control and not things that are necessarily beyond that. And I think in Medicaid care delivery, if you look at the evidence of, you know, what works at actually improving outcomes and recent costs, you know, not very much of that actually takes place within the four walls of a hospital system or a primary care practice. And so, you know, it's actually appropriate for us to take that downside risk for engaging members in the community and doing the things that can actually move the needle but not necessarily, it's not necessarily right for every provider to enter into that risk agreement. I can, I can I jump in on, on the, the the point I raised about uh risk adjustment, go for it. So uh you can't have taking risk without risk adjustment. You need risk adjustment to be able to make sure that we don't get, uh, lemon dropping, you know, whatever skimming the cream, whatever type of things. Um, but it is absolutely true that I think it is done at the, the, the game around discretionary coding really hurt. I think the perceptions around Medicare advantage, risk taking providers because it was just too easy to make money focusing on adding diagnoses. And I'm really glad we started on the traditional Medicare Medicare savings program where that was not an opportunity. And I think it's actually a really important proof point that if the only way to that is proven is not on just risk code, I think that's a, it's really important to like get that point out there. There are a lot of risk taking providers who became specialists in risk adjustment, but that is not the, that is not the, the, the evidence is not entirely rely on for sure on, on, on that group. And there are plenty of groups now who have done it the right way and actually reduced total cost of care. So, on that point, I'm gonna jump in and, um, we are all clearly fans of value based care that's, you know, you're all dedicating your lives to it. Um, and we know, I think we all know the ball case and we're probably all kind of advocates for the most part in this room. Um I'm gonna put you all on the stand and, and give me, give me the opposite, give me the bad case. Um And, uh, you know, we only have a few minutes left but uh, so do it, do it in a way that, that has a little brevity. But um I'm gonna ask you first. Well, the thing is that, uh the, the, the problem with value based care, especially in an A MC like Stanford, where we stand for providing innovative care. That's where it it is at the crossroads, that how we provide innovative care and how we provide value based care. So that's why I mentioned that it always has to be a hybrid model in a, in a, in a academic medical center because will have patients who will come to us for the care that they need and that won't be provided anywhere else. And another thing is that the crossroad is always there. But we see from the specialty perspective, from the specialty side, it is at the crossroads of revenue and utilization. And I hear from every specialty clinical leader at Stanford, why are we doing this? But I think, but at the end of the day, it is the right thing to do and provide physicians are very smart, right, doing the right thing at the right time, right place. And that's that is what we are trying to do with the other part of our tripartite mission is education educating all of our young physicians, medical students, fellow, those residents on the concept of valid this care. We have created a curriculum so that they can incorporate it as they start practicing medicine because without it, there will never be a fire starter. So there's your, there's your bear case for specialist. Why are we doing? Why are we doing this? We're doing fine. Yeah, we're doing fine. Uh My bear case is um, is that if you're uh big, you don't need to actually embrace value care. So the competition and is lacking in health care consolidation has gotten worse. COVID made it worse. And the FIFA service game is the bigger you get, the more power you have in the negotiations. And if you're big enough in the negotiations, then you don't need to take risk any real risk. So you can get some fig leaf value based contract. It can be called an AC, but really it's just another way to pay you more and no one's gonna like, like no one's going to hold you. You're not actually going to be held to account. You're never actually going to be accountable. And I think short of some serious regulatory action in this country, we're going to see entire parts of the US basically handed over to monopolists and, and no, no value based care can succeed where monopoly reigns. I couldn't agree more. I got it. Not just you. Well, well, I, I, I couldn't agree more. Here's, here's the challenge. My bare case for value based care is we've sort of made value based care, the destination when actually it's not a destination, it's, it's the Vietnamese. And so, you know, C MS has a goal of putting 100% in value based care. By 2030 every state Medicaid agency has goals around moving to value in Medicaid. And basically, what that's done is in my mind, created one of the biggest barriers to true care delivery transformation. And that, you know, for, as I called the fig leaf, I often call them value veneers, which is, it technically checks the box of a value based arrangement. You know, there's, there's some shared savings, there's some bonus program, it does nothing to change care delivery and it actually doesn't matter financially for the provider. And so you don't change provider behavior, you don't change care delivery, but you sort of now attributed a member to a value based arrangement. That member can't be part of another one. And so I think making value based care a goal in and of itself is detrimental to the underlying cause of let's improve outcomes and do what's worked. What works, value based care is important because it allows you to do things that aren't paid for under fee for service. And if you're not doing that, it probably doesn't make sense to be in a value based arrangement. Do you think we're going to meet that 2030 goal. No, that's ok. We're gonna make, we're gonna make progress towards it. We're about a third of the, of the primary care doctors in this country are now in, in what I would consider they've actually changed their practice patterns. A third. It's a lot. It'll, it'll, it'll grow, but maybe two thirds. That's ok. And 50% of Medicare beneficiaries are in Medicare advantage. So, um, cool. Yeah, I love the fire we're bringing today. This is like not what I expected to evaluate care panel, but it's great. Keep it going. Um What is the, what do you think is the specialty that will be the first of all in terms of just widespread acceptance and adoption and primary care? Yes, I mean, primary care is the obvious one. But what's next? I'm seeing a fair amount of interest uh in, in among the specialist sub cap or shared risk on oncology. Cardiology are the two that I'm seeing and nephrology are the three that I'm seeing the most where they kind of take accountability for the patient in the same way. No, I I would agree or is coming behind two in a way because so much, so many Medicare beneficiaries need or visits and interventions and so forth. So I would agree with that, the cardiology, nephrology, oncology and or maybe counterintuitively where we're seeing. Actually quite a lot of interest is surprised me. It was not our thesis, but you know, big health systems because for them, especially in Medicaid, where they tend to lose money on each interaction, whatever they can do to keep people out of the hospital, make hospital stays shorter is, you know, hugely creative to their bottom lines. And so we've seen, you know, big health systems be really interested and moving to and again, the value part of it doesn't matter, moving their poor people to. No, no, it's not that it's actually like, what can we do to improve care outside of our four walls? What can we do to actually bring care closer to the community where you can create a new workforce, you can do things that are cost effective that like we can't do in a big hospital system. And they recognize that the wrong point of care for, for a lot of a lot of patients, look, I'd be really happy if the health systems embrace having fewer hospitalizations for their, you know, good case mix patients. I haven't, I don't see the financial incentive for them to do that. And I think people act according to their financial institutions act according to their financial incentives, not people in that, that financial incentive should be universal. Um With that we're out of time and I felt like we had a, an element of debate club on the stage today which I appreciated. Um Thanks for doing the bull case, the back case, everything in between. Um what an incredible group and, um.

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