The Race to Value Podcast

Achieving health value demands the formation of a new social construct, one that puts aside self-interest and builds systems of care for the common good. One that prioritizes health and equity for all, including the underserved and most vulnerable among us. This effort requires stronger leaders and better leadership than ever before. Getting Medicaid right, transforming addiction and substance use disorder treatment, reframing behavioral health, and removing silos – these are a few of the efforts of this week’s guest as his work exemplifies the mission of achieving health as the seminal American institution to drive social connectedness and economic prosperity. Our guest is David Smith, CEO and founder of Third Horizon Strategies (THS), a Chicago-based, boutique advisory firm focused on maximizing human potential through a better health system. David serves on the Health Care Council of Chicago, the Alliance for Addiction Payment Reform, the board of the Sinai Hospital System, the Founder’s Council of United States of Care and as a Senior Advisor at AVIA and a Project Executive for their Medicaid Transformation Project. 04:55 Facts on Medicaid: 75 million Americans covered (1 in 5 Americans), 50% of US births, $600B annual spend 05:40 Medicaid beneficiaries may even approach 100M in the next five years 06:00 Background on the Medicaid Transformation Project (MTP) 08:00 “The Medicaid program is the single most important endeavor in our country, PERIOD. And that’s not just in healthcare, I’m talking about in total.” 09:00 Health is required to serve in the function in the full human capacity. 09:45 The neglect of the Medicaid program over the years and why we need to get it right to improve health in underserved communities 10:18 “Getting Medicaid right improves health, and improving health creates economic development.” 10:30 Disparities in public health are drawn across racial lines 11:00 Transformation Factor #1:  Evolution of payment models and realignment of incentives 11:45 Transformation Factor #2:  An evidence-based approach to Care Model research and implementation 12:15 Transformation Factor #3: Leveraging technology innovation for underserving communities 12:40 Transformation Factor #4: Social impact investments to fuel innovation 13:00 Transformation Factor #5: Social determinants of health 13:30 Transformation Factor #6: Growth in Medicaid enrollment requiring scalable solutions 14:10 Lack of government boldness, states not moving fast enough, MCOs not eager to develop new payment models 14:40 Partnering with health systems in the MTP to look for disruptive solutions that with financial self-sustainability 16:40 Facts about Substance Use Disorder (SUD): 23.4 million Americans affected, 81,000 drug overdose deaths per year, 1 in 5 Medicaid beneficiaries, 46% of the total Medicaid spending 18:40 David shares how he has personally been impacted by drug overdose through the loss of his father, brother, and sister 21:25 The role of Big Pharma in creating the opioid problem and how Addiction (the “dopamine rush”) is the #1 most common human failing 23:00 How the system of care is setup to treat patients with SUD as “bad people” 23:35 “If we think our fee-for-service system is bad for our physical health, it is a dumpster fire for people who struggle with addiction.” 24:15 The total cost of care for a patient with high acuity SUD is $31-32k per year, and how that creates a $17k value gap. 25:20 “There is no “cure” for Substance Use Disorder; there is only reducing a person’s risk to a baseline.” 25:50 The Value Gap due to waste and inefficiency in the treatment of SUD that also results in poor outcomes in long-term recovery. 27:05 The Alliance for Addiction Payment Reform and its role in advocating for a new value-based payment model for long-term recovery of SUD 29:30 Partnering with commercial payers to develop APMs for Substance Use Disorder 30:30 Multi-billion dollar Big Pharma payouts from civil lawsuits presents an opportunity to focus capital in supporting SUD patients throughout the care continuum 31:35 “The human cost of the opioid epidemic in this country is unfathomable, and solving it is within our grasp.” 33:30 Creative partnerships with technology companies to usher in a new age of digital health transformation and care delivery innovation 34:20 Scarce, finite infrastructure and resource limitations in behavioral health care delivery 36:00 The challenge with digital transformation being viewed as a panacea 37:00 Integration of data with Artificial Intelligence to more effectively deliver care 37:30 The need to look at technology resources as an asset class of tools in a toolbox – which one should you use to serve the underserved? 38:10 The impact of the COVID-19 pandemic in creating a new social construct in society which portends future progress in telemedicine 40:30 The Health Care Council of Chicago (HC3) and its focus on addressing racial disparities of care 42:30 David shares a personal reflection on health equity when driving through a violent inner-city area in Chicago and seeing a little girl play outside 44:50 David acknowledges the presence of systemic racism and the need for intellectual awareness of its presence in our society 46:40 David realizes as he unwittingly participated in a system that supports segregation by the choice of his neighborhood 48:00 Reflecting on Martin Luther King, Jr.: How you pull yourself up by your bootstraps without having a pair of boots? 49:10 Challenging yourself to be anti-racist in order to drive a new intergenerational way of thinking 52:00 Silos and individual fiefdoms keeping us from pursuing efficiencies and common good 53:30 Too many healthcare leaders are self-interested – “We need a different type of leadership in our industry.” 55:00 “Healthcare doesn’t focus like a normal economic industry. We don’t have information transparency, information symmetry, rational decision-making, or incentive alignment.” 57:00 Hospital consolidation due to unprecedented M&A activity and its impact on healthcare costs 59:00 Department of Justice & Federal Trade Commission lack of understanding of what competitiveness means in healthcare 1:01 Challenges in healthcare market competitiveness without information transparency and data aggregation 1:02 David addresses the Open Letter to the Healthcare Industry he wrote one-year ago about COVID-19 1:05 Health is the seminal American institution to drive social connectedness and economic prosperity. 1:06 Using the challenges of 2020 as a crucible for growth and for refinement (shifts in culture, change in social compact, payment models, civility) 1:07 $4T (20% of our GDP) is more than enough to do more than we are doing in healthcare. WE CAN DO BETTER!

When Thomas Edison created the electric light bulb, he didn’t stop with that one incredible invention. He took the next step and created the industry that would maximize the benefit of that light bulb, the infrastructure needed to make that light bulb become a permeating and permanent piece of society. This is the type of vision needed for the health care system as a whole, and the type of vision that is occurring in Dallas Texas. Catalyst Health Network’s physicians are intent on the vision of “Primary Care for All”, serving communities that are mired in a systemic, multi-generational crisis—where one in three children in Dallas lives in poverty, the third-highest rate of child poverty in the nation. This week’s guest, Dr. Christopher Crow, President of Catalyst Health Network, has connected and aligned a network of more than 1,000+ Primary Care Providers with nearly 1 million lives across North Texas, to build a better care model for patients that improves health and lowers cost. His work with Catalyst led them to be the first North Texas physician network to hold value-based contracts with the top four major carriers: Aetna, UnitedHealthcare, BCBSTX, and Cigna. To date, Catalyst has saved an impressive $100 million for the communities they serve. Dr. Crow and Catalyst are a bright example of leadership in the race to value! Episode Bookmarks: 04:00 Thomas Edison’s signature invention of the light bulb was a little more than a parlor trick without a system of electric power generation and transmission 05:00 How Catalyst you’ve been able to imbue a full spectrum of innovation with its value attempts 06:00 The origin story of Dr. Crow and Catalyst Health Network 07:20 Systems thinking design and strategy as a leading force to payer collaboration 08:20 Dr. Crow’s A-Ha moment when seeing Catalyst’s performance data and how value design and PCMH really does lowers cost and utilization 09:30 How growing up in the small town of Hillsboro, Texas inspired Dr. Crow to help communities thrive 10:50 The three pillars to helping communities thrive are health, education, and business. 11:20 Building a healthcare system to deliver more value starts with team-based primary care. 12:45 f an independent primary care practice can thrive (not just survive), the data shows that the community will thrive as well. 13:30 Centralization of population health management with deep personalization 15:00 Leveraging trust of the physician-patient relationship by extending it to the entire care team at scale 15:35 The concept of relationship compounding in value-based care and how it leads to lower costs and better health 16:40 The income and public health disparities in Dallas, Texas and how life expectancy differs by 24 years between neighboring zip codes! 18:10 Dallas is a tale of two cities – affluence and poverty.  What is Dr. Crow’s vision to help everyone in the community thrive? 19:30 Dr. Crow’s vision for “Primary Care For All” to improve longevity and prosperity 21:00 The impact of COVID-19 on building virtual care and telehealth capabilities within the practice 21:30 The importance of telehealth in addressing issues with Behavioral Health and “healthcare deserts” 23:00 Creating the Catalyst Community Foundation to provide access to affordable, quality care, starting with COVID-19 testing and vaccinations 25:15 “If you really want to create impact with high leverage, go upstream with primary care and social services”. 26:20 Building a business model for a self-sustaining, community-based foundation that will ultimately lead to Primary Care For All 27:30 Private Equity investment and provider consolidation – what does this mean for the future of primary care? 31:00 How Catalyst helps small primary care practices build the table stakes for value-based care from a technology and service standpoint 34:45 Catalyst receiving URAC’s full accreditation in Clinical Integration and how they were able to build a CIN with a network of independent physicians 38:30 Engaging physicians with a playbook for clinical integration 39:00 Joining forces with another prominent CIN (Baylor Scott & White Quality Alliance) to bring even a higher level of innovation and integration to the Dallas market 40:20 Developing a health insurance product for individuals and small employers that offers Primary Care for All in a subscription-based model with prospective payment 43:00 The exploding costs of employer-sponsored health insurance with ‘poor health’ costing employers $530B on top of the $880B they already spend in premium dollars! 45:30 Collaboration with employers and how “Relationships Matter” is the #1 core value of Catalyst Health Network 46:45 How Catalyst generated $100M in savings primarily with a commercially-insured population (not Medicare or Medicare Advantage) 48:30 The thought leadership of Dave Chase and “How Healthcare Stole the American Dream” 48:55 Unnecessary spending and low value healthcare deprives future prosperity of communities 51:00 Redesigning employer plan benefits with an emphasis on Primary Care and prospective payment 52:45 COVID-19 as a wakeup call for large employers 54:40 Medicare Advantage with prospective payment and shared risk 56:00 The new CMMI Direct Contracting model 56:30 How PPOs are the wrong model for value (the “PPO Buffet”) and the HMO backlash 57:24 “If you want a longitudinal model for primary care, with the benefits of relationship compounding, you must pay for it prospectively.” 59:30 How Integrated Pharmacy with a focus on medication adherence can reduce healthcare costs through reduced inpatient hospital stays and emergency visits 1:00 40% of drugs purchased in healthcare are not even taken! 1:02 Integration of pharmacist with a care team to help providers and patients make the right decisions 1:03 “90-day refills are bad for your health!” 1:05 Moving adherence rates for patients with chronic diseases – from 60% to 90%. 1:07 “The Infinite Game” mindset for leadership in primary care transformation 1:08 Winning in America is stock prices and EBIDTA.  Not a different purpose-driven game based on relationships leads to a better future.

Decades of poor outcomes in terms of cost, quality, and access have not created societal commitment to confronting the issue of low-value care in hospitals. Despite medical errors serving as the #3 cause of death, unpaid hospital bills leading as the #1 reason for personal bankruptcy in our country, vast disparities in care prevalent across racial and sociodemographic lines, and a general sense of pricing opaqueness, we have not yet seen a community-led movement towards hospital accountability for health equity, quality of care, and avoidance of low-value care.   If hospitals are to equitably deliver the high-quality care that is essential to improving community health, the time is now. Assessing how well hospitals are serving all of their patients in their communities is a key first step in improving their quality of care. The Lown Institute, a think tank generating ideas for a just and caring system for health, has developed a tool to answer the question, “Are hospitals providing high-value care, achieving excellent patient outcomes, and meeting their obligation to advance health equity in their communities?”   Today we are joined Vikas Saini & Shannon Brownlee of the Lown Institute to discuss The Lown Institute Hospitals Index, a novel way of evaluating and ranking hospitals in order to help them better serve their patients and communities and to hold them accountable to addressing social determinants of health. This unique hospital ranking system is breaking new ground as we move forward in the race to value.   Episode Bookmarks: 02:00 Despite decades of dreadful outcomes, society has yet to confront the issue of hospitals providing low-value care 04:30 The legacy of Dr. Bernard Lown, as a pioneering cardiologist, humanitarian, and early advocate of value-based care 08:20 Dr. Lown’s philosophy of value-based care and the subtle distinction between doing as little “to” patients, but doing as much as possible “for” them 11:15 A new hospital ranking tool is needed in value-based care — one that factors in civic leadership and racial equity 12:50 The Lown institute Hospitals Index is the first ranking system that actually measures overuse and unnecessary care 13:20 Economic tradeoffs matter when you look at racial equity 14:05 In ranking hospitals, the value of the care is as important as clinical outcomes. 15:05 Good hospitals are vital to healthy communities, but how you define and measure “good” matters. 15:30 The Civic Leadership component of the Hospital Index which accounts for spending on charity care, pay equity, and racial inclusivity 19:00 Variation in social and civic leadership metrics with academic medical centers, particularly inclusivity and pay equity 20:20 How Black Lives Matter has forced hospitals to reexamine their culture and commitment to health equity 21:45 Neighboring hospitals with drastically different racial inclusivity scores and the impact of residential segregation 25:00 Segregated (“separate and unequal”) hospitals with disproportionate impacts in COVID outcomes for those in low-income communities 26:30 The way we have organized and funded the hospital sector will not meet population health needs for communities 27:30 The need for regional coordination, changes in payment mechanisms, and global budgeting for health care transformation. 29:00 The Big Business of Healthcare and why “Health care is too important to leave to the Healthcare sector.” 30:00 Having a hospital system based on cooperation in population health versus having individual healthcare businesses competing against each other for volume 31:00 The disappointing, yet predictable, inequitable distribution model for COVID-19 vaccines 36:00 Low-value care is a significant portion of waste; estimates of spending on low-value care range from $100 billion to $700 billion each year! 39:00 Vikas discusses how his clinical training with Dr. Lown provided him with a deep sense of humanism and commitment to addressing low value care 43:00 Shannon traces her interest in eliminating low value care when researching the overuse of the PSA test and how it was actually causing patient harm 46:30 The release of overuse data from the Lown Institute on May 4th (2021’s TOP HOSPITALS: AVOIDING OVERUSE) 48:00 The new Hospital Price Transparency rule that just went into effect requiring hospitals to list their negotiated discounted prices online for all services 53:00 The biggest pressure for downward hospital prices will come from insurers and employers in the future 55:00 How consolidation and monopolization in healthcare is creating the opposite effect of competition driving down costs in a market-based economy 57:20 “This Race to Value is one of the most important things we can do in this country…” 59:00 The need for health democracy at a local and regional level to create a radically better system

Chronic kidney disease kills more people than breast or prostate cancer each year – it’s the 9th leading cause of death but you won’t see NFL players wearing socks and gloves to increase awareness. Thirty-seven million people in the U.S., or 15 percent of adults, are impacted by CKD, and around 90 percent of those with the disease don’t even know they have it! Treating kidney disease costs the Medicare program $130B and although patients with kidney failure account for only one percent of the Medicare population, they are responsible for over seven percent of all Medicare spending. Over the last 40-50 years, kidney care has experienced significantly less transformation than other areas like diabetes, cardiology, cancer, and HIV/AIDS. We have been failing in kidney care for far too long, and instead of focusing just on dialysis, we need to realize that kidney disease is more than just ESRD, and there is way more to ESRD than just in-center dialysis. This historic stagnation in kidney care with a large population now in crisis is a hugely abundant opportunity for innovative companies like Cricket Health to come in and change the game. In this week’s episode, we are joined by Bobby Sepucha, CEO of Cricket Health, a specialty care management company leading the way in the Value-based kidney care space. National Kidney Month is the right time to discuss how we can win this Race to Value with integrated nephrology and dialysis care for people with Chronic Kidney Disease and End Stage Renal Disease. Episode Bookmarks: 02:00 37 million people in the U.S., or 15 percent of adults, are impacted by CKD, and around 90 percent of those with the disease don’t even know they have it! 02:15 Medicare pays well over $100 billion for people with all stages of renal disease, which was nearly 20 percent of all Medicare spending last year. 02:45 While just one percent of Medicare beneficiaries have kidney failure, kidney failure accounts for over seven percent of all Medicare spending! 05:35 The system is designed to fail patients with chronic kidney disease 07:45 How the 1972 Medicare enrollment eligibility provision for ESRD patients created an unintended consequence of earlier stage CKD patients getting neglected 08:09 President Trump’s Executive Order on Advancing American Kidney Health (July 2019) 08:35 Bobby recalls his work with CMS and Congress to bring the ESRD Seamless Care Organization (ESCO) alternative payment model into fruition 09:00 “Unless we go upstream and start engaging patients prior to kidney failure, success in value-based kidney care will be limited.” 09:30 40% annualized mortality rate for dialysis patients can only be addressed by upstream CKD intervention 09:40 The new Kidney Care Choices (KCC) and the ESRD Treatment Choices (ETC) payment models 11:50 “Only 12% of ESRD patients today in America dialyze at home – that lags other nations to such an alarming degree.” 12:15 “If you were going to design the worst imaginable healthcare delivery system for kidney patients, you’d come up with the one we have here in America. Costs are astronomical, outcomes are terrible, mortality rates are through the roof, everyone is dialyzing in a center instead of home…it just doesn’t make any sense.” 12:55 60-65% of ESRD patients “crash” into dialysis with an ER visit 14:00 Cricket’s model for upstream CKD intervention 15:00 “Getting patients to dialyze at home is a multifactorial problem.” 16:15 The overlap of nephrology and palliative care 18:00 Telehealth is the silver lining to the pandemic 18:30 A patient story about the success of transitioning to home-based dialysis 19:55 The appalling lack of kidney care innovation over the last 40-50 years 22:20 The obesity epidemic and exploding kidney care costs over the last few decades 23:00 Working with payers for a more holistic approach to value-based kidney care 23:45 Payer goals: 1) reduce CKD hospital utilization prior to onset of dialysis, 2) address transition cost spike from CKD to ESRD, 3) reduce ESRD hospitalizations 24:50 Cricket’s goal to deliver the “right care to the right patient with the right team at the right time and place” 25:20 Predictive modeling algorithms for early CKD detection and risk stratification 26:20 Fostering intentional patient relationships based on trust 27:00 Leveraging virtual platforms in CKD patient engagement 30:00 The importance of Primary Care in early detection of CKD and referral guidelines between primary care and nephrology 31:30 Filling the gaps in primary care with AI 32:00 “The ideal kidney care delivery system is primary care physicians taking the lead in treatment of patients with early stage kidney disease.” 34:00 Evidence-based pathways in value-based kidney care 35:30 Cricket Health’s partnership with Baylor Scott & White 37:15 “There might not have been a better time to be an investor or an entrepreneur in the kidney space, it is a perfect confluence of events to make some intelligent bets” (Bryan Sivak, KP Ventures) 40:00 Partnership with physicians, systems and payers and the sharing of financial risk 43:40 CKD as a microcosm of everything that is broken in the U.S. healthcare system 45:30 The story of the founding of Cricket Health 46:30 Patient consumerism and health literacy in kidney care 48:00 Recreating the “digital sidewalks” for patients in accessing education about their disease 48:30 Disproportionate burden of CKD and disparities in outcomes in the African American population 51:00 Designing tech-enabled, multi-modal population health deployments to address health equity challenges 54:30 Parting words on how to win the Race to Value in kidney care

Last year, research at Johns Hopkins showed that healthcare consumes nearly half of all federal spending, which includes funding for Medicare, Medicaid, Social Security, military health benefits, health benefits for federal employees and their dependents, plus interest. Our federal government spends 48% of its money on health care and still healthcare devastates state budgets all across this country, with serious consequences in public health, education and other national priorities. This week’s guest, Dave Chase, is the Creator, Co-Founder, and CEO of Health Rosetta. Health Rosetta is an ecosystem enabling public and private employers and unions to reduce their health benefits spending by 20% or more while improving the quality of care for plan members. Dave is also the author of Relocalizing Health: Relocalization is a strategy to build communities based on the local production of food, energy and goods.  When applied to healthcare, a relocalization effort bring about systematic change – it could lead to strengthened local economies, improved population health, higher value in care delivery, and health equity. Dave expounds that health doesn’t start with a pill or in a hospital. It starts at home, with parents, with neighborhoods, with workplaces, and communities. Relocalization will be an important key for winning the race to value! Episode Bookmarks: 04:05 Defining the Relocalizing Health strategy and why it needs to be applied to healthcare 05:45 How to create systems change at a grassroots level 06:25 Applying a systems change model that focuses on adaptable replication (not scalability) 07:15 The Nuka System of Care in Southcentral Alaska as an example of a successful effort to relocalize health care 07:25 Rosen Hotels as another example of creating a consumer-oriented redesign of health care 07:40 Learning from the Jönköping Health System in Sweden 08:35 “Transformation moves at the speed of trust, and trust is built on complete transparency.” 08:50 How the legal and economic underpinnings of health plans are ‘completely rotten’ and must be made transparent 09:15 Seeking transparency in the way health insurance brokers are paid 09:27 “There is no well-functioning healthcare system in the world not built on proper primary care.” 09:35 “Healthcare isn’t expensive — only 27 cents of every healthcare dollar goes to clinicians who are the value creators. What’s expensive is profiteering, price gouging, administrative bloat, and fraud.” 10:00 Dave discusses the advancements of modern-day computing as an example of why we need to work on the fractals of healthcare (i.e. the piece parts) 11:05 Research from Marty Makary showing that the federal government spends 48% of its money on health care 12:55 A broken financing model for hospitals steals from public health, kids, education, social services, and public infrastructure 13:15 Economic Development 3.0: Playing the Health Card 13:35 How considering every hospitalization as a failure is a starting point for reform 14:30 The economic depression of the middle class due to wage stagnation, and how that was caused by healthcare costs 15:30 The Millennial Generation is the first generation in American history where life will not be better for their parents because healthcare is stealing their future 16:35 Referencing David Goldhill’s Catastrophic Care: Why Everything We Think We Know about Health Care 16:55 “I believe the Millennial Generation can be the greatest generation of this century.” 17:45 Massive student debt and how healthcare has driven up the costs of Higher Education 19:51 The national opioid epidemic crisis that is devasting communities.  More than 760,000 people have died since 1999 from a drug overdose, and two out of three drug overdose deaths involve an opioid. 21:45 The opioid crisis isn’t an anomaly – it is our healthcare system.  The key unwitting enabler is the employer. 23:45 The #1 cause of death for Millennials is opioid addiction 25:00 “Proper primary care is the answer to the opioid crisis, and that is the bottom line.”  (referencing Rosen Hotels approach to primary care) 26:00 Eric reflects on his experience visiting a concentration camp and how we must never repeat history 27:00 Employer-paid Benefits tax break estimated at over $600 billion, making it the largest tax break in the tax code, and the primary wage suppression driver 28:05 Policy recommendations to the Biden Administration: 1) Enforce ERISA, 2) Fix the procurement process to eliminate fraud and waste, 3) provide flexibility to  Community-Owned Health Plans 31:30 Using social Impact investing and opportunity zones to support promote health equity and social justice 32:45 Zubin Damania and The Health 3.0 Movement as a roadmap 33:55 Comparing the LEED green building standard to how relocalization of health at the community level can drive system change 35:00 How Paul Grundy got the name the “godfather” of the Patient-Centered Medical Home 36:30 The 5 things business leaders can do to make healthcare “LOCAL” 38:30 Fully-actualized, value-based primary care is the linchpin to success and how it allowed Rosen Hotels to spend 55% less per capita on health benefits than their competitors 39:40 The mistakes made by Haven (the Amazon, Berkshire Hathaway, and JPMorgan Chase healthcare partnership) and why jumbo employers struggle to drive change 40:40 Mid-market (companies that have 50-5,000 employees) is where the disruption really happen in employer healthcare 41:15 The Wal-Mart / Oak Street Health partnership as an example of effective large-scale change in managing complex medical conditions 42:30 Over 50% of so-called “healthcare dollars” are extracted out of local economies by out-of-town health systems and health plans 44:00 Community-owned health plans and the importance of employees having an “owner mindset” 46:20 Why Harris Rosen invested in Tangelo Park and related community programs in Orlando, Florida (Rosen Hotels Case Study) 50:00 How COVID-19 is like a WW2 event and comparisons to the building of the NHS 51:00 Nurses, Doctors, and Pharmacists should use the trust the community has in them to lead change (“Everyone has influence”) 54:00 Serving one’s calling and how that is better than just having a job or a career

Stephen Nuckolls grew up listening to his physician father talk about how healthcare could save money for Medicare if it was accountable for outcomes. It was with this intent that he built Coastal Carolina Health Care (CCHC) in 1998, a multi-specialty practice managing 36,000 patients with 60 providers across 16 sites of care in Eastern North Carolina. CCHC serves in both urban and rural communities, with a mission is to promote the health of its patients by providing high quality, compassionate, comprehensive, and personalized health care. It’s no surprise that Stephen and his team formed one of the first 27 MSSP ACOs, Coastal Carolina Quality Care. Currently in the 8th year of the Medicare Shared Savings Program (ENHANCED Track), the ACO performs at the highest quality levels nationally and has saved consecutive years. The ACO exemplifies the vision of Stephen’s leadership, captured in the ACO’s slogan, “Tomorrow’s Health Care Delivered Today.” Episode Bookmarks: 05:00 Stephen reflects on the influence of his physician father who championed value-based care early on 05:40 Setting up Coastal Carolina Health Care, PA (CCHC), a multi-specialty group practice, in 1998 to be accountable for cost and quality 06:00 Leveraging ancillary services and electronic health records to prepare for the future state of value-based care 06:45 The passage of the Affordable Care Act in 2010 as an opportunity for Stephen’s practice to demonstrate value 07:00 Stephen and his physicians head to Washington, D.C. to collaborate with CMS on the early design of the Medicare Shared Savings Program 07:20 The struggles of balancing FFS and VBC in the early years of Coastal Carolina Quality Care (CCQC) ACO 08:45 “It’s not the actual doctor services that are expensive.  The real big costs are in hospitalizations.” 09:00 ACO Care Management dropped Hospital Admissions per 1000 by 22% 11:00 Engaging physicians in the early years of the ACO before Shared Savings performance 12:30 Mandatory transition to downside risk in the “Pathways to Success” MSSP final rule and how ACOs should evaluate potential for future success 13:30 Getting comfortable and fully understanding the ACO benchmarking methodology 13:50 “Ultimately we need to have risk in the game, but we need to recognize that different ACOs are in different periods in their transformation.” 14:00 How CCQC ACO is consistently ranked among the top performers nationally in quality measure performance, clinical outcomes, and Shared Savings returns 16:00 How having one practice in the ACO with one electronic health record supported quality outcomes 17:00 Selecting “true north” standardized quality measures that are managed consistently across the entire payer contract portfolio for all patients 17:20 Implementing a successful point-of-care quality measure reporting dashboard 18:00 Developing an equitable physician compensation/incentive structure as a key to success for driving quality 19:00 ACO concerns related to diminishing returns over time due to sustained performance in comparison to the benchmark 21:00 Advantages in specialist integration within the ACO due to multispecialty practice model 23:00 Capital investments required to build an ACO population health management infrastructure 26:00 Efficiencies gained by being a one-TIN/one practice ACO and how Advanced Payment ACO Model funds were used to build a Chronic Care Management program 27:00 Investments in automated dashboards for quality reporting to identify and manage gaps in care 28:00 Annual Wellness Visits (AWVs) as a source of funds for practice transformation in primary care 29:00 Reinvesting funds back into the ACO versus distribution to physicians 29:30 A recent investment in an “extended care” clinic  (a higher acuity center with ER physicians, hospitalists, and nurses) 31:00 How the extended care clinic resulted in an ER visit per 1000 rate of 25 for self-insured employees (compared to statewide commercial ER/K benchmark of 200) 31:30 Implementing a palliative care program to improve end-of-life care and chronic disease management 34:00 Recent changes to ACO benchmarking methodology that includes a regional efficiency adjustment and how that affects rural communities (“the rural glitch”) 36:30 Stephen provides guidance to ACO executives on understanding the impacts of benchmarking methodology and risk adjustment 37:30 “Our industry focuses so much on Risk Adjustment, especially in Medicare Advantage plans.  It is a ‘necessary evil’ by nature of how the system is set up, but we really need to focus on taking care of the patient and making them healthier. As long as you are doing those things, the money will work out.” 40:00 Stephen provides his perspective on the new Direct Contracting Model 41:30 The Geographic (“Geo”) Direct Contracting model has a different risk adjustment methodology than Medicare Advantage 42:30 Congress and the ONC’s role in promoting interoperability and preventing information blocking 46:00 Stephen’s thoughts on the future of value-based care in the Biden Administration 48:30 What CCHC is doing to ensure equitable distribution of COVID-19 vaccines to high-risk patients in rural communities

In this episode, reflect on the importance of Black History Month, an important time to recognize and honor the contributions and achievements of the millions of African Americans who have helped build our nation and enrich our culture. We also address racial disparities in care, which have become increasingly evident during the pandemic and vaccine distribution response. And we consider how value-based care can work to ensure true population health and parity in health outcomes for all. This week we are honored to speak with Dr. Lerla Joseph, an African American physician, businesswoman, humanitarian, role model, mentor, and philanthropist. In 2012, she founded the Central Virginia Coalition of Healthcare Providers (CV-CHIP) one of the nation’s few minority-owned Accountable Care Organizations. Dr. Joseph not only leads a successful ACO, she has also led medical missionary trips to Haiti for the last 16 years. As a community leader, she has also served on boards for Richmond Community Hospital and the Bon Secours health system and was the 1st woman elected President to the Richmond Medical Society. This year she was a “Strong Men & Women in Virginia History” Honoree, a program that honors prominent African Americans past and present who have made noteworthy and admirable contributions to the commonwealth, the nation, and their profession. Dr. Joseph is a shining example that black history is around all of us. Episode Bookmarks: 01:45 Black History Month is a time to contemplate the faith and sacrifice of every black ancestor. 03:00 “As leaders in value-based care, we endeavor to create the opportunity for health equity.” 03:30 Intro to Dr. Lerla Joseph, Founder and CEO of CVCHIP ACO (one of the few African American-led ACOs in the country) 05:30 “Of all the forms of inequality, injustice in health is the most shocking and inhumane” – Martin Luther King, Jr. 06:30 Outcomes research on racial disparities of care showing that inequities are built into the healthcare system. 07:45 A medical career devoted to bring about health equity to African Americans 08:20 “Having a health insurance card is not enough in terms of getting the proper care that African American need. Our populations needs physicians like them that understand their cultural background.” 09:20 The Accountable Care model as a vehicle for both access to care and health equity 10:50 How do we begin to have an open conversation as a society when it comes to recognizing systemic racism exists? 12:15 “Your health should not be determined by your zip code.” 14:15 Dr. Joseph speaks about her experience growing up with segregation and benefiting from affirmative action 16:05 An opportunity for America to overcome supremacy 16:55 Creating a movement for African Americans and White Americans to come together to have a conversation on race 18:20 Unwillingness of African Americans to take the COVID-19 vaccine due to past experiences that created distrust of health system 20:55 “As long as there are disparities in health care, the costs will remain high.” 21:20 Creating CVCHIP ACO with the recognition that African Americans were getting left behind in the value-based care movement 24:20 A recent study showing that life expectancy dropped sharply to its lowest level in 15 years, and even lower for Black Americans, during the first half of the coronavirus pandemic 25:35 The mission of CVCHIP to sustain the viability of the independent practice and how Dr. Joseph’s ACO helped practices during COVID-19 27:30 Implementing telehealth and ensuring patient access during the pandemic 29:00 The impact of COVID-19 on African American patients 30:00 Dr. Joseph’s medical missionary work in Haiti and her commitment to help others in the world 31:40 The most rewarding experience in her life and how she inspired others to serve 33:50 “Living in America, even with all of the disparities and inequities, is still the best place in the world to live.” 36:35 Convincing doctors that Fee-For-Service was going to end and how Dr. Joseph engaged physicians at the beginning of CVCHIP starting as an ACO 39:00 A personal patient story of how the ACO engaged community resources to help someone in their home (“looking beyond the diagnosis”) 42:00 Our nation’s long-standing mental health crisis that has been exacerbated by major societal stressors: the covid-19 pandemic, racial inequality, and a heated election season 43:55 Forming partnerships within the ACO to provide access to Behavioral Health services and treatment for Substance Use Disorder 48:00 A coalition led by the Larry Green Center to reform Primary Care Financing 49:30 Establishing an advocacy effort within the ACO to speak on behalf of Primary Care 51:50 “The lack of African American ACOs in the country is regrettable – all communities must be represented.” 53:00 “My mission in life is not merely to survive, but to thrive; and to do so with some passion, some compassion, some humor, and some style”.  – Maya Angelou. 53:50 Dr. Joseph shares her perspective on leadership and how others can lead in the value-based care movement.

Our health care industry excels at rescue care – when a patient needs to be saved, our system has answers. However, we are not well suited to address the challenges associated with serious illness, death and dying. Evidence shows that palliative care and advanced care planning improve health value. These tools lead to better management of pain and symptoms and improve both the quality and length of life. The preferences of patients and their families and caregivers are better accounted for, and their satisfaction is much higher. Healthcare utilization is reduced and outcomes are improved. ACOs that have successfully implemented a palliative care program have demonstrated reductions in 30-day readmissions, avoidable hospital admissions, and ED visits. So why do only 10% of ACOs have palliative care as one of their foremost strategies? Our guest this week is Stephen J. Bekanich, M.D., the co-founder and Chief Medical Officer of Iris Healthcare, a disease-specific advance care planning service. Prior to this he served as the CEO of Ascension Health’s Texas ACO (with 2,500 physicians and shared savings across government and commercial contracts), as well as the Chief Medical Officer of the health insurance joint venture between Cigna and Ascension Health. Before moving to Austin, he held the rank of Associate Professor of Medicine at the University of Miami Miller School of Medicine and the University of Utah’s Medical Center where he started and directed their palliative medicine programs. Episode Bookmarks:  05:00 A journey in health value that is heartfelt and deeply personal, as it is associated with a personal tragedy 06:45 The loss of grandparents to serious illness and the call to change medical specialization to palliative care 07:21 “The era of antibiotics and airbags” – people no longer dying from infections and trauma like they did historically 08:10 Serious illnesses (COPD, Dementia, late stage malignancies, CHF, etc.) have become the new killer in an evolved society 08:31 Society is not prepared to deal with serious illness and the inevitability of death 10:30 “It is incumbent upon us to get people better prepared for what they will be facing. Almost 85% of us will face serious illness, yet healthcare literacy skills are so low. Something is clearly wrong.” 11:00 Research showing 70-80% of people with incurable cancer believing they will be cured is a failure of physicians to appropriately set expectations. 12:30 Stephen’s shares the personal story of his grandmother’s terminal illness and the difficulty of confronting death 14:00 Palliative care as a force for value and the appointment of a palliative care expert to lead CMMI (Brad Smith) 15:00 “Over the past five to ten years, a number of studies have repeatedly demonstrated how advanced illness programs can consistently provide high patient and family satisfaction, reduce hospitalization by nearly 50%, and decrease costs in the last year of life by 20% to 25%.” (Brad Smith) 16:00 Algorithms in population health incorrectly focus on last 6-12 months of life instead of providing a pathway to earlier intervention with Advanced Care Planning (ACP) 17:20 “In the last year of life, we are often delivering care that is unwanted, unnecessary, or nonbeneficial. That is not a good experience for patients and their loved ones.” 17:45 Patients with high symptom burden and in distress cannot focus in discussions about setting goals in care. 19:00 A calm environment prior to serious illness onset results in a better ACP conversation (better for patients). 19:30 Nonbeneficial care starts to occur in the last 12-15 months of life as a second reason to move interventions upstream (better for ACO bottom line) 20:20 Treatment plans should occur only after a patient is educated 22:35 “So much of palliative care is Advanced Care Planning.” (>70% of palliative care consults related to goals of care and ACP) 24:00 How the medical-industrial complex often inflicts therapies on terminally ill patients that actually shortens lives or increases suffering before death. 25:00 A recent survey by Leavitt Partners and NAACOs shows that only a 10% of ACOs selected palliative care as a top priority for improving efficiency and lowering costs. 26:00 CMS and CMMI efforts to lay the foundation for palliative care (e.g. Primary Care First’s Seriously Ill Population (SIP) option, Direct Contracting, Kidney Care Choices, Oncology Care First, BPCI Advanced) 28:30 Why hasn’t palliative care taken off with the level of scalability we would expect? 29:00 Reason #1: Workforce shortage in palliative care and how the specialty doesn’t lend itself to patient delight (instead more focused on a less difficult journey) 30:45 Reason #2: Lack of awareness of palliative care (people are still confused about what palliative care physicians do) 32:40 Reason #3: The business case not always a clear path because palliative care is viewed as a cost center. 34:30 The Conversation Project found that despite 92% of Americas saying it was important to discuss their wishes for end-of-life care, only 32% have had those conversations 35:20 Advanced Care Planning as an unexpected, collateral benefit of the COVID-19 pandemic 40:50 Facts about costs: $270B wasted annually on unnecessary care, one-quarter of overall Medicare spend ($700B) goes to 5% of population in last year of life 41:20 Research about ACP impact pm costs: ACP reduces heath costs by $9,500 per member (JPM), ACP with cancer patients demonstrated costs savings of $22k per member (JAMA) 42:30 Physicians are the least expensive patients because they are the masters of avoiding what is not beneficial (insider information that patients and families often do not have) 45:00 Advanced Care Planning often results in more conservative, less costly end-of-life care 46:00 Use of lay health workers in Advanced Care Planning 47:15 Prescribing opioids via telemedicine (recent interview with Dr. Bekanich in MedPage Today) 48:45 Iris’ Net Promoter Score of >90 and how palliative care/ACP can lead to improvement in the overall patient experience 49:40 The power of words in medicine and how conversations can improve lives. 52:10 “The loss of control when dealing with a serious illness is a terrible feeling.  Anything you can do for people that will help give them more control over their life will be accompanied with gratitude.” 53:45 The importance of having inclusivity of caregivers and family in the ACP process 55:00 ACP as a “Crucial Conversation” (Stakes are High, Feelings are Strong, Feelings Differ) 56:45 Challenges with complex legalese in standard documentation for advanced directives 1:00 “Advanced Care Planning should not be a one-and-done conversation.  It is a living conversation.” 1:01 The impact of loneliness with those living with a serious illness

An industry inflection point is coming in the transition to value: federal and state governments are feeling an insurmountable level of pressure as public debt and spending increase, large employers are reeling from high healthcare costs, and provider organizations are being crushed by the current environment as they realize that FFS is perilous in the middle of a pandemic. Health system executives not leading with a strategy in health value are increasingly facing significant financial uncertainty. The coming industry shift to value is all but inevitable, however, pivoting successfully will require long-term strategic planning and investment in cultural alignment, technology and infrastructure, and partnerships. When Travis Turner heard Dr. Don Berwick speak about the transformation to population health and value-based payments, he listened. Berwick had said the worst position to be in when transitioning from fee-for-service is static, stuck with a foot in each canoe – the change must be fast to achieve critical mass that enables modifying provider behavior. This became a priority for Travis, something that has been aggressively pursued and which has driven to his organization’s success. This week, we speak with Travis Turner, SVP Chief Population Health Officer and COO of Mary Washington Medicare Advantage at Mary Washington Healthcare. Mary Washington Health Alliance is a physician-led, physician governed CIN – founded in 2013, the ACO has 437 participants that cover around 60,000 lives. During the 2017 MSSP performance year, the ACO achieved $11.9 million in savings. For the first three years it participated in the CMS Bundled Payment for Care Improvement program, it achieved $12.6 million in savings. The ACO now participates in the Next Generation ACO model and is active in the BPCI Track 2 for all 48 episodes of care. Episode Bookmarks: 3:30 The inflection point in value-based care for employers, providers, and government 4:40 The value-based care journey of Mary Washington Health Alliance (MWHA) over the last 7 years 6:15 Transitioning from the upside-only MSSP to taking institutional risk in the NextGen ACO and BPCI programs 7:25 Entering downside risk by applying lessons learned from other value-based contracts 7:40 Reaching a critical mass in value to change the behavior of providers 8:00 Don Berwick’s influence on MWHA’s fast transition to value 10:00 “There has to be a bottom-up, top-down acceptance at every level for population health to succeed in a value-driven organization.” 10:30 Travis reflects on the slow uptake of value-based care in the national landscape and how learning environments will catalyze adoption 11:10 VBC is key to partnering with independent physicians 11:30 “Reaching critical mass in value is all about achieving the Triple Aim. That will overcome any perceived risks of demand destruction.” 12:15 The challenges of adapting to CMS changes to payment models 13:30 NEJM on care patterns in Medicare and the challenges of fragmented, uncoordinated care 14:30 “A true, clinically integrated network will be able to drive enterprise-level change with data.” 15:30 The challenges in siloed initiatives like Oncology Care Model and ESRD Treatment Choices Model in driving system change 16:00 Democratization of data with FHIR-based technologies and how that will improve population health analytics 16:45 Success in clinical integration means treating all patients the same (even those that are not attributed to value-based contracts) 19:15 Taking advantage of clinical integration by entering into single-signature commercial agreements 19:45 Stark and Anti-Kickback concerns associated with clinically integrated networks 20:15 The win-win-win advantages of employer and health system partnerships 20:45 Single negotiated rate advantages with clinical integration 22:25 How FFS can co-exist with VBC in reaching critical mass in value 24:20 Bundled payments as a way to engage specialists in value-based care 25:13 Going “all in” in all 48 episodes of care in the BPCI program! 25:45 Data driving outcomes in episodes of care (Quarterly “Q-Cards” for providers) 26:40 MWHA’s Q-U-E (Quality-Utilization-Efficiency) Program to engage specialists on internal cost savings initiatives (e.g. costs for medical devices) 27:40 Certified Advanced Practitioner Program (APPs rounding with surgeons in the hospital to improve continuity of care) 28:10 How the QPP 5% Bonus incentive often excludes specialists by definition of what counts as a Qualifying Participant in an advanced APM 28:50 The impact of population health data on PCP referral patterns to specialists 31:10 The evolution in the design of physician compensation models to create activity-based incentives 38:00 Capital Investment allocation decisions within the population health infrastructure 40:00 Process improvement as the “motor skills” to work with the “brain and spine” of the infrastructure 41:30 Setting up a Medicare Advantage Plan to get closer to the premium dollar 43:40 Challenges in establishing interoperability within a clinically integrated network of independent providers 46:00 Leveraging activity-based incentives for Annual Wellness Visits (AWVs) and Advanced Care Planning (ACP) 49:25 Launch of the Mary Washington Medicare Advantage plan 50:33 Essence Health (Missouri) as an example an example provider-sponsored health plan 50:45 Collaboration with Lumeris on the MA plan 52:00 Establishing network adequacy and benefit plan design in a market with low overall MA market penetration 56:00 Travis discusses the shift toward virtualized, asset-light care delivery models and how hospitals need to adapt 1:00:00 Travis’ Leadership Philosophy: 1) Stay True and Remain Innovative, 2) Stay Hungry and Never Be Satisfied, 3) Build Trust Through Transparency, 4) Build Partnerships

The health care industry is experiencing a digital transformation that has been decades in the making. In this era of COVID-19 disruption and heightened consumer expectations for care delivery, the industry needs trusted leaders like Ed Marx. As one of the leading experts on artificial intelligence, machine learning, and other disruptive technology innovations in healthcare, Ed Marx is the trusted advisor that healthcare organizations seek for advice on successfully navigating this digital transformation journey.   Our guest this week, Edward W. Marx, is Chief Digital Officer for Tech Mahindra Health and Life Sciences. As CDO, he oversees digital strategy and execution for providers, payors, pharma and bio-tech. Ed has had a phenomenal CIO career in leading the development and execution of digital strategies that have positioned his organizations for success and long-term relevance, including Cleveland Clinic, NYC Health & Hospital, Texas Health Resources, and more. Ed is a Fellow of the College of Healthcare Information Management Executives and Healthcare Information and Management Systems Society. He has won numerous awards, including HIMSS/CHIME 2013 CIO of the Year, and has been recognized by CIO and Computer World as one of the “Top 100 Leaders.” Becker’s named Marx as the 2015 “Top Healthcare IT Executive” and the 2016 “17 Most Influential People in Healthcare.” Edward also races for Team USA Duathlon, is an Ironman Triathlete, has climbed some of the tallest mountains in the world, and is a cancer survivor. In this episode, we speak with Ed about his most recent of 5 books, the new 2020 healthcare bestseller “Healthcare Digital Transformation: How Consumerism, Technology and Pandemic are Accelerating the Future.” Join us as we consider consumer-centric, data-driven care delivery — enabled by technology innovation – as a blueprint for the digital transformation that will lead to success in this race to value! Episode Bookmarks: 01:45 Introduction to Ed Marx and his new book “Healthcare Digital Transformation: How Consumerism, Technology and Pandemic are Accelerating the Future” 04:30 Eric’s chance encounter with Ed at SXSW 05:20 “The unexamined life is not worth living.” (Ed’s passion to live life to the fullest) 06:00 Ed’s philosophy to “Risk Boldly and Often” during our short time on Earth 08:10 Experiencing the deaths of two young girls in Saint Petersburg, reflections on his own mortality, and finding inner peace with dying 09:30 Climbing Mount Kilimanjaro and creating a medical clinic in Tanzania 09:55 Fighting cancer and using his inner purpose (with the help of great clinicians) to heal 10:45 “When written in Chinese, the word crisis is composed of two characters — one represents danger, and the other represents opportunity.” 13:00 Ed reflects on the opportunity for healthcare digital transformation in the pandemic crisis 13:40 “We have to completely reengineer and reimagine the financial aspects of healthcare today and move swiftly into value-based care.” 15:20 How the velocity of change and disruption from new entrants and non-traditional players will impact current healthcare providers 17:00 The introduction of retail giants (CVS, Walgreens, Wal-Mart) into the healthcare arena and their “digital first” approach to patient engagement 17:30 The decline of virtual ambulatory care visits from the peak of COVID telehealth deployment and how that retreat is a bad signal for digital transformation 18:30 Payers reaping record profits during the pandemic; how payers will leverage capital reserves to aggregate providers and deliver care directly to patients 19:55 “Care is going to be directed more and more by new entrants (e.g. retail, pay-viders) which means that hospitals roles in their communities will be significantly diminished.” 20:45 The data explosion in healthcare and how there are 40X more bytes of healthcare data than there are stars in the observable universe! 22:30 The glacial pace of healthcare transformation and the need for inspired leadership and key investments in the provider community 24:30 How Cleveland Clinic developed an AI-enhanced capability to detect prostate cancer at a 95% confidence level which transformed care delivery and patient experience 25:45 The Quadruple Aim and Digital Transformation 26:15 The need to move faster in AI/ML capabilities to create scale and impact needed for transformation 27:00 US digital health venture funding on track to set annual records for overall funding, number of deals, and average deal size. 28:15 Data custodians (EHR vendors), enabling platforms (Google, Microsoft, Apple), and arbitragers (Accenture, Deloitte) as leaders in technology transformation 29:30 The importance of healthcare leaders breaking with tradition and forming unique partnerships with tech companies 30:00 Ed’s first role as a CIO and how he forged a partnership with a Cisco to implement VoIP technology to transform communication capabilities 32:30 High profile partnerships (e.g. Ascension-Google, Mayo-Google) as examples of hitting a “home run” to accelerate success 33:40 Partnerships with companies in other industries outside of healthcare 34:30 Healthcare experience being overrated in digital transformation.  Most Chief Digital Officers are coming from companies outside of healthcare (e.g. Starbucks, Disney). 35:40 “Financing of healthcare digital investments should not be considered as a one-time project to fund – like an EHR investment. It should instead be considered as a fixed portion of operating cost that is funded in perpetuity.” 39:12 How having a “digital front door” will be a powerful tool for differentiation in the competitive landscape 40:56 “Don’t allow tradition to get in the way of progress. Your EHR vendor will not save you if you lose patients to new market entrants.  Focus on creating a ‘digital front door’ capability to improve the patient experience.” 42:00 Remote patient monitoring and real-time, automated clinical insights 42:40 Digital-only concierge practices and health systems that can deliver care across state borders 44:10 Tech-enabled, consumer-centricity outcomes (lower costs, improved quality, increased patient retention, expanded market share, and happier physicians) 45:00 The “hospital-at-home” model as a promising approach to deliver acute-level care. 47:15 “Only 5% of hospitals have a digital strategy.” 48:45 Ed cites an example of “heresy” when he tells the C-Suite that they need to get rid of urgent care centers and instead double-down on virtual care 50:50 “You can stand up virtual visits in a week.  You can stand up remote patient monitoring in 72 hours.” 51:35 “Bed-less hospitals” that take care of patients from a centralized unit (e.g. Intermountain, Mercy) 52:09 “No brick and mortar required” for the hospitals of the future 52:30 90% of patient needs can be taken care of in the patient home (e.g. physical therapy) 55:40 Comparison to The Social Dilemma and data collection in healthcare 57:15 Social Determinants of Health (SDOH) data and AI to provide population-based care 59:00 The Cleveland Clinic as an example of how to use data to create incentives that align healthy behaviors to outcomes 1:01 “In the Race to Value, you need to make sure that part of your digital transformation includes excellent analytic capability.” 1:04 The moral and ethical obligations to regulate Data Blocking in healthcare by EHR companies 1:06 Open APIs and FHIR as an initial step to interoperability 1:07 Interoperability and the role of government to create open standards 1:10 The importance of workforce development in healthcare digital transformation 1:11 “Investing in people always pays off with great dividends.” 1:12 Hiring digital natives with absolutely no healthcare experience 1:14 Establishing a mentoring program to create a long-term engaged employee 1:15 Exchanging best practices in leadership and analytics with others inside and outside of the industry