What’s Really Holding Back Value-Based Care? w/ David Snow, Chairman & CEO, Cedar Gate Technologies

Welcome to Healthcare Rounds, where we talk with leaders across the healthcare ecosystem about the trends shaping the future of healthcare delivery. I'm John Marchica, CEO of Darwin Research Group. And today I'm joined by David Snow, Chairman and CEO of Cedar Gate Technologies. Dave's had a remarkable career in healthcare leadership from leading Medco Health Solutions to helping build organizations across the payer and provider landscape, and now focusing on the technology and analytics infrastructure needed to make value-based care work in practice. So today, I'm excited, we're going to talk about where value-based care is actually working, what's holding it back, and how data and the ability to connect information across payers, providers, and employers may be the key to unlocking its full potential. So, Dave, welcome to Healthcare Routes. Thank you, John. Thanks for inviting me. You know, Dave, you've had a unique perspective in healthcare given the different positions that you've held over the years. And I was thinking about this. When you look back to the early days of managed care, say early 1990s, late 80s, versus today's value-based care movement, what feels different to you and what feels like maybe history is repeating itself? Well, I would tell you that back in the 80s, uh, I was involved with value-based care with a company called U.S. Healthcare out of Bluebell, Pennsylvania. And uh we were doing primary care attribution deals. They called them primary care gatekeeper back then. Uh, we were also doing capitated deals. The big difference between back then and today is back then the technology did not support the play, meaning you still had green screen computers. You were still moving data on floppy disks. And uh the name of the game in value-based care is having powerful uh uh data that is turned into valuable insights that allow you to manage risk. And without that data, without that computing power, uh, you're taking risk blindly. You're not you're not able to manage the responsibilities you've taken on. So uh it's kind of refreshing today to revisit value-based care uh because that limiting factor, which is technology, is no longer a problem. Cloud computing, um, massive amounts of data can be crunched very quickly. Uh, and uh it's a different game. If you have the right analytics, uh you can be successful in value-based care regardless of model. And uh I think that's exciting. And we are seeing uh accelerating growth in value-based care. Don't don't make any mistake about that. So you started Cedar Gate or launched that over 10 years ago, right? The 2014-2015 time. I start I uh to be exact, I started in April of 2014 and partnered with my private equity firm to build out the company in August of 2014. That was GTCR out of Chicago. So in my mind, that was right about the time when maybe there was a bit of a cultural shift um in people's thinking about what could be accomplished. I'm wondering if that is that is that coincidental that you made that move at a time when value-based care and sort of the the idea of really getting to better outcomes and reducing costs and all these things around the triple aim is was that a coincidence? Uh no. Uh clearly there was a very strong tailwind developing uh because the federal government was fully uh onboarding. And that means CMMI was coming out with value-based care initiatives, uh, and it was very strongly encouraging delivery systems to participate in these value-based care initiatives uh for Medicare. You know, and so CMMI came out with a primary care attribution model. CMMI came out with a uh bundles, a retrospective bundles model, and they came out with a capitation model. So they're pushing all and they're experimenting all the time. They're modifying these as they learn, uh, and it's a real tailwind. But make, you know, right now the federal government is put out team bundles, and uh they're man, they're mandatory for over 700 hospitals. That's a big step, going from voluntary to mandatory. And it doesn't surprise me. Their goal is to have 100% of Medicare in some form of value-based care by 2030. Uh and they're sure they're doing all the right things to make that happen. So, from your vantage point, thinking about these different models that were launched, you know, as you said, around that time or a little bit before that time, what models are proving to be most durable today? Is it the ACO? Is it capitation? Are they these bundles? Like, in your view, just taking a snapshot today, what's what seems to be working best? I would tell you that primary care attribution models, both upside only and upside, downside risk, work very well for primary care physicians. Um, they have a panel of patients there responsible. Uh, and they're responsible for hitting quality measures and uh hitting certain metrics around medical loss ratio. Uh and with the right kind of information as a primary care physician, you can do an awful lot on the preventive side to prevent the acute onset of a problem. So I would say that works great. I would tell you that for specialists, prospective bundles are the best in my mind, because prospective bundles are an episode of care. All the players are in a single price. They need to work together, they need to understand uh what it is they do that drives great outcomes at good cost, uh, and they they really have to study it. And uh their incentives are to optimize both cost and quality, and you it's easy to measure. So we have a very robust bundles program, uh prospective bundles program at Cedergate Technologies. Uh, and I would also tell you that we have a lot of capitation on our platform. So um we, you know, we have primary care capitation, we have specialty capitation, but I would say the most popular uh is global capitation, where you're literally moving out on the risk paradigm where you're basically taking 85% of premium and you're responsible for outcomes and cost as an insurer would be. That's the closest step you can get before you become an insurer. Sure, sure. Now you mention bundles and perspective with some of these specialists. And I think of like hip and knee replacements, things that like orthopedics, right? But what about chronic disease management? What about an oncology? What about um I'll just I'll draw out GLP1s, which are huge, right? Yeah. So you could absolutely do a bundle with that. You know, the challenge with bundles are that they usually have a defined trigger point start and a defined trigger point end. Chronic disease doesn't have that, but you can absolutely set up a prospective bundle uh which is which is annualized. But I will tell you today, uh, in terms of types of bundles we we promulgate and administer, we're doing cardiovascular bundles, orthopedic bundles, um, neurospine bundles, uh, women's health bundles, both OB and GYN, we're doing transplant bundles, uh, and we have done some oncologic bundles. So uh literally uh you can put into a prospective bundle literally any procedure or any disease state and work out metrics that drive the right behaviors in a patient-centric way. Dave, I've I've got a ton of 30,000-foot questions like like um like the ones I've been asking, but I just want to park those for a second and get into Cedar Gate so that because you you talked about the bundles that you're developing. For folks out there that might want to understand a little bit behind the hood, how does it work? Are you working, are you going to employers? Are you linking employers with insurers? Um, like in practical terms, so that people can understand what your your company now is doing, help us understand that. Yeah, so uh I I would tell you the primary uh catalyzer for prospective bundles is providers. So large groups of physicians who want to uh who know they're high quality, meaning when you when you look at uh both quality and cost, they typically perform to the left of the mean of the bell curve all the time on scientifically valid end. So they know they outperform and they're willing to package it and take the risk because they're that confident. Uh so um our cardiovascular bundles, we we're in the entire, we're doing them across the state of Texas, we're doing them in Tennessee. Um, you know, uh we're and we don't just do one type of bundle, we do a portfolio of bundles around these physicians. We have hospitals who have come to us to develop prospective bundles where they take them directly to the employer. We have a number of those situations. Uh when we work with a group of physicians or a health system that wants to do prospective bundles, they always will need a payer relationship as well. Cedar Gate helps them negotiate that so that they in fact have a payer contract, and we we administer the claims between the payer and the provider uh in order to, you know, so what we do is we get the claims associated with these cases, uh, we package them, we send a single bill to the payer, we collect the payment, we do the downstream distributions to the participants in the bundle, and we manage a risk pool on their behalf. It sounds complicated, but it works incredibly well. So I like your comment on a typical knock-on bundles, which is that they do great at kind of holding the line on costs or being predictable about costs, but nothing about um rampant utilization. What are your thoughts on that? So I I'm a fan of a prospective bundle because uh everything's visible and transparent to all the participants, and it really does uh avoid unnecessary care. Uh it does avoid uh care in the wrong setting, uh, and it does encourage proactive care to avoid the acute onset. I'm not a huge fan of a retrospective bundle. Uh can our analytics help? Absolutely. We're involved with the team bundles program. Uh, I won't be a bit surprised if down the road CMMI goes to a prospective bundle. The reason I'm not a fan of a retrospective bundle is exactly what you just said. Physicians don't really know who their team is in a retrospective bundle. They just know that this total hip is going to be in the bundle, but they all just bill fee for service. And then some magician comes out and says, Oh, you went over the total price. They don't know all the pieces coming in. So they just bill like they always do in fee for service and just pray that they'll get as much or more than what they built. Um, but they don't have a really great handle on why. Uh, you know, because they're not organized as a team, collaborating together and really trying to get at the root cause for uh less than optimal performance. So um, you know, I would always recommend a prospective bundle um just because it aligns the incentives better. So um we're gonna go back to 30,000 feet for a few more questions. So in doing my research and uh before uh this conversation, I noticed um that you do, or a theme that you talk about is connecting data across payers, providers, and employers, right? And that's really what we've been talking about behind the scenes. Why is that still so difficult in 2026? And we talked about technology, but why it still is a challenge, right? Why? What are the problems? Well, because there are so many sources of data that are meaningful in the delivery of healthcare. So Cedar Gate, with all of our clients, we did we do all the work to onboard the various the data from the various places it comes from. But let's think about it. The the four most common pieces of data you have to have is the payer medical claims, the PBM pharmacy claims, the EMR uh uh data uh and eligibility. That's four. Cedar Gate takes over 50 types of data. So we take workers comp, we we take dental, we take vision, you know, we take wearables, we take 401k, believe it or not, because we have a large number of broker consultants who put all their self-insured employers on our platform. And these brokers are advising, they're the trusted advisor to the self-insured employer, and they're using our analytics to give them the insights to for benefit design. You know, so um, you know, it is it's hard work. We Cedar Gate has done a very good job automating all the different uh places data comes from. We know all the formats. We we've uh we've very much automated all the scrub routines you need to do to get the health to take out the typical problems in healthcare data. You know, so think about it. We have a we have large broker consultants, national broker consultants. Every single one of their uh employer customers has a different PBM, a different health plan, you know, different, different other vendors, and we're not only on boarding them when they go live, but we have to refresh that data, either weekly, bi-weekly, monthly, depending on the cadence. So we're we are truly a large-scale data shop uh doing all that hard work so that the analytics actually are meaningful. So when you're talking about scrubbing or keeping getting the data clean and all of that, it makes me think of the role of AI. And believe me, I know we could talk about AI, so hot topic, right, for the last couple of years. But but I'm just thinking about in your world, what are the practical applications of AI and value-based care? And is actually is AI actually solving problems? I would tell you that it is it is uh there are two key areas we focus on when it comes to AI. One is administrative simplification and speed. So, and yes, you're seeing some nice returns there, and uh, but there's a lot of opportunities. So uh you never say you're done. Uh I I think the second very large and powerful opportunity is clinical insight. You know, things like a digital twin, um, you know, where you in fact can better predict a person's outcome based upon the data you have today. Uh and uh, you know, we are we're we we're a very we have multiple types of analytics on our platform. You know, we're an end-to-end value-based care platform with all the types of analytics you need sitting over a single source of truth. And you know, when we when we um our clients use our technology, they for the most part, we've made it so that they they can do run the analytics themselves. It's not like we're a consultant holding their hand. We can show them how to do it, but they're doing it themselves. So we're using AI right now and developing the ability for someone to ask a question in the English language, and it will come up with these beautiful reports and charts and lay it all out for you uh in a way that just makes you even faster uh and shows you exactly, transparently, how we've done the math so that you can get comfortable that the AI is actually correct. Which is the same thing. Yeah, it's a lot, there's a lot of opportunity here. Uh, and I would say, broadly speaking, healthcare is still in the first inning of this of this ball game. So I saw a little gleam in your eye when you're talking about predictive analytics. I mean, is that where the is that where the action is? I mean, really, I hate to put it like that, but yeah, absolutely. Prescriptive and predictive analytics. I mean, even before AI, that that you you could do predictive analytics. I mean, think about it. Uh we have a lot of actuarial math in our analytics, and that's a another way of predicting the future by looking at the data going backwards. Uh and we so we have a ton of that, and we've we've always had that from day one. You know, I'm thinking about the my first question going back to the 90s, and then there's that that time frame 2012 through 2015, 2016, things are starting to heat up. But I just have this sense that we're we're still kind of crawling along with value-based care. I mean, part of what I do, I do a lot of executive interviews at Darwin, qualitative uh research interviews, and I try to figure out what their pain points are. And even still today, I'm hearing the uh, you know, one foot in the canoe, um, one foot, you know, you know, on the shore kind of thing. Like, what are we what are we gonna do? So, what what is taking so long? Or maybe it's just me. I'm I'm uh I'm looking at it differently in the wrong way. It's no, it's a really good question. Um, I I will first tell you that today as of today, technically 60% of all health care is delivered in some form of value-based care. 60%. Now, that includes a fee-for-service model with quality kickers and metrics, right? So um, you know, that to me is value-based care with training wheels, but nevertheless, it is a form of value-based care. Um 40% is in real value-based care today, meaning primary care attribution, bundles, or capitation. So that's not bad. Um, Cedargate has 75 million lives on its platform today, and uh we've been our growth has been accelerating over the last four years. Um so you know, I just see it in the numbers. The pay, the the the here's the big challenge, and here here's I I think what drives your perception. Value-based care is a completely different set of incentives than fee for services. Completely different set. So it really takes a total training of an enterprise, whether it be a group of doctors, a health system, to totally rethink how they deliver care when they're in these value-based care models. And when the value-based care models are not mandatory, when they're voluntary, it's very easy to put your toe in the water and say, uh, this is too hard and walk back to the fee-for-service world. Uh and CMS is seeing that too, obviously, because now they're going to mandatory. So, you know, my best advice to anybody who still hasn't started going through the learning curve, value-based care is a new learning curve. Start going through it now because ultimately there will be mandatory programs across the board. And if you've done nothing to train your organization, uh it's going to be a rough ride when you go into these value-based care programs with no choice. Um, you know, and we've seen remarkable, remarkable uh learnings uh using our our tech stack, using our technology, where um we've seen delivery systems who really didn't know what to do or how to do it become very competent and get bonuses each and every year in primary care attribution models uh as well as in bundles models, where um, you know, they paid attention, they learned the business, and if you ever said, hey, do you want to go back to the old way now, they would say no. Because they're very comfortable with it. They've got the muscle memory now, they know how to do it. It takes forcing a vent. And by the way, one of one of my favorite things to say to people is that when you're on the fee for service side of the world and you want to get to the value based care side of the world, you cross this rickety bridge across a chasm of death. And when you're in the middle of that bridge, 50% fee for service, 50% value based care, you are schizophrenic. Uh, you are just schizophrenic. And that's the critical point where do I keep on going, do I turn around and go back? And we've seen all of that over the years as this evolves. But nevertheless, we are moving in the right direction. More and more people are in some form of value-based care. There is a tailwind and it is encouraging. So it's it's kind of like the way that I've always thought about this, and and I watched it from kind of from the sidelines, not on the provider side, but it is cultural. It is sort of um a mindset shift that people need to need to undergo. So I'm curious, when you're doing these, you know, you've got a big physician group, how do people enter, you know, sort of the conversation of just your typical physician, your typical docs, how do they enter that? And then what is it like when when you get to the end, what happens through that transformation? It always takes leadership. I'm always I I find that uh whenever you have physicians who are pro-moving to value-based care, is because they know it's the right thing to do and they're intellectually curious and they want to do the right thing. Um you just need that leadership. Uh, you know, payers are also using financial incentives to encourage, you know, people to participate in the various uh value-based programs that they they are pushing. So um I I look for leadership first. Someone who says thee for service is the wrong way to go. Uh, and I'm I know I'm going to be left behind if I don't learn this different way of managing care. Um I'm assuming you're saying physician leadership, right? Physician leadership can also be um health system leadership. We've seen some health systems that are very proactive. They know it's the right thing to do. And um obviously uh on the payer side, CMS has been very aggressive. Um, and commercial carriers are saying right now they want at least 50 percent of their total population is in some form of value-based care by 2030. Um, so they're they're pushing harder today than they were when I started the company back in 2014, no question about it. And Medicaid, it would said it would like to see virtually all of their patients in some form of value-based care. You know, uh so you know I I think I think the incentives are there financially. I think the pressure is there from a programmatic point of view. Uh and I uh I can't imagine sitting on the sideline and not starting to train the organizate your organization to manage in this the the incentives of this very different world. It it it's to me that's that's a management mistake. Sure. One of the things I've been also dying to ask you is just given where you've been over the years, I'm sure that you've had some pretty incredible conversations with employers over the years in in your different roles. Yeah. What without saying any any specific person, but what do they tell you privately, you know, kind of behind the scenes about the way that healthcare works, the way this movement of value-based care, and how have you seen their perspectives change? Yeah, that's a great question. So we have about 130,000 employers on our platform. And and uh you know, many of them come come onto our platform from third-party administrators who are using our analytics to advise them. Um, but also the the big broker consulting houses across the country are putting their customers on our platform. And I will tell you that 15 years ago, employers were largely focused on health benefits as a way to attract employees and retain employees. It was a benefit, period. But the rate of inflation inside healthcare is just eaten at the bottom line of most employers so dramatically that they realize there's a lot more to management of that benefit than just employee retention. They need to pay attention to how they're spending their money. They are the fiduciary. They know they're the fiduciary. So, what we're seeing is the employers are getting much more aggressively involved, looking at where they're spending the most money, looking at what programs they might implement for their employees to drive better outcomes at lower cost. And they're using analytics to measure ROI. They weren't doing that 15 years ago. Now they're saying, okay, if I implement this program, let me see the ROI on it after it's been in place. And if it's not, there's no ROI, I'm moving on. This one will stop and I'll do something different. So, you know, what do they do? They look, you know, is type 2 diabetes a problem in my population? Is congestive heart failure a problem? Is CKD a problem? Wherever they're spending their big dollars, they're looking at, okay, what am I doing to make sure my employees have access to the best, you know, the left side of the bell curve, both in terms of cost and quality. Uh so they they they are now demanding that kind of visibility. They weren't asking for that kind of visibility because they said, oh, my payer takes care of this, and they didn't want to get their hands dirty, but they are now. There's no question they are now. It's almost like the the benefit is the table stakes. They know that as a fiduciary, they have to provide the benefit. I mean, I small business, I have to provide it, otherwise, I can't hire people. It's an expectation. But when you get to a certain point, you've got to say, and maybe that comes back to the technology. Maybe in the wellness programs of the 90s, that was kind of feel-good stuff because they didn't have the metrics to be able to track it. And so now today, with better technology and working with groups like yours, they have the ability. So can can you think of an example? And again, not with mentioning any names, but where somebody looked at a diabetes program and said, you know, after a year or two, this is the ROI, positive or negative? Oh, yeah, absolutely. Absolutely. And it's funny, you know, um now uh because the employers are looking at that, I have the companies out there that are selling those kinds of services to employers coming to us and buying our technology so that they can measure their own ROI to make sure they're delivering and make sure they understand what they might do to further deliver, right? They before they were just acting without measuring. It's it's driving them to measure as well, which I think is a healthy thing. I do. Dave, we work with uh a lot of pharma, pharmaceutical companies here. Um just quick little um diversion. I'm just curious about your thoughts of value-based arrangements in pharma. I mentioned GLP ones, which is huge right now. But what are your thoughts on that? Well, I have more thoughts than we have time for, but I let me, you know, both short. The short version, right? Yeah, both from my MedCode days, but I will also tell you that uh in October of last year, Cedar Gate became part of the IQVIA family of companies. So IQVIA purchased us back in October, and most people who know IQVIA know it's very focused on delivering uh better health through clinical research and powerful data. Uh so they're very, from a mission standpoint, they're very much aligned with us. And what we've been having a lot of conversation about is how how incredibly suitable it might be for pharma who are bringing first-line defense drugs to market to be in a prospective bundle. Think about that. They they put skin in the game. Yes, it might be as a as a drug more expensive than that generic from the last generation out there, but if you truly, which you I always heard when I was running Medco, this drug's so much better and it's going to save you money. You'll have fewer hospitalizations, fewer emergency room visits, fewer surgeries, those kinds of things. Well, if that's true and you're willing to take some risk inside a prospective bundle, why why don't you think about that? It would serve two purposes. Number one, um, basically, if you're taking risk and you're taking out the downside for a payer, you're much more likely to be on the formulary. That's number one. That's always kind of one of the most important things to pharma. But number two, with MFN coming down the pike, and that's a whole other discussion. If you're inside this kind of bundle, you don't technically have a unit price for the drug. You're out, you're acting outside of MFN. That's a pretty interesting concept. So working with ICUVIA, I would I think there's a really interesting opportunity here for pharma. So to me, it seems like you're sitting in a really nice place because we've we've been researching this particular topic for a number of years. In fact, just recently, at the end of last year, we finished another um health system study. Yeah, and one of the tactics that we looked at is exactly what we're talking about, these pharmaceutical and value-based arrangements. And very, very um, I wouldn't say popular because there aren't that many of them out there, but a lot of interest, but the common thread is way too complicated. Yeah. You don't have the data, right? I mean, you've heard this. Well, well, when I was running Medco, pharma would come to me and say, hey, we're willing to take risks on this drug. We know it's that good. And in my head, I'm thinking prospective bundles, but I didn't have an ability to administer it. But Cedargate has the ability to administer. We have a custom built and designed claim engine that manages prospective bundles. So you put in the trigger point start, the trigger point end, the inclusions, the exclusions. We can manage this now in a way I never could when I was running Medco. So that's why I'm I always liked the idea, but I'm more excited about it now because we take the complexity on. We do that work. It's it it makes a big difference. So given some of the larger categories, just what comes to mind? What what what kind of prospective bundles would you be thinking of? Is it as as large as you know, obesity, maybe some kind of weight control program? Yeah, weight management. A prospective bundle with the GLP ones would have made all the sense in the world. Um, you know, we're starting to see the prices come down already now because they've been out there a long time, but in those earlier stages, I think, and you had competing GLP ones, that would have made a ton of sense, um, for sure. I think uh, you know, I I'm very much fascinated with pharmacogenomics, meaning there are there are um drugs that are specifically important tied to your unique genetics, and tying uh knowing what your genetics are before you ever dose that person is critical. So putting management, clinical management programs around these drugs and making sure you have the compliance along the way is a really enormous opportunity. And so uh it does pull, these kinds of programs would pull pharma more into clinical roles than just manufacturing roles, but it's to make certain that the drug is used as prescribed to drive best outcome, and you want that when you're taking risk. If you're not taking risk, you don't care as much. Can you see oncology? Can you see this kind of prospective bundle working in oncology? Because you know, you mentioned genomics. Yes. Um what is you know, what is the outcome that you're measuring? Uh would you do something on a bundle on breast cancer or on prostate cancer? Yeah, how would that work? There are some there are some cancers you absolutely can do this with. Um, and my teams run a number of models um uh for oncologic cases. Uh there are some where, you know, so for example, uh I think if you've got brain cancer as an example, or uh, you know, uh something that's just metastasized everywhere, that's just not really bundleable uh in a in a reasonable way. But if but if it's contained uh and it's caught early, it's absolutely something you could bundle. And you'd have to bundle the disciplines, meaning it it what are the what are the defenses here? Is it surgery? Is it drug? What is it? But you can design these things and put them together and create a center of excellence around it. Outstanding. Dave, I have a few more big picture questions before we wrap up. Um the first one is if you had to fix one structural problem, I know healthcare is very complicated, right? But if you had to fix one structural problem in American healthcare to accelerate value-based care, what would that lever be? Well, I mean, I've said it a few times. I I have to say it again. Root cause for uh our spiraling costs in healthcare and our less than optimal quality is fee for service medicine. Fee for service is a foundationally perverse incentive. You see it people acting out on it all the time. In fact, when I got out of graduate school, I ran hospitals. I thought I was gonna run hospitals my entire career. After five years, and by the way, I implemented DRGs when they first came out right out of grad school. So that was that that's a form of value-based care. It's an you know, for hospitals. But um I was so disgusted with how people behaved around the incentives of fee for service, I couldn't stand it. And I joined the HMO movement, you know, very early in my career. That gave me some of the passion I've had for the last 40 years to do something about what's broken in healthcare. So given that, is there a tipping point? Is there a tipping point where you know you mentioned the 6040, right? Where the economics of fee for service, I think we would agree on that it's not working already, but when it really is just not working, and a tipping point where say we're we're moving as a society completely towards value-based care. Yeah, so he he I've always viewed uh us as hitting a heading toward a tipping point where we have to decide between our current privatized version of healthcare or a socialized system, which nobody in this country really wants. Right? So fighting hard to preserve what's good about the private practice of medicine is a noble cause in my mind. That's what this is all about. There's going to be a point where we'll have no choice. We don't want to get there. You know, I uh and that that will be the ultimate choice. So mandatory programs, things that drive the right incentives, not the perverse incentives, are critical. And it's not like we have forever to figure this out. We don't. I think if we don't get to the goals that have been talked about in 2030, people are going to start scratching their heads. Because what's happening is the government takes action. So let's go to MFN with pharma, right? The the number one place we've seen a lot of cross-subsidization for our healthcare systems, both Medicare and Medicaid, is the commercial side. So when there's a shortcoming on the MFN uh for government, like MFN's driving MFN for drugs given to Medicare or Medicaid, is it going to be cross-subsidized by the by the self-insured employer? How much longer do you think that's going to last? These are real issues that we need to get our hands around, and we we really need to be proactive about it. Well, that kind of leads to my final question, and I don't know that there's a great answer for this, but I I want to know your thoughts. Um Who has the power? Who has the most juice to be able to affect change? Is it payers? Is it providers? Is it employers? Is it the government? And I know it's some level of of those, but where do you think that that the biggest push is going to come from? It's definitely the payer. So Medicare is showing the push. They they are able to mandate, um, they are able to uh create these programs and push. Commercial insurers are a little bit further behind. They don't have quite the same mandating authority, um, you know, because you know that they have competitors, right? So you you know, you always have to be careful what the competitor might do uh if you um push too hard. But um, I'd say the number two strongest is the commercial payer. Uh and I would say that the self-insured employer through their TPA, their third-party administrator, or their payer who's processing their claims is a distant third who's just starting to wake up. Dave, do you have time for uh for some lightning round questions? I feel like I've um I've got a few. Just a short answer before we before we wrap up. Is that okay? Yeah, hit me. It can be fun. Um one healthcare innovation that people are underestimating right now. Ah, I think I think this whole uh science, uh uh genetic science and genomics is going to make major contributions to quality of life, uh, and they're gonna solve some problems that up till now we've been unable to solve. And I'm hoping that includes oncologic uh discoveries. But uh this the the on uh you know the use of the human human genome, the whole human genome, to better understand you know the genes that create the diseases that are so devastating. And can we tailor those genes? That's that's just fascinating to me. And there have been some early wins. It's it's encouraging. Yeah, yeah. I would have probably said the same thing. Yeah. Um the most misunderstood concept in value-based care. I think the most misunderstood concept is that value-based care is all about saving money, period. End of story. It's not. It's it's uh it's really moving to a patient-centric model where you want to keep that person well enough that they don't need to be hospitalized, that they don't need the emergency. You want to be proactive and paying attention to them, making sure they're compliant with their med routine, because you know they're vulnerable. You know, uh, in fee for service, you're actually getting rewarded for doing things you don't need to do. You're actually getting rewarded to give sick care, not well care. Uh, and you get you are really being incented in value-based care to drive better outcomes, both clinically and financially. And it is a patient-centric set of models. So it's a good guy, it's not a bad guy. That's where I'm that's where I'm going with this. Yeah, and I'm I'm sorry to interrupt the lightning round, because I just have to ask. Don't you think then that payers, really, the insurers, would be all over value-based care, right? I mean, if they are. Because if you get to keep more of the of the premium dollar. Yes, we are we have a large number of payers on our platform. And you might say, why does why does a payer need Cedar Gate? Well, payers historically haven't had to take their big data and lever it for insights that the delivery systems can use, right? They use it for their own underwriting to file for the insurance commissioner and all those neat things. They didn't have a mechanism to share information and partner and collaborate with the delivery system. That's what Cedar Gate has built. We take this data and we render it so that it's useful to the payer, but it's also highly insightful and useful to the provider who's sharing risk with that payer. And another big challenge that this kind of technology helps uh eliminate is the trust factor. Payers and providers don't trust each other, generally speaking. So having a model that's transparent and gives delivery systems what they need to modify outcomes in a positive way is nothing but good. Uh, and so payers are hiring Cedar Gate to use our technology to collaborate with providers. And it's it it really does work. We see just dramatic improvements in relationships and clinical and financial outcomes. Last last uh lightning round. One change that CMS could make tomorrow that might accelerate value-based care. Uh one word. All the programs they've already built, make them mandatory. Mandatory is the key word. Mandatory is the key word. None of this, none of this volunteer stuff. Got it. Well, Dave, this but this has been great. Um I I hope you can come back. I feel like um I've got pages of questions. We got through uh a lot of them, but this has been really, really interesting on a topic that I know a lot of people are interested in. Um I really appreciate your perspective um given given your background and everything. So thanks again. I really appreciate it. Thank you. Thank you, John. And the questions were great. I enjoyed it. And thanks for joining us today on Healthcare Rounds. And thank you for listening. If you enjoyed this conversation, please make sure to forward it on to folks that you know or or subscribe wherever you get your podcast. And so until next time, see you next round.