What’s Holding Back Value-Based Care? w/ Don Calcagno, Founder, ValuesEdge

Welcome to Healthcare Rounds, the podcast where we talk with healthcare executives, operators, and investors about the business policy and technology forces shaping the industry. If you're working in healthcare and you want unfiltered conversations like this each week, please follow the show on Spotify or Apple Podcasts so you don't miss upcoming episodes. I'm John Marchika, CEO of Darwin Research Group, and today's episode kicks off a new healthcare round series focused on value-based care, a topic we've spoken a lot about here, but really focused on where it's succeeding, where it's failing, and where we expect the next decade of healthcare transformation to come from. And so today, my guest is Don Calcegno, former Chief Population Health Officer at Advocate Healthcare and now founder at Values Edge, an AI-driven platform and much, much more, which we'll get into. Don has spent years operating inside one of the country's most sophisticated healthcare systems while also thinking deeply about how policy incentives and operational realities actually intersect. And now he's trying to solve a different problem how healthcare leaders keep up with the speed and complexity of the value-based care ecosystem itself. So without further ado, Don, welcome to Healthcare Rounds. Thanks for having me, Don. Looking forward to the conversation. Yeah, me too. So start with um, I don't know if this is the easiest or the or the hardest question, but uh look, you've had a front row seat for a long time to value-based care from both the operator side and now kind of on the consulting and information intelligence side. But if you were to zoom out, where do you think we actually are today on the value-based care journey in healthcare? Uh believe it or not, despite well-intentions, I think we're in the early innings. Let's call it inning one, inning two. Um I do believe that health care as it exists today in the United States is not sustainable. So it is going to change. I do not think if you flash forward 10 years though, the value-based care models that we have today are going to be the ones that continue. I just think there's too many problems. So it's been a good start, but it's not going to be sufficient to get us to where we need sustainable high-quality health care. Well, that's both a surprising and refreshing answer, right? I mean, if you're saying we're we're at the the start of the ball game here after we've been at it for what, I don't know, at least 15 years in one form or another, maybe 20, right? Yep. Um So I I guess given that, you're with all of your inner interactions with executives, I would bet a lot of them would would probably agree with you. But where do you find sort of a level of misunderstanding about value-based care? Because it's just this buzzword, it's almost becoming useless. It's used so much. But where do you where do you find that maybe your vision into things with your experience is a little different than a lot of the executives you run into? Yeah, no, it's a great question. Um, quite candidly, I hate the term value-based care. Um, it it implies that value doesn't exist or has not existed. And I'll give you a perfect example. I had ankle surgery in February. It was not, from all I can tell, in a value-based contract. Um, the doctor fixed the problem I had with my ankle. That's value to me. So one of the problems with value-based care is if you're a clinician, which I am not, clinicians like, you're saying I'm not creating value. Well, yeah, if you're managing someone's hypertension or uh diabetes, et cetera, you're creating value. So this label we've stuck on at value-based care is just it's kind of a misnomer and it's become this catch-all. Uh, if you throw on pop health, population health instead, uh, in the middle of COVID, everyone's like, oh, population health. That's like what the people are doing. No, that's not pop health either. So I think we've we've done a big disservice by calling it value-based care. And what I talk about a lot is if you think about any organization you're running, I don't care if it's a healthcare provider, if it's a payer, if it's a manufacturing plant, any company has three things. They have a governance model, an operating model, and a business model. The governance model is strategy setting, operating model is what you do, and business model is how you get paid. The problem in healthcare is the malalignment between operating model and business model. Right? The operating model is put together to really do widgets. The more I do, the more I get paid. And the business model is paying folks for that, but that isn't what the purchasers of healthcare want, right? They want they want to detect cancer at stage one, not stage three. They want to control somebody's diabetes, somebody's hypertension. Um, they don't want to spend time going to the emergency room. So there's just this disconnect. And that's one of the things I think we've labeled that disconnect value-based care. We're going to change incentives, etc. So I think that's really the root of the problem is we need to think differently about what is value-based care. You hear people talk about a foot and two canoes. Drives me crazy. Drives me absolutely insane. And the implication, right, is if you put a foot in one, then you put a foot in the other, the two canoes slip out, and you land up face first in the water. I vehemently disagree that if you're smart enough to run a hospital, because they're complex places, you're smart enough to run a sophisticated medical group, um, you can certainly run two lines of business. Um, and you know, some of the pushback I'll get is oh, but you need density for value-based care. And I don't disagree. Like if I'm a doctor with a 2,000 patient panel, if I only have 10% of people that I have to treat this way and 20% that way, and 30% this way, yeah, that would be a problem. You do need density. But the problem is the foundation of value-based care is chronic disease management. And if I'm a clinician, I'm managing that hypertension, that diabetes, that CKD, I'm managing that regardless of what contract you're in. Right? So, so at the basis of what the root of value-based care is, you're doing that in fee for service and in value-based care. So to think that you can't do both is just uh insane. And I always tell people the problem is we don't set expectations, we don't give people tools, and then we don't hold them accountable. That's really the problem with the two canoes. Well, it's interesting that you I've heard that two canoe problem. I've also heard the one canoe problem, which is the one foot on the shore, one foot in the canoe. And we're stuck in the fee for service world because that's how we get paid. And you want us to go, you know, across the lake in this canoe, and I'm not sure exactly where to go, which is, I mean, it's a it's a similar issue, but it's a little it's one that I run into most commonly, which is if I'm interviewing somebody, let's say for a research interview, and they say, you know, we want to go in this direction, but Medicare has us all set up in this other way, which kind of goes back to your business model point. So how do you maybe this is where we're gonna go, or more of an advanced question, but how do you align those incentives appropriately such that? You know, and and me, and I'm gonna actually I'm gonna leave it there. How do you align those incentives appropriately? Because I have a follow-up to that, Don. Um if you uh entertain me for a moment, um, let me even back up a little bit. Um the word incentive, right? Um, one of the challenges I used to have. So I I had 17 networks, uh, over 20,000 doctors, ACOs, CINs, joint ventures, etc. So lots of different um structures, if you will. Um, and you know, some of my colleagues, um, not in value-based care of pop health, would say, Oh, why don't you just incent the primary care doctor more? And I'm thinking to myself, okay, my primary care doctor is working 12 to 15 hours a day. He's on a he or she's on a treadmill. Um, incentives aren't sufficient at some point if somebody doesn't have time. Right? Um, it's the old adage of it's it the clinicians aren't bad clinicians, they're in a bad system, right? And and so so to me, it's it's incentives, probably the wrong word. It's more how do you tighten alignment? And the way I think about it is, and you may have heard me talk about this before. The way I think about healthcare is hey, Michael Porter came up with this concept of value chain. So at the at the macro level, what is the healthcare value chain? And I like to think about it in very simplistic terms. So I'm gonna leave out a lot of detail, but if you think at the very macro level, a payer creates a product, they then go and get networks, so provider networks to provide services for that product. You then have distributors, think benefit consultants, brokers who sell that product to purchasers, typically employers, but it could be individuals. And then if I'm an employee, I get my healthcare through the employer, right? Um, if you go through that whole chain, the problem that you really have is it appears that the macro level as a system, but the reality is each chain, each link in that chain is optimizing themselves. So if you read Edward Deming, theory of constraints, right? It's it's if you if you want to optimize the system, you have to suboptimize the subsystems. But we're doing the opposite. We're each optimizing ourselves. And it's like nobody's right, nobody's wrong. We're just optimizing ourselves as you would expect. And so the system thereby is um is uh suboptimized. So going back to your original question on incentives, to me, what starts the whole cascade here is that that gap between the payer and the network. Like, how do you close that gap? Incentives are one way, um, structures are different ways. Like you you can't do that. Let me let me let me interrupt you there for a second. Help me understand that gap even even more. Go if you could go a little bit more in detail. I mean, I'm following you what you're saying, but what exactly is at the root of that gap between the payer and the provider? Yeah, well, so think about what a payer does, right? They they charge an employer, let's just say, uh, a premium and the employees a premium. And so they're bringing in money. And if they pay out less money than they bring in, they make a profit. So their optimal position is to bring in as much money as they can, but then to pay out as least as they can. Because, right, that's an expense to them. Well, what's the flip side of that? The network, just say a medical group, a physician in a medical group. That expense to the payer is revenue to them, right? And they're on the opposite side of that. They want as much of revenue as possible, right? So the gap is neither one of them are wrong. I'm gonna be super clear. Like, this is a system problem. This is not judging payers versus providers, etc. It's it's just a part of the problem that what optimizes the payer is paying less, what optimizes the provider is receiving more. So that gap is they're not on the same page. So, how do you close that gap? Again, you could do it with a capitation contract, so you're passing risk on, you could do it as a joint venture, you could do it by vertically integrating. You know, you got uh United Health Group that owns uh Optimum, you have Humano with Centerwell, you have a bunch of IDNs that have PSPs, uh provider-sponsored plans, right? And so there's ways to close that gap, but I think until you get everybody on the same page where it's not it's not just an incentive, because the incentive has to be high enough to overcome activation energy or or inertia. Um, if you're on the same page where you are both living or dying by the net income, you're gonna be much more closely aligned. And so I normally would say vertical integration is not something I'm a fan of, but I don't see any other way that you can close that gap. And and to be super clear, I'm not saying all the payers should be buying providers, and I'm not saying all the providers should be standing up pairs. There's other structures that you can do to close that gap, but you have to be on the same page. Um, when I was at advocate, we had a joint venture with a health plan for MA, and it was the best health plan we had because we were doing the bid together. We're doing benefit design together. Like we were living together. That is always going to be better than trying to incent somebody. But those doctors in the advocate model, they were, if I'm not mistaken, they were employees, right? No, no, not necessarily. So of my 17 networks, uh, three of them were clinically integrated networks. So the largest, um, the one that I started with, I was president of advocate physician partners, APP. Um, APP is one of the most sophisticated um CINs in the country. And our physicians, when I left, we had about 4,500, um just shy of 2,000 employed. So, you know, roughly 2,500 aligned, we'd say. So we always talk about independent doctors, which are doctors on your medical staff of your hospital, aligned doctors that are inside some type of alignment model, a CIN, an ACO, et cetera, and then your employed doctors. So, yeah, most of them, actually, half of them were basically aligned. And in our other CINs, we actually had more aligned than employed. So we had a smattering of all flavors, if you will. So this kind of goes back to what you were saying about different flavors of vertical integration, if you will, right? Because oh, we've we've had Robert Pearl on the show a couple of times, and he's pretty adamant, like the Kaiser model, you know, five Kaisers across the country or whatever. I'm paraphrasing, of course, but um, is really where we're gonna need to end up, which is that own physician model. And I will tell you in our own um, we'll call it a Darwin model, we've got to call it a value index, one of the variables that we look at is the percentage of physicians that are employed. And I can tell you that, I mean, I've done research interviews like this where somebody exactly like yourself in your old role would say, you know what? Some of our most innovative doctors are not employed, and they they respond to being part of a CIN or an ACO, exactly what you said, right? They can they know how to respond to that. Um and so I guess what I'm saying is, and I'm I'm agreeing with you, that there's more than one way to skin a cat here. Um, but there are those that say there is kind of only one way, and that is the the owned physician, totally completely vertically integrated payer provider. Um, yeah, and and and on the owned or um aligned independent, um, quite honestly, the way I think about it is there's pros and cons to both. If you're an employed physician, you probably have a better um work-life balance. You probably have access to better infrastructure, be it the EMR, be it you're buying all your supplies through a huge IDNs GPO. Like there's lots of pros. Um on the flip side, the the negative is you're another employee, right? And some physicians like that, some are frustrated on it. But I forget years ago I read somewhere that the largest entrepreneur group in the country were physicians. I gotta believe that's not true anymore. Um but you know, I do think there's something to be said about an independent physician remaining independent if that's what they desire. Again, some love employment and that's what they should do. But others that want to own their own shingle, I think they can do things as well. The problem is, particularly if you look at all these CMMI models or all even these payer models, they're super complicated. If they don't have somebody like my old team dissecting it and telling them what they have to do to succeed, it's it's really hard to be independent anymore. Um, and I do think there is value in having some of those independent doctors who are able to be more agile, more innovative, and do more things. I like to think about it, even though, as I said, in our our Darwin value index, we have that that employed physician um percentage in there. I I like to think it's almost like diversity in the workforce, that you get different ideas from people who are coming at it from different ways. And as long as the goals are the same and everybody can agree on the goals, and I 100% agree with you on the kind of like lifestyle choices. In fact, um I've had conversations on the show about what is the doctor coming out of medical school today? How are they different? And are they any less entrepreneurial or more entrepreneurial? And part of it is you know the debt levels. And if some of these health systems are saying, you know, we'll help pay off you know hundreds of thousands of dollars in debt if you're you know work with us for X period of time, that sounds good to a lot of people, right? Um so how much thinking about the the the back to the model again, another I guess it would say criticism is with these models, a lot of it is about moving around risk, but is it really providing better care? Are you really getting better outcomes, or are we just talking financial models? Yeah, I I I think one of the reasons I say we're in the early innings, and I've talked to a lot of physicians outside of advocate, uh, one of my conferences and things about this. Um, a lot of value-based care today is the business model, the payment model. It's it's less about the clinical care. Um I'm an optimist at heart. One of the things I'm optimistic about, though, is um, particularly with some of the changes to risk adjustment coding and things like that, um, we're getting into real management um now, uh, then probably some of the early days, you could win by just making sure you're risk coding correctly. And I do think though, if you look, and I use advocate as an example, um when you looked at my aligned physician, so my independent docs and my CIN, and looked at their heat as scores on things that are objectively important, you know, again, hypertension, CKD, diabetes management, all that stuff, um, they overperformed the market. And I think the reason they did that was because of our clinically integrated network structure, which was really built on a value-based care chassis, right? CINs were were ACOs before ACOs were a thing. CINs were were value-based care before value-based care was a thing. And so I do think we do see it show up in chronic disease management. Um, I think what dirties the water a lot is this whole raft coding thing. And there's no right answer, right? Because there's no doubt a polychronic patient is more complicated, requires more time, is harder to manage than a healthy person of the same age, right? So the risk risk adjustment is important. I think, as in a lot of things, when you tie incentives to it, it's pinched on swung probably a little too far. So, you know, one of the things I'm optimistic about, and it may not happen in my lifetime, but think about ambient listening, where they're putting AI in physician offices and it's documenting everything that goes on. Wouldn't be far-fetched to imagine a scenario where risk adjustment, I mean CMS could create their own model and make it open source so we can see how it does it, but it wouldn't be out of the um uh crazy idea to think that ambient listening actually says, oh yes, you know, Dr. John covered diabetes, covered like you don't have to code it. It can actually tell you what you managed, um, and you'll know how sick that patient is, right? So let's take the game out of it, because risk adjustment is important because people are not all equally acute. Um, but we got to get out of the gaming of it. It's gonna be important. And then even regulations don't help, right? Just like statutorily, um the uh the risk normalization factor is like almost 5%. So if you do nothing, you lose 5%. So in a perverse way, our regulations is consenting us to the code, right? So we've got to get out of that conundrum, uh, absolutely. But I do think we've started to make progress on the things that are easier. Um I have a good friend, uh Dr. Ken Cohen, who's actually at Optimum. He's a chief medical, he's an interim chief medical officer right now, but he's been running a translation lab where he's been looking at specialists and procedural work, and he's published in JAMA, so you you can find them all over. And they're building in like, are these types of procedures low-value care? Like, or are there is there evidence to support them? So that's real utilization, right? That's gonna make a material impact if you stop doing procedures that are on the big picture, low value care. So I do think with risk kind of being tempered, risk adjustment being tempered, you are going to see more people focus on outcomes, much like CMMI is. You're gonna see people more focused on low value care and utilization. So I think that's That's going to drive us quite a bit. And that's where I think things look a little more persnickety, right? Because right now, if I'm a health system hospital and I'm like, oh wow, you're taking patients out of beds. Well, most value-based care today doesn't take patients out of beds. And the ones that they do take out of beds are medical emissions. And most hospitals lose money on medical admissions. So there's no reason anyone should be upset about that. It's better for the patient, better for the hospital, et cetera. But as we get into low-value procedures, I think things change a little bit. So I do want to. Oh, sorry, I was going to go back to your comment on the risk pool, but guys. So, real quick on risk pools. I am a big fan of capitation. I believe you need to have a provider and a pair that trust each other because how you set the cap rate matters. But that that pool that you get when you're managing that that cap rate, you know, there's a misnomer that, oh, you have to have 5,000 patients or 10,000 patients or 20,000 patients. That's all a misnomer, and I'm no actuary, nor do I say a holiday in express. But at the end of the day, if you just think about it, a risk pool is multidimensional. Knowing the size, the N is one part, sure. But knowing the variation, like how long have I had had these patients and the churn? Do they turn over 20% a year? Like there's so many other, what's my MLR running for the last five years? There's all these other things. And when we would look at bearing risk, yeah, N mattered, but there's so many other pieces you have to look at. And I think people are a little too quick to simplify that. Um, but I do think to your point, sharing that risk does close that gap between payer and provider. So that that is part of that solution, but it's it's not it's not perfect because there's games you can play if you don't know what you're doing on either side. Well, I had a couple of follow-ups. Um, one is I wanted you to talk just a little bit about when you when you say low-value procedures, because that's not really value-based care in the way that we talk about it. To me, that's a it's a narrow definition, or maybe it's um overutilization of services or misutilization of services, things like that. So we talk a little bit about that. And then my second, which is completely in a different area, I just wanted to know if you were aware of in ambient listening kind of models, AI models, have they gone beyond charts? Have they gone to the to the place where what you're talking about is you know, really assessing what happened in that room and and maybe even assessing that patient. And so I'll leave it at that. Those two questions. Yeah, um, so let's talk about low value care. That's kind of like the holy grail, right? So I think if if if you just parachuted into value-based care without any backdrop and didn't realize it was more about um payment models than some of the other stuff right now, one of the things you would immediately gravitate to is, well, let's stop doing care that doesn't actually create value. So then your issue is how do you know what's not value-based, what's low value care? And so there's been a lot of analyses that you can look at in a lot of different ways, and in many ways, it's in the eye of the beholder, right? Um there's a uh health affairs article, I think, in 2017, and this is one I always refer to. So if you think about a lot of health, uh a lot of CIN's risk-bearing entities focus on things like high cost imaging, right? Because MRIs are expensive, CTs are expensive, and so most have some type of prior authors or some other medical necessity algorithm to say should you be doing that or not. Um, but when you look at the health affairs analysis, they find that high volume, so think like CBCs, blood draws, low cost make up something like 90% of the cost versus high cost, low volume MRI CTs. And so you may actually be better served focusing on doing cheap things that you do a lot of versus putting all your eggs in the basket of MRIs or CTs. Um, so anyhow, the reason I say that is low, low-value care is kind of, you know it when you see it kind of thing in some ways. So, how do you how do you really drill down on what it is? When you move specifically into procedures, that's where it's gotta be evidence space, right? Administrators like myself can't make that call. It's gotta be a clinician or group of clinicians that have to agree, you know what, we agree this does not produce value. This is low value. Um, and that is some of the um, I think that's some of the sticky wicket stuff, if you will, because even some of the articles I mentioned, Dr. Cohen wrote, there's not everyone that agrees with it, even though the evidence looks pretty darn compelling. So I think the problem you get into is you know, is a um say I'm not a clinician, so I'll screw this up, but something like a spine stimulator, is that valuable? I have no idea, but really smart physicians somewhere do. And you can also look at the data, and the data say when this was done, did it improve care or quality of life or whatever. The second problem of low-value care definition is valued sometimes in the eye of the beholder. Like I mentioned, I had ankle surgery, I found that incredibly valuable to me. Um, but if a um if you have a let's say a knee procedure, and let's say the insurance company says this isn't necessary, but now suddenly you can go run again like you weren't able to do, or able to bend down and play with your grandkids, right? There's value to you. Um and so that patient reported outcomes concept is growing. CMMI just put some stuff behind it. So I think what's important, what's value is so nebulous in many ways. Um, but you look at some of the literature, we look at things like 30-day readmissions. Nobody wants to be readmitted, no one wants their loved ones readmitted. But if you tell me I'm gonna be readmitted, but then I'll be able to go running and do all these other things, that's probably what I'm focused on, right? So anyhow, it it I think low value care is you know it when you see it to some extent. I think we have to get really, really good at being able to define is this procedure creating high value? Is it for a suit, certain cohort of patients? Is it a certain um um kind of uh problem it's trying to solve? So I think we need more energy spent on what is low-value care. I think some things are kind of obvious. Like if you've if you've had um three CTs a year for five years, you probably didn't need all three. But if it's a certain procedure, we need some really good clinical experts to kind of evaluate that. Well, uh being a tennis player and having various surgeries and ailments over the years for as a patient is always very frustrating. Some doctors, not all. It goes back to the the imaging where okay, you you just did an x-ray, we know it's wrong, and we know we're gonna do a procedure. Why do I have to go for an MRI? It's almost like there's that additional, you always have to go for an MRI, always have to that next step. And I'm thinking, you know, really? You know, that that to me, it it feels wasteful. And if something feels wasteful, it's kind of like you know it when you see it, right? It it just Well, yeah. And I'll give you another example. I I I I have a cervical C5, C6 thing, and you know, every so often I need to get imaging just to see if I need to do something about it. And uh I go to a doctor's office where he spends literally 30 seconds with me to order the imaging. Well, why couldn't you do that before I came? Like if we all agree it's medically necessary, it costs me co-pays, it costs the insurance company, and again, it's revenue to the doctor, but does the doctor want to spend 30 seconds with the patient? Probably not. So there's just systematic things that we've got to get better at. They're marginal, they're not gonna bend the cost curve massively, but the frictions that that cause added expense and don't add much value at all. Well, I think you've really I want to I want to put a pin in this for future conversations as well. I think you've really nailed it when you say value-based care it's kind of taken on this thing around financial models or risk-based, you know, two-sided risk, one-sided risk, ACOs, things like that, that, right? But really, I think most people could understand it better, even people within healthcare, if it's like we want to really eliminate those things that we do out of habit, or we do because we're afraid we're gonna get sued or whatever. But they just don't generate a lot of value. Why couldn't you do that before I came in here, Doc? You know, and do we really need this other this other MRI? So anyway, thank you for that. Um back to the second question. Are you aware? And this, and we don't have to get into the AI and all this stuff, save that for another conversation. But are you aware of advancements in that kind of ambient listening that have taken it really to another level? I haven't seen it myself. It could be out there. Um, in my strategic advising roles, I am advising a couple startups that you are using AI for a lot of things. Um, this one in particular isn't one of the things, but I think it's only a matter of time because a lot of what the AI is focused on, be it um prescriptive um or predictive analytics. But what what I used to say when I was an advocate, we had 2.4 million value-based lives. And you know, I had um I had well, I was able to touch 1% of them with human being care managers, right? So that's 50,000. So what am I going to do with the other 2.35 million, right? And so the the problem I was always trying to solve for, and I worked with lots of different companies that try to do this, including Oracle and Soringer and others, is I want you to list my 2.4 million patients in order of impactability. So I call that the next best patient. And then I want you to predict or prescribe what the next best step is. So next best patient, next best best action is what we refer to it as. And I think that that's that's where AI has a ton of promise because we've all seen the risk models. Hey, it's high risk, rising risk, blah, blah, blah. Those are labels that are just too blunt. That's like a butter knife. Um, because I don't know, like in somebody's life that's living in this zip code with these SDOH issues, with these polychronic things, like, can I detect a signal somehow that says I need that person to talk to a person today, or even have the AI intervene directly. Like, we I think that's the promise of AI. I used to tell my primary care docs that um primary care in many ways is an AI problem. And some people get upset by that, but if you unpack what I'm saying is let's say you have a polychronic patient, let's say he visits you, the physician, five times a year. So that means 360 days a year, he's not visiting you. Right? So that's like 98.5%, almost 99% of the time. What happens between those visits? That's an AI problem, right? You can have a chat bot, you can ask about symptoms, you can ask if you took your blood pressure, did you take your um did you take your meds? You can ask so many things that you can't ask today. There's no model that's A gonna pay you, nor can you um do it with humans. There's just too many of them. So I so I do think it's it's what happens between physician offices where the promise in the future with AI is. Um one more question on advocate. You kind of touched on this with advocate um physician partners and mentioning the the advanced nature of the CIN and talked a little bit about technology as well. How much of that do you believe is cultural? In other words, you know, going back 10, say 10 years, people were still kind of understanding the value-based world and where we were going, right? But but what you were able to put in place and manage, and how much of that was, okay, now you've got to establish this culture? And this is kind of ground well-tread ground, I guess we could say, and talking about that. But I want to know specifically in your experience, how much of it was that? And if it was a substantial amount, what you had to do to bring people along to have it part of sort of the you know, the the advocate ether, if you will. Yeah, uh, it is a great question. Um culture matters a lot. And in uh in retrospect, I can say um the really tough times we had reinforced that culture throughout the organization. You know, I think when you've been around as long as APP, there's obviously some very uh scary moments in time about you know the existence of the organization, what you could do because of a bad payer contract or bad risk or whatever. And so we've had issues, we've had times when our board made decisions. And remember, our board is 50-50 physicians and health system. The board made decisions that were in the best interest of the CIN, not necessarily the best interest of the physician, not necessarily the best interest of the health system. So there they had to act fiduciarily and make hard decisions. And every rep of making those hard decisions reinforced the culture of the organization. And so those near-death experiences actually are quite valuable to really reinstill who you are. And so the value APP has today is a super mature board, has gone through enough reps of really painful decisions that they've seen when they stick together to make the right calls, they can do it. And so that doesn't mean the the physician members are always on board, right? So there's been some hard conversations after boards made decisions with individual physicians. And you know, fortunately, there's such a track record that physicians are willing to give the board the benefit of the doubt. Um, but any CIN or ACO or any other organization, right? It's it's a volunteer organization. Like you can leave, like you can go somewhere else. And and and and so to to me, it's when your physicians don't leave and you have a constant influx of people coming in, it shows you you're doing the right things, um, if you will. But culture is really important because when that patient shows up at that physician office, what's gonna happen? Like, what are they doing to manage the diabetes? What are they doing to prevent ER visits? And and when you have a sophisticated organization, the value you get is team-based care as well. Like we now, way, way, way back, one of my early jobs as a research assistant in the pharmacy at Lutheran General Hospital in Parkbridge, Illinois, um, we were running an anticoagulation clinic. This is um 93-94. And we were trying to figure out can an anti-coagulation clinic manage INRs for warfarin patients better than a primary care doc. Um, at that time, docs were up in arms about that. Well, our evidence was incredibly clear. The clinic did a much better job. Um, flash forward to today, we have pharmacists that are managing metformin off of a protocol, they're managing warfarin. Like I did an article once where I called um pharmacists were like the secret sauce of so many things is farm Ds are clinical, they know stuff, they get their physician extender that's amazing. And so I think to help build that culture, you need to give your physicians this support team where they know their diabetic on metformin is going to be titated correctly. They know that their warfarin patient is gonna have the right INR. Like they need a support system around them that makes it easier for them to do the right thing. And that further reinforces the culture. But you know, APP and any other CIN out there, like there's physicians that don't fit. Um, CIN's ACOs that ask physicians to leave all the time. Um, it it's it's it is culture's a super important piece and it takes reps. But for those that don't feel you have that culture yet, one thing I'd call it is you got to start somewhere, right? And in my experience, I can't think of a single physician but doesn't want to do the right thing, right? They they want a better practicing model. And so they may be skeptical because they've lived through a lot of uh half-baked promises, but you begin earning the right to serve them, and they're gonna come along really fast because they're gonna see their patients are better for it, their lives are better for it. We're way past the check the box quality initiatives that weren't real quality. So I was gonna ask, um, at the risk of oversimplifying, is is the cultural glue patient centricity? And then after what you just said, I'm wondering, is the cultural glue a sense of doing the right thing always? I mean, and maybe that is even more overly simplistic, but but just wondering, you know, what is it that binds that helps you get through those hurdles, that helps you get through those? Because it's a leadership challenge, right? Yeah, it's it's culture is always a leadership challenge. And one of the things I used to tell my teens is um culture's gonna happen, right? And culture is a product of how you make decisions and how you behave. And culture is gonna happen. And you while you can't declare culture, you can't say, this is what our culture is gonna be. Um, you can certainly shape it. So you have a choice as a leader. Am I going to let it randomly shape itself, or am I going to put some touchstones in place to keep tacking back to center to where we want the culture to be? And so I agree with you, it's a leadership challenge. And I think what successful CINs and ACOs do is they put structures in place to keep tacking back to the ideal um culture. And um, to your point, in healthcare, it has to be about the patient. Um, I I believe two things. It's got to be about the patient. Like, if you created a CIN or ACO that's about making money exclusively, um you're in a really hard time enrolling clinicians. Like, sure, everybody wants to make more money, but it's about the patient. And so you gotta be patient-centered. Um, the second thing is it's really hard to be a nurse and a doctor, right? And so I think the other point that is really important is this is a clinician-friendly environment. This is where we're going to do everything we can to make it easier for you to do the right thing. And I want to be super clear, um, that doesn't mean you know the customer's always right. This doesn't mean like if a physician wants to do something that's not in the right interest of the patient or strategic decision. No, that doesn't work. But as we make strategic decisions, we take into consideration how do we do this with our physicians. So, you know, right now in value-based care, there are so many point solutions. You, as a CIN or ACO leader, can go sign up a thousand different vendors. And so many of them miss the point of keeping the primary care doctor informed. Like, like if I'm gonna make a physician-centric organization, that means if I'm doing things on behalf of the doctor, or even not on behalf, but when that primary care refers to the specialist, that information needs to come back. That that physician feels the duty to manage those patients. And so so it's just, I'm gonna call it little things, but it's a million little things that kind of get you there. Right, right. So, um, Don, a couple of more things before before we wrap it up. I started this off by saying we're doing this new series on value-based care. And by the way, I don't like the term either, so we're we're in agreement on that regarding the and kind of where we are and where we're going. And you said we're maybe in the first or second inning. And as I said, I think that's refreshing to be thinking of it not negatively, but very positively, all the things that are going to be coming. So if you were to be advising chief population health officers, heads of physician groups, large systems, smaller systems, what would you be looking for this year and next year as sort of, you know, either trends or indicators, things that are saying, all right, maybe we're moving to that third inning. We're going in the right direction. What are the and they could be policy things or they could be could be technology. What is it that you see that that we should be looking for as we look forward? Yeah, I think there's a couple things. Um, one of the things that was unique at Advocate was um we we had what we call the Valley Based Care Council, which was uh I was fortunate to have great uh C suite support. The COO of the organization and the um chief medical officer organization. Basically with executive sponsors. Um I I uh I kind of organized it, but the report out on value-based care stuff was done by operations. It was not done by Pop Health. And and that I firmly believe I've said a lot, I spoke a lot about value-based care can't be a side hustle. And what I mean by that is operations has to care, right? Because the only way we get to a better place, and let's forget the term for a minute, but we get to a better place, is when the work we do to create more value is just part of the work we do. It's part of what operations does. It's not this little side hustle living in the closet and a different floor. It's part of our DNA. So the first thing I'd look for is how integrate it. It's got to be integrated across the enterprise. It shouldn't be its own little side hustle thing. Um the second thing is I think the way we think about the entire um portfolio needs to change. Um, as I talked to a lot of folks, how do you do value-based care contracting versus fee-for-service contracting? In my mind, that's not even a question. Like what's your whole portfolio contracts look like? How do you align them to do what you to pay you for what you do? And you like we already established chronic disease management is what you do. It doesn't matter if it's value-based care or fee for service, right? And so how do you how do you make sure that that business model and operating model get much more tightly aligned? I think that's the second thing I would look for. And that has a lot to do with contracts and partnership with payers. And we've got to bridge that gap on trust with payers and providers. Again, not pointing fingers, but they gotta get closer together. Um then third, and I've already mentioned, but I think AI is a huge, gonna be a huge uh tailwind for all this. Um AI, I I kind of break it down at the highest level into clinical versus administrative. Um, we are a very asset-heavy um business, and that asset heavy is the hospital, the MRI, CTs, but it's also the human capital for labor. And there's certainly a lot of things in the business side of things that can be more automated with AI. And then there's things on the clinical side that AI can augment or support our clinicians and others to be more effective and more efficient, if you will. And then, you know, you just keep pulling the AI thread, if you will. Um, one of the holy grails in value-based care that I don't know the answer for yet is patient engagement. Like getting patients to care about their own health, and health literacy is so poor, giving them to understand what they need to know about their health. And I think AI is really good at that. I I have a buddy that uh I finally convinced them that, hey, given your family history, you should have a CTA geogram and uh Apo B and Lipo A and that, and he did that, and his APOB was high. He's like, Well, what's this mean? Well, he works in construction, so I had Claude, I said, describe what APOB is as a construction uh analogy, and made a great analogy and got it completely. So I think there's hidden things like how do we engage patients? Because all the clinicians in the world will tell you that a patient that doesn't care about their A1C, doesn't care about their hypertension control, like you can do all the right things and you're gonna be biting around the edges. Until they're engaged, you're not gonna get the results you need. And I think that's where AI is gonna have a lot of hope. And you just get into the technology, be it mRNA, be it genomics. I mean, the fact that Google DeepMind can um predict the 3D protein, which is what a medicine is, like there's gonna be a whole litany of incredible clinical advances. But again, it's always people, process, technology. If you don't have the people and the process aligned with the technology, it isn't gonna move the needle. Well, what I would say is, Don, I I that's a couple of things. Number one, your your your point one about operations. No, no self-respecting, you know, true operations person wants to be a side hustle. Right? I mean, they they want to be part of the game, they want to be contributing in exactly the way that you talked about. That's what gives their purpose, their, you know, their work meaning rather than you know, kind of being on the side. The second thing I would say is my concern, and this has come up multiple times on this show, my concern is all of the misinformation that's out there around healthcare. And yes, if AI can combat some of that, um, versus you know, the latest uh homeopathic or whatever remedy or, you know, go stare into the sun for five minutes when you wake up in the morning, whatever, whatever the latest fad is, people, you know, you're it's really hard to do anything about the person that you talked about with if they don't care about their, you know, controlling their their uh blood sugar or their hypertension, there's not much that you can do if they don't really care about that. But when they do, but if they're going, if they're if they're being hit through you know TikTok and Instagram and all the other social media out there, and they're being coached to do things that really aren't you know getting back to the low value, right? Really aren't doing much for their health. Um that's what what concerns me. And it seems to be that part of it, the misinformation, seems to be getting worse with technology rather than getting better. And I'm hoping that with Claude and things like that, that that it can combat some of what we're seeing on the social side. Yeah, no, I I I would absolutely agree with you. And I think what's tied into that, um, have you heard the the quote of how long does it take new evidence to make it into just common application in healthcare? No, I haven't. 17 years. And and it's been studied multiple times, and I'm sure there's people that argue with me, oh, it's not 17, it's 10, whatever. It's a long time. And when when you begin to unpack it, it's essentially generations, a new generation of clinicians comes in, right? So I think what AI is going to do, be it open evidence and other things. Again, I am not a clinician, so um, I can't imagine how difficult their lives are, but I think these are things that are going to help them because we need the evidence, once it's real evidence to your point, it's been tested and proven and whatnot, we need to get it to mainstream more quickly. Um, and there's a whole economic issue with some of that stuff too, but that's a whole different discussion. But but I do think shortening the time from proving out evidence to um adopting it uh study stream is going to be uh shortened, which I think is gonna be a good thing. Don, before we go, um tell me about Values Edge. And before you tell me about Values Edge, I want to tell you my experience, um, which is I think how we got connected to begin with. Um, this website is so friggin' cool. I mean, it is and my the my daily news feed, but just the the ability to go in and say, all right, well, what's the latest on you know Medicare Advantage, or what's the latest on the you know, what CMS is saying about the newest ACO model? Whatever. It's right there on the dashboard. And so can can can you tell me a little bit about and tell our listeners a little bit about how that came into being and what your plans are for that? Yep. No, appreciate the kind words, John. So uh a partner and I created values edge. So go out to values with an s, edge.com. Um, basically, one of my biggest challenges as a chief pop-up officer was there's so much information. What are the, in my limited amount of time, what are the few things I can read? So one of the things my partner and I sought was number one, how do you sift through all the noise to find the signals, we call it? So as you know, John, we send out a daily email that's called the value signal. And what that does is I've written my partner and I've written a handful of agents that read anywhere between, I think it's at up to now five to seven hundred articles at night. Um, we've got some algorithmic stuff and some AI stuff that goes through it and decides which of these are the highest value. And so the email will tell you here's the signals, and it's usually 10 to 15 signals, and it's usually um you'll find, oh wow, this is stuff I really need to know. So we've gone through a lot of iterations. We're very proud of that work. Um, doesn't mean it's perfect every so often. We get some feedback and we'll keep tweaking it. But if you need to sort through all the newsletters you signed up for to say what are the things I need to read, this is it. Um we are going to be launching a different one called The Noise, because some people are like, Can you tell me all the other articles that you didn't put on the signal? I'm like, okay, kind of defeats a purpose, but sure, if that's what you want. So that's the number one thing is like what matters. Um, the number two thing is kind of what um you mentioned, John, is there is so much CMS, CMMI stuff out there. Our CMMI section, we do our best to have the agents scour all the things put up by CMS, CMMI, give a values edge take as to well, what what's like the summary of this? Um, what's the values edge take? Like what should you worry about, what are strategic questions you ask, what's your traps and concerns, and then next to it list any articles that have been written by it. So if you want to go learn more about lead, which is on people's minds, type lead into the uh search or go to CMS CMMI. You can find everything you ever dreamt about on lead. And our second game here is twofold is we want to create a discussion group. Um we we are free for a month and then charging 10 bucks. And the reason for that is we're eating through a lot of AI tokens, quite frankly. And um, we we want to create a home that's affordable, so 10 bucks a month, where we get value-based care of people because we essentially want to have discussion groups. Like, you know, there's other places that do this, but the costs are very high. We're just trying to create a home where, hey, suddenly, you know, John cares about lead. He throws a question up to the group and people respond. So it's been super well received so far. We're continuing to take feedback, so please check it out and give us our feedback. Um, somebody described it to me if you're in the finance. It's like Bloomberg for uh value-based care, the Bloomberg terminal, if you will. Um, but we have we have envisions, this is value. We intend to add finance, revenue cycle. Like there's just we want to have one-stop shop that if you care about this part of healthcare, you can find it really easy. I'm just gonna I'm gonna derail the conversation before we end it by telling you something really quick, Don. My first business, fax watch, was basically predicated on the idea that we could give you everything that you needed to know in a one-page fax. We've advanced. Yeah, we've advanced, right? That was that was 1994. And uh, of course, you know, it morphed into other things, but that was that was the initial kernel of an idea. And I'm literally thinking of this when I'm looking at the website. I'm like, wow, this is 2026. This is fax watch, you know, 5.0 or something like that. So pretty pretty cool stuff. Um, John, thank you so much. Uh, we could talk for another hour. I want to have you back, so I want to be respectful of your time and and cut this off. Um if if you mentioned values edge, is there any other way that you want people to get a hold of you? Otherwise, um uh we can we can wrap it. Yeah, if anyone wants to reach out, you can always reach out to me. It's my name dot last name. So it's don.kelcagno at gmail.com. Great. Don, thanks again. Um, I really do appreciate it. And thanks to our listeners for sitting with us today. If you're in healthcare and you found this conversation valuable, please follow Healthcare Rounds on Spotify or Apple Podcasts so you don't miss future episodes. And if you have a minute, leaving a quick review really does help other people find healthcare rounds, so please do so. And all of our episodes are up on DarwinReseearch.com as well as any of the podcast platforms, including YouTube. I'm John Marchica, and we'll see you next round.