Inside the Rural Health Transformation Program w/ Dr. Tim Ferris, InterSystems

Welcome to Healthcare Rounds, the podcast where we speak with healthcare executives, operators, and innovators about the business, policy, and tech forces shaping the industry. Today, my guest is Dr. Tim Ferris, Vice President of the Healthcare Practice at InterSystems. Tim has held leadership roles across some of the most influential healthcare organizations in the world, including Massachusetts General Hospital, Mass General Brigham, and the National Health Service in England, where he served as National Director of Transformation. Today he works with health systems around the globe on some of the healthcare's most pressing challenges, including interoperability, care coordination, digital transformation, and improving access to care. So today we're going to discuss the future of rural healthcare, why interoperability remains so elusive, lessons from transforming the NHS, and what healthcare leaders should be paying attention to over the next decade. So a lot. Wow, thank you for that generous introduction, and um, it's a pleasure to be here. You know, but before we get into it, I I was looking at your background, and I know I put this into your introduction, but very few people that we've had on this show have senior leadership roles in a major U.S. academic medical system, uh ACO, Pop Health Organization, NHS serving 50 plus million people, a health tech incubator, and a healthcare technology company. And so I've been wanting to have you on for the for the just the simply the diversity of your experience. But then as we were kind of winding up and getting ready to record, we were talking about my previous experience at Dartmouth in their PhD program, and you were talking about your early pioneer experience. So before we get into the questions, and we're going to start with rural healthcare, but just tell me a little bit about that um that experience with Pioneer ACO back in the day, and and maybe some of your early lessons, I think that that would be well worth hearing about. Well, um, thanks for raising it. And and um, you know, it has been, I I've noticed that and and listened to your earlier podcast about why value-based care hasn't uh you know really um gotten the traction that we all thought it would 10, 15 years ago. And um uh and uh let me just say uh a couple of things uh about my experience. One was that um boy, there is nothing that galvanizes change like signing a contract that puts you at risk for tens, if not hundreds, of millions of dollars. Um and I just remember the board meetings at Mass General and Mass General Brigham basically telling the leaders who are like top of their game in fee-for-service medicine that we we have we've got to think differently about how we deliver health care. And I just happened to be the instrument present at the time to lead that. Um but it it was really the the senior management's um decision to A allocate resources and B put a foot in two canoes, you know, the classic analogy where we are trying to drive revenue in a fee for service system, and at the same time, we are trying to for populations that we have been have been attributed to us, we are trying to be more efficient and take care of them um uh in a more efficient way. What's amazing to me, and it it's sort of similar story to the Massachusetts story around getting everyone insured, Massachusetts got got up to 99% insured, um uh, is that it worked, and it worked better than um I think most people understand. And let me illustrate that with two points. If you look at the um what the state of Massachusetts, because they required providers to take risk, um their ranking on states in terms of the cost of medical care pre and post, and the widening gap between the projected expenditures on health care and what Massachusetts has all had and ended up spending. There's tens of billions of dollars difference between those. And at the same time, Mass General Brigham, the the population health programs and the taking of risk has been accretive to their bottom line. Wow. That's that's sort of win-win, right? Exactly. Yeah. Um, and so when people discuss, you know, well, why hasn't it taken it off taken off? I would say the problem is in Washington. Because you know, there was this uh very highly cited paper that came out, which was a New England journal paper about, you know, have these ACOs been successful, the federal Medicare ACOs. And and unfortunately, the the the press and even the writers of that article came to the wrong conclusion. Because they said what they measured was 1.5%. They got a w there's a 1.5% annual benefit. And and you know, and they said, uh, it's modest, you know, it's not making a difference. Oh, wait, wait, hold on. Healthcare inflation over the last 40 years has been 5%, general inflation has been 2.5%. The problem in the cost of healthcare is not the absolute cost, it's the annual rate above inflation that is the problem. And a voluntary program cut that difference in half, and it was just getting started. I call that a massive success. Like, well, can you imagine a public policy program that actually removed half of the problem of healthcare cost inflation that was voluntary? Like, I mean, and and it was accretive to the bottom line of the participants. Like, why isn't that the law of the land across the United States? Uh, I just don't get it. I just don't get it. Um so well, for me, um, as as one who toiled in a lot of that data um at the time, for me, the issue was always the physicians themselves and in that ACO model, was there enough of a benefit, especially not for the mass generals, you know, mass not for those organizations, but for some of the, let's say, more rural organizations, ones we're gonna be talking about, or ones that weren't quite as just overall advanced. And I and and just kind of back in the envelope looking at the numbers and saying, okay, we had shared savings, we're gonna distribute this, some of this is gonna go to tech, some of this is gonna go to infrastructure, and the rest we're gonna share with the docs as like 500 bucks. Yeah. And when you get down to it, and so that was always my issue. I've been a fan, people have heard me evangelizing this model for eight years on this program and for longer before. But that was always the rub for me. Like, is that enough of um because I get the the so-called paradigm shift in thinking about value-based versus volume versus value and that kind of thing, but at the provider level, was it enough for to change behavior just in terms of the shared savings alone? And I don't know that anybody has really sufficiently answered that. I I mentioned to you um before we got started that Ellie Fisher's gonna be on again this summer, and I'm sure I'm gonna ask him this question. Yeah. Um, because I last time he was on several years ago, I didn't ask him this question. But I don't know, what are your thoughts on that? I guess what I would say is um for large organizations, you know, um large provider organizations that are pushing the boundaries of um uh let's just say um antitrust, um the the populations they cover, um their market share is is a significant fraction in their region. I think a hundred percent of them should be at risk. Like I just think the problem, and and this is you know to your point about are the doctors getting their share of this, um I think that model breaks down when you have smaller organizations that have much smaller margins, and you um and the inherent instability as you move away from that scale and get down into smaller populations, that model of attributed population and savings against the projected costs of that population um becomes trickier and trickier. So my I guess my response would be we we have a solution that works, but it it doesn't apply to everyone, it just applies to the to the big integrated delivery systems, and every one of them should be at risk um uh in the same sort of way. But but there are different solutions for the small and medium practices uh that are in safety net populations and in rural um places, because honestly, it doesn't make sense. Their margins are so tight, um, and the the percentage of their revenue that they've got to spend on the infrastructure to do that population health, like that's that's not fair. Um it's fair to do it to the big ones, and not only fair, but it's the right thing to do. Um but but we need a different approach. And and I've got some ideas about that approach when we talk about the rural um stuff because because uh here the underlying financial um resilience can't sustain taking risk, and therefore we we need a way to uh manage populations that is efficient and effective, but not reliant on the the wherewithal of the providers in those rural places because they're underwater both financially and from a demand perspective. Um, so so we need a different solution. I think that solution, or let's just say, I think we could generate that solution from what is contained in the rural health transformation um initiative. Well, we are going to get to that, but I I think implicitly in what you're saying is things like you know, the aimed ACO investment model, um, and I forget what it was called before that, but things like where the government is really trying to put some money into these smaller systems and in subsequent models, maybe those haven't been quite as effective, right? For a variety of reasons. Um but again, it kind of comes back to, and I think of geez, just recently we had um uh Don uh Calcegno from uh previously with Advocate. Yeah, and one of the themes that he kept coming back to is there's no really one size fits all around all of this stuff. That you know, as you say, Tim, maybe for the big systems it should be mandatory, or those that have you know substantial market share own their markets, right? But in the maybe the mid-sized markets, or maybe in the rural, that that kind of model, two-sided risk, heavily incentivized, um, you know, just just doesn't work well. So, well, let's let's turn to rural health care. And one of the questions that I think that you know listeners of of of this show, and I said this before we got started, I think primarily healthcare executives, probably not the consumers that are listening, have it have a general idea of the problems in rural and administering healthcare in rural settings, right? Um they talk about technology, they talk about um uh absolutely resource allocation, physicians want to and and other professionals want to be located in these areas, like this whole host of things. But what do you think, in your experience, is kind of maybe misunderstood? Um that really getting beneath it, that people just don't understand what really, you know, not only why is rural healthcare so important in in this country, but what we're missing, what what what we're misunderstanding. I think one of the things that I that I one that I perceive is that we are allowing our rural health providers, we're basically starving them, and we're allowing them to go under. And you you know, I don't know if you've seen this, but if you look at a table of the OECD countries and the number of acute hospital beds per 100,000, the the US as a country is in the bottom decile, but rural areas are at the lowest point on an international comparison scale. And what that means is that the basic services that people in urban and suburban areas just know that they're there and they can depend on are simply not there in very large swaths of the United States. Um and knowing just personally having relatives who live in very rural areas who are two hours from a medical facility. Um and hospitals, rural hospitals in this country have been closing at a steady clip since 1972, I think was the peak. Um and uh and there doesn't seem to be any um effort to stem that uh before this rural health transformation program to stem that um that that trend. Uh and and I have to say, I'm not sure the rural health transformation program is gonna stem that trend either, because they get most of their funding from the the delivery of care to Medicare and Medicaid patients, both of those payers pay below cost, right? And so it's the suburban and urban hospitals that have commercial patients that subsidize the care of Medicaid and Medicare patients. And so my my big take is that that in the big picture we are losing critical services for uh rural America, and no one seems to be sounding an alarm bell. Now, of course, the rural health transformation program was catalyzed because with the current administration's cuts to Medicaid, the rural hospitals, the rural states, you know, their advocates said, hey, wait a second, this is this is going to accelerate what has already been a process that is not helping the people of our state and the and the rural regions. And so this is a the rural health transformation program, is a five-year stopgap. But I'll I'll just say, you know, it's a five-year stopgap, but there's a cliff at the end of it. This is not ongoing funding for the delivery of care. In fact, the rural health transformation program, for all of its benefits, and I am a big fan of it, it is not gonna solve the the sustaining rural health care problem. Not at all. It's gonna, it, I think, when, and we'll hopefully get into it, I think tech we can do a lot more with technology to deliver services to rural patients, a lot more. But but as our, you know, the silver tsunami, as our population ages, the need for acute hospital beds in rural areas isn't going away anytime soon. And yet we are losing those beds. So I I don't want us to get confused by the fact that yes, there's an opportunity here with the rural health transformation program to literally transform the delivery of care in rural areas, uh, an opportunity that that I'm I'm I I want to make sure we pick up on and and um and take this opportunity. But that other problem still is still there, it's not going away. We haven't fixed that. We've just put it off a little bit. Have you ever driven across country? I have, yeah. You know, I I think that that many people, I'm just gonna guess, I probably haven't had done that exercise. But when you do that, you realize that we're really just kind of a kind Yeah, we have big cities, but it's it's one small town after another. Yeah. And it's not just in, you know, so-called flyover country in the middle. I mean, it's everywhere. Go through New Jersey, go through, you know, Illinois, go through my own state now of Arizona, yeah. Right? I mean, it's just so it's just one of those things. I I I think that if more people did that and experienced, look, this is really what our country is. It's a connect, yeah, we have big cities, but it's a connection of small town after small town after small town. Um I don't know. I think maybe we pay closer attention to it. But I but I want to get back to before we get into a little more about the the rural health transformation initiative. Can you just kind of set the stage for everyone? Because we're not all policy wonks. And just kind of what is, you know, you said said okay, five-year stop cap, but what are the nuts and bolts of this project or this demonstration and what's it trying to accomplish just to kind of help us get our bearings around what it is that we're talking about? So it's um $50 billion for 50 states for five years. And so you can do the math, you can do divide. It up and interestingly enough, um so and all of the states, the states had a very short time to submit their responses to an RFP. All of the responses, the RFP and all the responses to the RFPs are on the CMS website. Um, you can uh look through all of them. There are some great AI-based summaries of all of them. Um and and they go after a bunch of things. They go after um uh chronic illness, uh, of course, as it should, um, mental health and um maternal and infant services. So on the clinical side, you the proposals had to address those areas. On the um uh they the uh wanted to address interoperability to make sure that um that providers of healthcare were able to speak to one another. And I need to say I just said something that I need to correct, which is providers of health care, no, providers of health and social care, because social determinants of health is a big part of this, and we need to connect both the healthcare providers and the social uh services uh to make sure that people who are eligible and need those services are connected to those services. And so it's interesting for me to come from England, where I spent three years, where social services and healthcare services are explicitly part of the same program and funding system, and and they they are much more connected than here. It's it's wonderful to see the US making progress to connect the social services with the healthcare services because because we all know about you know social determinants of health, and and you know, food and housing are um uh as good, if not better, predictors of health as whether or not you're getting you're on the right hypertension meds. Um and so uh and so it's it's great to see that explicitly acknowledged um in the funding. That's about the sort of interoperability piece of it. It also talked about remote monitoring and AI. So, you know, what can what more can we do to get remote monitoring into people's homes so that they don't need hospital beds, um, so that we can monitor for um uh for changes in their status, their health status, uh acute changes, uh, and and in what ways can AI, again, required to be part of the responses, um, be used to enable um home-based monitoring and um and the systems of interoperability for the delivery of care. And then um those oh, and then of course the workforce, and you mentioned this in your opening remarks, you know, the the workforce is a major issue in in rural areas. The though those wonderful clinicians of all people delivering services, um are generally overwhelmed and under-resourced, and they are they are heroes. Um, but heroes, even heroes need support. Um, and so how are we going to support uh the the rural health care workers, health care and social care workers? And um oh boy, you'll you'll remember the name of this group, but I'm blanking on it. There's this wonderful program in the Southwest where GPs, groups of GPs can get online with specialists and present their tough cases and you know, form basically form a virtual community around where you know I could walk into the office next door if I had a question at Mass General and or or meet someone in the hall about something that I really needed an answer to. But if you're alone in a rural area, who do you talk to? Um, who where do you get your support? Where how do you get help on difficult issues? Um AI will be a solution there. Almost every doctor in the United States has now used open evidence. Um I find it spectacular to use, uh almost magical. Um, and so there's some making sure that our rural clinicians have access to high-quality decision support tools, um, that's gonna help, but also helping them be part of virtual communities where where they can be connected with each other and with specialists in urban areas. So workforce support was the uh another pillar of the um of the transformation program. It seems like things like the commun the the virtual community that you talked about. It seems like the workforce support, things like tuition um reimbursement or you know wiping out student loans. It seems like that those home monitoring applications of AI, these they're not easy, but they're easier to address in this rural model. What I can never seem to get my arms around is delivering babies. Yeah. What is what can we do, whether regardless of whether it's part of this initiative or or not, what can we do when people really do need physical access? Yes. And that that seems to be one of these, you know, you get broadband in, you get all these things, right? Yeah, but but how do you how do you wrestle with that? How do you solve that particular problem when you need that physical um, whether it's an operation delivering a baby, whatever that may be, but they need to have hands-on care. Yeah. So um, so I think of the needs in three categories: the digital data category, um, and all the infrastructure that goes with that, the physical uh structures, like an obstetrics unit and an OR, um, where you can um um have a cesarean section if emergently if you need one, and the workforce. And in the physical, um I also include diagnostic tools, uh, you know, um ultrasounds, CT scans, MRIs. In Boston, there's there's practically an MRI scanner on every block. Um, but but I was just on the phone with someone in a in um in in Georgia, and they were talking about driving an hour for an MRI scan and calling me and saying, Tim, do I really need this? Um and and you know, my answer was actually, yeah, you do. Um, and so yep, you're gonna you're gonna drive an hour. Um and so I was gonna I was gonna add chemo or other kind of infusion services, things that you need to have on a regular basis. You don't want to be driving an hour or two or force people to drive these long distances for those kinds of things. So that's right. Although interestingly, I'll tell you uh one um solution that um I help support in the NHS. So there's several small islands off the coast of England, um, and some of them have rural hospitals with cancer patients, and they actually used drones to fly the chemo, which was made at the main mainland hospital across to the hosp the rural um location, so that patients didn't have to leave their island home to get their chemotherapy. Yeah. Very cool. That's a creative, yeah, isn't that a creative solution? It's very cool. Yeah. Um so how how I think I have an idea of the bones of the program, but how from your perspective, at the end of all this, at the end of this program, how are you gonna judge a success? What are you gonna be looking for to say? Because right at the onset, you said, Tim, it's not it's not a panacea, not your word, but that it's not gonna solve everything. But what are you gonna be looking for as success measures? So one of the things we learned during the pandemic is we do not have great real-time views of the health of our population. We get state reports usually a year after you know they analyze the data and blah, blah, blah. And um, and by that time, no one's really that interested because it's uh it was a year ago. Um and what I would like to see is the infrastructure necessary to give our state health departments, public health departments, near real-time status on things like gaps in care. So I always use the same example. Um, the number one cause of preventable morbidity and mortality in the United States is cardiovascular disease. And we are as a nation just slightly better than 50% of people eligible for secondary prevention are getting it. That's terrible. Yeah. Right? Yeah, yeah. But, you know, we've got all these HIEs in, you know, New York and Texas and Montana, Ohio, like most states have some are some are more fully developed than others, but most states have a health information exchange. It there's no reason those states couldn't be reporting real-time gaps in care, right? So think about that. What if we knew in uh the the particular regions in Ohio where secondary prevention is low for what whatever reason, we could focus our attention there. And but we could do that. Uh so you asked me what would be a measure of of success. Like I knock it out of the park success would be actually at five years, lowering preventable morbidity and mortality from cardiovascular disease. That that would be home run. Amazing, amazing, yeah. But even if we were just had the measures in place so we knew what we needed to do and where we needed to do it, that I would take that as a victory as well. And I don't want to be dismissive because all the cancer folks are I'm hearing them in my head right now saying, What about us, Tim? What about cancer? Yes. So cancer screening, we should know in real time who's eligible for cancer screening and do outreach to them. And so whose responsibility is that? So that's the kind of thing in the NHS, when I was across the pond, the NHS, it was the NHS's responsibility. Whose responsibility is it to tell, you know, uh Joe Smith, who turned 60, that he needs a colonoscopy, uh who lives in rural Oklahoma. I I I don't know that I can point to whose responsibility that is. And because we don't allocate responsibility in this country for for the delivery of preventive services, um we don't do very well at it. But the rural health transformation program has embedded in it that uh the payment and the development of the technology which will make all that transparent. Not, of course, not disclosing any individual patient-identified information. But for example, and here I'll just do a little plug for inner systems, you know, our unified care record, healthshare technology, which underlies 11 of the state's health information exchanges, has the capability of having everyone in the state get an app on their phone that gives them from all the different locations of their records a unified care record that says, oh, by the way, you're due for these immunizations, or you're due for colonoscopy, or you you are you have uh known, you have diabetes, which is uh an equivalent risk factor for coronary cardiovascular disease, you should be on a secondary prevention lipid lowering agent. Um all of that would be possible and not very expensive to deliver, like it, like it all could be automated through the infrastructure that this transformation program is paying for. But we have to want that. We have to that has to be our goal uh in order for that to happen. Um it's certainly possible, but sorry, that was a long answer. No, it's a great answer because it's in my mind it's getting to that sort of state level policy, national level policy, right? And especially if you're tying together these health information exchanges or have the ability to do that across states, because there's a lot of people, I mean, think about Medicare population. Okay, now I'm I'm being quite stereotypical, but think about those that spend part of their time uh in New York, yeah, and then part of their time in Florida. I have relatives like this. I say I'm being stereotypical, but I have plenty of relatives like this. Or um, you know, a lot of people here in Arizona, they spend a lot of time in California in the summertime, as much as they can because it's so flipping hot. I hear it gets hot there in the summer. Yeah. So so it and I can all at the same time, I can see you know, your roots in Massachusetts and where where you were doing all this early work at the CO is very advanced in my mind as a state in a lot of different ways on the policy side. Um, you know, as you said, you MRI machine, from maybe too many MRI machines, right? But but but but there's this sort of advanced nature, and then there are some other states too that you wouldn't think about. I mean, there's some elements of Arkansas that have advanced, you know, really good advanced care, right? So there are pockets in certain places, but do you try to execute this or implement this at the at the state level, or can something like a rural transformation initiative, and maybe I'm answering my own question here, is that maybe you can set the goals nationally and have the incentives set up nationally, or however you want to talk about that. And if one of those goals is reducing cardiovascular disease, mortality, and morbidity, it's sort of like a national framework or goals around that that states and maybe you incentivize them with bonuses, more money if they do better, right? Those kinds of things. Um I don't even know where I'm going with this question, but I just No, it's interesting it's because implicit in the RFP and the evaluation of what of each state is whether or not they are actually making gains in health. It is, it is, it is actually, I shouldn't have said implicit, it is explicit. It's interesting now that you say this, I hadn't thought about this, that they didn't actually say cardiovascular disease or cancer. They didn't they didn't call out any particular uh disease burden. Um they they did call out mental health and um and maternity care, but they didn't they didn't set any goals. They just said improve. But I I'm because you know every state is starting from a different position, both infrastructure and current performance. But just the idea, I mean, you know, I'm sure you've seen the this the Commonwealth Fund state by state, their annual state by state comparison, and they rank the states. And um and what's what what's interesting, I'm just reflecting on this now, is that yes, we've had that for 20 years or more. We've we've been watching the states, and mostly the states that are doing well stay up at the top, and the states that aren't doing well are still at the bottom. This this opportunity with the rural health transformation program actually gives us the opportunity internally within the state to set some targets and then in a rapid cycle measure whether or not we're making progress. Like that's something that the Commonwealth Fund report doesn't do, right? It's it's a it's it's an exercise that doesn't have an effector arm. This is trying to build an electronic, a digital effector arm for the delivery of public health of preventive services that serve a public health benefit. So I'm wondering, and I'm I might as well just throw out my interview guide at this point. We're 40 minutes in, and this this is way better discussion than maybe the the questions that I was going to ask you. But uh the implications for me on state level public health programs, right? And we can lament at the national level, kind of where we are right now. A lot of these issues came to, I mean, people have known about them for years, but COVID and all of that brought a lot of these issues to light. But now, with some of the cuts and what's been going on nationally, I wonder is it gonna make it harder to implement because I feel like you you need to have a robust state public health program to be able to corral all of this. Yeah. Um I don't know. What are your thoughts on that? Well, um the first thing you need is the just you need to have the ambition. You need to think we could do more, we could use this funding to do better. Um and then you need, and this I experienced being in the government in the UK, you need alignment. And I'll just say like any, and I and I don't mean to use the word pejoratively, but like any bureaucracy or set of units within a bureaucracy, the state, you've got Medicaid, and you've got, you know, the HIE, which is a nonprofit associated with the state, but not part of the state. You've got um the health policy um group under the governor, you've got you've got different pockets, they have different interests, and getting them aligned around a um uh a direction is um is a real challenge. I've talked to some uh state uh uh Medicaid and HIE directors just in the past month. I've talked to quite a few, in fact, and um they talked about the challenge of getting alignment with all their stakeholders and partners, and um and I I empathized uh with that. I keep coming back to okay, how can people Not be aligned with the number one cause of preventable morbidity and mortality. Like just that one thing. Like, let's go after one thing. And if you had to pick something, you would pick cardiovascular disease because it's the number one thing. The number two thing I would say is adolescent mental health. It's on everybody's minds. Um there's a real opportunity here to um several states are thinking about bed allocation and capacity for mental health beds. Um I love that. It's a huge need when we had patients in the emergency department and Mass General, every single patient, we just calling all over the state looking for a place that had a bed. Um uh why in 2026 do we have to call like an ask somebody at each place? Like, there's gotta be a better way of doing that. Um, meanwhile, that patients wait for days in the emergency department. So, and that's not we shouldn't be doing that to our adolescent um uh population. So I hope you can hear in my voice some there's there's an opportunity here, but we've gotta we've gotta have we've gotta pick some goals and we just have to drive after them and get everyone aligned around those goals. Can some of these can or can you think of, because I know the answer is yes, but can you think of any examples where in the private sector, where you know, Mass General Brigham, say, for example, or where institutions have done a good job collaborating, partnering, whatever word you want to use, to accomplish some of these objectives through their own CINs or through the Health Information Exchange? Like, can you think of any examples where that's where an instance we can say, well, yeah, Kaiser did this with uh you know Sutter or something. I don't know, I'm just making that up. But can you think of any examples of where the private sector has has done well by focusing on a goal like that in cardiovascular um disease mortality or even um partnering on the rural side? You know, I know there are great examples, but I'm but I'm coming up empty right now. Um most people are gonna be listening to this, but if people could see your face, you had the same kind of quizzical thing. Like I like I was saying, I know, in fact, I feel like I've written about these these things, but there aren't any sort of bellwether banner case studies out there that people can point to. I know they've been they've they've been happening, but you know, as things are in this country, we always tend to look to the the private solutions, which yeah, I I I you know we're getting close to the end, and I just I have to ask you, Tim, yeah, um, which you've probably been asked a million times before, so I apologize. But simply because you took this detour in the UK, um what are you know misconceptions that people think about the health service over there? And are there any you've talked about some of the lessons and things that we can learn. Yeah. But are there are are are there any kind of misconceptions? And are there things about that system that you think that we could we can port over to the US system that would work well? A couple of misconceptions that even when I was on the board there before I went over, I still didn't know until I got there and actually had responsibility for it. One misconception is that um people here tend to be, it's either gotta be total cost of care value base or it's fee for service. And the NHS is total cost of care false. The NHS has a mixed model in which they pay for some services fee for service, a lot of services fee for service. Why would you pay a fixed cost for a variable service? They don't do that, so they actually allocate money according to volume, and a lot of people who are on the total cost of care, value-based care think that is the solution. The fact is, health care, the delivery of healthcare services, some of them should be fee for service, and some of them should be, you know, total cost of care, population health. It's just that it appears as though administratively, it's just too complicated to do two simultaneously, either when you're receiving the payments or if you're doling out the payments. But I wish we could come to the realization here that it's not one or the other, which is how the debate usually goes. It's both. It's both. Um that's that's thing one. Thing two. Can I just interrupt you one second with thing one? Yeah. We we we definitely do that here. We definitely do that in these conversations about value-based care, as if it's a transition to a hundred percent. Right. Right? It's this transition to everything is going to be this this new model, right? Whatever that is. Yeah. But what you're saying is it's both. It's both. And we and we need to get our arms around. So for instance, maybe it does make us make sense to do bundles with hips and knees and certain procedures, right? And that's one value-based approach. Maybe it does make sense to pay for care coordination in in certain instances in the oncology models or in um in rural care, right? Or fee for service for preventive services, like the more the better. Like we we should pay more if you do more, right? Yeah. I mean, it's not like people are gonna abuse, go go back for more colonoscopies. Uh right. Very true. I'm I'm due for one, by the way. So David made me laugh. So I'm sorry, I interrupted you. So point two or thing two?Well, point two is just that um people think all the data is available um and that it flows. Not true. The um the GPs are in a separate contract, and they use the fact that the NHS and the government does not have access to their to their data as a negotiating tactic for their pay. And um and the the BMA, which is the doctor's union in in the UK, um, for all the GPs, or for all the doctors, but the GP unit of the BMA, uh, British Medical Association, um is doing a serious disservice to the health of the country by blocking access to GP data, um, which was borne out in the um uh in the during COVID when the health secretary um uh unblocked it because of public health powers. And so for two years, the whole the country had access to all the data it needed, and that's why you saw such extraordinarily great research on COVID come out of the UK, because they had they had everything. And uh, but as soon as the public health emergency ended, the the um gates were closed, and um there is a there is a path to undoing that that there that I worked on there. I never completed it, um, but uh I did try to convince serial health ministers one of the best things they could do for the health of the country was to unlock access to GP data for public health purposes. Um and um uh and so uh again there's sort of a mythology around universal that that they've got it all uh set up in a beautiful way. Not not quite. Well, it's it's very frustrating that and I I I get it, you know, politics is is one one uh thing that that politics is supposed to uh I guess achieve is allocation of scarce resources, right? We elect people to, and healthcare is a scarce resource, and so almost by its nature, uh healthcare can be political, but it feels just so overly politicized in in this country. And I I don't know what the roots are of that. Um but I I I bring that up because there's almost this oh, UK healthcare, oh, Canadian healthcare, oh well, what they're doing over in you know Sweden doesn't apply over here. And the reality is all these systems are different. You can't just say, yeah, oh, it's it's universal, and that's the way the rest of the world does things. There are a lot of different models. Um can I put a plug-in? So please I wrote a paper, a New England Journal policy paper, about lessons from the NHS that the US should learn. Um, and I published it last January, um uh January a year ago. Um and um and so I made a bunch of points about misconceptions about the NHS, but also things that we can learn from the NHS experience. Well, um if your listeners are interested in learn in in more of my thoughts about that. I feel like I've I've it's it's in the it's in the distant past, but I feel like I've seen that paper. So I'm gonna go back and and reference reference that. Um Dr. Tim Ferris, this is this has been great. Um I I thank you. I feel like we've scratched the surface. I'm telling you now, I'm gonna ask you to come back because there's a lot more that we'd we'd love that I'd love to talk about. Um any other final words before I give uh give a sign off? Well, and thank you for doing this. We we need more discussions on this topic, on this set of topics, and you're uh a great medium for getting that word out. So thank you. Thank you. And uh thanks to everybody for listening. Um and thanks for um for spending time with me and and Dr. Tim Ferris. If you're in healthcare and found this conversation valuable, please follow Healthcare Arounds on Spotify or Apple Podcasts so you don't miss future episodes. And if you have a minute, please leave a quick review. It helps other people find the podcast. And all of our episodes, as they will be on your favorite podcast platform, are also available on DarwinResearch.com. I'm John Marchica, and we'll see you next time.