Are We Measuring Health Care Quality All Wrong? w/ Dr. Rachel Werner, Professor of Medicine, UPenn

Welcome to Healthcare Rounds. I'm your host, John Marchica, CEO of Darwin Research Group. Today I'm talking with Dr. Rachel Werner, Executive Director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, professor of medicine and healthcare management at Penn and Wharton, and a practicing physician at the Philadelphia VA Medical Center. Dr. Werner is one of the most rigorous and clear-eyed health services researchers working today. Her career has been built around a deceptively simple question, which is when we design programs to improve health care quality, do they actually work? And who do they help or hurt in the process? At least from my research, it looks like she spent decades studying how payment incentives and quality measurements shape what providers actually do. And she's found repeatedly the answers are a little bit more complicated than policymakers might expect. Her work on nursing homes, home-based care, and elsewhere is particularly influential. So with that, Dr. Werner, welcome to Healthcare Rounds. Thank you so much for having me. I one quick caveat, which is I am currently the executive director of LDI, but I only for another two weeks, and then I'm stepping down. Okay. Fair enough. Thanks. There's always this little clarification. I do my best to kind of get things right. And then it's last one was we had the chair of MedPAC. And then I was the chair, but now I'm stepping down. So I understand. But thank you. Thanks so much for being a part of today. So let's get into it with uh a little bit on quality and health policy. And look, I think that, at least in my experience, most pop most policy starts from say a reasonable premise, and then something goes wrong, right? There's sort of unintended consequences. So my first question is really that your career has been spent studying these programs and studying quality and quality measurement. They were designed to improve care, but there's always that catch, things that, as I said, unintended consequences. And so I don't want to say that policy is built on wishful thinking, but maybe a better way of asking that is do the problems with measurement, are they a people problem? Are they a measurement problem? Are they a design problem? In your experience, where do the results kind of mismatch where the policy intention starts? Well, thanks for having me. I'm looking forward to this conversation because there's a lot we just don't know. We don't really know how to get it right. And so the problems with quality measurement is all of the above, I think. And we're taking a step back, we measure quality and report quality because otherwise people who go to the doctor really don't have a good sense of the quality of care that they receive. And the idea, so back when I was in training as a medical student and then a resident, was that if you started reporting quality, at least consumers or patients could choose the physician or the surgeon that they thought was going to be best suited for their needs. But what we quickly found out, and what I actually heard surgeons talking about when I was training here at the University of Pennsylvania, was that surgeons were scared to take care of the sickest patients. And they were worried that if they did, their ratings, their report cards around those patients would suffer. And so it was a problem of not being able to accurate. So we could measure the outcomes of those patients well. Do they patients in this case die or not after bypass surgery? But what we missed, or what we couldn't do well enough, was how sick are they and what was the expectation around what their survival. And so it that was sort of the beginning of the road for me to try and understand the things that can go wrong when you measure quality and how these well-intentioned policies and things that really seem on face, on the face of it, to be quite sensible sometimes go wrong. And so that was early in my career studying and showing that often there's what we call cream skimming. Patients who are the sickest and might need the care the most don't get it under these voluntary programs where physicians or hospitals are rated based on their quality of care. But there's other problems too. There are problems related to what we measure. And we often think of this as the problem of looking under the lamppost, the lamp, the light of the lamppost, which is that we only measure what we can easily observe. And often that's under what's under the light. But what matters most to patients might be something else. It might be something having to do with their recovery after surgery, their future functional status, their ability to live at home over the long term. And those are things that we don't study or we don't measure in quality because they're hard to, we don't have great data. And then there are other problems. As I mentioned that I studied report cards initially, as we became more sophisticated about ways to improve quality of care, we began tying payment to quality. And then there's a lot of questions that we don't that about what the best way to tie payment is, how much payment we want to use. Are we talking about global payment or piecemeal payment? So there's just a lot we don't know. We've experimented a lot around all of these pieces, but getting it right has been really hard. Again, I always have a million follow-up questions with big topics like this. And I'm going to admit to you and to anybody else who's listening, what I didn't like in business school and what I absolutely didn't like in my PhD program was the duming stuff, like the traditional TQM. If you remember, like back in the day, it was super popular. And but this kind of quality measurement I find fascinating because it goes back to what you were saying. It starts with the premise we want to make healthcare better, like a huge premise, right? And we want to make the patient experience better, or we want to have better outcomes. We use these big terms, but then we say, all right, well, how do we measure that? Because it's an old management principle principle. If you can't what I said it's an old management principle, and I'm not getting it right, but if you can't measure it, right? Yeah, then how do you improve it? Or how do you plan for it, or any of these things? And then there's, I think also innately, as humans, we want to know that we're making progress. If we're investing all of this in an area, we want to know that we're getting better, right? And and we've talked about Goodhardt's law, which is the idea that a measurement that when it becomes a target, it stops being a good measure. And then there's a sort of this notion, which this just came up last week, and I'm again I'm forgetting, but the idea that when you measure something, you've changed it. And right? We talk about the quantum, like quantum physics and all this kind of stuff. But really, realistically, when you measure it, you're changing it. So boy, I guess my my point is when you're when you have all of these problems, all of these issues, nothing is going to be perfect. But how do you discern which are the right measures, which are the ones that are decent proxies that can kind of get you approximately where you need to go? And I ask that question in the and just in thinking about the ACO's program since its inception, it seems every year a few quality measures drop off, and then a few get added. There's just this constant adjustment process. So back to my question, how do you prioritize how do you go about doing that? Great question. How I think it depends on what we're trying to accomplish. How do we choose the best quality measures? It depends on what we want to do. So for many years, I talked a little bit about cream skimming or risk selection. For many years, people were very concerned that hospitals or providers were going to avoid the sickest patients. And so people stuck very closely to using process measures. So, did patients get the right medications at the right time, or was the right test done at the right time? And part of the reason for that was that they're much harder to game in terms of sick patients. Like all patients should get come in with a cough and a fever, you should get an X-ray, no matter how sick you are, pretty much. And so there was a really strong belief that we should be measuring the processes of care rather than outcomes. Do I get readmitted to the hospital or do I die after having an pneumonia? Because those are much more closely tied to how sick a patient is. I think that what we found is that, or what I have found is that those process measures, although they're important and often they're very closely tied to clinical guidelines, they aren't well correlated with the outcomes that we really care about, what happens to patients over the long run, as I said, the things that patients care about. And so we can do a lot of work to improve the kinds of tests you get, when you get the medications that you need and those kinds of things. But at the end of the day, it doesn't do a lot to move the needle on quality of care in terms of patient mortality, other kinds of outcomes like functional status. And so I think that there's been a real swing towards trying to measure outcomes instead. And I've been advocating for this for many decades. And I think part of the reason actually we're really swinging in that direction now is not just because we've given up our process measures, but also because the amount of data that we have is so much more than what we used to have. And our ability to use that data to help risk adjust or level the playing field across patients based on their level of sickness is so much better than it used to. That I think there's a more of a sense of ease about using outcome measures to measure quality. That said, the way what you then do with the outcome measures, how you want to try and improve outcomes, I think becomes tricky. And whether or not those outcomes are under the control of providers, hospitals or other kinds of providers will sometimes worry that what happened, for example, for a hospital, what happens to a patient once I discharge them is beyond my control. And so why should I be penalized if they get readmitted or if 28 days down the line they have some complication over which I had no control? And so there's a balance here. Getting it right is really hard. I think the other point I might make is that the amount of quality that we measure has just ballooned over the period of time that I've been studying this, and particularly, I think, even more so recently. That's exactly where I was going next, but just to finish the thought. I think one of the problems is that providers only have so much bandwidth. So I think that you mentioned sometimes measures are used and then they're taken away. And what we see is that when providers are held against a specific metric, they tend to get better on that metric. But then once that measure disappears, they get worse again. The other thing we find is that providers will get better on whatever it is they're being measured on at that time, but the stuff that's adjacent to it but not directly related to it, they may not get better on. And so it's been very hard to find measures that really encompass the full spectrum of healthcare and get providers to give them the bandwidth and capacity to pay attention to all of that. It's very hard as a provider to do that. And so these are fundamental problems. Yeah, my sense is that at least the argument that I've heard why measures drop off is CMS says we've, I don't want to use the word perfect, but we've got that under control. Now let's focus elsewhere. But then you see what happens is we're not focusing on this, which kind of goes back to my first point. If you're not measuring it, then maybe you're not improving it, or maybe you're not you're just not paying attention to it. So, how do you get to that sort of like golden set of priority quality measures that are that is reasonable for providers, hospitals to be tracking, and perhaps, and we'll talk about this in a second, link to payments, versus all these other measures and process measures, the slew of when you went back to the ACO again, and you look at the first scorecards that were coming out, 30-something measures that that they were tracking, and it just seemed like a big burden, right? And so what how do you get to that that sweet spot, the the Goldilocks set of set of quality measures? How do you prioritize that? From whether it's from a and maybe this is where why I really wanted to talk to you, whether it's from an economic perspective or economist perspective, or policy perspective, medical perspective, how do you get how do you get to that? I think I don't know the answer. If somebody out there claims they do know the answer, I would question that. I think we don't really know, particularly I think in the US healthcare system where our care is quite fragmented, it is often profit motivated, and it there are a lot of cracks to fall through. I think it's very hard to get there. I think the natural answer for me is to stick to very broad measures of population health, things like longevity, a quality of life, functional status, because they measure broadly what we really care about, what we're trying to accomplish as doctors is to improve those things. But we operate in a healthcare system that it really doesn't work well with those measures, right? We people are, if you're commercially insured, the average amount of time you're commercially insured is relatively short. And so the time horizon by which an insurer might be interested in improving my health is short. It's only within the time, the amount of time during which I'm insured by that insurer. It may be longer. So then the quality measure has to be short term. Right, which is probably less important from a health standpoint. Yeah, you could make a different argument once people age into Medicare or enroll in Medicare for other reasons, that Medicare is on the hook for the rest of their lives, but with the increase in commercial Medicare plans, like Medicare Advantage, that's less true. And there's still churn among those Medicare Advantage plans. And so it's a I think it's a really hard problem to solve. I think the other piece about measuring population health is there are many factors that are socially determined that we think are related to health outcomes, income, education, housing, food, which are maybe beyond the purview of providers, but also affect health. And so trying to balance all those pieces is just I don't have a great, I don't know what the right solution is, but I think that, especially in the United States, is complicated because of the way our healthcare system is set up and it's hard to accomplish. So the this a common theme. So this is not a a new topic, but one of the themes around value-based care, value-based payment models, value-based contracting, it's been a through through line through from the very beginning. But recently we've been saying, what is the state of value-based care? And I intentionally didn't want to make that just the only subject of because there's a bunch of things I want to talk about with you. But taking a step back, because that pulls in the incentives, that pulls in the payment along with it. What is your assessment, your honest assessment of where we are today in this world of we'll just use the term which is really starting to irk me, but value-based care. Where are we today on this journey?Yeah, I will say value-based care is at a low point right now in its public perception. I think when the ACA passed, and there was a lot of enthusiasm about reforming fee-for-service payments so that we're not just paying for intensity of care and the amount of care that we're providing, but we can organize providers into ACOs and hold them accountable for the total amount of care they're giving and outcomes, that enthusiasm has waned substantially, I would say. I think that when most people objectively look at the evidence around the effectiveness of value-based care, I think most of us say we haven't seen a lot of home runs. We've seen some modest wins with reduced costs, reduced utilization, particularly for bundle payments, and somewhat for ACOs as well. But those were, those are modest, and there's a lot of concerns about whether they are long-lasting and other potential problems that arise simultaneously. That said, my pr my take is that there's still a lot of potential in value-based care. I don't think the answer is go back to fee for service, because we know that there, I think is we know there are problems with fee-for-service payment. But I think we could think about more critically about how to fix some of the problems that we've or some of the challenges we've had with value-based person purchasing or payment. Many of them is just around the design of the programs. A lot of them are voluntary programs, and so providers are not required to participate in it, which creates difficulty in assessing a true effect of the program from an evaluation standpoint. The people who are most likely to succeed are most likely to participate, not surprisingly. But there are also problems, some of them related to timeline. We need, we think that value-based payment, I think, would take a several years at least for providers to really optimize the care they're giving and improve under the kinds of incentives that have been created. But we don't we don't tend to use those very long timelines in assessing the success of the programs. And then many of the incentives themselves are relatively weak. We don't ask providers to bear a lot of risks. There's only upside. And so I think there's a lot of ways in which we could improve the design of the programs and that they could be successful. But I'm not quite as bullish on value-based payment as I used to be, because I think, as you said, like getting there's a sense of fatigue around this. And I think that it we haven't, if it was a home run, we haven't seen it. We all would have done it. I mean, it begs the question, and I feel like like some of these questions I'm asking are maybe you have in classes that you're teaching or something, like these big picture things. But look, this is what we really want to know, and what I think our listeners want to know, which is, and I've heard both sides of this. I've heard recently we're in the second inning of it or third inning of a long haul. And I've heard others say, hey, maybe we've only done marginal improvements, but the amount of money that we're spending on healthcare is so extraordinary that even the margin we should take the wins where we can get them, in other words, a very optimistic view. But I agree with you that there are so many moving parts, there are so many ways to look at these value-based models that really what I'm wondering is have you thought about how do I ask this question? Is there a way to leap to another kind of way of looking at this problem? In other words, I think we've been fixated on these incentives and linking saying we're not going to pay for lousy health care and we're going to try to encourage doctors to behave in a certain way, or maybe encourage patients to behave in a certain way. And the result of that has been all of these sort of complicated quality assessment and quality management programs tied to payments. Do you see that there's a way to kind of leap forward? Or are we, and if you do, is what is that is hypothetically, or are we stuck in this for the next decade? It's a good question. I think that there are a few things that we could do that I think would improve the trajectory that we're on. Some of them I mentioned already. So I think that CMS, CMMI need to make these programs, most of these programs, mandatory rather than voluntary. I think that would have a big effect. And then people would stop trying to figure out how to like we not do them, and then everybody would be forced to participate. And then maybe you'd we'd weed out the not so good hospitals, providers, and so on and so forth in that scenario, in theory at least. Yeah. I think that when we use value-based payment, so you'll you probably hear people say this, but we mostly have built these programs on a fee-for-service chassis, right? And so we use fee for service payments still underlying the value-based payment. We just increase the per visit amount or the per admission amount that, or decrease it depending on value of the care that's delivered. An alternative way to do is to really lean more heavily into capitated or global payments that have two-sided risk sharing, right? So more upside risk and downside risk. I think that there is evidence, if you look at the data, that those programs that have two-sided risk sharing do have greater impacts than these programs that are like value-based purchasing light, they'd look a lot more like fee for service. And that's understandable. I think physic providers, people in general are motivated by the fear of losing in income in part, not just gaining more income. And that I think would be more effective. And then I think there needs to be more coordination across programs, right? There's like a whole lot of programs out there, and some of them are commercial, some of them are Medicaid, some of them are Medicare. They're not all trying to solve the same problem. So harmonizing across all of them is hard, but having similar rules where the programs don't butt up against each other and create conflicting incentives and also give physicians narrower or a more focused set of things to focus to work on and to improve care, I think would be helpful. I think it would also help coordinate care across different settings more effectively and create smoother transitions of care across healthcare settings. And so I think that there are ways to do it. I'm not sure, those are big changes though. And so I'm not sure if there's the will to do that. I think we are so from the government programs, Medicare, Medicaid, there's not a lot of will to, I think, change them right now or build new programs and really expand them. And I think from a commercial standpoint, there's just it's I think we're more focused on consolidation and other factors that we are that have risen to the top of sort of what we worry about rather than trying to think about how to harmonize care or coordinate care across multiple pairs who don't who don't really want to work together. So when I think of what CMS at least has attempted to do, you have let's say the readmission rate quality measure, right? And that appears in different places or measuring improvement in blood pressure control or measuring improvement in intractable diabetics. Right. Those you'll see it's listed as this is a hospital measure here and this is a physician group practice here and this is an ACO measure here and this is a nursing home and it gets very confusing to the point of what you're saying. If you're imagine if you're say the CEO of a large health system and you've got your commercial, you've got your Medicare, you have all of these different systems, all these different payment processes, all these different quality measures. If you were giving, say, advice to the leadership of one of these large health systems, how do you make sense of all of that and simplify in a way that physicians, operations people, that everybody can get on board and advance the ball, if you will? When I think about health systems that I have worked with and help them think about how to respond to all of these incentives, they're largely motivated by Medicare because Medicare is one of the biggest payers. And I think that having the commercial sector follow more closely with what Medicare is doing would be helpful if they're willing to do that. And that doesn't help take care of quality measurement around maternal morbidity, mortality, things like that. But I think that there's a large number of chronic conditions where we worry about the quality of care that Medicare could lead on. And so get having commercial, the commercial sector try and harmonize with Medicare, I think would be super helpful. I think that there was a, this was probably like 15 years ago, there was a demonstration in Pennsylvania, which was a multipayer demonstration trying to improve quality of primary care. At the time we called it the patient-centered medical home. But one of the things that was remarkable is that payers came together from across almost the entire state: Medicaid HMOs, Medicare Advantage programs, commercial insurers, to create a single program that was focused on implementing the patient-centered medical home and improving care within these primary care practices. And I think the motivation was that they were all struggling to solve the same problem and didn't know how to best do it on their own, and that they recognized that there was more effectiveness in the coordination and the cooperation across the pairs to create a single program. And it was actually some of the evidence around is that it was effective, particularly when there was two-sided risk sharing. So I think that creating the economic argument and the ROI argument that we need to coordinate these measures and these programs is important. I think that there's a potential downside though, which I mentioned consolidation. And one of the criticisms that alternative payment models fall under or value-based payment falls under, is that it has accelerated consolidation. It has created incentives for hospitals to buy practices, for insurers to buy PBMs, for all of these types of different types of consolidation to occur. And that increases prices, commercial prices. It probably worsens quality and it has the opposite pressure on healthcare delivery that we hope to achieve through a value-based payment. And so I think we need to think about how to better implement these value-based payment programs across different pairs, but simultaneously have regulations or rules in place to prevent further consolidation. As somebody who's been in this field for a while, do you have a sense, because I'm getting the sense from this conversation, just how I'm feeling, do you have a sense that we've maybe gone a little too far? In other words, we've tried these different measurements. There's so many different competing programs, ways of measuring things that we've tried. And I guess that was getting back to my previous question, which is which is how to simplify. If I'm running, which I'm not, but if I'm one of these running one of these large health systems, I need to be able to communicate something simply that everybody can get on board with, right? So it's this year's focus is on diabetes, or this year's focus, and I know that some of them do this, but this year's focus is on maternal health, whatever that is, and then trying to pull all of these behind the scenes, all of these quality measurement, quality measures, excuse me, all the various different programs where there may be incentives aligned and just kind of keep it in the background, and then you have one more common goal. Again, the level of complexity is astounding of where we are today versus where we were 20 years ago, in all in an effort to improve quality. So I I don't know if there's a question in there, Dr. Warner, but it just comes around, it comes to the point of have we gone too far and can we simplify? Yeah. I'm out of, I hear what you're saying about complexity. I think that I often am in conversations about the way we pay for health care, health insurance in the United States, or the way we've built the long-term care system or value the value-based payment system. And in all of these cases, I think we come to the conclusion that had we had a coordinated approach from the beginning, we never would have built a system that looked like this. And that most of these symptoms systems are built piecemeal as we go along and try and do one more little thing and tinker around the edges. And we end up with these sort of bohemoth complex systems that don't sometimes feel like they don't work well for anybody. So can we knock it all down and start again? Sure. Where do we sign up from? And who's gonna be the one to do that, right? So one one topic I I really wanted to get into with you, which is long-term care. You mentioned it, it just sparked an idea, which is immediately I went to COVID. And kind of where, and not that things weren't bad before that or not the sort of suboptimal, but it really shone a spotlight on nursing home care and some of the issues. So without retreading all that ground that we're pretty familiar with, where are we today in long-term care and in nursing homes? And I should say I have a particular interest in this because recently, not into nursing home, but we recently put or put my mother-in-law into a really nice assisted living area where she is thriving, I will say. She's thriving in that environment after losing her husband, and now she's in this environment and really doing well. So setting that aside, I admitting I have a personal interest in hearing where all this is, what is your assessment of where we are today? The nursing home industry in many ways was a tinder box, like just ready to go up in flames. And COVID was the spark, I think, that caused it to go up in flames. And I think many of us at the time thought there was an opportunity, a policy window that might allow real progress in the way nursing homes and long-term care is delivered in this country. I think that we were overly optimistic, and there hasn't been a lot that has improved since COVID in a really substantial and structural way. I think the things that have really changed since that time are a couple. One is that people have always wanted to age in place and live at home for as long as they could. I think that the COVID pandemic accelerated that trend, and more people are really trying to stay at home or in assisted living facilities for as long as they possibly can rather than moving into a nursing home. The other thing that has really changed in nursing homes is that there's always been a workforce shortage in nursing homes, but it's much worse now than it used to be. And so it's been very hard for people who work in for nursing homes to get adequate staff. There are very high rates of turnover within nursing homes, and there are, as a result, shortages and probably enclosed beds, even within nursing homes. There hasn't really been an uptick in closures of nursing homes, but nursing homes that aren't fully occupied. And so the industry itself, I think, is continuing to suffer. It suffers in part because we don't have a comprehensive way to pay for long-term care in the United States. And so we rely very heavily on Medicaid for people who have spent on their assets or have low income. That's actually a relatively small portion of people in the US. And Medicaid doesn't pay at rates that are very high compared to the costs of caring for people in nursing homes. And so there's a real financial burden on nursing homes to provide high quality care. We think we don't have a lot of actually, there's not a lot of transparency around this. And so we don't have a lot of clear insight into this, but that's the impression is that nursing home care is expensive and Medicaid rates are pay below how much it costs. As I said, many people want to, what we call age in place or stay in the community as long as they can. For that kind of care, again, we don't have a comprehensive way to pay for it. Medicaid will pay for home and community-based services for a subset of people in most states, though it's an optional benefit. And on the isn't it pretty limited too in terms of what you can get for home care? Yeah. So it covers a pretty, yes, it covers a limited number of hours, better than nothing, not enough. And the remainder usually falls on family members and other unpaid caregivers. We also expect that benefit to decline in the coming years as Medicaid financing is contracting. It's because it's an optional benefit, states and states have but you know constraints on their budgets. When we've had seen this happen before, declines in Medicare funding, Medicaid funding, states have cut back on those benefits. And for so for people on Medicaid, they get some help, help from home and communities care. For people in the upper income, the high, the wealthiest people in America, they can pay for it out of pocket. It's most this is mostly a big challenge for people and who are middle income in the US, who mostly rely then on unpaid caregivers to provide this care for people living at home or bankrupt themselves so that they can qualify for Medicaid. And there's a lot of challenges in the long-term care system. There have been a variety of proposals to try and fix it. None of them have really borne out to date. So is it really just a mismatch? And I hate to simplify it to this point, but in funding, if you're understaffed or you can't get people in beds, you raise wages. But if you can't afford the higher wages, right, then that catch 22. Yeah. Yeah. And I think about I'm gonna let you answer that question, and then we'll go on to the next. Yes, I think this is a mismatch between need and funding. I think that if nursing homes, I will say that there has been some research and some press over the past five years about some sort of like some financial shenanigans at nursing homes, particularly for-profit nursing homes, private equity investment in nursing homes. And there is some concern that just throwing more money at the problem may not solve it because the money is being siphoned off into profit instead of care or direct care for residents. I think if we could address that problem and give more money directly to the care of nursing home residents, including staff, that would help solve it. It's a very expensive problem to solve, though. Yeah, that was actually my follow-up, which is the kind of role of outside money and private equity and how that may have influenced that industry. So thinking about home health, because you said people want to age at home, people want to be in the home, I couldn't agree more. I hope that I have that opportunity one day. Hopefully I'm far away from that. But when the time comes that I'll have that opportunity. And I remember years ago when I got into the, we'll say the research business, my first my starting point was in home health care. And I dove deep for several years in this world. And it always struck me as it seemed as if there was a really strong value proposition. When you looked at caring for a patient with say particular kind of disease, but are you gonna care for them in the home or are you gonna care for them in a hospital? Again, all things equivalent, some things you can't do at home. By and large, people are happier at home, the care is about as equivalent, right? But my senses over the years and about is equivalent, and studying this over the years, so much of the focus goes on the doctor visit, the hospitals, and kind of that acute care. And of course, big groups in oncologists like cancer care, the focus goes there. And it seems very little focus, very little attention gets paid to home health care, in-home personal care services. Do first, do you agree with that? And if you do, why do you think that is the case? Because it seems like to me, it's kind of this low-hanging fruit that nobody wants to pay attention to. Yeah, no, I think you're absolutely right. We have traditionally provided health care in a brick and mortar setting within the four walls of my clinic or my hospital, and that's what insurers historically have paid for. So that's where the care has been delivered. That's a byproduct of the way Medicare was conceived and Medicaid as well. It has evolved over the years to be a little bit more flexible. I think it particularly evolved actually during the COVID pandemic when Medicare began paying for more care that we would normally think of as institutional level care, but at home in home-based settings because of the pandemic. And you certainly see many more examples of hospital at home or sniff at home now than you used to. We're back into a place right now where many payers won't pay for it, but I think that people who are reading the tea leaves think that at some point that is going to turn and there's gonna be more reimbursement for care provided at home. It's become easier to provide that level of care at home and in non-institutional settings because technology has evolved so much and there's the ability to monitor people remotely, use telehealth more effectively, video conferencing, and to monitor my vital signs and those kinds of things remotely. But we still are constrained by this sort of like the brick and mortar version of healthcare that we built in this country. And I think that people who are that I know who are most innovative and how they think about healthcare delivery are really investing in thinking about how to get it out of people's the doctor's office and into people's homes and other types of settings. And I think that we are moving in that direction, but haven't quite gotten there yet. So I guess to before we wrap things up, a final question. I want to leave on a positive note here. What are you hopeful for? In the midst of AI, which seems like every day there's something in the news, particularly in healthcare with AI, right? With everything that we've been talking about, as you're looking forward as look, meaning into the future over the next three to five years, is there anything that makes you optimistic? Is there anything that makes you hopeful about where we are today as a nation and where we're going? So I think that what I'm most hopeful about is that we have so much more data and so much more ability to use that data to both predict who needs care and when they need care, but to better manage the health care of people both in the hospital or in the physician's office and at home, that I think that it just opens up a world of possibilities. And I think it creates a more holistic healthcare system and a system that's less reliant on the one hour that I'm in my physician's office versus the 49 weeks where I'm not in contact with the healthcare system. So I think that we really have the opportunity to use AI, use other sort of sorts of digital technologies to improve the way healthcare is delivered, innovate people living at home with robots and detecting falls and having digital caregivers and things like that. I think there's a lot of opportunity, and that does give me hope. And I think we can imagine a future healthcare system that is really much more comprehensive using those kinds of technologies. I'm hopeful as well. I don't think I could come in and work every day if I didn't have some hope for the system. Dr. Werner, this has been a pleasure. I really it's been nice to meet you and have this conversation. Love to have you back at some point in the future. This has been a lot of fun. And thank you for your research, for the work that you do. We appreciate it, and thanks for coming on Healthcare Rounds. It's been super fun. Thank you for having me. I've enjoyed the conversation, and I'm glad that you're doing the show. It's great to have it. Thank you. So that'll do it for another episode of Healthcare Rounds. Um, if you found this conversation interesting, please make sure to share it with a colleague. And if you haven't subscribed, whether it's on Spotify, Apple, YouTube, we'd love to have you subscribe. And a rating or a review really does help because then other people will find the podcast. Thanks again to everyone. I'm John Marchica, and we'll see you next round.