What’s Next for Value-Based Care & Health Tech w/ Dr. Patrick Conway, CEO, Optum

Welcome back to Healthcare Rounds, where we give you smart conversations with the people moving healthcare forward. I'm John Marchica, CEO of Darwin Research Group. Quick reminder, if you have a question or comment for me for a future mailbag episode, please send it to healthcare rounds at darwinresearch.com. And if you're not receiving our weekly newsletter, you can also subscribe at darwinresearch.com. Today, I'm speaking with Dr. Patrick Conway. He previously served as CMS's chief medical officer and director of the Center for Medicare and Medicaid Innovation, where he helped architect the value-based care models that still shape reimbursement today. He then went on to lead Blue Cross Blue Shield of North Carolina, and has now held multiple senior leadership roles inside UnitedHealth, including CEO of OptumRx and CEO of Optum Health, and most recently as CEO of Optum, the company's full health services division. Patrick, welcome to "Healthcare Rounds." It's great to be here. Thanks for having me. That was, um, a difficult, uh, intro to do for you because I don't know how many boards you sit on as well. I mean, you've got a very long CV. I'm glad you kept it short. Uh, but I appreciate it. Thanks. So I'm sure you don't remember this, but I met you over a decade ago at an ACO conference where you were presenting either just before or after, uh, Mark McClellan, who's actually, we're recording with him next week. Um, so it was a long time ago. But in my mind, I say that because I always think of you as value-based care, you know, kind of like you're the guy, you're the, you're the evangelist. You were there at the time, at the start of everything. And so I guess my first question is, is when you look back at your time at CMS What, what assumptions or beliefs did you have back then when you think about value-based care and where healthcare was headed versus where you are today and kind of the beliefs that you, you have today? Yeah. First, John, I appreciate it. I think that was probably a NACO's conference, by the way. Here's what I would say. Back then, as you alluded to, so if you go back, I w- I'm sure we both look the same, but I've gotten a little older. Um, you know, it was in the early stages, which you alluded to. So I, I mean, I distinctly remember in 2012 when almost 0% of payments in Medicare were tied to value. Uh, so there were some very small pilot programs, and we're just getting CMMI started. Um, you know, in those early years, uh, you know, Pioneer ACOs. So I was actually the second director, um, but was still when models were just getting launched. You know, Pioneer ACOs, bundled payment, primary care medical homes, many things have become sort of household names across the public-private sector now. At that time, we really didn't know if people were gonna adopt them. And then we set a, a goal that President Obama announced to go to over 30% of payments by 2017, and we actually reached it ahead of schedule, the beginning of 2016. Um, which I think was a testament to that early team and value-based care and, and honestly, all the health systems and providers and states and others, payers that participated. Actually, at this time, I don't usually-- Actually, private sector was coming to me at the time, and we're literally copying the models, which I think that's shifted a little bit. So as we did bundled payment and ACOs, private payers and others would sort of copy those models into the private sector. Um, you know, then we've gone through phases. Then after that, you had a phase, uh, with Adam Boehler and Brad Smith and others at CMMI, then, then Liz, uh, where, um, you know, you go into two-sided risk and, you know, evidence that as people move into two-sided risk, the performance is better. You know, so the evolution of the ACO program. So Pioneer ACO worked, improved quality, lowers cost. You scale that into the national ACO program, which happened. Um, even prevention programs like diabetes prevention program, you scale into the, the core program. Integrated collaborative care, which we may talk about mental and behavioral. You know, we put that in place when I was at CMS, and it, you know, now it's scaling across the private sector, including at Optum. So I think we're on the right trajectory. Um, you know, I always wish it would go faster. Um, and where that comes from is, um, you know, we still have people falling through the cracks in the system. So in a fee-for-service fragmented system, people, uh, can fall through the cracks, not get the care they need. And so I think the better solution for our US population is an integrated, coordinated care model, which, as you alluded to, I've worked across a lot of different perspectives now, but I still think it's better for the people we serve Yeah, I mean, when over the last several months I've had, I don't know, a bunch of people on, including Elliot Fisher- Oh, yeah one of my former professors at Dartmouth, and asked them to grade- Yeah … you know, kinda like where, where we are. And boy, he was maybe one of the toughest of all. Yeah. I mean, just kind of, I wasn't expecting that. I thought it'd get a little bit of a rah-rah, but he just, he was like, "Ah, it's not really fulfilling, fulfilling the promise of what, what we had expected." Look, uh, and I'll give credit, Secretary Leavitt, who I worked for, Governor for people from Utah. I worked with him in the administration when I was a White House fellow, and then his chief medical officer. You know, he talks about it, and we have talked about, we may be on like a 40-year journey, and we may be in a year at about 20 or 25. Um, then how do you accelerate through that? So I actually, I'm a little more bullish. I'm sort of naturally optimistic, but I think I see it at Optum how it works. I've seen it in Blue Cross North Carolina how it works when you implement value-based care correctly. I think the challenge we have now is how do you scale it across the whole population, all the providers, all the health systems, all the payers? I think that's the core of where we are now. And if you look at major changes in history, um, a lot of them do take time. So you may have sort of decades that add up over time. And in a complex healthcare system like the US, I'd like to go faster, but I think we have to have a reality that we need to keep persistency on the journey, 'cause we'll eventually, you know, look back five or 10 years from now and be amazed about how much progress we achieved. So I, I read someplace this is a while ago, that said Optum's strategy had strayed from the original intent maybe a little bit. Um, and so I guess just in, in general, let's take a step back or maybe include value-based care, but What is today, considering all that you've been through and all these different positions, what is, what is your overarching strategy for, for Optum, and what are some of the things that, you know, you've been able to implement since you've, you've taken the reins? Yeah. So, um, integrated value-based care does work. So, you know, uh, we've published on this in JAMA and other articles, you know, decreased admissions in complex population, 17%, ER visits decreased 14%, star ratings, you know, in our Optum at Home program, you know, 80-plus percent and four-plus stars, NPS patient experience, you know, 80s to 90s. So that, that's sort of the data and evidence. Then to answer your question on the s- on the sort of straying part, you do need to take risk in ways that you can manage. So what is the population? What is the physician groups and the network to manage that care? What is the data and technology you need to manage that population? You know, what is sort of the time horizon of managing that? And I think Optum Health, you alluded to this, I was the CEO for a period of time, probably strayed from that original intent, uh, you know, in the pursuit of, um, you know, largely in the pursuit of growth, uh, which happens for companies, organizations, people, right? You're trying to scale, and you scale a little too fast at times, and then you have to get back to the original intent, which is what we did. Uh, that, that business is performing very well, and importantly, uh, Krista Nelson, who's the CEO of the business now, talked about the clinical programs they have in place, decreasing admissions, post-acute care management, integrated mental and behavioral health, which she and I both talked about. So when you put those pieces together, and, and we still have work to do to have the model, uh, optimally work, um, but we are seeing that model get back to its original intent and perform well, most importantly on behalf of patients. Now I'm gonna ask you a question that I've asked multiple people over the years on this podcast, um, because I still-- I don't think I've had a, heard a good answer, and I still struggle with it. All right. And that is, how do you get to patient accountability? I mean, I think about like the- Yeah… ACO models and a lot of these value-based care models, they're, you know, focused on finances or, or what levers can- Yeah … you pull or, I mean… But, but when it comes down to it, if I wanna eat Twinkies, I'm gonna eat Twinkies. Yep. And, and just a, a, a quick story. I'm sitting, I'm sitting on the couch, this is a couple weeks ago. I'm sitting on the couch with my, my wife, and, um, mother-in-law w- was over and, and she's always, you know, sweets, sweets. She's gotta have her sweets, right?"Can you pick up some s- can you pick up some shortbread or whatever?" Whatever it is. And, and I just so happened she was taking her meds. My wife Rhonda was putting everything together for her mom. Yeah. And I look and I see metformin And I looked at… She's a nurse, by the way, my wife's a nurse. And I looked at her and I, and I said Wait a minute, your mom's diabetic? And she looks at me and she just, she goes, "Yeah." And she's, I mean, she's shoveling ice cream and sweets all the time at night. And it just- By the way, I hope your mother-in-law does not listen to the podcast. She- She-- I guarantee you she's not listening to it, but we s- we still, we ev- uh, it's almost like every night- Yeah … we keep laughing about this because- Yeah to me- Yeah … you just don't do those things when you're diabetic, but the truth is you do. Some people do. Yeah. And so how do you get to patient accountability in all of these models? I appreciate you sharing that story. I do like a good dessert as well. Um, but, um, I am not diabetic. Uh, so look, I would, um… I actually think it's a great point. So we-- let me tell you what we did and then where I think we need to go. So we did try to do, like, shared decision-making and value-based insurance design in a number of pro- a number of programs at CMI. I did some of them in North Carolina. We do some of them now at Optum that try to get, uh, decision-making incentives, et cetera, at the patient level. I actually think we're even earlier innings, to your point, on the patient engagement and how you really do that. We have products, for example, in UnitedHealthcare, one's called Surest, uh, that gives sort of wraparound data information on your phone, try to get patients to the right information. In our value-based care programs in Optum and Optum Health, we're increasingly engaging patients, and how do you incentivize them in various ways? How do you engage them? How do you incentivize them? So we are doing it. You know, is it optimal yet? No, uh, 'cause I think we're, if you think about the trajectory of value-based care, I think we're farther along on the physician provider side 'cause we've probably been doing it for longer. I think we're earlier innings on the patient, but I think you're right. At the end of the day, you know, I go back to my clinical training. There's some clinician and some patient, and you gotta work that dyad with a care team and engage both the patient and the clinician in a value-based care arrangement. So I think, I think your point's right, and I think it's actually a fair point, too. We're probably earlier in the trajectory of how we really do that on the consumer side well. I do think you'll have digital tools and technology that, uh, make it even easier, uh, to engage patients in, in real time. It's just, I just think about myself. I think about the times going through when am I working out more, when am I working out less? When do I pay attention to certain things? But I don't have any major health issues, and I haven't. Yeah. And I've, you know, knock on wood, if I had any wood in this office- Yeah … I'd knock on it. But, but I think about it was the, it was the constant refrain from physicians that I heard in the sort of trajectory of the ACO world back at NACos, right? Yeah. In that timeframe where they'd say, "You're holding me accountable to th- for things that I don't have control over." Yeah. That's very frustrating. I mean, and from a management setting, you don't wanna hold your employees to account to things that they can't control, right? And so it's this, it's, maybe that's a bad analogy, but I think about that, like getting, giving them tools, giving them the technology to, to do these things, but there's that, "Hmm, what's gonna get them to change their behavior?" Totally. And, um, I don't know, maybe we look to the behavioral economists for that. But- Yeah. Actually, that's one of the answers probably. So yeah, agreed. Probably. I, I, I wanted to get to, 'cause you had, you had mentioned, um, care in the home. I wanted to get to these wraparound services because- Yeah … I feel like sometimes they, I don't know, they get ignored or there's so much focus on just traditional primary care, but behavioral health, pharmacy, you know, Optum at home, like- Yeah talk to me about those services in the context of value and where we're headed, please. We are trying to care for people's physical, mental, pharmacy, social, and financial needs. Wherever they are. Uh, we do that across populations. And then you actually hit on a critical point. We certainly do that in clinics with primary care, you know, a, a core part of the model. But we also do it in the home, and I like data and stories. So the care at home model that you alluded to, uh, you know, uh, we will do that for dual eligibles on Medicare and Medicaid, complex Medicare Advantage. We'll also do it in other populations, but it's all about keeping people healthy and at home. So the-- one of the stories I'll share, you know, 91-year-old, 14 plus chronic conditions, been hospitalized 10 plus times the year before we start caring for her. You know, geriatrician going to the home, loves the work, by the way, not doing fee for service medicine, you know, really spending hour plus with patients that she sees them in their home. Uh, you know, now this woman is hospitalized zero times. You know, we actually, when she had her husband pass away, provided virtual mental health care to her. She was lower income, so we helped her with food and housing changes she needed to prevent falls and make sure she had the nutrition she needed. So I mean, it is a holistic care model. That's, you know, one example. Um, and, you know, we do home health, we do hospice, we do the sort of entire care trajectory. Integrated mental and behavioral, one of the stats I gave this morning, we've been co-locating, uh, behavioral clinicians plus doing virtual. We're seeing engagement of 90 plus percent of our patients. So you see, when you-- You know, mental and behavioral he-healthcare in this country is hard to access sometimes. If you provide accessible access in an integrated model, it actually works. You know, we do ambulatory surgical centers. Why do we do that? Because when people need procedures, we, on the margin, it is cheaper and more convenient for them to do that in the ambulatory s-setting. So we wanna provide for that. Specialty pharmacy and, and home delivery and, uh, infusions are all pharmacy interventions so that we can provide, once again, the right medicine at the right time affordably to the patient. So I think you're 100% right. I think part of the reason our model performs well for patients is because we have the whole set of services that we can wrap around the patient, uh, to serve them, you know, whenever and however they want for any need that they have. So it's two-part question, follow-up. At Optum, who is accountable for seeing all of that? And if you think of like, um, traditional IDN, like an Intermountain- Yep… whatever, how, who has eyesight into that? Yeah. Who's accountable? Because, you know, traditionally those are things that are siloed, right? Yeah. Yeah, so we actually, think of us, uh, and we've been talking about this, this, you know, people often think of an Intermountain or a Geisinger, you know, an integrated network in a, a various geography, or a Kaiser. We actually are building an integrated, uh, care model at scale nationally. Like, that's at the core what we're trying to do. Uh, and we are deeper in many geographies than others, but the go- we service all 50 states, uh, over 90% of rural counties in some way. We do when we take, and we do it in full risk, we also do care in other ways, so more episodic care. When we have a full risk arrangement, we do have an accountable entity even within our system. So it could be a clinic and a primary care doctor with a care team wrapped around them. It could be a geriatrician or a nurse practitioner going into the home with a care team wrapped around them. But we do have an accountable care team at its core that they know, you know, uh, your, stick with your mother-in-law, if she was in one of our models. Your mother-in-law, we're accountable for. And, you know, when we go into that home or that clinic, we're gonna care for everything that he or she needs because our incentives are aligned with better healthcare for the patient, you know, decreased hospitalizations, better medication management, you know, true population health and prevention. So that's what I love about the model. It actually aligns incentives with what you'd want out of the system. And honestly, we see our physicians and clinicians with less burnout, higher patient, you know, higher experience ratings. And I think the core of that is because we are putting a system around them that lets them do what they wanna do, which is provide amazing care to patients. So in, in the, in the IDN model, where do you s- where do you suppose, I guess, that that- Coordination or that accountability, not coordination, the accountability, where that would lie. Is that a chief medical officer that, that has eyesight into, into all of that? Yeah, we have, uh, it's a good question. So for us, uh, you know, for any entity, we've got sort of a CEO running the legion- region. We have a CMO or a clinical leader paired with a operational leader. Um, so think of it as a dyad or triad type structure. Yeah, I think that's pretty common in other, you know, whether you look at a Kaiser or Intermountain or others as well. So that's how I think about our care model and how we think about the accountability. And then that keeps drilling down, right? So if you've got a regional leader, then you've got leaders in the various smaller geographies. So, and that's actually when you talk about getting back to basics, we pro- we, we made sure we had that sort of fully built out across our entire network nationally. That was one of the things in Optum Health we did to get the business operating at full capacity. One of the things I find is fascinating, I've been sort of on the sideline studying all of this now for, this feels like decades. But when the IDN world, let's set aside, uh, you know, the Kaisers, Geisingers, you know, Intermountain, set those, that model, the old managed care model aside. Yeah. And if you look at the IDNs that have at least attempted to get into the world, to, to your world or to United world, they fail. I mean, consistently. Yeah. And maybe there's some partnerships, you know, Banner Aetna here in town, the things- Yeah … like that, but they fail. But what you're doing is you're sort of approaching it in the opposite way, and you're starting from understanding how to manage risk- Yeah and then going out either through employing or through contracting with or having- Yeah … affiliations with these different providers, and that seems to be working better. What are your-- I don't know. That, that's my thought, but what are your thoughts on that? Look, I think you hit a great point. Uh, I'm usually a believer of and, so I think both models can and will work over time, right? And actually, we do, increasingly we're doing work through our Optum Insight business and through Optum Health. How do we support various health? So we work in some way with health hospitals and health systems, about 80% of the country. Um, you know, today a lot of that is, um, various technology solutions. Increasingly, we have actually conversations I'm super excited about. All right, um, you actually named some we've talked to recently. You know, how would we partner, uh, with you on value-based care? So you wanna go on this journey. You've got a set of assets and capabilities. We've got a set of assets, capabilities. Why don't we work on it together? And then you figure out the structure to do that. Tell you another thing that may surprise you. In home health, we have over 400 JVs with hospitals across the country. These are literally, you know, you wanna get people out of your hospital in a timely manner. We, uh, you know, provide home health. Let's work together to get people out of your hospital in a timely manner into a home health agency that you have an affiliation with. You know, uh, often, as I said, over 400 times, a formal JV structure with. So, look, one of the key things that we think we need to work on over the next year at UnitedHealth Group and Optum is relationships with these external parties. So whether it's, you know, a health system or a payer or a employer, how do you have stronger relationships and partnerships?'Cause no single organization do everything. If our goal, which it is, our mission, is to make the health system better for everyone, we're gonna have to do that through partnerships and relationships. So that's, that's what we're trying to drive. So you had, um, this is gonna be a sort of a non-sequitur, but I've gotta get to it. I wanna make sure that we- Yeah … talk about, about AI. Yeah. And I think about, I think about the scale that you have at- Yep. Optum, but, but say United, right? The im- Yep … immense scale that you have. You probably have more infrastructure, more data than anybody on the planet as it relates to healthcare, I would think So you probably have not, I'm assuming you're not an AI expert, neither am I, but you probably have some idea where AI is really performing well- Yep … and maybe where we're seeing a lot of hype. Just your sense, again, we'll have plenty of AI people on here, but your sense- Yeah… as, as with the data that you have, where is it really working spectacularly well? Yeah, look, um, I'll give you the areas. It is funny 'cause you-- I do use AI at a personal level, so we have Agent PC, which is an agent that mimics me, that gets better and better that we worked on. We had at our e- our executive meeting, you were supposed to build an agent, and I think they were surprised I actually showed up and built agents, and then apparently I built the most agents. But I actually think it's like, I think it's super interesting, and actually the coding, I'm not a coder. My kids know how to code. I don't know how to code. It'll change everything in our business and in healthcare, that sort of thing, one. I actually don't think that's hyperbole. Then how are we using it? Administrative functions, so we're going pretty deep and we're seeing results, where how do we make the system simpler, better, faster? Give you a real example, you know, digital prior auth, where you can get to 99-plus percent approval. Um, you know, processing of, of, uh, claims, clinical information, call. You know, in call, we take about 300 million calls a year. We think that could go down to 150 million and keep going down because you're handling people's problems through an AI digital agent infrastructure, with humans handling the most complex task, maybe humans overseeing teams of agents. Um, so really interesting in that area. Next area I'd call out is what I'll call new products and services. You know, you can name, never name all our things, but Optum Integrity One, it basically takes a chart, turns it into a clean claim code for revenue cycle. So, you know, all the doctors and coders and people that, you know, have to comb through information, y- you, you, you will still have the doctor look at it. We still think clinicians make the final call, but you're queuing up all that information to them, uh, to that, you know, physician and coder. Um, so new products and services. Optum Real is another one they're working on that is sort of a spectrum of how you real time settle claims across the system. And then clinical, I think, is really interesting, and I, you know I like data and stories. So my first, um, my first week as an attending at Children's Hospital Philadelphia after I'd finished residency at Boston Children's, I have a child comes in, uh, been referred all over America for two years. This happens at children's hospitals. Uh, I get to page 487 of about 1,000-page chart, uh, after hours of reading. Um, and I'm like, "Oh, I think this kid has a rare mitochondrial disorder." Uh, that ended up being the diagnosis. But in an era of AI, that child should get that diagnosis anywhere in America, maybe anywhere in the world, within seconds or minutes. Um, and then in our area, how are we using it? We're starting to tee up those kind of things to our clinicians. If we got a nurse practitioner going to the home, let's tell him or her about the patient going in. As they do the visit, ambient listening that documents for them. As they're, you know, doing follow-up care, instead of them trying to find what to do, let's tee up to them from their panel, "Hey, these 10 patients need, you know, a hemoglobin A1C. These five patients need, we think need their medication adjustment." Once again, then that clinician makes the final call, but I can tell you from practicing medicine, it is hard to keep track of a whole population, especially a population that may even-- you may not be coming into your office. So how to use AI to, you know, monitor and support care of a population both in the office and virtually. I can think of, um, a million applications in the home, right? Yeah, totally. Just being able to, to, to manage these difficulties. What about, and I know this is, it's been written about a lot, but I just… You're a clinician, you're a doctor, I wanna hear your sense of this Is there, is there maybe an age divide in how doctors are accepting AI or not? Yeah. Um, is there-- do they feel threatened, right? I have my, my sequence- Yeah … in thinking through problems. I'm thinking of Dr. House right now. But where, where are you? And then I'm sure you have lots of plenty of meetings, communications with physician leadership. Yeah. Give me a sense of where we are today with, at least within, within Optum. Yeah. So f- look, for, for Optum and me personally, we're embracing the technology, but we're embracing AI and technology on, uh, on what we talked about, value-based care, how does it give you more time with patients, how does it support your care model. So, uh, you know, I'll give you a few data points. I, I still take boards, uh,'cause that's how medicine works. So it used to be, you know, I, I always answer the question first, but for my boards, and most of them you can look online. So, you know, originally, AI was wrong quite a bit of the time. I will tell you now, I just finished my last quarter of questions. AI was right 100% of the time. That is not uncommon anymore. So I think we need to train physicians and other clinicians how are we gonna use AI and technology to support you in your work. So I do think we need to think about medical training differently. I was, you mentioned boards. I was on the Walton School of Medicine board, to name one of them. Uh, you know, the reason I served there f- for Alice Walton and that team is I, I actually think it's quite interesting to think about how do you think about technology in a whole health way, you know, powered by AI and technology, which is what they're trying to do at the Walton School of Medicine board and some of these leading, you know, educational institutions. So look, I, I think it'll change the way we think about medical training as well. The age aspect, you-- there was a study in radiology, as an example, that showed AI and radiologists. In that study, uh, younger radiologists were more likely to adopt the technology than older radiologists. But I think, like most things, you're gonna have people of all ages and types, right? There's gonna be variability around the individual humans. So for us at Optum, you know, we're deploying it across our clinicians. 90-plus percent have ambient listening and documentation, for example, available to them today. And what they tell us is it's making their life better, it's making their ability to be with patients and look them in the eye better, as opposed to typing on the computer, and it's helping them manage aftercare, which is,"Okay, I saw a bunch of patients today. How do I make sure I don't miss anything?" I'll tell you what worries me, and I think, um, we're probably about the same age. Maybe you're a little younger. I don't know. But we're about the same age. I feel like the people who've been through it, been through the education, have a better understanding of exactly how to use AI. And I'll use a, I'll, I'll use a Darwin example here. So I have a- Yeah … a small consulting and market research company that focuses on the topics that we're talking about today. And we, we do that for m- mainly pharma biotech clients. Yep. But we have a young, say 20s, early 30s, a young group of people that I'm trying to train to become analysts, thinkers, um, who understand how to use data, who understand how to interpret information, and then make recommendations, right? Yep. Not, not doctor stuff, but it's kind of the same logical flow. Yeah. And I bet if you went back to thought about how you learned in medical school- Mm-hmm… flashcards maybe, constant Yeah … over and over again, it gets burned into your brain. Yep. My, my concern is, this goes back to the medical school education, and I, again, this has been written about- Yep but I think about it a lot, is the, the actual in-depth learning. Mm. And the example that, that I often use is, you know, remember back in high school or in college, you're supposed to read this book for your English class. You didn't read it. You grabbed the CliffsNotes or SparkNotes, whatever it is. You cram your way through it, and you ace the test the next day, right? A month later, you have no idea what that book was about. Yeah. Right? Yeah. So I worry that there is, um, you know, a lack of an ability, maybe I'm not saying this right, but the ability to learn, especially these students in medical school, that they're gonna hand it off to AI, and they're gonna lose those critical reasoning and critical thinking skills that are essential for being a good clinician. Yeah. Look, uh, I have a nephew in medical school. I've got a son in college who's engineer and knows coding. Um, uh, so here's what I'd say. I, I think you're right. We still need to teach people, you know, core clinical reasoning, ability to learn. Honestly, um, the Continuous learning, right? So one of the things I say internally and externally, I just want myself and all of us to get better every day. Literally, when I interviewed at Blue Cross North Carolina to be the CEO, I was like, "Look, I will not be the best out of the gate 'cause I've never run a payer." And I knew they had a bunch of people that were already CEOs interviewing. But I'm like, "I, I'll work really hard, and I'll try to learn fast." So I do think you need to p- teach people, you know, learning, um, critical thinking, et cetera. You know, one of my-- I, I was at Cincinnati Children's early in my career at that time to learn quality improvement. The mentor at the time, uh, told me, I said, you know, "What's the most critical thing to improving?" It was Dr. Uma Kodagal, and she said,"I've trained thousands of people. It's cycle time." And I still carry that with me to that day. Cycle time of learning, cycle time of testing, you know, whether it was the innovation center at Blue Cross or now at Optum, you know, how do you cycle quickly? How do you learn? And I think any, you know, if I'm in a clinic, uh, which I do a lot of traveling around, seeing customers, seeing our people in the field, you know, I, you can get a sense of, you know, are they learning? Are they testing? Do they have on the wall what they're doing? You know, are they using technology plus other things to improve? So look, I think that's what we're trying to do at Optum. I think it's, it's key to the health system. We have to improve faster. So, so now that you sit where you do and you have, I mean, at one point you were, you were building or second, as you said, in building some of these federal models. Yep. And now you have real leverage- Yep… across all of these different areas. And it must be like, you know, a kid in the candy store sometimes when you come in every day and just say, "Wow, look at all these opportunities." But what are you focused on? Where do you see the biggest opportunity, I guess that's a better way of phrasing it, Patrick, when you have- Yeah all of these different components to address the affordability issue in healthcare? I know there's-- we can get more s- we get smarter, get more efficient, value-based care, all these things, but there's this affordability issue- Yeah… with a lot of patients. How do you leverage all that you have to address that? The macro… Look, uh, uh, for our country, the public-private sector, there's kinda two options. If you don't bend the cost curve on affordability, eventually we will have to raise taxes or lower benefits or both. I don't think that's a good outcome for Americans. So the alternative path is through value-based care to drive better, affordable, better quality experience. I think you heard that we have evidence it works in the public and private sector. I gave a bunch of them. I won't say it all again. We've got evidence from Optum, we had evidence from CMI. It works. Now we gotta scale it faster, 'cause if you look at affordability in this country, it is the pr- in polling, it is the primary concern of Americans, affordability of healthcare. So I tell a patient story. I worked in the hospital weekend before last. 21-year-old single mother comes in with viral meningitis, almost goes to the intensive care unit, is now better enough. She's not better, but she's, you know, well enough to talk, and her first words to me are, "Get me out of this hospital. I cannot afford it. I'm a single mother. I got a kid at home. Get me out." Um, that's scary. That's affordability in a human. We did figure out how to have her safely leave the hospital. But that, you know, this affordability, you know, I grew up in a, an environment where I understood affordability, um, on a personal level, um, and the impacts it has on families. That has an impression on you for the rest of your life if you grew up in an environment like that. Um, it makes you-- I care for a population clinically that is, you know, 80-plus percent Medicaid and 20% uninsured at a safety net hospital in Boston. You see affordability, the cracks in the system, you know, in real time. It brings it home to, like, why this work matters and why we need to do it at scale. Yeah. It's, um, I like to feel that what we do around here at a very, very small scale, but at least at some level is, is, is getting some improvement in that area. Yeah. Um, last question, and, um, I know our producer is listening and probably is gonna tell me, "Don't ask this question last," but I'm gonna ask it anyway. As you prepare for 2027 What are you paying attention to, and more specifically, what's keeping you up at night? Look, um, I always give the same question. Well, first of all, nothing keeps me up at night. I fall asleep in about two seconds, probably 'cause I need more sleep. But, uh, if something kept me up at night, um, look, I worry about-- it's honestly, it's where I started. I worry about people falling through the cracks. In any large system, you know, at Optum, we're caring for, you know, millions and millions of people. Um, there's somebody not getting the care they need. There's someone, you know, not getting the mental and beh-health, mental and behavioral care they need. Um, it was the same when I was at CMS. Any decision had people it helped, and it had people it might not help. So how are you gonna reconcile that? How are you gonna keep the system operating better? You know, then specifically for Optum for 2027, I-- look, uh, I'm excited about our momentum. Uh, I've, I, I do count time. I'm now slightly over 18 months. Um, I break my life into cycles, uh, 168 hours in a week, uh, six-month cycles. This will give you some psyche into how I think. Look, our team is a much more high-performing team, but at the end of… The reason that's important is because then the impact we can deliver on the people we serve, patients and others in the system, you know, just gets better and better. So, you know, Optum Health, integrated value-based care. We spent most of the time today on that. Optum Rx, a real leading pharmacy model that's transparent. You know, I-- sorry, I'm gonna take, take time with the last question to, you know, specialty. We didn't talk about this one. I love this one. Specialty medicines. Built an AI-powered tool that saved over a billion dollars out of pocket for consumers last year. That's the data point. The story is, uh, a gentleman who emailed me and was like, "I have cancer, and I was going on and off my medicine, and I didn't wanna tell my wife 'cause it was really expensive. Now, with this tool, it's $5, and I'm on it, and I'm doing better. Thank you." That is, like, the best, right? We, we helped people in the macro over a billion dollars, and then you understand it's, like, a real human that we helped at Optum Rx. And then, you know, Optum Insight is our data technology business. We're in an era of AI. You know, our complex, fragmented system, we should be able to have a system that's simple, fast, easy. The payer knows what they're gonna pay. The provider knows what they're gonna be paid. The consumer knows in real time. They can swipe their card or, you know, put their phone, and just like everything else in our lives, it's an actual system that works and is transparent, and you have choice, and you can be engaged in it, which is obviously not what our healthcare system is today. So, you know, we think with Optum Insight and Optum Financial, we can help build that system for people and are doing that with payers and health systems and employers across the country. So look, I'm excited about the future. I'm natural that way. Uh, and I know we gotta improve faster. I said it was the last question, but you brought up one more that I'm, I'm thinking of. Yeah. So I mentioned that we work with, uh, a lot of the pharma, biotech companies. You talked about that savings, right? Yeah. And I know that you understand the pharmacy component Yep. In my experience, pharma as an industry, they're trying to do better, they're trying to do different, they're trying to, right- Yeah versus the old, you know, detail a doc kind of model. Yeah. Of course, there's plenty of direct consumer advertising that, that- Yeah… you can watch on any, any given night or when you're watching football on Sunday. But from your perspective, Patrick, what should, and I'm not talking about contracts. Yeah. What should the industry be doing, that industry be doing differently to be a better partner to Optum, to be a better partner to United, frankly, to be a better partner to health systems? Like, how should be they, how should they be thinking about future? And I'm only asking the question 'cause I know there's plenty of pharma people who listen to this- Yeah … podcast. Yeah, so two things. One, look on the positive side, and I, I've said this at forums with pharma. You know, there are literally diseases of children that I took care of that used to be the diagnosis, you know, w- would mean the child would die, that now you have gene therapies and other therapies that children with that diagnosis will now live the rest of their life. That's amazing. So pharma has developed some amazing products that have, you know, incredible positive impacts on people, uh, literally life-saving. Thank you. And I, and I mean, I deeply mean it. Then we've got an affordability challenge, which you know. We've gotta make those medicines as affordable as possible, so we actually work with pharma on that. We do work with pharma. We've got an Optum life sciences company that data technology support pharma, like how do you find the right patients? How do you get the right therapy to the right patient? Um, so the, we partner in those areas. It is. It really is. Exactly. We-- That actually, we're s- we're doing some clinical trials. We're probably gonna do more of that. How do we partner with you to help you do real world evidence in clinical trials? We've got a big clinical care system, so we do some of that today. I think you'll see us do probably more in the future. And then, you know, I'd call out, like in specialty medicine, we actually talked about on the earnings call today, but we've been talking about it internally for a long time. How do we partner with pharma? D- Same idea. We've got a big care system. How do we get the right specialty medicine to the right patient at the right time, you know, as affordably as possible? And that's actually in pharma's interest, it's in our interest, and it's in the patient's interest. So that's, that's the kind of work that, you know, we'd like to do with ph- the pharma and the biotech industry. Wow. Well, this has, this has been great. Patrick, anything else you wanna add before we wrap up? I know we've, we've hit a bunch of topics, and by the way, I've, I hope to have you back maybe in a- Yeah… you're a very busy guy, so, but, Look, uh, where do I start? Thank you for having me. Um, you know, I've, I've now been doing this for a while, uh, so I'm, uh, 25 years in or so. Um, and, uh, yeah, I think we've made a lot of progress. It's had impact as a, as a country and, and as you alluded to, and it sounds like you have other guests who said this. You know, I hope the next five, 10, 15 years we make so much progress we look back and we're like, "Uh, we're keeping people healthier, we're keeping them out of the hospital. We've, we've bent the, you know, trajectory of the cost curve in this country so we have a sustainable healthcare system." And yeah, that's the work, that's why I show up every day. Uh, last story I'll end on, when my, my father passed away about 20 years ago, but, um, I, I asked him about, you know, he said, "What do you wanna do, Patrick?" And I said, "I wanna change healthcare in America," which was pretty funny 20 years ago that I actually said that, but I did. Um, uh, uh, 'cause what did I know? Uh, and he said, "You know, Patrick, that's really hard, but you're really persistent." Um, so there is something about persistency, so we gotta keep working on it together and, um, uh, I'm optimistic about the future. So thanks for having me. And thank you. Thank you so much. And, and to our audience, thanks for joining us on Healthcare Rounds. If you enjoyed this episode, please forward it to a friend, rate, review, and subscribe on your favorite podcast platform. Remember, positive reviews help people find the show. And if you have a question that you'd like me to answer in an upcoming mailbag or anything related to this episode with Dr. Patrick Conway, please send that to healthcare rounds at darwinresearch.com. I'm John Marchica, and we'll see you next round.