 Good afternoon, on behalf of the McLean Center for Clinical Medical Ethics and the Center for Health and Social Sciences, Dr. David Meltzer and I are delighted to welcome you to the first lecture in our 2018-2019 lecture series on improving value in the U.S. healthcare system. The lecture series will consist of about 20 lectures and will meet during the fall, winter, and spring quarters. Thoughtful reform of our healthcare system is essential to improving quality, managing costs, and contributing to sensible and effective coverage programs. We hope that this series will examine these kinds of questions in the context of the current, how shall I put it, volatile political climate and the uncertain future of the American healthcare system. Speakers in the fall quarter will include next week Ashish Shah from Harvard, who will do an international comparison of healthcare costs, the following week Kate Baker, the dean of the Harris School of Public Policy, the week after that David Hyman, professor of law at Georgetown University, but a graduate of this medical school and this law school, will be speaking on why Americans pay too much for healthcare. The following week Ralph Muller, who for the last 15 years or so has been the chief executive officer of the University of Pennsylvania health system, but before that was for 15 years the president of this hospital, and at the end of the quarter John Wasson, an emeritus professor from Dartmouth, will be part of the speakers. It's now my pleasure to introduce our speaker today, the keynote speaker in our series, and that is Dr. David Meltzer. David and I go back a couple of years, probably well over 25, when David was a fabulous medical student here at Pritzker, and while at Pritzker, David also did his PhD in economics, working with the late Gary Becker. David is the Fannie L. Pritzker professor of medicine, chief of the section of hospital medicine, and director of the Center for Health and the Social Sciences. David's research explores problems in health economics and public policy, with a focus on theoretical foundations of medical cost effectiveness, and David also serves on the faculty of the Harris School and the Department of Economics. Currently, very exciting, David is the recipient of the Centers for Medicaid and Medicare Innovation Challenge Award. In this award, he and his team are studying the effects of improved continuity of care on the doctor-patient relationship. This relates to having the same physician care for patients, Medicare patients, who are hospitalized frequently, and care for such patients, both in the inpatient and the outpatient setting. Today, Dr. Meltzer's talk is entitled, as you see behind me, Specialization in Value in U.S. Health Care. It's a delight to give a warm welcome to David Meltzer. Thanks. It's a pleasure to be here. I don't want to speak about dates, because according to my slides, it's September 3rd, but I think it's actually over 30 years. So I was only four at the time, but it's okay. So this sounds a little loud. Can we bring it down a little bit? Is that okay? Does it sound good, bad? I hear an echo, but I don't know if anyone else does. Is it good? Okay. So I'm going to talk today about specialization and value in U.S. health care. And this is the kickoff, not because I'm arrogant enough to think that I have the most important things to say, but because I help Mark organize it, and the person who was supposed to give the talk, I'm backed out at the last minute. But I'm going to take advantage of the opportunity to, we should just turn that off. There, that's better. Okay. I'm going to take advantage of the opportunity, both to talk about this topic that I think really is critical to thinking about value in U.S. health care, and also to talk a little bit about value itself, because that's going to be a critical concept throughout this series. So let me begin by giving you a little overview of the key points. The first is that the U.S. health care system offers poor value compared to alternatives, and that the primary reason for this really is an excess of cost, although there are real issues about outcomes as well. The second point is that the U.S. health care system is a very high degree of specialization, which there's good reason to believe may increase costs without improving outcomes, particularly at the margin, and I'll talk about that. On the other hand, there's evidence, and this is where I'm going to talk about our comprehensive care physician work, that reducing specialization, if done thoughtfully, can improve outcomes and value. I'm going to show that and talk about how we've approached this intervention that really goes about defragmenting care. And then finally, I'm going to end by talking about some of the challenges in improving value through efforts to reduce specialization, and I think it'll really come down to overcoming some of the powerful political and economic forces that have produced the current system. And I think as you hear throughout the course of the lecture series, a variety of ideas about what's wrong with the system and how to make it better, you're going to hear again and again, if not explicitly, at least between the lines, how essential the political problems are here. Let me also say this lecture series has been given in the past in a much smaller room, and in that sort of room it's a lot easier to interact directly during the course of the lecture. I want to see if I can split the difference. So people feel they have a burning question during the course of the lecture. Let's try it and see if it works. If to the end, my plan will be to get done early enough that there's meaningful time for discussion. Okay, so value in U.S. health care. So the first thing I want to touch on is sort of what is value? And if you look at the dictionary definition, it's illuminative. So it's the worth of something relative to its price or cost. So are you getting something that's worth what you're paying for it in essence? Now you'll see often things like value equals cost divided by quality. I don't like that. I don't know what the word is, but I particularly don't think quality is the only thing that people value in health care. So I just want to say that because you may see this and it always annoys me and I want you to tell them it annoys you too. One thing that value may mean is sort of cost relative to outcome. And the delta there means the sort of the change in cost relative to change in outcome. How much more are you paying for something relative to some alternative? And how much incremental benefit are you getting relative to some alternative? This is essentially the idea of cost effectiveness. And I'm going to touch on some results about that as I go through the talk. So but this begs a couple of questions. First, what is cost? Well, economists have a pretty clear definition of this. It's what economists call opportunity cost. In other words, what do you give up when you choose to do something compared to the alternative of not doing that thing? This is a surprisingly tricky concept to understand because it depends a lot on your perspective. So for example, when you think of cost for health care, you may think what do you pay as your own co-pay? That may be cost to you, but not cost to society as a whole. Moreover, when you pay too much for something, more than it costs, for example, or more than it's worth, particularly more than it costs, that in some sense is a transfer, right? It's profit for the individual who you've paid too much to. And that's not necessarily waste. That's resources they get and get to use. So that's not really wasteful in a sense. In fact, it's those profits that might allow you to be hired. It might allow you to get a grant from pharma. So how you think about cost really matters. And that's gonna be a hidden fact that you should think about a lot when you hear about why the US healthcare system is, quote, so inefficient. A lot of money is transferred in a whole variety of ways in the system. It may work out, but it may be inefficient. And in some sense, what we should care about are real inefficiencies. Actual uses of true resources that don't produce value. I'll show you some examples of that. So what's outcome? Well, I would argue that outcome is what people see can choosing something, that what they're trying to accomplish. Often that's measured in outcomes research using sort of length or quality of life sometimes combined together into outcomes like quality adjusted life years or qualities. These are simplistic measures. I think we all recognize that individual and societal values may be both very important and we have to figure out how to measure them. So this is not, understanding value itself is just an entire lecture series. But I think the big picture is that value is maximized when outcomes are maximized given the prices and costs that you face. I think that's the basic idea we're striving for. Now, economists, I'm an economist, as well as a physician. And economists think about this in terms of what we call production possibility frontiers. It basically shows the trade-offs that we face between the things we want to accomplish. In this very simple graph, we want to be healthy on the y-axis. We want to have money to do a bunch of other things on the x-axis. And in general, we're sort of happier the further up we are in this area. Now, there's nothing that tells us what the right point intrinsically along this curve is. It really depends on our value or preferences, right? You may value health a lot and give up a lot of other things to do it. You may not value health very much and want money for a lot of things. The one thing we can clearly say without saying something about preferences is that being down here is not a very good thing, where we basically are spending too much money for the health we're getting or the equivalent. So that's bad value. I say that because the US seems to be in that curve if you compare us to other countries. This is a figure I'm sure almost every one of you has seen. The little dots are countries. This is health spending over here. This is life expectancy over here. You can see this beautiful curve showing kind of the more you spend by large, the more health you get, except for this dot, which is us. And it seems we spend way too much money for the amount of health we get. Now, that's a complicated statistic, right? Maybe it's the healthcare system's really bad. Maybe it's that we have a bunch of other problems as a country that hurt people's health that somehow aren't the responsibility of the healthcare system. We can argue about that. But clearly, we're not on what seems like a production possibility frontier in a global sense. Now, you can see if you look at that, that our life expectancy is also somewhat below a bunch of countries up there at the top, which are largely OECDU countries, but not completely. And one striking thing is that if you look over time, actually when I started on the faculty here, our life expectancy was kind of like those countries, and now we're a fair bit below that. I don't feel personally responsible for that, but it doesn't make me feel good. So something clearly is not working the way we might want it to. Now, you can also look at these sort of life expectancy and cost statistics over time. And this is a figure that plots that. So the line here shows sort of US healthcare spending kind of per capita going up over time and life expectancy sort of flat. And I saw this figure, and I thought, oh, this is kind of cool and interesting. And being an economist who does cost effectiveness, I couldn't resist doing a cost effectiveness analysis of this. So I sort of asked the question from 1970 to 2014, how much more did we spend, which turned out to be about $6,000 per person per year, and how much extra life expectancy did we get, which turned out to be about four years, and thought, is that cost effective? The little mathematical trick here is that $6,000 isn't over a whole lifetime, it's in one year. So if you sort of extrapolate, you're really spending about half a million dollars more than you would have in 1970 in real terms over a course of a lifetime, and you're getting about four years, which turns out to be about $120,000 per year saved, which by most standards would not be considered particularly cost effective. There's no right number, but estimates range between $50,000 and $100,000 or $200,000 per life year, and that number assumes that every increase in life expectancy that we've had is due to healthcare, and no one really believes that. So in a macro level, I would say the U.S. healthcare system is kind of eking right along at a rate of change that we should worry whether we're getting our monies worth even on average, but on average isn't good enough because it's still very possible that we're spending a lot of money on particular things that's totally wasted, okay? And so let's look at that in a little more detail. Well, one state of individuals for whom the system really may not be working that well is those who are underserved in race is a pretty good proxy for that, and so I'll just point out that healthcare spending is high across many, many racial and ethnic groups, but that in fact we're really not doing a very good job of increasing life expectancy or having a high life expectancy at least for many and relatively underserved groups. I'll also point out that if you look at how we spend healthcare dollars in the U.S. compared to other countries, we're an extreme outlier with respect to healthcare spending here. The top bars here is actually all the money that we spend on non-health related social services. This is a slide from Betsy Bradley's work. She's at Yale. She's actually a Chicago MBA grad, and the really striking thing is we're like right in the middle of the pack when you look at social service spending added to medical spending, and yet the only reason we're in the pack is because we spend so much less. I look at this slide and can't help but feel that to some extent we are crowding out social service spending by virtue of how much we spend on medical care, and I think that puts sort of a sharp point on how we should think about this problem and think about issues like health disparities. But I want to drill down a little more specifically to why I think there's so much sort of fundamental structural or at least my belief that there is so much structural fundamental inefficiency in the system. And my favorite example of this is in a cost effectiveness analysis of the use of pap smears in the United States. So I think we all think pap smears are a good thing. They prevent cervical cancer, mortality, it's something one should do. The question is, how often should one do it? And there's literature, and I'll talk in a minute about how all of that literature is, looking at how much gain in life expectancy you get depending on how frequently you get a pap smear. It turns out if a woman gets a pap smear every three years over the course of her life expectancy, she adds about 70 days of life expectancy. That may not sound like very much because most people die of cervical cancer anyway, even if they don't get screened. And that turns out to cost about $2,600 per life you're saved. Well, what if you get it every two years, as opposed to every one? Well, you get 71 days. That's not 71 days more than 70 days. That's one day more than 70 days. And then that turns out to be about the incremental cost, so relative to the benefit you would have got by doing it every two years. It's actually $91,000 per life you're saved. That's something most people would say is not particularly cost effective at the margin. And then what if you do it every year? Well, you get 71 days and eight hours. So you're probably spending most of those eight hours actually getting pap smears, which is not, presumably, most people's preferred activity. And then it's about $830,000 per life you're saved. So it's wildly inefficient. And this last column here shows you how many pap smears in the US are actually given at those frequencies. It turns out that only 7% of pap smears in the US are given at this sort of cost effective frequency, and that 93% are given at these higher frequencies that are not. So in other words, you could argue we are wasting 93% of our spending. And this is the kind of story I think you could tell repeatedly, not always, but repeatedly in US health care. One interesting thing to look at is if you look at the overall cost effectiveness of pap smears in the US, despite the fact that we use 93% of them inefficiently, it's about $6,400 per life you're saved. In other words, it's incredibly cost effective. So this is a great reminder of how careful we need to be when we think about rationing care, because there's super high value care that can get easily mixed in with low value care, and we don't want to throw out the baby with the bath water here. That much said, there's a lot of bath water. So specialization, how does this relate to that? So first of all, what is specialization is important. Again, let me go back to a dictionary definition. It's the process of concentrating on and becoming expert in a particular subject or skill. So it's often used in the sense of the division and specialization of labor. So the division of labor is a common term. Why is this important? Well, as an economist, I can't help but go back to the very first sentence of Adam Smith's Wealth of Nations, where he talks about why specialization is so important, and he uses this to justify why we should have markets and why he's going to write a book about markets. And he writes, the greatest improvement in the labor is the cost of the next hour, telling you all the problems with specialization. But I want to be very clear about that. First of all, some of my best friends are specialists. Secondly, if I needed to have neurosurgery, I would not want a general internist doing it even Mark. So I don't want you to leave this room with the sense that I don't respect the specialization. But I do want you to leave the room with a concern that we haven't figured out where to draw the line correctly and that it really matters for value. Now, I've set advantages. I've tried to make peace with specialists. Let me talk about the disadvantages. So in Smith's Wealth of Nations, he talks about sort of the need for the extent of the market. And what he means by this is, as we become more and more specialized, we have to put more and more people into some broad task. And that means a lot of people are doing something. So in Smith's example, we're going to make a lot of pins really efficiently because we have a bunch of people doing these different tasks. Then we have to sell the pins. In England, in this period, in order to sell the pins, you had to have ships. You had to have safe access to markets. And so you had to take over many countries and suppress lots of people. And that didn't, I think, bother Smith completely, but it was costly. So that is clearly a problem. And I would argue that the efforts to expand the influence would have continued to be a problem today, whether it's countries that try to control markets or specialties that try to control how healthcare is organized. There's also a second problem, which I'll come to a little bit more in detail later about specialization, which is coordination costs. And Gary Becker, who Mark mentioned and Kevin Murphy still here on the faculty, wrote really very elegantly about this, about the time I was a graduate student, about how when you divide up tasks among people, you have to then coordinate all these actions. And that's costly and error-prone. So that's another big problem. Two more problems, monopoly behaviors. Specialties tend to control spaces. And as monopolists, they raise prices and decrease access in a variety of ways. And then something called monopolistic competition, which I'll talk about a little bit more, that leads to another form of inefficiency in markets that are controlled by particular groups. So what's happened in specialization? Well, one thing that you can see very clearly in the United States is that there's been incredible growth in specialization over time. If you look here, you can see this is the number of generalists over time in the U.S., and this is the number of specialists. Extraordinary growth. This is all since 1965. And you see similar trends around the world, although I would argue particularly in the U.S. This is a figure from a recent paper published by Ashish Jha, who you're going to see next week. And you may see this figure again. And what this shows is comparison of specialization in the U.S. compared to other countries. And if you look at this, it looks like we're not sort of way out of the dorm, although the dark bars here are sort of special. You can see countries like Netherland, Switzerland have a much broader sort of class of what they call generalists. It's interesting, when you look though at what the U.S. calls generalists, at least listed in this paper, it's quite a different story. So we have more than anyone other, we call a group of OBGYNs of generalists. Some of them would argue that they are generalists, but I think others would really view them as very specialized. Then over here, we have pediatricians who are sort of generalists for kids, but that actually includes pediatric specialists too, so another issue. Then over here, we have the very bottom is family practitioners. I think all of us would call them generalists. And then these are internal medicine doctors. Now, so you can sort of say, well, these may not be specialists. Are these really specialists? Well, it turns out that some of them are sort of typical general internists. If you look at the actual numbers, it turns out to be about 100,000. This bar represents more like 150,000 people. Who are the remaining 50,000? Well, probably they're hospitalists, okay? And you can argue about whether hospitalists or generalists or specialists, but they're clearly not primary care doctors. So I think the bottom line is the U.S. has a system that is much less reliant on the provision of ambulatory care by generalists than others. Now, why does this matter? Well, there's a whole rich literature on the relationship between specialization and outcomes. You can dig a little deeper and ask, well, you know, is this really related to specialization? And I'd like to tell you that there's no evidence at all, but I really can't honestly tell you that. When you take a look at the sort of history of specialists in the U.S., what you see is they tend to really believe in and follow the things that they do. And again, I'm gonna go back to the Pap smear example. This is a paper by David Eddy, basically, showing that if you do Pap smears very frequently, there's really very little benefit to doing them more frequently. The results that I showed you essentially are based on that. This is a set of guidelines for the American Cancer Society, the American Society for Cognoscopy and Cervical Pathology, the American Society for Clinical Pathology. These are sort of the main guidelines about how frequently you should give Pap smears. These took a while to get from David Eddy's work to guidelines, in fact, from Ronald Reagan's presidency to Barack Obama's. So, David's work originally was in 1987 based on studies that predated that by a number of years. It was not in until 2012 that the professional size actually said, yeah, yeah, we don't need to do annual Pap smears. Why? Because they knew this is what brought women into their offices and money. And this is a story, unfortunately, we could tell many times over. The other challenge, of course, is just salary. It is a fact in the United States. Doctors tend to make more in some other countries, but not all doctors. It's really primarily specialists. So, this looks at earnings of generalists in the US, primary care doctors, a little more than in other countries, somewhat higher cost of living in some countries, but that doesn't really even explain it there. But look at orthopedic surgeons. Incredibly higher, okay? And so, this is what monopolies are good at doing. They're good at keeping salaries high. Why do they, how do they keep salaries high? They keep salaries high by keeping people out, okay? How do we know they're keeping people out? Well, one way we can tell is by looking at how hard it is to get into residencies. This is one of my favorite graphs in all of health economics. It plots on this axis median specialty salary and on this the fill rate for specialties. Essentially, every spot in orthopedics or neurosurgery, the highly paid specialties gets filled, okay? And in contrast in the low paid specialty, many, many go unfilled. And this is a classic sign of monopoly behavior. There's another sort of related idea behind straight-out monopoly behavior. It's what's called monopolistic behavior. And it's a more subtle idea, but let me just try to give you the gist of it. Physicians face, any economic entity faces a demand for their product. But when an entity has market power, when they're sort of a local monopoly, they tend to be able to hold on to their business to some degree when they raise their prices, okay? Because they know this, they tend even though they're monopolist not to raise their prices so much, and they tend to make profits, okay? Nevertheless, and this profit here is what the monopolist makes, setting marginal revenue equal to marginal cost. This demand curve is reflective of the price they can charge at that quantity where they set marginal revenue equal to marginal cost. At that point, they make a profit. One of the things that happens when they make a profit is that other people wanna get in the deal. They wanna be in that same market and make profits. When they do that, the demand curve shifts in, and as the demand curve shifts in, it basically shifts in until profits go away. The consequence of that is in the end they don't actually make more profits. They expend a lot of resources building up practices that they then underuse. And so one of the signs of monopolistic behavior is excess capacity, and the US specialty market has it all over the place, okay? So this is sort of showing the sort of expenditures, the expenditures are high, the fees are high. The quantity of services offered in terms of specialty services is not actually that high. But the number of resources is very high, that's over capacity, and the use of the quantity of resource relative to what's supplied is very high. So in other words, we have a highly specialized system where specialists by and large are not fully utilizing the very costly resources that they've gotten in terms of their training. And that's again a sort of sine qua non of a non-competitive market. Okay, so this is kind of most of the end of the bad news. Okay, now what I wanna do is try to turn to a more positive view of opportunities that we have to improve outcomes and value by changes and specialization. And here I'm gonna tell you about the work we've done with our comprehensive care program. And I wanna emphasize that this reflects the work of a whole big group of us, and I'm gonna largely base what I talk about on a presentation we recently gave at Academy Health earlier this year. So let me give you a little background about this program and why they sort of think it's important. So, you know, as the US goes to try to control healthcare costs and improve outcomes, we know that improving care for patients at increased risk of hospitalization is really critical. One of the reasons for this is that a very small fraction of patients account for a very large fraction of healthcare spending. We know that hospitalization related costs are a large fraction of these costs. And we also know that improving coordination of inpatient and outpatient care is really a key opportunity. There's been new payment models recently. They're increasingly aligning incentives for this sort of improvement. We had mission penalties, accountable care organizations, shared savings, capitation. But as we've tried to sort of solve this problem, it's turned out that solutions are really not as easy to find as we thought. This is a slide that describes Medicare's experience with care coordination programs over a 20 or more year period. There have been about 35 different programs that Medicare's tried. Typically what they do is they hire a care coordinator and the job of this person, for example, is to coordinate inpatient and outpatient care. What they've concluded is that on average, these patients, these programs, they sometimes decrease hospitalization, but often not. And they've never consistently been shown to even bring back their costs. So they often don't work. You can stratify these programs by how much interaction there is, since there's typically like a patient, inpatient doctor, an outpatient doctor, the care coordinator talking between them. You can stratify them by how much interaction there is between the patient and the care coordinator or the patient and the inpatient doctor or the patient and the outpatient doctor. The programs work a little better. The more communication there is between all those people, but even so, on average, they don't really work. Now why is that? Well, I think you can understand the problem down here. We start right now spending some money in ambulatory care and a lot of money on hospital care. We wanna shrink this bar. But we're not gonna shrink ambulatory care because that's what's keeping people out of the hospital. Care coordination costs money. We gotta make that money back, which means we have to shrink hospital care a ton if we're gonna actually save money. And the answer is we can't shrink it that much. And I think that's why these programs fundamentally don't work. So we'd really like to find a way to better coordinate care but without having to undergo these sort of expenses for care coordination. So incomes, hospitalists, okay? And hospitalists are a change from the traditional model of primary care or PCPs who care for patients in and out of the hospital. They were hoped to improve care and lower cost. They, an example of specialization, the advantages in patient expertise present, disadvantages, discontinuities of care, the fragmentation I talked about, loss of the doctor-patient relationship. What's been the effect of this? I've studied this with colleagues here and elsewhere for a while. I would say it's modest, okay, if any savings. So this got us interested in kind of why did hospitalists grow? And we think they grew originally to some degree because people believed that they would improve hospital care even though they turned out not to produce big savings. But the other reason we think they grew, at least in retrospect, is the needs of primary care. That over time, there was a declining number of hospital patients relative to ambulatory patients. Primarily because the ambulatory clinics got bigger and busier and busier. And what this meant is that the typical primary care doctor could spend their whole day seeing patients in clinic and almost never have a patient in the hospital. Which meant it didn't make sense for them anymore to block out their morning to see patients in the hospital the way they'd previously done it. And with these declining volumes in the inpatient side, increasing volumes on the outpatient side and the organization of physicians into groups, it just made sense for primary care doctors to pass this off to hospitalists. Now, what I've just described to you is kind of a theory of why hospitalists grew. And being an economist, I'd like to write this down in a mathematical terms. And we did this a number of years ago, writing down sort of the time costs of two models. A traditional model where the traditional internist spends their time seeing patients in the hospital and clinic and then has to spend time in transport. And a hospitalist PCP model where the hospitalist spends their time seeing the patient in the hospital where the PCP spends their time seeing patients in clinic. But now they each have to spend time to communicate with each other. So there's a trade-off in some sense between transport time on the one hand, in the older model, and communication time in the other. And this equation here essentially describes that trade-off in mathematical terms. And when you analyze this equation, what it shows is that the cost of the PCP hospitalist model, the new model compared to the traditional model falls, the fewer admissions you have relative to ambulatory visits. And I just told you that shit happened. As communication costs decline, so it gets easier to just call the hospital rather than go. And IT got better. Transport costs rise. Think how hard it is to park in the big parking lot here, for those of you who have to do that every day. And finally, a physician work fewer hours, which they do, both male and female physicians. These pictures on the right here are all pictures from the TV series Marcus Welby. He was the most famous TV doctor of the 1970s and known as the doctor who was truly engaged with his patients. And these pictures show these trends in his own practice. Him seeing the healthy patient in clinic, him on phone, calling rather than going in, him unhappy in the car. And then the guy in the motorcycle is the young doctor, Stephen Kiley, who liked to ride motorcycles and didn't like to work hours and long hours. So that's sort of all symbolized in this. That's sort of all anecdotes. But we actually tested this empirically using data from the community tracking study. And we're able to show that every one of these variables actually predicted whether primary care doctors gave up their practice in the hospital in order to just see people in clinic. And every one of the theoretical predictions was supported. So we conclude that hospitalists grew not necessarily because they were better, but because primary care doctors really no longer founded economical to do the old job. Now, why should this worry us? This really gets at the question of what's the value of the doctor-patient relationship for the hospital setting, and for whom does it matter? And let me just say there's an incredibly rich literature on this, on the value of the doctor-patient relationship, emphasizing trust, interpersonal relationship, communication between the doctor and patient knowledge of the patients. We know patients value seeing their own doctor in the hospital. If you ask them, they won't necessarily pay a lot of money for it, but they say they want it. There's some amazing observational studies that show lower costs and better outcomes with cognitive care. So for example, patients who were cared for by their own PCP for more than 10 years have 15% lower Medicare costs. Lung cancer patients cared for by their own doctor in their terminal hospitalization have 25% lower odds of ICU use, presumably feudal care. The next study is there's one experimental study. It's one of my favorite studies, and it's by John Wasson, who's going to be one of the speakers in this series. And what he did is he randomized about 800 complex patients in the VA, either to see the same physician in every visit or a completely different physician in every primary care visit. And the Continuous Care Group had an amazing 49% lower emergent hospitalizations, 38% lower hospital days, and 74% lower ICU days. I don't know what more evidence anyone could want of why continuity matters in care. So I conclude that discontinuity is harmful and costly, especially for complex frequently hospitalized patients, and that better coordination of inpatient and outpatient care may improve outcomes. But the question is, can we do it without offsetting any savings, for example, with the models that I showed you before? So this is where the Comprehensive Care Physician model came in. Essentially, the idea is we risk stratify patients according to how likely they are to be in the hospital. If you're at low risk of hospitalization, you get an ambulatory-based primary care physician, and in the rare instance you're hospitalized, you get a hospitalist, but it doesn't happen very often. And then for the patients at high risk of hospitalization, we have you cared for by a doctor who only sees patients at high risk of hospitalization. So they can have a clinic that's small enough that they can give those people all the primary care they need seeing them only in the afternoons. And yet every morning have enough patients in the hospital that they can provide care for them in that setting. What are the advantages? Most frequently hospitalized patients get their own doctor in both settings. This continuity is valued by doctors. By patients decreases unnecessary testing and treatment and errors is easier for the doctor. Much easier to see a patient you know than a patient you don't know. All hospitalized patients get doctors with significant hospital experience and presence. They even can be specialists. Patient choices restored. The model can work practically for a physician with a smaller panel size. You can do this in a patient-centered medical home bundling with readmission penalties. A smaller primary care base can fill a community hospital think angles, which needs more patients. Challenges are enough patients wanting to switch. Will doctors let patients switch? Will doctors do the job? And can it be economically viable? So I'm not gonna go through all the details here, but in 2012 we began a study with funding from the Center for Medicare and Medicaid Innovation. We randomly assigned 2,000 patients, either receive care from a comprehensive care physician or a doctor who was a different doctor in the inpatient and outpatient setting. And if the patient wasn't happy with their doctor, we got them another one. And our aims were really figure out whether this CCP model was better than standard care with respect to really the triple aim of better experience with care. So satisfaction with providers, health outcomes, self-rated general health status and mental health status, and resource utilization, particularly hospitalizations, but also costs. So I'm gonna show you some of those results. These are a couple of the key elements of the program. We focused on patients at increased risk of hospitalization. People who've been hospitalized at least once in the past year. We kept the panel size small for the doctors, about 200 patients per doctor. So they spent the morning on the wards, a little time off in the middle of the day and then the afternoon in clinic so they could maximize the time they spent with the patients. We built a tight interdisciplinary team that works together and is critical to this. We kept costs low with a small, well-connected team focused on care transitions, prepared for a variety of financial incentives, tried to support the team in caring for this very sick population emotionally, significant mortality rate in this group. We used rapid cycle innovation techniques with data-driven meetings and we studied all this, as I said, through a 2,000-person RCT. I'm gonna show you some results, mainly from patient-reported measures. We surveyed the patients every three months and I'll show you the results of that. In these, we got physician ratings. How would you rate your doctor on a scale of one to 10 where 10 is best? Self-rated general health status and mental health status were five is best and one is worst. Self-reported number of hospitalizations each quarter and then we analyzed this very carefully using longitudinal data techniques controlling for a variety of covariates and dealing with things like non-response rates. These are the baseline characteristics of the patients we randomized, very well matched in terms of demographics and health outcomes at baseline, including the rank of the previous provider, general health, mental health, hospitalizations in the previous 12 months. For the general health, the mental health and provider rank, we had baseline data. We had slightly different measure of hospitalization and baseline so I won't show you before after comparison except to point out that there were no differences before here. This is physician rating. Basically what you can see is at time zero there's no statistically significant difference and then as you go out to three, six, nine and 12 months and we've now carried the results forward P less than 0.001 better. Essentially, patients start out at the beginning of the study, oops, in the 20th percentile nationally. The control group goes up to the 80th percentile. The intervention group goes up to the 95th percentile. So people love these doctors. General health rating, no significant difference there at any of the follow-up points but interestingly just by chance the intervention group started out a little worse than the control and sorry and it got better over time. So we'll see what happens with this. I haven't given up yet but we may have actually improved general health status. These are mental health ratings. Again, no difference at time one and then statistically significant improvements later on. Follow-up hospitalizations, this is directly related to cost and what you can see it turns out to be about a 20% reduction in hospitalization rates sustained over a full year and when you do some of the calculations I'll show you what that translates into monetary savings. So some of the conclusions, we built this program, it actually worked and seems sustainable from the perspective of a hospital as well. We improved patient outcomes and reduced hospitalizations. The number needed to treat here is extraordinary. You enroll four patients and you prevent a hospitalization. So we estimate that our program provided about 250 hospitalizations and 1,000 patients over a year. That's savings of about $4,000 at the hospital cost per patient per year and the net savings of this program absolutely dwarfed the program costs. There's some limitations, self-reported data. We're waiting for Medicare data. There's some issues in dropouts and Medicaid. It's a single site but nevertheless I think really interesting. So what are the next steps with this? We're doing further analysis of this here at the UFC looking at elements of the doctor-patient relationship and of life care. We're expanding it at the UFC into Medicare-shared savings and other value-based contracts expanding to Ingalls Hospital. We've gotten an incredible set of contacts outside the University, Vanderbilt, Kaiser, National University, Singapore all implementing similar things with Medicare. We've been running a learning collaborative with the support of Project ECHO here. CMS is now recommended to the secretary of HHS, a physician-focused payment model that would support growth of this and we're really hoping to engage others in this, trying this. We're also doing some work to look at greater, sort of give greater attention to social determinants of health. I want to spend a minute talking about it because that again gets back to this issue of fragmentation. Turns out there's about 30% of patients who even though they're offered participation in this study, never really engaged. There's no one demographic sort of descriptor of these people. One thing we clearly hear is a lot of unmet social needs and these are reflected when we talk to patients about this. And so we've developed what we call the Comprehensive Care Community and Culture Program, or C4P that's been funded by the Robert Wood Johnson Foundation. It begins with CCP and then adds to it. Systematic screening of unmet social needs, access to a community health worker and then access to community-based arts program really to try to engage and empower patients and align resources across sectors to meet patient needs. It essentially is the CCP model but we add a community health worker and extra supports through social work. I just want to briefly talk about some of the patterns of unmet social needs because they think they're so important to understand why fragmentation is a problem. We use an instrument originally developed by Health Leads that looks at 17 different domains of unmet social needs. One of the most striking findings is that although there's some respondents who have very few needs, almost all the needs are concentrated in a small fraction of the patient who have many, many needs. And this is really problematic because when someone has 10 needs, you can't send them to 10 different organizations to deal with those needs one at a time. Moreover, you can't just ignore the needs, some of the needs, because in fact there's no set of needs that even characterizes close to the majority of all the needs of these patients. So you start to do creative things like look for pairings of needs, like if we could address these two together, could we actually solve the problem? You try to support them with community health workers and other things. We've actually with the help of students from the Public Policy School done a latent class analysis that helps us group patients into groups. And it's interesting, there are sort of five groups. The first group is kind of that everything is wrong. It's only 8% of patients, but they have sort of multiple, multiple unmet needs. Then we have a group of people who have their main needs around engaging and enjoyable activities and healthy eating. Another group here, money related needs. Another group here, children related needs. And then one group where frankly nothing seems to be wrong more or less. And so we've designed a new wave of this program that's targeted around these particular clusters. A social service alignment learning collaborative, which tries to bring together social service agencies to address the needs of these super complex patients. A community garden program with exercise and healthy eating and things like that. For those for whom healthy living and social engagement are issues. An insurance financial planning counseling group around those with health insurance and financial needs and a child related needs group. So we've been building this and we're gonna be studying this over the next few years through another RCT. I also wanna just touch on sort of patient activation because that really is a big issue in this, particularly when the programs aren't well coordinated. And there's something called the PAM or patient activation measure that gets at this. And we use it, it breaks it down into sort of four categories. Essentially ranging from not believing activation is important to really taking action to help yourself. And what we see is that about 20% of our patients are in the lowest two categories. They're really not very activated. And moreover, those patients who aren't activated have many more substantially more unmet needs. We also see really interesting patterns over time where basically the more needs you've got met, the easier it is to resolve needs you have. But if you're not activated, you're not gonna make progress regardless, particularly with the things that aren't working right now. And so you really need to get at all these things. So sort of getting at conclusions, these unmet needs in this population are diverse and concentrated. You can try to identify clusters. Patient activation is a big problem for this and these unmet needs sort of change a lot over time. And we really need to do future work to figure out whether interventions can change activation or needs and how they affect things over time. But in terms of this talk, what I really wanna emphasize is that defragmentation of provider relationships and of social service delivery may be really important. This problem of specialization is not unique to medicine. It is the problem of how we have organized our society in general, particularly for those people who are not activated and not able to coordinate it well themselves. So in the last minute or two, my remarks, let me talk a little bit about political and economic barriers to improving the value of healthcare through changes and specialization. So first some barriers. I think we need to face one very serious reality which is that specialists profit immensely from the system and that they hold substantial political power. Specialists are powerful lobbying groups. They influence our payment models, the resource-based relative value system which was designed to reverse access payments for specialists has been a complete failure. I think in this room, we also need to recognize that specialists have a huge amount of influence in academic medicine and that academic medicine has a huge amount of influence about the practice of medicine. So we need to look at ourselves at the same time. I also think we need to recognize that the incentives are not well or easily aligned for collective efforts. The chances are very good that none of us, neither specialists nor generalists or patients, really in the end benefit from this system as fully as we could and yet how we work together to make it better is very unclear. I think it's also really important to recognize that this isn't only a doctor issue, that there's a whole series of other interests in healthcare, hospitals, pharma, insurers who have all aligned with specialists in various ways for their own interests. So for example, the 340B program, which was supposed to give drugs to people who couldn't afford them, has been really distorted honestly by both the pharmaceutical industry and hospitals to bring money into their coffers. And they use it probably for very good reasons. It supports academic medicine, it does a lot of good things, but that's not really what it was intended to do for and healthcare is sadly full of that. Partially because we in many ways don't have the political courage to really pay for the things we want to happen directly. So we pay for them through these other distorted and distorting mechanisms. Also for example, restrictions on delivery models. So insurers may work with specialty societies to say, we're only gonna pay for a certain procedure done by a certain specialty, even though in fact maybe someone else could do it very well. So these are the types of alignments we need to worry about. The other big problem we have is the reduced healthcare utilization in the United States may in fact decrease local employment and savings may not accrue locally and in fact they may even promote the local health economy. So if you look at academic medicine in the United States over the past half century to century, it used to be that the greatest cities of academic medicine were the biggest cities of the United States. You know, were those with an incredible history, Philadelphia, Boston, Chicago, Los Angeles. What are the leading up and coming academic cities? They're Pittsburgh, Nashville. Why? No competition. Okay, and so in these competitive markets there's really not good incentives to work locally to solve this problem. Now another barrier is there's gonna be in the next couple of decades or even sooner increased demand for specialized care due to baby boomers. That's gonna only increase the demand for specialty care, give them lots of power. There's growing income equality. Also could increase the power of specialists. And of course the healthcare system is incredibly complex and politicized. So even if the solutions were obvious, it's not clear. You could solve them. So what is some potential for change? Well, one good thing is this movement from fee for service to prospective payment and managed care. It may decrease the influence of specialists. It may increase the incentives or pressure on specialties to use care more efficiently. There's the choosing wisely initiatives that were originally started by the American Board of Internal Medicine to get specialists to sort of work better to improve cost. I think this will also play out at the individual specialist level. As these payment models change, specialists go from being revenue generators to cost centers and the most successful specialist is the one who can give your patients good outcomes without spending a lot of resources. Maybe we will get there. There's also a lot of disruptive change in healthcare. The partnership between Berkshire Hathaway, Amazon, JP Morgan Chase, Apple's movement into this Google, the rise of global pharma, US political and budgetary challenges. This may change many things in healthcare and destabilize a lot of the current alliances that have supported this system. There's also the growth of electronic health records. This could facilitate movement towards evidence-based practice with the caveat that sort of algorithmic medicine has and always will have certain challenges and there will be limits to what we can do for that. There's also the possibility that with the aging of the baby boomers and increasing income concentration, there's gonna be a tremendous demand for specialty care and they may be having so much demand and making so much money that they don't resist change just because they're too happy. But I'm not counting on that. And then finally, the failure of the US healthcare system to serve the population may drive change. It's interesting, there was an article published by Lee Goldman in the Journal of General Internal Medicine recently, I don't know if anyone saw this. It was a pretty interesting article. He basically showed that those counties in which opiate deaths rose the most were those that were most likely to switch from Democratic, i.e. Obama in the last election to Trump in this election. So it gives you a sense that people are hurting out there and that they reflect that in their demand for change, whether that actually benefits them or not. So let me stop there. I think we have good time for conversation and I look forward to it. The attribution of the benefits that you showed to the care coordinator versus the position as the coordinator, the theater, instead of the plan with the coordination here and the patient outpatient, did that make the bigger difference? So just to be clear, we didn't add care coordination in the model. We really just added basically the same doctor in and out of the hospital. We actually ironically used fewer care coordinators probably than a lot of standard models. And a lot of the care coordinator time is basically communicating between the inpatient and outpatient physician. So we essentially are able to eliminate that step. We're working on a new model, Andrew Stram, I don't know if Andrew's here, but basically we're working on a new model. We call the rounder model where we have essentially a hospitalist who rather than working sort of very long days for half the year works shorter days almost throughout the year. So that every time the patient comes in the hospital they can get the same hospitalist and then that doctor can partner very directly with a specialist for example. So but the core intervention we think is this continuity of the physician between the inpatient and outpatient setting. We have some statistical ways to sort of test that a little more directly and we're working on that now but that's our belief as to what's going on. The patient said help you out. Yeah, yeah, so we were really worried about that when we started. It's turned out not to be a problem at all. One of the reasons why is that this is a pretty morbid population and patients pass away and then there are new patients that come in and those new patients are often very likely to be hospitalized. And the model is such that you don't need a ton of patients in the hospital just enough to justify your presence there. And so it's actually worked very well but we have a whole portfolio of strategies including in the extreme the remarkable but also for example backfilling CCP services if we needed to with other patients that could allow us to do this. And we're actually as we're beginning to work with all these partners trying to give people a whole portfolio of strategies to manage that. But we've basically been running the program now for five years and we have never had to ask even one patient to leave the model because their utilization wasn't high enough in the hospital. So it's turned out not to be a problem. Really fascinating stuff and whenever I talk to patients I always tell them the way that I say the healthcare system is broken is it doesn't serve doctors, it doesn't serve patients and it's too expensive. So the only thing we know is there's gonna be change but I'm really interested as a primary care physician in this multiplicative model of patient needs because I think this is a really big issue is that the most complete, so two of the biggest challenges in primary care is you know what somebody needs and you just can't figure out who can help them or they have some need that's really like if you just knew the right person who could help them because their house burned down and they're waiting on legal aid. And so I'm interested in how you're, since you're a hospitalist and also practice in the primary care group, how we can have that bleed into the general medicine practice because right now I find that the social needs are often the biggest challenge and those are the things that really get in the way of the care. So I don't think there's one answer here, okay? And I do think that if you can prospectively identify people as being at risk and put them in a model of care where people can really focus on that, that's a great way of doing it, okay? But there are people who have well, very good established relationships with their doctors and shouldn't give them up. And for those people I think you wanna try to find the right supports for them. Some of that is really good social work and community health workers and integrated programs to do this and we now have a care coordination program for high risk people here and I think for those people, I think that's great. They're not necessarily gonna save money but I think it's gonna improve outcomes. So I think that's an important part of it. I think that we can try to improve the continuity with the inpatient setting, for example by identifying patients as at high risk of hospitalization even if they don't give up their primary care doctor having them admitted again and again to the same hospitalist so they don't have to constantly be reinventing those relationships. There's a set of skills that I think the CCPs have learned by virtue of how much experience they have. They know so much about social service administration. They know things about how to sort of manage complex relationships that I took me years to learn if I even have learned, just cause they've seen so many more of them. They also get the opportunity to learn from each other. So this learning collaborative we've done through Medicare is amazing. Like just being on the phone every week, we don't do it every week, we do it in chunks with these other doctors from places around Chicago and around the US who are caring for these things. I think we're getting the kind of expertise in caring for complex patients that specialists get when they care for condition again and again and again. And so I think those are all things. I don't think there's one simple solution. I guess if I was gonna add one more thing I would say, let's not forget the patient in this. That there are patients for whom complexity is irreversible but there are many patients for whom if we can get at the root causes, which may be behavioral, they may be social, they may be interpersonal, then we can begin to make change. And so that may be spending more time with them in a visit, it may be referring them to behavioral health, it may be talking to their family. It could be any of those things. Michael Masal, excellent presentation. I'm wondering when you showed all those multiplicity of needs, there was a model that I was involved in more than two decades ago as part of the Wilbur consent decree. And Wilbur consent decree involved individuals who were adults with intellectual disability, autism, CP, refractory epilepsy who were in state institutions that were nothing to rave about and received Geraldo Rivera appropriate publicity. And what we came up as a model for this complex population who had seizures, who had aspiration pneumonia, who had mobility and judgment and communication and sensory and dental and I'm going on and on challenges was an idea of a schmo, a social HMO and we implemented it on a systems level like this. First, we made sure that there was regional primary care. Second, which is what I wanted to bring up for the unmet social needs, we use the community advocacy groups, the ARC, ARC for Association of Retardant Citizens, UCPA, People's Inc, et cetera as the community case managers for resources that dramatically decreased what I call nonsense, running out of medicine, no transportation, no tie with family member. And then we wrapped around a consortium of subspecialty resources for the things that were overwhelming. Psychopharmacology, mobility, frequent medical frailty. I'm wondering if that's where you're headed but nobody wants to have skin in the game on the community work that needs to be done. So I think there are a lot of good things you described in that model, including that it's a model and that people work together that it addresses the social stuff. I think there's also a huge challenge which sort of the word schmo kind of gets at it it sort of reminds me a little bit of schmuck. You know, yeah, but I think here's the big problem. If you look at sort of health maintenance organizations, which this is a form, what you've seen is consistent pressures towards underfunding and low quality and turnover. And that turnover leads to discontinuity and the discontinuity leads to distrust. This is one of the problems that we have. Like we have an amazing, it's Justine here. I don't see her. Justine's our community health worker. Like she is one of the most mission driven amazing people in the world, okay? And you know, it's very hard to find people like that and retain them. And the record of retaining them and manage care organizations and community health centers is just really bad, right? So I think there's a lot of good stuff there but translating it into meaningful practice is really important. I would feel a lot better about a model like that if it included things in it, for example, payments based on retention of staff and defragmentation of care and quality measures like that. So I think it's possible. I think we gotta think carefully about how it plays out. And I think one of the biggest issues in terms of continuity of care is like jumping from hospital to hospital. I think about your model and yeah. Amazing it would be if one of my clients stayed somewhere for years. Like when generally when I get someone, it's like, oh, I saw this person a year ago. I don't remember their name. I think they were down south and then I saw this person out west and like HIP is great in terms of protecting privacy but then I'm just kind of left to like try and make sense of what's near what train line and where they might have been. And so I'm wondering like how you think we should be serving people who potentially lose insurance pretty frequently so can't maintain care and how do we serve those people? I mean, I think that the insurance part is a big deal. And the state of Illinois has wrenched people around with a whole variety of things. And I think that's something we should think about with a new administration. But practically the reality is that for these frequently hospitalized patients they very often get driven to the nearest hospital. So when you look at our patient population for CCP, I am shocked how close they live to us. And that doesn't mean that they live in Hyde Park. They live in Woodlawn or they live in Oakwood or Garfield Park. I mean, they're nearby. And so that's one part of it. I think the other thing we can think about is how do we educate the ambulance drivers and change policy around bringing people and then motivating the patients? I'm amazed by how often the patient wants to get here but because an ambulance is free and an Uber is $5, calls the ambulance, right? So dealing with situations like that, those are structural things that we can address are really important. And of course, if you can identify the problem before you even need the hospitalization and bring them in, of course, that's great too. But I will tell you that I'm pretty convinced from the data we've seen so far and there's still more coming in that because of being in our program, people do actually concentrate their care more here. And I think that's a really good thing. Yeah, yeah. When you look at your unmet needs and they're investing heavily in AI, do you think that they understand that if you cannot activate, you may or may not be able to get the outcomes? Is there anything that's being measured in terms of that aspect? And your other slide when you showed ambulatory versus hospital, is the surgeons are going to AI at a tremendous rate? Is that gonna widen the barrier? So that's question one. And it's supposed to be Dartmouth but I know you will be facile with it. And then the second question is looking at your slide where you had the margins when the monopoly is there. Can you comment because you are with Medicare, the influx of concierge medicine, what do you think that's going to do to those specialties in terms of their margins? Okay, so I haven't had lunch so let's go through them again. Okay, what's the first one? The first one was about the disruptors in their movement with AI. Oh, yeah. And how can you activate if you're gonna have this thrust? There's a huge variation in my experience. I've had particularly after some recent news coverage of this I've gotten sort of amazing opportunities to talk to like CMOs of Blue Cross Blue Shield and Atul Gawande and Jeff Brenner and these sort of amazing leaders. And there's a spectrum from people who get activation and understand the patient perspective and understand vulnerable populations to people who see it in a much more traditional way. So there's a lot of variability there. There's all sorts of interest in AI everything. And that includes social determinants and other things. I'll share my personal bias. It's gonna be extremely difficult to get meaningful data out of AI about a lot of these things because it's dependent on what the doctor puts in the note and that's largely cut and pasted from something else and not that useful. I think that people will be AI in this sort of stuff for a very long time and that the signal to noise ratio of the AI stuff is gonna really be a big problem. So that's the first one and the second one. When you're looking at concierge movement, how will that be harder for the specialists to keep doing what they're doing and getting that right? I don't think concierge medicine is gonna be the big driver here. I think it's still gonna be a niche. I do think we'll see more high deductible health plans and more selectivity in that. I do think we'll see more managed care. I think managed care is gonna be the bigger driver of this. I think high deductible health plans are not good for a small fraction of people all the time. Let me put it this way. For everyone, they are risky all the time and only a small fraction of people get hurt at any point in time, right? So yeah, people speed, but they don't drive 120 miles an hour even when they're alone, right? And there isn't a policeman there. And I think a lot of these high deductible plans really are that for people. Bankruptcy is not a good thing for most of us and it is a predictable outcome in the long run with plans like this and we're already seeing that. And all you need to do is hear a couple of stories of that from your friends when suddenly this does not sound so good for you. So I think managed care will continue to be the bigger picture. I also think that the Achilles heel of managed care are the ability to appropriately measure quality and to adjust for risk in some of these things and that is where I do think AI could really make a big difference in machine learning and everything else. But we're gonna have to push the markets to do that and they don't always have the incentive, but we'll get there. Hey, sorry, one more question. If you think about the traditional models, so say in surgery for instance, we continue to still have continuity between our ambulatory and our inpatient services and that's been sort of maintained over years of training, which is how primary care was initially. And certainly there were market forces that changed the model to where it is right now which you described. Outside of remuneration, are there factors that you think lifestyle-wise, training-wise, culture-wise, that have changed in primary care that have separated ambulatory and inpatient that you may have to overcome in suggesting a model like this? Because in surgery, it's a core. It's our fabric. We see them outpatient and inpatient as well. Yeah, yeah. I mean, we mentioned some of them like duty hours and things like that just, and people working fewer hours. So I don't know what that is. Some of the, we may have a hurricane or a tornado, but we're in the safest possible place. So I think that's some of it, but I do think there's cultural stuff. I mean, I guess I'm old enough to worry about what it means to think your job is done when the clock hits an hour, as opposed to a patient has a need. And I'm also young enough to think that your job has to end at some point and you do need to go home. But I do think that for a variety of reasons, not all of which are good. We've increasingly rootinized and protocolized what it means to be a professional. And I'm not sure that's very good. And I will tell you, one stealth, true secret weapon of the CCP model is that you keep caring for the same person over again and again and again. And if you don't do a good job, they appear on your service and they say, hey, I called you and you didn't answer. And you have to explain to your colleagues, you know why the patient is annoyed at you. And that sort of accountability is just profound. And that's a negative way of saying it, but a far more positive and I think equally powerful way of saying it is the deeper you get to know these patients, the truth is the more you care about them. And that caring is the essence of what makes them trust you and you trust and understand them. And it makes it easier to do the really good job. So I want to credit Mark because I think, you know, however, 75 or 400 years ago when we first met, Mark was interested in the doctor-patient relationship. And I really think it isn't rhetoric. I think it's real. I think that we have done great disservice to it over a series of decades. And I think that if we elevate it in a meaningful way to a health system issue and strategy, that we can really provide way better care than other places and really help people. But we have not done that yet. There is a real agenda in rethinking how we do care. And maybe in surgery we've held on, you know, better than in some other places, but I know you guys face huge challenges in this related to network depth and the ability to see people. Bundling is not gonna help. You know, it may do it in the short run, but it doesn't do it in the long run. I mean, it's gonna be a really interesting conversation. But I think it's important for all parts of medicine. Okay, thank you so much. Great, thank you.