 Good afternoon. On behalf of the McLean Center and Chess, Dr. David Meltzer and I welcome you to our lecture series this year on improving value in the US health care system. It's my pleasure now to introduce today's speaker, Dr. Trent Hayward. Dr. Hayward is Senior Vice President and Chief Medical Officer for the Blue Cross Blue Shield Association. As you know, a national federation of 36 independent community-based and locally operated Blue Cross Blue Shield companies. The Blue Cross Blue Shield system is the nation's largest health insurer, covering one in three of all Americans. As the Association's Chief Medical Officer, Dr. Hayward supports the innovation of Blue Cross Blue Shield in communities around the country in an effort to improve quality and patient safety. Dr. Hayward is also responsible for the Office of Clinical Affairs, which includes the Center for Clinical Effectiveness and the Center for Clinical Practices. Collectively, this Office of Clinical Affairs supports opportunities between Blue Cross and Blue Shield companies and stakeholders to improve the choices for affordable, high-quality health care to all members. Dr. Hayward also serves as President of the Blue Cross Blue Shield Institute, the first of its kind as a benefit corporation established to address social determinants of health through technology and strategic collaborations. In addition, Dr. Hayward oversees the National Council of Physicians, which consists of Chief Medical Officers and Chief Pharmacy Executives that guide the clinical direction for Blue Cross Blue Shield companies. Today, Dr. Hayward's talk, as you can tell by looking behind me, is entitled Selfies and Social Determinants of Health, Improving Health Care Value Propositions. Please join me in giving a warm welcome, Dr. Trent Hayward. Hopefully you can hear me OK. Are you able to hear me OK? OK, great. I'm going to walk around, and then we'll get into the lecture. This seems to be a relatively informal setting, so I'll keep it relatively informal at some point because it's University of Chicago. If you decide we want to make it more formal, you give me some signal. I'll stand behind the podium, and we'll do it that right. I appreciate you having an opportunity to come over with you guys to spend your lunch time with you. I know this is a lecture series in which you guys are focusing on value. I've had a lot of experience in a lot of different places, and so I'll walk through some of those particular activities where I was at the bedside. I was at CMS. I worked with community health centers around the country, and now I'm at Big Blue Cross Blue Shield. By show of hands, just so I get a sense of who's in the room. Medical students, are they any medical students? Is there a reason why the medical students don't really want to raise their hand? Do you guys beat up on them or something? They barely raise their hand. Nurses, great. So medical students, nurses, I think I heard that there's ethic fellows or the ethic fellows, ethic fellows. Physicians, great. Any other allied health professionals that I'm missing? What? Psychologists. What else? Anything else I missed? Great. Pharmacists as well? Pharmacists go to the industry. What does that mean? What are you doing here? Pharmacists go to the industry. Tell me more. What do you mean by a pharmaceutical industry? Like what? Like what part of a pharmaceutical industry? Marketing. Marketing for public health. OK. By the way, I'm not one insurance payer that hates pharmaceutical companies just for the record. And we can get into that in a minute if we want to as well. Any other ones that we didn't cover? OK. Research staff is here too? Perfect. Research staff? OK. I see you got some attitude with it too. OK. What else? Anyone else who we didn't cover? OK. So there's a very diverse perspectives in the room given where you have the particular job ties or what you're seeking. So when we get into something like value, obviously value has something that's unique and specific to the individual or the perspective that you bring to bear. And so because we are comfortable in a 90 minute session, I'm going to allow you to please feel free to stop me, interject, engage any way you want. You can tell by the title that I picked that I don't take myself too serious except when it gets time to make a difference for patients or the members we serve. And then we get into some specific serious issues around that. Otherwise, life is short. We try to keep it fun and interactive. So that's what we're going to do here. Now that I've warmed you up with raising your hands, raise your hands if you love health insurance companies. What the heck just happened? Like I purposely had y'all do that test run so you got comfortable raising your hand so that I get everybody to raise their hand. I got like three people. OK. So let's talk a little bit about that before I get into my presentation. Anyone that didn't raise their hand that would be willing to share why they didn't raise their hand. Tell me, shout it out. Why didn't you raise your hand when I said, tell me if you love health insurance companies? Why? Why didn't you raise your hand? Go ahead, start. Child, I'm in my own care. I'm fighting constantly to get a neuropsychological assessment that is why we're going to do this for different reasons. Great. So you have barriers as it relates to the health insurance companies. You said you're fighting that constantly? Great. Thank you for being honest and sharing. Others that didn't raise their hand. Yes, please. And can you kind of, you have to project in this room because it's a big room so you have to throw your voice out there. Thank you. Explain why you think you need that test of process position for a very busy person. Great. So that's helping. You said his name is Scott, what was your name? Jemana. Jemana? Thank you for sharing, Jemana. Yes, sir. My name is Aziz. And it's chapter voice out because it's, again, it's a big room. The problem is it's kind of helped me explain much so that they have a fixed percentage of claims. A fixed percentage? Yes. Fixed percentage that what did you say? Protection of claims. You believe at least your experience is that the health insurance have at least a certain fixed percentage that they're going to reject all those claims? Great. OK. So good, David. Government. You're going to spread the love of the people that you dislike. I like my perspective is like this is an interlocking that they're all trying to figure out how to survive in a screwed up system that ultimately doesn't help. I think you guys are any worse than anyone else, but I feel like you would fail. That's OK. I'm willing to pick a peer group and be in the best among a bad lot if that's the, if that's the, if that's the choice that's given. I have a simple one. Yes. Pre-authorization. Tell us about pre-authorization. What is it about the pre-authorization? Many insurance companies require that you get advanced authorization to order diagnostic tests, to prescribe medications, and it takes an unbelievable amount of time to work your way through that. Great. So we also heard, so another barrier, time. And this one, pre-authorization, claims adjudication. You guys talked about it. Yes, in the middle of here, you have two more here. Go ahead. The administration to assess the price of the procedure and how to assess the price of the call. That's not what people were even first or when they do try to do that, it just makes perfect. I always take over. Great. This system itself, I have an idea of paying doctors for what they do by the piece you preserve as opposed to insurance company. So it helps to really get us in the way of paying caretakers. So if we were paying in a different model, you'd be more supportive of a different model or you have a fundamental problem with paying, paying clinicians at all? When you try to figure out how to set devices then? I mean, should physicians really be like priests or nuns and just go ahead and go that route instead of worry about reimbursement all the other? Like teachers, Chicago's public school teachers? And then you had your hand up. OK. And I'll tell you on that one, Amy Risk is here with me. Amy, you can stand up just to say hello. So she's going to take all the tough questions like that one at the end. No, she's going to make certain that I remember that come back to that one. We'll come back to that one because that gets really specific about how we do product or benefit design and what we put into the market in terms of what people actually purchase. Because in a private sector, including, you can even say, government programs such as Medicare Advantage, you put a product out there. And people are actually having to compete for that actual product. And then they actually purchase that product. What we call an insurance product. Within that insurance product, it has certain benefit designs and they vary. And maybe at the end, we'll come back to that specific question. And for some reason, we can't get it all in. Then maybe we'll follow up with you directly to get your answer. Yes, sir. Great. OK. So a lot of reasons not to fall in love with the insurance company. So I'm a kid originally from Southwest Oklahoma. And I grew up. And by the time I was in fourth grade, my teacher came to me and said to me, you got to make a decision on what you want to do in life. I know. It's ridiculous, right? But I was nine years old. It's Southwest Oklahoma. And if your teacher says you got to do something, you got to do something. So over the weekend, I had to come back and tell her what I wanted to do. I didn't know what I wanted to do. I just knew I didn't want homework over the weekend. That's about as far as my thinking was at that particular time. And so I was pretty talk about disparities. I was a straight A student. And I didn't understand why the straight A students getting homework for the weekend and the other kids get to play. Right? So I said to my parents, what do I need to tell her? Like, what are the great career choices? And they pretty much said, oh, be a doctor or a lawyer. Both of them are great professions. Pick one of those. My parents were a teacher's aide and a counselor. Pick one of those and you're fine. So I just walked in and told her I'd be a teacher, a doctor. And so the fine time from, I was in ninth grade, all the way up through med school, I pretty much was on that path purely because my fourth grade teacher told me that's what she wanted. Right, literally. Now, fast forwarded, we ended up seeing my bio at all. I did go back and get a law degree as well at what was normally considered a competitor to the University of Chicago Law School in the city, which is Northwestern Law School as well. So I ended up getting both of those as well. Now, when I got the medical school degree, and then we're going to get into some of this reason why I was asking you guys these basic-grad girls, my parents loved it. They were just blown away. Look at my boy, you know, we started from humble beginnings, became this doctor in the big city of Chicago, blah, blah, blah, look at all these great attributes about being a doctor. And then when I came out, then I decided to go to law school, became a lawyer. They weren't certain what was going on, but they said, okay, you know what, he got another degree, it's not a bad problem, don't worry about it. And then when I came out of law school, I went to work for CMS. Then I got worried. And then they said, okay, we thought we had this son and we all understood the story. We were telling our neighbors and friends and family back home how great it was to be a doctor. He's decided to go work and become a federal government employee, right? Then finally, fast forward, you know, I did that, redeemed myself a little bit because I went to work for big health systems. And then finally you see, I ended up at a big bad insurance company and they lost all hope. So my parents aren't dissimilar to you in the crowd in terms of falling in love or in and out of an insurance company. Now, if you notice that when I asked you guys, what is it about health insurance companies that you didn't like, a lot of it came to do with certain aspects, not all of them, so I'm being general for the sake of the discussion. A lot of had to do with all the barriers that you were dealing with. Impediments to getting done with the job that you believe that you need to do for the patients that you're trying to serve. And that's the reason we ended up coming up with this particular title, Selfies. And then now I'm gonna get into this disclaimer here because anytime I do a presentation, I've tried not to be too boring myself, but if nothing else, I like to enjoy the presentation myself and then hopefully you get something out of it. That's how I do it. And so I said, well, every time I go, especially this time of season, you know what, even though the calendar's changed, what season are we in in Chicago? What'd you say? Okay, see, Amy grew up in Texas and I grew up in Southwest Oklahoma. And by the time you got to May, we considered it something no matter what you tell us, right? It was already summer to us, like, May or summer. I had to come up north and did not realize you guys called May, spring, because day's like today. But the reason why I'm asking you what season it is, if you walk across, if you're downtown, like where we're located, what season it really is, it's selfie season. This is a season that the tourists are all coming to Chicago, people from the suburbs come into the city as well. You can't get past the bridges on Michigan Avenue or any of those because everybody's stopping to take a selfie. It's selfie season. So by the time you get to May to all the way to at least late September, just be clear, if you come downtown Chicago, it's selfie season, don't get upset with people because they're gonna have the selfie sticks out, they're gonna stop in the middle of the street and they're gonna take a bunch of photos. The question is, that I wanted to play with this is, selfies now are simple and easy to do. It's relatively quick and efficient to get what you want out of a selfie. That didn't used to be the case when you actually used to do other photos, right? If you go back, are there any photographers in the room, anybody that, okay, do you have any ideas or thoughts about what it used to take to take a self portrait? So in the settings, you were using a mirror to try to make it happen. So now it's so simple and efficient, you know immediately whether you like it or not. And so the issue that I was raising and playing with when I decided to do this is like, hmm, if we really improve the value proposition within the healthcare, would it be as simple as actually taking a selfie where it would work that efficient? So that's the idea that we were playing with. As we continue to move forward, we'll play with other aspects about how we actually create value in healthcare and how we end up creating efficiencies as well. So let me play with that construct and then we're gonna get into how you might fall in love with the insurance company. I'm gonna let you pause on that for a second cause you're trying to envision what this insurance company might look like that you could fall in love with, right? All right, we got it, all right. So this is a disclaimer because anything I say can not be attributed to Blue Cross Blue Shield or Blue Cross Blue Shield plans or anybody that you might know other than Trent Haywood, okay. That's the legal side of me getting the disclaimer out the way. So taking a selfie, there's a lot of reason why people take selfies. I'm only gonna use three of them because they just allow for jumping off of discussion purposes. And keep in mind, we're gonna have discussion here, right? So even though I'm supposed to be doing a lecture, as you can tell by my format, it's kind of give and take. And I'm quite comfortable with you guys pushing back and forth about how I do some of this. So please feel free to. One reason that they do it is just pure documentation. You see that all the time on the bridge that I talked about, if you're on Michigan Avenue and you're going across the river, you know, a lot of times they're just taking that selfie for pure documentation. So they wanna memorialize the situation. Whatever's occurring at that particular time, they just wanna memorialize the situation. They're not necessarily at the beginning of that putting any value propositions or judgment on that just yet. And we'll come back to that because someone's already raised this issue of when I asked about insurance companies, one of the issues that they found problematic, okay. So taking a selfie, just like social determinants health, all you're doing is documentation or you're memorializing the situation. So what are the examples of that? So this is a pointer, right? Has anyone seen this photo or know what this is? Or if you're not, you can guess too, right? This is not the, you're not in this literature, you're not graded good or bad if you guess, by the way, right? So what do you think this is? Let me do it another way then. Let's get closer to it, right? We'll do a deductive reasoning. What area is this? What time period is it? All right, so outer space, great. It looks kind of old. Looks kind of old, like how old, old? 1960s. Yes, this is, so this is the 60s. Most of this crowd never heard of the 60s, is that correct? No, so this is the 60s. This happened to be 1966, right? This is Buzz Aldrich, 1966 in the Gemini. And so this is literally a selfie. Well, he literally did a selfie to show that he was outside the Gemini capsule and wanted to be at a show that he was actually in outer space. Documentation, I was here, right? Just memorializing the situation. Memorializing what actually occurred. Last year I had the same situation, even though it wasn't a selfie, I would feel these as not selfie, but it worked for the conversation about documentation. Who's this short guy right here with the bow tie? Wild guess. Me, right? So you got one short guy over here with a messed up tie and then you got a taller guy over here with a messed up tie here too. So we got two guys. Who's this guy over here? People in the University of Chicago don't know who he is. Y'all don't know who he is? Only Texans know who he is? The South Side of Chicago doesn't know who this guy is? Who's that guy? George Davis. You start to look like his dad. Yeah, and this was last year. And so this is last year in Florida and we happen to host the former president. And so you can tell this is just a photo where we're together and it's nice that he gives me a nice hug and it's really nice that we both have our tie screwed up and that's pretty much it, right? Pure documentation. Take a photo, you can tell family and friends that you met the former president and he was nice, whatever you wanted the A to do. How do we do that in healthcare? So you guys are talking about value. What is the value of documentation? So someone talked about E&M codes a little bit or start to at least get into that a little bit when they started talking about some of this. What is that? What is the E&M codes? What's the E&M codes? What is that about? Do you guys know? Does anybody in the room know? Billing for all patients. Okay, so billing codes, right? So these billing codes relate to documentation but what does that have to do with value? What's the value in the documentation of the billing codes? What? Okay, so let's take that. What's your name, ma'am? Thanks, Marsha. We really appreciate you helping us out because the other ones are too shy, Marsha, so we need somebody to work with me. So if I said to you guys, one way to improve the value of the healthcare system is to improve your documentation, you agree or disagree? Wait. We know, I can guarantee you that I can find resources in this great institution that spends their time improving the documentation of clinicians. I'm pretty sure about that. And you're telling me they're not having an impact on improving the value proposition of healthcare? Tell me more. Why? Tell me. No, here and then I come back. That's been a lunch, so I think it's only fair for them to talk and then I come back to you after they finish splitting. I'm just teasing you guys. Go ahead, the two of you. Yes? I'm more and more at a billing document as opposed to actually documenting what's happened with the patient clinically. Okay. It's become more luminous and less afforded to the clinicians that are actually providing the care and the purpose of the procedure that become a billing document. Okay. So... That's frustrating as a clinician. So if someone came up to you again just to clarify, let's assume, let's stipulate that's true for now. Then you would say that's not really about improving healthcare. It's just purely documentation for the purpose of documentation that allows for reimbursement purposes, but it's not necessarily to improving the care, at least the way it's done. I like that or lack there of reimbursement. I like that. And did you wanna say something as well, ma'am? Okay. Sir, in the middle here with the glass. You just got it? Any others? So this whole room, if you see someone that their job in this institution is about improving documentation to help clinicians improve documentation, you would say that's nice. It's a necessary job, but it's not necessarily related to improving the value of healthcare. Is that the consensus? Yes, ma'am. What'd you say? So I don't think it's not necessary. You don't think it's even necessary? Oh, okay. You think it's necessary then that you have it, but it might not be ready to improve in healthcare? Is that correct? The value? Okay. So yes, ma'am. It's a plenty to associate a diagnosis with it. And for some reason, the code that I've always used in the past were screening mammograms weren't working. So I had to go find someone who could tell me that you actually had to use this template to order it. And only then did you associate it. I probably wasted a bit 20 minutes. Wow. Just around trying to find that code. And as I understand it, part of the dilemma in this is that it is, I guess, illegal to put hints in an appic as to what a diagnosis is that makes something billable because they think that doctors are gonna change the diagnosis for this. But that's an example of the type of thing that I think frustrates me. Yeah, so let me tell you, and building off that, since I gave that big disclaimer, I'm not gonna give legal advice, right? So that's the other disclaimer I can give. So I'm gonna opine about the legalities of what you can do or not do in EHR, whether it be Epic or Suna or any of them. When I was at CMS, one of the biggest issues that we spent a lot of time on this, and we'll talk a little bit about this with RVUs as well, about how much documentation we were gonna require, right, for your evaluation and management codes, and what would it require, and particularly back then, because it was much more about what level was required for a particular documentation. And to David's point, we would sit there and I would tell them, I'm like, I'm not fully understanding why we're spending so much time on verifying the level within here, because as soon as they do implementation on EHR, you can default to level five if you want to, and actually just make certain that you answer all the questions and you'll get a level five. If that's what you wanna do, you can get the documentation done. Now to your point, there's ways in which, so then we have to distort it and say, well, don't allow the default to be on there and all this other stuff that we have to necessarily do. I used to go around and when I was helping hospitals, on the same thing, I would go around and the hospitals would complain to me, just again, when I was at CMS, and then subsequently when I left CMS, and the surgeons would say, you see this? And they have a stethoscope around them. This is particularly as I'm in the pre-op, it's something like this. I said, yeah, I see, you got the stethoscope. It was like, yeah, it makes no sense that I have this stethoscope on me. The only reason I have this stethoscope on is because I gotta do this documentation, and so I gotta do all this stuff for documentation purpose, but if you guys had another way where I could still get the same reimbursement at the hospital and the surgical team needs for the same particular procedure, I wouldn't be spending my time doing the documentation because I think it has no impact whatsoever on how I'm gonna actually care for that particular patient. So those are situations to us that if we're in agreement, this in and of itself, there are ways to improve this. And Martin talked about prior authorization. That's a big debate right now. I spend a lot of time with the AMA, the American Medical Association on this particular issue. There's a lot of legislation within the Beltway right now about what we should do about prior authorization or not. It's a big fight at state government, state houses right now about whether or not you can allow health insurance companies to continue to do prior authorization the way that we do prior authorization or not. Now you gotta understand because we're talking about this series about value, and I think someone raised a question earlier on about the product that Amy's gonna come back and talk a little bit about at the end or she'll at least she'll remind me to. On the other side, and for now I'm gonna talk about commercial then we can talk about government just on this one particular issue I'm talking about commercial. Keep in mind that that insurance is a contract. So it's not, we're not talking on social contract. We're talking about a real contract right now within the four walls of that, four corners of that particular contract. So if you have a big employer, University of Chicago could be your employer, but if you have a big employer they reached in agreement with that health insurance company about how to abide by that particular insurance contract. And you only supposed to do what's medically necessary and nothing more, nothing less. And so there's ways in which to be able to determine whether or not something is medically necessary. I have a lot of responsibilities in that particular space as a chief medical officer working with chief medical officer across the entire Blue Cross and Blue Shield system focusing on just that issue. Medically necessary. And Amy will tell you, because lately yesterday I spent a lot of time on trans or incisionless frontal plication. Is it medically necessary or is it not? Does it really make a big difference or not? How much evidence is really there to support it or not? All that relates to this particular issue here. But let's assume ENM for now just to keep moving forward. Let's assume ENM codes alone is not going to necessarily improve the value proposition for healthcare. What about this? Documentation of quality measures. Clearly that's not the same as ENM codes, right? I used to leave the quality measurement at CMS for nationwide when CMS decided to actually link all their first public reporting to quality measures. We spent a lot of time saying, here's what we're going to do. We're going to document to the public the level of quality of the services that you're providing for your patient population. What about that? Is that improving the value? And then I come back here. Yes. R-C-Q-A, right? Yes. We basically went through 20 years of quality improvement and third is measurement. I would say that their summary is not that much. Not that much, that's what air concluded? That's it. Okay. In the back. Similar to your first conversation that it's actually not the documentation of quality measures, it's the documentation of the documentation of quality measures that you are not measuring quality, you are measuring how I document it, which is a very different piece. And so you were saying in the current, at least in the current way that we actually do the quality measurement. And I just used your example, documentation of documentation, not necessarily documentation of the quality. You don't believe right now that all the work that we did on quality measures are particularly, I'm gonna come back to linking it to payment, but for now I'm just talking about the public reporting portion of it. Documentation that allows public reporting of quality measures. Improving the value of healthcare or not? It was almost a low time validator part that got raised. Is there anyone that's willing to argue the opposite? Your hands. Let me ask you another way to I'm gonna build up on your point. Do we want a world, cause we can go back to a world where there's no quality measures that's out there for comparison purposes. We can go back to a world where we don't have public reporting, right? Cause we had that world and it wasn't too long ago, right? So do we believe that's a better way to do improvement of value? Is to no longer do the public reporting on the quality measures? Does anyone believe that? That we should get rid of it and not do it? Yes. The principle looking at revealing quality measures I think is a proof. In case the nature of the measure and the levels in the detail, and what some of the measures it seems are things that are easily quantified that aren't necessarily actually reflecting true quality. And that's I think where the problem comes in. The principle of measuring quality to Google and having people be aware of it, what do you have? Okay, so let me take your comment and say, if I hear you correctly and I think that was similar to another comment about not just documentation for the documentation of the measure. If we could implement it properly and I'll put what our property is in quotes, documentation of the quality measure could improve the value of healthcare? You believe it could? Yes. All right. So you are making a distinction at least between the EMM codes and the quality measures. You think this has more of a chance of improving the value than the EMM codes or not, really? Tell me more. For the sake of quality and somebody has to pay for it, everybody that's willing to pay for it, it's within the portfolio of the contract, they need to get some money out of it, to get some money out of it, they need to measure, the way to measure is to do the code. Okay, so you're thinking this might be a means to this particular end. Okay, go ahead. I mean, just a couple things. One is that we know that there's a lot of resilience and so if you're doing things in diagnoses where they're not really indicated, that's a problem. So EMM is critical. So I mean, I think the big problem of quality measures is that many, many of them are focused on very easy to measure things. Like for example, preventive care. But it's not only just that, it's easy to measure things that the powerful parties want to measure. So like if you go back to HEDIS measures, a lot of it's around preventive care. Why? Because capitated organizations that get incentives to provide capitated care, make their money from my perspective and caring for healthy people. Not in the realistic complexity. For them, it's pretty easy to make sure they get their mammogram, yet to make sure they get their pass care. Now that is quality. But in the world of what healthcare does, is that enough to really create the value case around so many things that we've done? And that's what gets unclear to me, especially when there are other mechanisms that really can promote quality, such as the reputation of a really extraordinary clinician caring for really complicated cases in the context of an environment where there's knowledge of peers. Right. That is to some extent in competition with these sort of approaches. Because these sort of approaches favor institutions that are huge and powerful. And invest a lot in technology. And the other sort of approaches favor institutions where you have intimately connected individuals who together have a reputation that they care about. So I just came earlier today from Ingalls Community Hospital, which is, I would say, almost a relic of that era of American medicine. And I'm not sure that the new system that favors this sort of stuff is a whole lot better always than some parts of the other. So I guess my question is, like, how do we go? All right, so we're gonna, I agree that, you know, so what Dave was reminding me of is so, on that, I'm not taking all that in, but one of the problems we had when we started to do quality measures early on with CMS and the public report, before we started linking it to payment, to Dave's point is we knew, like, internists and family practice physicians, we could easily get a bunch of measures. As we got into some of the surgery specialties, less so. There's less literature in surgical specialties altogether. And because there's less literature, then there's less of an ability to be able to create quality measures that we'd find acceptable. And so I remember today's point, calling surgeons saying, hey, we're gonna do this with you or without you because we can't have these gaps where only the internists or family docs are doing these measures, but the specialists get a pass, right? Because then that's just putting more pressure on PCPs and family physicians, and that means that they're less likely to wanna be able to continue to do that because they're getting less reimbursed than the specialists anyway. And so we literally would ask them, like, okay, if you're a family member need this particular, especially this surgery, would you know how to go about and find the appropriate surgeon for that particular family member? And if you can answer that, then we say, well, then that's what we're gonna use to be able to actually build a measure, is how you would actually make that determination. So there are ways, as David said, that we would actually go ahead and do that. All right, so I'm gonna keep moving because we just started the discussion. So this is just one area, which is just about documentation. It sounds like a mixed bag in this room as to how much documentation really improves the value of healthcare. It might be necessary, but it's not as sufficient to necessarily improve the value proposition of healthcare. And then at the end, we'll talk about what we clearly mean by the value proposition of healthcare. So I call this examination, might not be the right term, but the idea is that it goes beyond documentation. So when you're taking that self, it's a little more than just documenting whether you're there or not, right? That you're really starting to examine or put some type of analysis into what you're seeing in that particular photo or how it's unfolding. So you can do it for examination first, where you wanna actually do some type of analysis. So you really wanna understand the interaction that's occurring at that particular time. And by understanding the interaction that's occurring, then it allows for opportunities for improvement. If you understand the interaction that's occurring, or at least you understand some of the relationship that's unfolding. So how many of you remember this selfie at all? So you got these three people and then you got somebody over here. The person over here doesn't look the same as these three people. What's going on in this selfie? Who can tell you what's going on in this selfie? Again, you don't have to be right. So just throw it out there. At minimum, what do you think is going on in this selfie? Somebody's left out of the picture. Yes, this person is definitely left out of the selfie, right? These three look like they're having a, do they look like they're having a good time or a bad time? This person looked like a good time or a bad time. And it's probably gonna be this person, huh? I'm assuming everybody at University of Chicago is required to at least know who this person is since she worked here, right? So who's that? You guys are so quiet. Yes, Michelle Obama, yes. So this is the former first lady. Honestly, that means he's the president. I'm blanking, she's the prime minister, Danish prime minister if I'm not mistaken. And then do you remember who that is? The British prime minister, right? David Cameron. So why is she looking like this and they're so happy? What's going on? Remember I said examination of herself and sometimes about understanding the interaction. What do we think the interaction here? Cause those three are enjoying themselves. She's not, what's going on? She's definitely not president but that never bothered her before. She never really wanted to be in the politics. What's going on? She was paying attention to the funeral. Who's funeral is this? So this is Nelson Mandela's funeral. Sombra moment, Nelson Mandela funeral. And the whole world is watching this go on and still Nelson Mandela's funeral. Michelle's not happy. And as you said, as soon as this was over the next photo all of a sudden Barack Obama is about to as stern as he can be and as solemn as he can be cause he got the side eye from Michelle, right? So that's what this stuff is about. It's an examination to understand them. But otherwise these people know each other, they interact, they're having a good time but there's a problem here in this particular selfie cause Michelle reminded them that they're not paying proper respect to the former leader of South Africa, Nelson Mandela at the funeral. Just a simple one for examination purpose. Now here, this is that short guy here with another bow tie on. It's a little dark in this photo but do you guys know who this is at all? Can you tell? Okay, this is Magic Johnson. So we just talked to Martin, Amy and I just talked to Martin. This was last week down in Texas. Magic Johnson happened to come and present to us. And yes, he's literally about two foot taller than me. He's like, he's six nine, I'm five six. So it's almost two feet different taller than me. But instead of the one with George Bush, what we're sitting up here doing, I'm trying to talk to him about something I talked to you guys about at the end, what we're trying to make a difference for certain communities and Magic Johnson Enterprise might be able to do that for us. And so we want to have this discussion and dialogue about that. So what you're really seeing is, I'm less interested about taking a photo with him. I'm more interested about getting some business done. So if you saw the previous one and President, former President George Bush just taking a photo, magic. I need a holler at you player. Can I holler at you? So that's what's happening here, right? Well, I'm truly just trying to holler at him and saying, I got to get something done. I think you guys can help us get this done. And so just so happens, somebody took a photo of me trying to get something done with Magic Johnson here, right? And then you got everything else. So here you can see all that played out a little bit different than what you saw with the previous one, just by the way that the photo looks. So now, what is the value of the examination? So let's get into this because we started off here a little bit where we say, okay, we're gonna go beyond documentation RVUs, what is RVUs? It has the word value in it. So you can't tell me that we're not trying to improve value if the word has value in it, right? I mean, you guys are gonna burst my bubble and tell me that. What is RVUs? Who knows what RVUs are? Okay, not just physicians, but yeah. And so, and what's the R? Do you happen to know what the R stands for? Okay, so the measure, you said measure of productivity. People argue about whether it's really productivity or not, but it doesn't matter for the purpose of this lecture series. To me, it doesn't lead for today. So relative value units. When you hear a term like that, relative value units, what does that sound like? Relative value units. What does that sound like we're doing? Comparisons. Flat out comparisons. Relative value of one thing, relative to another thing. And we just happened to have, we used units for it. And any of you that's ever actually spent time doing any of this, it goes through a process, normally at the AMA, through the Resource Utilization Committee or the RUC. You'll hear people use the term RUC, R-U-C. Spent a lot of time with that particular area because all the clinicians are arguing about their particular work should have more RVUs than the previous one. And you heard someone earlier on talk about the difference between procedures and whether or not we get higher RVUs for that versus if you're actually doing a mental, like psychology and some other things where you might not necessarily be able to do it as effectively. A lot of that has to do with whether or not you can quickly and efficiently identify the inputs for that RVU, right? Which means the cost of inputs, relative to others where you might not necessarily be able to put the cost of inputs into it. So let's just take this first for RVUs. If you work on RVUs, are you improving the value of healthcare? What's wrong with you working on RVUs to be improved the value of healthcare? There is no way to determine the value of what you do for patient. It is interaction. It is just like there is no RVU for your love for you and your children and your friends. Somebody could be artificial, like a cake, a lot of color on it. And it statistically looks so good. And someone could spend hours and find out what's the problem, how to guide a person, rather than shift them here, shift them there and shift them there. And that person's value is not recognized. So it is a good statistical thing like when you take your car, they have numbers that they could check whether they did it or they did not. At the end, there is a value for that. But the ultimate result is how the patient did and how did this person benefit from the time you spend it. Great. What's your name, sir? Sir, what's your name? Right? Yeah. What's your name? Javad, my name. Javad? I can hang out with you. We should talk. We should talk after this lecture. So let me ask you, David, I'm gonna come back to you. So RVUs, so I say relative value. So if you can understand by nature, it's designed to do comparisons. You have a problem with that or you're comfortable with that? I'm gonna come back, David. You had a problem or you're comfortable with that? Tell me. So if my value goes up, your value goes down. You're fine with that or you have a problem with that? It's a zero-sum game at RVU at the end of the day. You like it or hate it for improving value. It works or doesn't work. If you produce more value and it's a zero-sum, then I gotta ultimately produce less value under RVU system. You like that or hate that for improving the value of healthcare system? What do you think? You don't like it? You don't think it works? Dave, what are you thinking? Well, so two things. One is that there's my personal feeling about it and it turns out that if your value is higher than mine, I'm not gonna feel great about that. So that's one part of it. On the other hand, do I wanna live in a world or a country where values are recognized so that sort of value overall is increased? I probably do. So sort of like free trade. I may not like my industry going down but I love buying cheap things at Walmart. So I went on that way. But the one comment I wanted to make was, the word value here is kind of a misnomer because it's really not what was being described before. This idea of what does it mean to patients? It's what is it cost people? It's really a relative cost human. And cost doesn't equal value. So it's again the way like health maintenance organizations. There are terms that sound really good but they're crazy because they sound really good rather than they actually do what they said. And were you guys using a specific definition of value here? Were you guys doing like quality divided by cost or some other? There were some discussions about early on but I think the idea was in the end most people would argue it was things that made people healthier while consuming fewer resources, increased value. Okay. Right? I mean, broadly speaking. All right, so we'll come to that at the end. Yes, sir, at the back. It doesn't do it value but it has to do with quality of it. Great. So again, I'm being dramatic for effect purposes. So far what I'm hearing is if you want to improve the value of healthcare the way that we're doing E&M calls right now that anybody's working on is not going to get us there. The way that we're doing quality measures right now is not going to get us there. Again, I'm putting the asterisk there because there's some caveats there. Now I'm hearing RVU's definitely not going to get us there. What about value-based payments? These, what is that about? Sir, as you might be understanding it's important to take into account another kind of efficiency but I think and I'm not sure correct me if I'm wrong and I consider it's about improving your clinical efficiency to give the most of the patient that are supposed to have or to get the most benefit from the dollar or cheap end. Right, so let me backdrop to answer your question. So you can decide how you want to do this. You can do it on effectiveness or on efficiency. So that last example I think you were talking about efficiency so for the same results with fewer inputs kind of a efficiency or at the same time from a resource stamp or you don't have to necessarily do that. So you can literally just say I want certain outcomes and if you achieve certain outcomes I'll pay more for them. So you don't necessarily have to have any efficiency component you can literally be an effectiveness component that says for certain outcomes I'm willing to pay more which also means for if you don't achieve those outcomes I'm willing to pay less. So let me just ask you with that simple analogy right with that simple approach we pay more if you have outcomes we pay less if you don't achieve those outcomes. What about that as a way to improve the value proposition in healthcare? You like that one? It's a tough crowd. You don't like anything I'm bringing forward. You like that one? Like this you're demolishing my whole career right in front of me. So I'm trying to figure out if I've wasted the last two decades. Yes ma'am. You can invest and prevent healthcare in order to save more in the future. No it can be that but let's keep it even simpler. Let's keep it even simpler. Let's say you're taking care of a panel of diabetics. You have a diabetics in your panel. Your diabetics hit their targets for hemoglobin A1C and so because they're better managed they have less complications. So I pay more for you than someone else's that's not able to control their diabetic population to get them to their targets. First group gets more money because they've achieved the outcome that goes that we've all agreed are important for those diabetic populations. Second group gets less money because they haven't been able to do it. We like that? We don't like that one either? Do we like that one? Yes you do all that. You can do all that if you want to. Yes. You can do the risk adjustment that all that you would need to be able to do that to make it comparable. What'd you say? I would say it's not the diabetics I'm saying. And second point is the outcome is sustainable. Right? Those are all valid points but before I answer those and I can answer those but before I answer those you gotta tell me if I can answer those do you like it? So let me ask you this you guys are being tough so let me ask you this. If I give you a car a luxury car for two years you don't have to pay anything on it. Nothing whatsoever on it. Yours for two years you like that car? All right we're getting somewhere. Okay so you like that? So at least I can get to an extreme right? So let's get to an extreme. You like that in principle then you can ask me a bunch of details about what this really take. Did I really steal the car? Do I own the car? You can ask a lot of stuff right? Is it really yours? We can get into those details but in theory if I can give you that you like that. So what I'm asking you guys in theory then we get into the practicalities of it right? Cause we're working on this now. In theory more payments to clinicians they achieve outcomes for their patient population less payment to clinicians that don't achieve the outcome that we think is appropriate for the population. We like that one? Okay. So I think the group said they're fine with that one and because there's apples in origin we get into the details. Yes over here. Someone have a comment or question? Yeah. You know so I just don't think that we can ever factor in all of the factors of justice and whatever. So no I don't like it. I think that you're three healthy patients and to push those who are unhealthy officers. Okay. I give a simple example as a surgeon. The value of an operation is not only person get better but could get back to what it was, go back to work, see how I'm done. So say an expert surgeon could do that in one hour. Yes. Up next down something. You are better, you go to work. That another one who is not expert could do that in two hours. That complication requires a second one. Right. Statistically the payment is more for the one who is less expert than the one that the outcome was better. Right. Statistically I could understand that it's better for insurance company to have something to work with. I know that. But if you're asking about value, if you don't know what value is, how could we base it even on that? But in that example, if I set up the payment where the first surgeon does better than the second surgeon because we're not gonna pay for the complications or any of that, you can have bundled payment, would you be supportive of a model where the first surgeon gets higher payments and reimbursement than the second surgeon? These are a statistical came 20 years ago. RU came I think five years ago because of the, a lot of charges was done to Medicare and their version, not in the honest way and they develop it. So these are for industries and for machines that they could have all of the machines work the same way and so you could put value on it, on a washing machine that works or doesn't. But in the healthcare, it's ambiguous. I know it is technical, but it is ambiguous. And so that's why the discussion come on. Perfect. So let me do this. So I think I heard again, in concept, this is the first one that I heard a lot of people would be comfortable with. The delts in the details. Is that what I heard? Like if we can't operationalize it, then you messed it up but at least concessually, there's some that disagree, but at least concessually, you might be comfortable with a differentiated payment for those that outperform or perform at a higher level than those that don't perform at that level. Is that what I heard? And so by agreeing with that, then this might be one way that you can improve the value proposition of healthcare? Yes or no? Yes or no? You agree that this is one way that you can improve the value of healthcare? Yes or no? All right, so we're split. Some agree, some don't. So let me take you to another one, this last one here. Networks. And I'm using it to mean for this purpose of this limited situation, I'm using it to talk about provider networks. Right? So these are networks. You might hear the term, are they in-network or are they out-of-network, right? It's an insurance term that's normally being used to be able to say, hey, if I have this Blue Cross Blue Shield card or I have a Signer or Edna, you matter, whomever, it doesn't matter. If I have this card and I want to go to this particular provider, are they in my network? Because if they're in my network, I know certain activities that go along with that including it cost me less to go see them than if they're out-of-network. Okay? So that's what we're talking about here. So we're not talking about anything out-of-net for now just so you get the concept down. So now what's happening is large employers are coming along and saying, again, large employers, pick any of them, doesn't matter, large employers are coming along and they're saying, hey, we think there's enough information to show that at minimum, you can probably get rid of the worst clinicians, facilities, whatever you want to talk about in your network. They don't perform at the same level as the people at the top tier. You know, we do desk hour performances. So let's say it's on a desk hour, so it's 10 desk hours. At minimum, in our network, if I'm a big employer, right? So I got hundreds and thousands of employees. I don't want them going to anybody that's in those lower two desk hours. I want them out-of-network for my employees. So for my employees, I want a high-performance network. What about that for improving the value of healthcare? What do you think about that one? So that means if you're an employee, you pretty much know that you're going to get a higher quality clinician than what normally would have happened because you would potentially have the broadest network possible. Yes, sir? If you're limited. Yes, you are? Live a little far. Our company is where there's close proximity to these providers, because they'll get enough of a provider that's close by. Let's say there's not a network adequacy. Let's say I solve for that. And I can't solve for that. A lot of places we can solve for that. You're right, in some situations, it's rural, it's geographically difficult for them to be able to get over certain terrain, things of that nature. It makes it much more cost-prohibited. But if I don't have that issue, are you fine with that approach for improving value? Yes, ma'am? I hope you better understand what's going on with your ma'am. Great, so you're supportive of this one? Yes, ma'am, as far as the works. I mean, we always have to operationalize it appropriately, as we just said over there for a network adequacy. But you definitely sound like this one here does have the opportunity to improve the value proposition for healthcare. Right, you have to operationalize. Others in agreement? Okay, so we got, it sounds like with this one, we're in agreement. What about you on this one? You don't like this one either? You don't like this one either? I don't like it. You measure the high-value clinicians, then you shouldn't have to do this network age thing because you should be going with the high-value clinicians as soon as you network and you're gonna have people included in your high-performance network who actually aren't high-performance providers, but they're just lumped in now. No, they won't be lumped in, they're teared out. They're taken out. They're taken out. Yeah, that's how it works. Really, that's how it works. I know you don't have to trust a bow tie, but that's how it works. That's a little how it works. You tear it, you decide how aggressive you wanna be on the tier and you decide how much steers you wanna be able to do for that particular tier and then you put a pricing around it. Well, no, so, because remember, no. Say that last portion again. Say that, I said to say that. Yeah. So you have a provider who is hybrid by interstitial problem, but maybe they're not as high-performing, but they get lumped in as being included in network because they are in the interstitial problem network. Got it. So let me, that's perfect, that's perfect. That is so perfect because that's part of the tension that unfolds, so I'm glad you clarified what issue you were talking about. So let me peel that back a little bit because this is where values actually bump up against each other all the time in healthcare, right? This happened and this is just a great example of it. So let's take the example you just gave and again, you saw that big disclaimer so this has nothing to do with unique to Blue Cross, Blue Shield, United, and the signal, we all do it, it doesn't matter. But let's say a university, we just have a university in Chicago, could be any other provider that's big and powerful, has a strong brand recognition, right? So that's one that doesn't, but someone like University of Chicago has strong brand recognition like you said. You're not gonna wanna be teared out of the network because it's gonna suggest to large employers and others that you aren't performing at the level that your brand suggests you're performing at to your point. So you don't wanna be in there. It's gonna be behooping to the insurance company if possible, you're right, if possible, you're gonna want the high value, the high recognized brand provided to be in there as well because it looks odd that you took them out of the network if the common understanding in that geography is that they're a high performer, right? Regardless of the measures right now, then you have to measure into it. So you're correct, if that conflict does happen, then you take it one step lower that says, let's assume you are gonna tear them and you're gonna tear them down to the individual clinician level. There's a lot of issues about getting down to the individual clinician level, depending upon what specialty we're talking about, whether or not there's enough sample size to really be able to do that, but let's stipulate that away for the purpose of the discussion. So you're correct. So now let's say to keep it simple, we say, okay, we got this great panel of clinicians, physicians in this situation, but some of them don't perform as well as the others in the group. Your question is, well, but when they come in, the people that don't perform as well in that physician group practice, do they still get access to those patients? Because I just hired a high-performing network with the expectation that they get to see high-performing clinicians, and now you got some of these ones that in that physician group practice that aren't performing, right? You're correct. That does happen, so then there's questions about how you actually address that, and there's a lot of different ways that individuals, whether you put the audience upon the health system to correct that, or whether you put the audience within the contracting vehicle, which there are ways to be able to do that, to steer away from that as well. But thanks for raising that. That is a conflict, and then you work through that particular issue, and there are ways to be able to actually work through that issues. Side note, we did that even with specialty physician preference items. You have physicians, this gets into group purchasing organization and value proposition, where you have clinicians, whether it be cardiologists, like interventional cardiologists, or whether it be surgeons, they have items that they prefer. That's how I do my procedure. I prefer this item, and they got trained by Johnson and Johnson or a court or whomever to go ahead and teach them how to do that particular procedure. So they love that item. Regards that that item might cost three times as much as a similar alternative option. And so in the supply chain in hospitals, this happened all the time. The supply chain measures trying to get everybody to get on the same because they get volume discounts and they pretty much function the same. But if those clinicians were trained differently, and oftentimes, but once you're outside of fellowship, you're trained by your colleagues or by the manufacturer, then you're gonna go with what the manufacturer say because you're not fit in the bill for it and you want the hospital to fit the bill for it. So then the hospital has to fit the bill for it because you're the permanent cardiologist or the surgeon. And so you're willing to go ahead and have it three times and has nothing to do with improving the value of the healthcare system. And we call those physician preference items and we spend a lot of time trying to get that out. And there's ways to do that. Part of that is transparency and show how different the variability is and that doesn't make any difference. And some of that is what we do here in value-based payment where we put contracts on top of it that forces the physician group practices to go back and have those difficult conversation with a colleague that says, you really are gonna cost us without showing any improvement whatsoever in patient outcomes. Are you sure you want this item that's three times more expensive because it has nothing to do because I'm getting the same outcomes or better outcomes again with a different device? Which says to them, if you wouldn't admit to me that I'm a better clinician than you, you can give this item. But you're telling me I'm a three times better clinician than you and I don't believe you really want to say that. So let's have this conversation. So there's ways that we get underneath that. All right, in the interest of time because I want to open this up for any questions that we didn't. Let me run through this last one right here. Again, it's just a term that I use. I call it reflection. It doesn't matter for selfies. So now we have selfies that did just pure documentation. We have selfies for examination so that you can understand the interaction. And now I'm just calling this one reflection. And so in this particular situation, what I'm calling this is like, this encompasses integration. This says I'm not gonna pick it apart by individual items. So when I was doing the examination, I want to see different aspects of it and understand their relationship. I just want to integrate it as much as possible. So now I'm trying to look at it from a holistic standpoint. So when I'm looking at that photo, I'm trying to take into consideration everything that's unfolding. So let's look at this selfie. Does anybody know who this is? This person here? Who? It can only be one person. Who is it? It's Beyonce. Of course it's Beyonce. You cannot have a lecture on value and not have Beyonce in it. Of course it's Beyonce. It's Queen Bey. So there's Queen Bey over here. Who is this? Who's that? Who's this? Her daughter? Who is it? Yeah, so this is her daughter, Blue Ivy. So this is her daughter, right? So this is a selfie. They had a basketball game. They took a selfie. So this is the relationship. So in this selfie, it's not about documentation. She doesn't need to necessarily document that that's her daughter, all that type of stuff. You can see they put the Snapchat filters on or had a little fun with it. So that's what this one is. Far different than when we started, right? Where Buzz Alders just wanted to document that he's in outer space. Far different than me, just wanted to document that I was with President Bush. This is much more about the family interaction that's occurring at that particular time, because we all know how busy Beyonce is. She's everywhere, all that type of time. She needs to be able to take time out and enjoy family activity. Who is this? Stand out for him so they can see who both of us is. Right. So she got Dalmatian years. I don't know what type of her is it. We got these long times. This was yesterday in the office. Right. Similar thing where we just wanna be at a show. We interact, we're on the same team. Not as tutors, Beyonce, obviously, but we can go ahead and do silly things too. And so that's us. So that's just a quick example of a reflection where you're having fun, but you're taking it to the totality. You see how people interact and so it's much more about the relationship than necessarily document that you've been together at one point to the time. Let's talk about this real quick and then we'll open it up for the last five minutes. So when you're talking about reflection, I said remember we're talking about to understand that the encompasses the entire integration. Consumer experience. What do we think about a value proposition related to consumer experience? And it can be patient, it can be member. We call them members for clinicians. It'll be patients. Other people call them consumers. So I just used the broadest term. So don't beat me up about that. Consumer experience, community relationships. What about that stuff? For improving the value of healthcare. You care about that, you know that? Yes. Tell me more. What do you care about? There's more value. Okay, sounds reasonable to me. Others care about that? Yes or no? You hate it? Since it sounds like E&M, you like it better or worse than E&M's? You like it better or worse than E&M's? Better. Better? Who thinks it's worse than E&M's? Tell us why it's worse than E&M's. You want to be consistent? So say you're really well-percuned. You're not sick at all. And you want a doctor who will, answer every problem wanted, every moment that has a great consumer experience. Should we use tax dollars to pay for it or subsidize it with tax breaks? I'm not sure. So that's one. Community relationships. I'm really deep and lean for community relationships that is really important, but I also know that the not-for-profit sector sometimes kind of corrupt and kind of get a commission. And sometimes those community relationships turn into money that goes down to holes or buys and stuff that does not bring social value. So take social determinants health to an interesting area. I've had community health workers who I've worked for who I would fight to my death in 2019, and I got some who used it as a paid vacation. Yeah, so all of that. So let me, I'm gonna run through these last two slides given and I'm gonna come back to David's warning, caution that just because it sounds good, it might not be good and there might be a lot of issues and might have a lot of unintended consequences along that and we actually might be even more inefficient which means more wasteful than we already are wasteful. So I'm gonna come back to that. So let me tell you what we did in the last couple years and Amy's helping lead this as well. And I say last couple years but it's really gotten going in the last year to be honest and this relates to that social determinants of health. So 80% of healthcare spend is affected by our social environment. In fact, you guys have probably seen this, right? Have you guys seen that in some form or fashion? Some might say 60% but most people say 80% which means whether you take the lower number of 60% or whether you take the higher number of 80% what it basically says is for the most part when we've been talking about value we spend a lot of time talking about healthcare services and we spend a majority of time on that even though that's only 20% of anything that's gonna have to anything to do with improving the health outcomes of patients. So the four walls within the physician office or the four walls within the hospital setting best case scenario is gonna impact 20% of those individual population health outcomes. That's it. The other 80% is outside in the community in some form or fashion and you'll see when they don't use the 80% that's because they reserve 20% for genetics and then they do the 60%, right? So anywhere from 60 to 80% has nothing to do whatsoever with the current way that we actually practice healthcare. Right? So then we came along and said, we're giving that reality and we started this. This is why we have this institute. So I'm the chief medical officer for the National Blue Cross Blue Shield Association. We launched a institute which is a wholly owned subsidiary that's focusing on all these social deterrents health that says, okay, we're gonna get outside the four walls of the clinical setting then to where people actually live, what are the barriers that's impacting their health outcomes based upon where they live, what communities are here and then how can we make a difference? So right to you. Rolling to health. Okay, real quick, because we're short on time. What we ended up doing was looking at all these areas where there's transportation deserts and we also looked at not only where there's transportation deserts, we looked at whether or not there's PCP capacity relative to the needs within those particular communities and when we actually did all the analysis, we also saw that there was PCP deserts where there's just not enough PCPs for the needs for those particular communities. And so we're gonna have to provide transportation because they're gonna need to get to a place where there was enough PCPs to meet their particular need. So we've been doing transportation now and now you're probably well aware of Medicare Advantage recently with the final letter first week of April, allow supplemental medical benefits. So transportation now is coming into healthcare, full steam. And in a couple of years you'll see that's gonna be pretty common that individuals will be screening for social terms of health. All of you guys that are doing clinical work or probably start screening for these social determinants of health and then being able to make referrals for transportation or whatever else needs are needs. Okay, so that's one way that we're trying to think about ways to improve the value proposition. Keeping in mind these are relatively inexpensive services in comparison to showing up in the ER or being bounced back into the hospital. So we think the savings are there to justify the service from the ROI standpoint. And then I'm gonna open it up for questions after this. Food queue. This has gotten a lot of publicity in Chicago because we launched this in March and we've been in everything. As soon as we launched it, we were in the Chicago Tribune, we were in Chicago sometimes, we were on WTTW, Chicago tonight, we were in food and wine, we were in forest, we went everywhere because it said for the first time we have big health insurance companies coming into nutritional services saying we think this fundamentally quickly important for people to maintain a healthy lifestyle. We have to make it convenient, have to make it affordable. And obviously people don't wanna eat food that tastes nasty, so it has to be flavorful, right? It has to taste good and it does taste really good which is why you had this up here. So you'll hear this, this is still on radio ads, there's bus signage around here as well, all this particular activity that's underway. Chicago was the first market, we're moving to Dallas next and we're just gonna keep building. Similarly, Medicare, my former employees have come along now and said, hey, similar to transportation, we recognize that nutrition is one of the reasons why people bounce back into the ER and bounce back into the hospital, they're diabetic, heart failure, you name it. And so now what they're doing on the Medicare advantage side is to go ahead and allow for you to add supplemental medical nutritional benefits to be able to say, hey, if you think nutrition can help those chronic conditions be a chronic, people with chronic conditions be able to maintain a healthy lifestyle, we believe that's gonna improve the overall value for our patient panels for Medicare members and so you can be able to do that as well, right? So that's a fundamentally different approach than everything that I start off with. So the first half of my career, I was doing a lot of things that I talked about in the first half of this about quality measures, improving the quality measures, value-based payments, leading to value networks. This second stage of my career, now I'm doing a lot more along these particular lines where we're trying to think that we're taking a more holistic approach so that as soon as you write a prescription, you're not realizing that they can't get to the pharmacy so they need a ride to get to the pharmacy and so we look at pharmacy desert, nutrition deserts, PCP deserts and soon, thanks to Amy's leadership, we're gonna be doing fitness as well and so we're spending a lot of time looking at fitness deserts and ways that we're approaching that as well. What about that for improvement healthcare? You hate that or you like that one? You hate that? You like that one? Oh! I feel like I got Howard Cosell that I can retires but how would I leave? All right, so we got one example that you guys like at least, we'll occur. Questions, because that's the end. We got like five minutes for questions, yes ma'am. So we will be expanding to Medicaid so Medicaid had more restrictions early on so what we said is let us operationalize it in the commercial market, move it to MA and now we're gonna start working with Medicaid to be able to figure out, because you know it's on such a state by state basis to figure out what's required on a state by state basis to do it for Medicaid as well. Absolutely, yes sir. So what's the place that we just discussed from other people? In your position now, do you feel like you have inherited this system or there's not much you can do to change the way things are? Do you think you have some power to change that where you are? Or is it more like we have to deal with what we're told and we're gonna find things like these programs to try to offset this? I think we definitely, we definitely live for ways to improve upon that first high. So all the issues that we talked about, so for example, just prior authorization, it's gonna be a big one. I think you'll see that we're gonna make some movements around prior authorization to ease the burden and the houses related to all that. On the quality measurement, that one is always tough because it depends on how we do it and it gets into a lot of debates and so on that one, I'm a little more nervous that I was, 10 years ago I was gun whole optimistic that we saw everything related to the quality measure. Now I'm a little bit more reserved in my aggressiveness on the quality measurement. The high performing networks are a value-based payment. That's here to stay at least in some form or fashion value-based payments. I say here to stay at least for the next decade. I'm 50, at least for the next decade. I'll revisit whether I care at 60, but right now for the next decade, that's probably here to stay. What do you wanna call narrow next work or tiered networks, high performing networks? Employers definitely want that. That's gonna happen. So, and it's gonna grow because that's what employers want and employers are the one that's fitting the bill for that. Even though we're having more and more individuals doing high deductible health plans and things of that nature, we're still primarily employer-based models for a private health insurance. So that's gonna continue to grow as well. And then what we're doing here to your point on your second half is we're trying to push in so innovative ways in which healthcare can continue to move forward where there shouldn't be a lot of debate among providers and payers about how we wanna be able to do this effectively and so because that doesn't have those type of concerns and we're not grading physicians on this one way or the other, then let's find that common ground and keep moving forward and improving it. And so I think you're gonna hear more and more discussions around community health and being able to talk about opportunities to make a difference because part of what we end up doing when we're doing this and we have all the spatial analysis and we do the visualization. So we can drill down. We drill down to the block group level anywhere we wanna go in the country. And then we upgrade it at zip code level. So we get pretty granular. So you'll see, when we're doing this stuff you're like the regressions are crazy there. It's like 700 million regressions just to be able to get accurate on this stuff. Literally it's crazy stuff. But it's pretty cool too. It really is for geeky people, it's pretty cool. But you'll see more of that type of activity unfolding where you'll see us continue to push more towards this now and on community health. What I was going to do is when I talk in other settings, I talk about that if you don't do this, it's gonna be very difficult for employers to put a facility or a distribution center or whatever into your hometown or into your community because they're looking at how sick that population is. Obesity, diabetes, hypertension, all that. And say, well, why would I go ahead and put a new distribution center in that neighborhood? Cause you're telling me these are the employees I'm gonna have. And I can tell you by looking at those employees they're gonna be really expensive. So civic leaders need to actually address these issues too. And so that's the reason why we also think there's gonna be groundswell where you have it from both the healthcare side that's looking at and then from the economic side in those local cities. Saying, okay, we gotta have healthy individuals in our community so that they can actually be hired. Yes, sir. Thank you so much. Thank you. The organization or entity trying to provide takeover for healthcare needs, precluded needs, transportation, I feel there's a lot of linkage to disaster management. And that may not be a bad analogy of where we are in the healthcare anywhere right now. But one of the things that seems to hold true with that is if we do break for a little while and then we affect years out and we even forget about it or we hit the next disaster. So what strategies are y'all taking? Yeah, that's excellent. So let me tell you, that's one of the reasons why we actually create the institute because of that issue. And we were concerned because agency for healthcare research and quality have put a lot of money in a lot of these different community efforts. And what we found was even the ones that were effective that they had proven to be successful, they wrote it up, they did a great job, RCTs even on some of this community-based stuff. But they weren't sustained. And so our hypothesis, we'll see if we're proving wrong or right, is our hypothesis was that all those weren't sustained because there wasn't a business model that actually allowed for sustainability. And so you notice everything that we ended up doing, when we first did transportation, we did it with Lyft and then we expanded it. But Lyft was gonna be in the business, we know other people that was gonna be in the business aligns with where their strategic priorities are. And so what we ended up doing on the institute side is we'll put something in the market with a business partner or several business partners with the expectation that it aligns with their strategic objectives and they see it as a growth opportunity. And so once we've proven the model, then we scale it and sustain it through the business. And so that's fundamentally different than the traditional approaches that's been either grand dollars or philanthropic approaches or something along those lines. Yes ma'am? Yeah, yeah, so let me clarify because the delineation about non-profit for profit matters on some aspects and doesn't matter on others. So let me walk you through it real quick. So my parent company, so that I'm CMO for it, right? Blue Cross and Blue Shield Association is a non-for-profit, right? So my parents are non-for-profit. We still pay taxes though. Even though they say non-profit, Blue Cross has to pay all these taxes so it doesn't matter from a tax standpoint. We pay taxes and all this stuff. Underneath that, we set this up as a benefit corporation. So I asked specific permission to set it up as a benefit corporation. So a benefit corporation is a hybrid because it's required to have a social mission just like a non-profit does, but I can gain access to capital like a for-profit would. And the idea goes to what you guys just asked at the back, which is at some point if I wanna go out and raise, do a capital raise, I can do a capital raise to deal with any short-term losses or anything of that nature so that it can sustain itself. Because what we'll ultimately do, which is what you asked about the business model, what we'll ultimately basically doing is taking what were like niche place. So if you think about right now, some of you probably like purchase healthy food options and have them delivered to your home. The price point is too high for the average individual in these particular communities, especially once you throw in delivery. So we reached agreement with our financial modeling that we're just gonna make it a volume play. I'm gonna push the price point down. I need to have enough volume to push that price point down. And so I need to be able to just sustain myself to be able to actually have access to capital sustain it. It's all right now funded through Blue Cross and Blue Shield either through our parent company or through direct plans like HSE, Blue Cross Blue Shield, Illinois. It's worth with us to be able to sustain it. And then we can go do capital raise if we need to go do capital raise outside of that. Great. I know we're up against time. Anything else more before we shut down? Thanks for having me look forward to. Oh, did you wanna do a selfie before we leave? Quick question. Can we all you guys come down? We just wanna do one quick selfie before we leave. That's okay. Just right in here. Sorry, thank you. Just right in here if you can come right down here. Please just come right down here in the middle. We're gonna do a selfie together.