Value-based Care

Are you interested in the challenges of implementing value based care in healthcare? Look no further than this insightful panel discussion. The experts discuss the obstacles facing payers, providers, and patients as they navigate this new landscape.

One of the biggest challenges identified is risk stratification. Traditional risk assessment methods, such as claims data, are insufficient to understand a patient’s risk profile truly. The panelists discuss the need to incorporate social determinants of health and external data sources to create a personalized risk profile for each patient. This next-generation risk stratification can potentially improve patient outcomes and reduce costs.

Another challenge is trust-building between patients and their care providers. Patients must fundamentally change their behavior to achieve better health outcomes, which requires a trusting relationship with their care providers. The panelists emphasize the importance of technology in scaling outreach efforts but also stress the need for the human touch to maintain patient engagement.

The panelists also discuss the importance of understanding the horizon of the customer. Payers have different horizons than providers, and it is crucial to provide an ROI within the customer’s timeline. The panelists discuss the need to focus on discrete pathways of care, rather than trying to tackle everything at once.

One example of a successful discrete pathway is the use of bundles for heart failure patients. By focusing on a 30, 60, or 90 day bundle, providers can use technology to improve patient outcomes and drive down costs. This approach has gained traction with payers and employers, and has the potential to be applied to other diseases.

However, there are still obstacles to overcome, especially in the Medicaid space. The panelists discuss the challenges of dealing with managed care Medicaid plans, which often prioritize cost containment over patient outcomes. These plans are not always willing to invest in new therapies, such as nutrition services, that have the potential to improve patient outcomes and reduce costs in the long run.

Overall, this panel discussion provides valuable insights into the challenges of implementing value-based care in healthcare. The experts offer concrete examples of successful strategies, such as next generation risk stratification and bundles for heart failure patients, as well as highlighting the need for trust-building and understanding the horizon of the customer. If you are interested in the future of healthcare and the challenges facing the industry, this deep dive is not to be missed. We were joined by Dr. Dave Amin, CEO of Privis Health; Vishal Bhalla, Chief Experience Officer at Atrium Health; Dr. Avi Gurwitz, CMO at Simplex Health; and Blake Marggraff, CEO and co-founder of CareSignal.


Value Based Care

Tom Bunn: good morning everybody, and welcome to iSelect’s Industry Overview webinar series. My name is Tom Bunn, I’m an associate on the iSelect Fund Ventures team, and I’m excited to walk you through today’s presentation, our panelists, and hopefully what will be a, nice interactive discussion for those.

New to these webinars, iSelect is an early stage venture capital firm in St. Louis, Missouri. Focused primarily on early stage companies in healthcare and agriculture and food. At iSelect, we are privileged to live at the forefront of innovation, seeing emerging problems, solutions, and macro trends at their beginning, before they make their way into popular culture.

We use these deep dive presentations not only as a way for us to better engage with and understand new science and technology, but also to engage with the experts and entrepreneurs where driving change and innovation in their respective fields. One such topic that we’re very interested in of, late is the shift to value-based care.

While this is not a new topic, We thought this would be a, good time given the underlying changes in the healthcare system over the past few years to take a look at it and to get a panel together to help us dissect what’s going on. So if you process comments, we are not soliciting investment or giving investment advice in any way whatsoever.

This presentation is general industry research based on publicly available information. Secondly, we have invited you to this because you are technologists, thought leaders, entrepreneurs, industry experts, early adopter customers or sophisticated investors that are part of the I Select Network. We value your thoughts, questions, comments, and insights into this topic and would greatly appreciate it if you actively engage during the presentation.

If you do have a comment or question during the call, feel free to just raise your hand and we can unmute you. I believe there are a couple other folks on panelists who likewise, feel free to, to jump in and comment as you feel fit. Thirdly, we ask that you put yourself on mute for the time being. However, again, we hope for this to be an engaging and inter act active presentation.

So if you do have questions or comments, please feel free to do those. And we will have some time at the end where I will open it up for broader Q&A with the, rest of the attendees. And finally, this presentation is being recorded and will be available for replay. So with that, I’m pleased to bring you this week’s topic on value-based care.

So a quick guidepost roadmap of what we’re gonna be doing today. We have four great speakers, four great entrepreneurs with us today. I will ask them to introduce themselves briefly, and then I will try to set the stage for what will be a good panel discussion among our stakeholders here. The background will be the, need for value-based care.

What it is, obviously there’s much detail that you can go into in this very complicated. Realm with many acronyms and a lot of legislative jargon. But we’re taking a, what I like to call a practical tact to, to the discussion today. Hope most of it will be around those in the market, working towards solutions in a more value-based way in the healthcare industry.

And finally, we will have some time for Q&A. And again, I invite the entire Zoom call to, to participate in that and hopefully it will be a dynamic. So with that, I would like to introduce our guests. Why don’t we just go left to right as I’m seeing them. Dr. Dave Ahman, would you give a brief bio, please?


Dr. Dave Amin: Thank you Tom. And thank you everyone for the, opportunity to be here today and participate in the panel. So a little of my background. I am currently the c e o of a company called Privis Health, which is got its corporate headquarters in the Raleigh Durham area of North Carolina. We have a distributed workforce of roughly 40 fts all across the country.

I, myself, am today headquartered and located in Greenville, South Carolina, which is where my full-time home is. My journey to privis Health has been, a long one and not always a linear path as I have professionally chased, how do we do something better for healthcare and better for patients over the course of my career?

To take a little step back here, I actually started my professional life as an engineer on active duty in the US Air Force. After about seven years working on spacecraft systems, I realized I enjoyed the life sciences more than drawings and schematics, and so I migrated into medical school, practiced emergency medicine.

In pediatric emergency medicine and still do just a couple days a month now. But about six, seven years ago I, began to realize a little, probably late to the game because I was so steeped in my clinical work that, that most of what I was seeing coming through the emergency department need didn’t need to be there.

80% of the patients I was taking care of were failures of the system. Wasn’t that they were non-compliant or that they weren’t going after the care they needed, they didn’t have access to it. And being the engineer at heart I, said about to tinker with the system and see what needed to be done to change that, I came to the conclusion that really what drives healthcare, and I think we can all realize this, is not, an epiphany to anyone that healthcare and what we do in healthcare is largely driven by finance and where the money is.

And so in a fee for service environment, if you incentivize. Volume, that’s exactly what you get. You can drive a lot of strange and what I would view as even perverse behaviors within healthcare and in any industry by doing exactly that. So I came to the conclusion that I needed to take a step back. I took a sabbatical for 18 months.

I picked up a business degree and really thinking about how we changed the flow of money within healthcare. And we moved the cheese for, the mice. And we, actually set about to put the patient at the center of the experience, drive wellness, drive prevention, and change the financial models that both the payers and providers currently work under.

That journey took me post-graduation from business school up to work as an a c o accountable care organization, medical director, and a chief health officer for a very progressive rural health system in New Hampshire, north Country Healthcare. I was there for a couple years, had tremendous success in the, Accountable Care organization with a, fairly small panel of Medicare patients, roughly 11,500 of the number one performing rural a c o out of about 28 or 29 in the country at the time.

And really, we did it with a lot of hardworking without the proper tools. So when that activity wound down for me, I literally went off into the world in search of the tools that we did not have. You can call those population health platforms, technology, all kinds of things, insight into patient risks, risk stratification, techniques, things using ai.

That, that really landed me at Privis, which is a company that about 18 months ago was, in, in need of some strategic reorganization and in thinking about the future of healthcare. So I had an invitation to join Privis. I now have a very nice canvas to paint on in terms of achieving all those objectives.

And it’s been a great ride for the last 18 months that I’ve been at the company. And we’ve achieved a lot of success over the last 12 months and I think it’s because we’re, speaking the right language to our customers. So thank you for the opportunity to be here. And, thank you, Tom.

Tom Bunn: Great.

Thanks Dave. Excited to, to dive into what that language is. I think it’s an interesting tact you’re taking. So we’ll get there in a few vial. Would you mind giving a, brief bio please?

Vishal Bhalla: Thank you for the invite, Dr. Dave. I’m already a fan, so my background is a little also non-traditional and not a, not linear.

I come from the hospitality business in a nutshell. I’ve worked in India, in the uk, Canada, Egypt, St. Lucia, then the Caribbean role, and then now back here. I also joined healthcare because of a, what we call a crucible moment or event in our family. My dad, for the last two years of his life was in a hospital and they took great care of him, but he had some unintended consequences.

At that time. I happened to be doing my MBA and after he passed on, decided to serve in healthcare and I started off as the Chief Experience Officer at Parkland Health and Hospital System, which is a county health and hospital system in Dallas. I’m still there actually. I started Atrium on Monday, and in a nutshell, Parkland has the busiest emergency room in the country.

We are the entire continuum of care from, your family physician, and so we have 80 clinics. We also have five buses that care for the homeless. We have 29 nursing homes. We care for the jail health population and about a thousand bed hospitals, plus or minus. We got into a brand new facility in 2015 and we were still in the 75th or 78th percentile in the country, and after we started this project for the last 11 quarters, I’m proud to say we’re between the 89th and the 94th percentile in the country where county healthcare system.

Also, the other metric I think that we can measure ourselves is as the number of people entering the work workforce in healthcare is going down and more people are retiring. And demand is going up. We’re getting into a buyer’s market, like a housing market, a seller’s market, like a housing market.

And so we have been really, my, my role also helps focus in on the team members and therefore retention. That means both physicians and, non-clinical support team members. And we went down from a 18.5% turnover rate to about 14 pre covid. So this has been our journey and I look forward to, discussing more.

We’ve, done some work on making sure that the people who don’t need to be there should not be there crowding up the system. And we’d love to share that and see how we can leverage technology to improve the health for not only our patients, but also our care providers. Thank you.

Tom Bunn: Great. Thank you Al.

Dr. Ravi?

Dr. Avi Gurwitz: Yes. Hi. Thank you. Thank you, Tom for, inviting me. I give you a little background on myself from Brooklyn, New York. So I’m a New Yorker, but currently in Philadelphia. I’ve been there. I went to medical school at Downstate, got both an MD and an mph, a very strong interest in public health.

Came down, went, did a residency at nyu and then fellowship at chop. And like the Dave, I am also in pediatric emergency medicine. I’m both chair of the Department of Pediatrics at all Redeemer Health System. I’m also do shifts at some of the other local hospitals, but where it comes, relevant to what we’re talking today is Simplex was started with my friend and co-partner, Dave David Rambo.

Who’s got the business end, and I have the medical end because we saw a need that was not being met. In other words, a lot of chronic disease came back to what we considered lifestyle disease, and lifestyle. Disease is another way of saying what you eat, what you do has a lot to do if your health down the road and all the complications and expenses that come with it, and nutrition probably accounts for almost 90% of your lifestyle, health.

And in general, nutrition is a cash-based business. Small boutique, little places not, within reach to the general population. So we came up with an idea of bringing it to the general population through insurance base. Nutrition based, when we can talk about this down when we get to that part.

But our goal was to bring nutrition to the masses to improve chronic disease, lifestyle, disease, whether it’s prevention or reversal of chronic, of certain disease, chronic diseases. And we’ve had quite a bit of success. We started our company about five years ago with three people, and we’re reaching about 50.

But more importantly is the the, success of the patients that we think we’re doing or helping out as part of a team that are in health systems and doctor’s offices. We play just an another role of co of counseling nutrition. So thank you for inviting me and I hope to elaborate more as we get down to

Tom Bunn: that slide.

Fantastic. Thank you Dr. Robbie and Mr. Marggraf.

Blake Marggraff: Thanks so much, Tom. It’s really a privilege to join everyone this morning. Backgrounds are, sincerely humbling. The longer I’m in healthcare the more naive I realize I am in so many different ways. So I’m, Blake. I founded the company Care signaled in 2015, and for the first two years of that business, we went about tackling the problem that resonated with the entire founding team, which is it’s not for want of technology, that most innovations don’t make it to the light of day for real patients.

It’s for want of evidence. And Dr. Amen, it’s exactly I think what you emphasize the the lack of incentive alignment as we shift more and more to value. We placed all of our chips on the concept that by tying evidence and outcomes to financial returns, that we could have a more compelling value proposition that would be adopted more rapidly by the market.

And I’m sure that I’ll dive more into exactly what Cares Signal is and does. But that’s exactly what we did. So we we started by partnering with hundreds of clinicians, ran more than 5,000 patients worth of randomized controlled trials and studies, and published really heavily showing that digital programs could drive outcomes equivalent to, and in many areas, superior to the currently available standards of care, whether they be devices or therapeutic pathways.

I’m excited to dive in. I think this will be a great discussion in the context of everything coming down the pipe even, over just the past few weeks as, round one of direct contracting kicks off. Tom,

Tom Bunn: thanks again. Terrific. Thank you all. Just to set the stage a little bit more, all of these gentlemen are with firms that act as Very compelling solutions in the healthcare space, but to, I think, appreciate what they’re doing.

I think it always helps to, take a step back and take a look at what the problem actually is. The best technology is ultimately solving a problem. So a couple fast facts that I think help to outline the problem. Looking at the US healthcare system from, above, you see some pretty whopping numbers.

First of all, it’s a 3.6 trillion industry on the right. You see how much of that 3.6 trillion accounts for total G D P. It’s hovering about around 18%. Currently it’s the nation’s largest employer, but that 3.6 trillion industry equates to $11,000 per capita. And then the final bullets here, I think is really, telling all of these waste unnecessary services, excessive admin costs, ineffectively delivered services, overpriced services, fraud.

Mis prevention opportunities, those all amount to about a trillion dollars, right there. These are actually old numbers from i, I believe, 2013. So when I look at this problem in relation to value-based care, I see an opportunity for a, fundamental sea change in, how care is delivered that can begin to tackle some of these, pressing problems in, healthcare.

Taking a step back, so what fee for service and value-based care are, I apologize, this is coming across as grainy on my end, but as, was mentioned earlier, fee for service is more of the volume type of play as, described on the left here, and value-based is described on the right here. Fee for service, think traditional service that you, have probably encountered before many, times where you go in to get a x-ray or you get some other imaging or you get a procedure done.

Providers are paid for, are paid by the number of interventions that they do. So fee for service, really think maximizing throughput and procedures regardless of value. On the provider side, they’re very siloed. A lot of the money we talked about being wasted on the previous slide, think unneeded tests, duplicated labs, poor transfer of records from patient to doctor and between doctors.

So siloed providers is one of the symptoms of volume-based care. On the right side, value-based care value-based prioritizes quality. And on the provider front, it incentivizes the provider to, do the right care at the right time to keep the patient healthy. This is oftentimes very team-based or so duplication.

And interoperability, be it with technology or between teams is very high and the goal is not volume but, quality and health outcomes.

They, there are four established tenants of value-based care. There used to be three and I’m excited to talk about the fourth one. I know Al has great experience there, but it used to be population health. So keep the population healthy, keep patients healthy, drive down per capita cost and increase the experience of care.

We have since added another aim to, or another tenant to make it quadruple aim so that the one being added is the care team wellbeing. Is the provider team flourishing? There’s been a number of reports about physician burnout, physician suicide, Obviously physicians can’t do their job well and treat patients if they themselves are unhealthy and unhappy and and, suffering.

So the four tenets of value-based care, again, patient experience, obviously Im improvements in health outcomes are population health, reduction in costs and care team wellbeing.

So there’s a whole deep dive we could do on this slide, but I wanted to give some idea of how the value-based continuum looks from a provider and a payer point of view, specifically in terms of risk and how these parties are paid. So this chart rationalizes value-based care by graphing risk and integration of parties.

So you have risk on the X or on the Y axis and. And integration on the x-axis here. So bottom left is fee for service. That’s business as usual. Then as you go up, you get more integrated and more value-based types of payments. So the second two stairs, there are the paper performance type of of, payment.

This is essentially still fee for service, but it’s a redistribution from those who do poorly to those who do well. So you think about on, the right hand side, pay for performance takes into account value-based purchasing. So whether or not you know, the patient has a high experience and other outcomes, you will be paid more or less based on those scores, readmissions, reductions.

So if you have a readmission, for example, for a heart surgery, you will be docked. Money ultimately from the payers or if you, if the patient gets a hospital acquired condition. So it’s kinda the same money, same pool of money, but it’s being distributed to hospitals based on net zero game, whereby if you do well you, get more money, and if you do worse you get less money.

So going up the, staircase a little bit, you get to more risk riskier financial situations for the, for both parties, but ultimately more integrated and the, ability to get a little bit better care. So you get, you have bundled payments here where whereby providers are paid a fixed amount to treat a patient for a specific condition.

So these are lump sums for different, episodes of care. Just think, for example, a total joint replacement, a doctors and care teams will get a lump sum for. That episode of care, and there are a number of those episodic types of indications or episodes that are quantified by or qualified by cms.

Then finally, you get up to more of the shared savings, which is oftentimes capitation. So providers are paid a fixed amount per patient, per unit of time to treat a patient for all their conditions. So this is much closer to the, kind of the ideal of the, value-based spectrum. But the point is, that, that it is a spectrum towards the, bottom end of the value-based care spectrum.

It’s really closer and more akin to, fee for service. So it’s interesting, it will be interesting to continue to track what, revenue is derived from which type of value-based care. Many payers are saying and touting that they are involved in value-based care. It’s important to dig a little bit deeper and, figure out exactly what those terms are and, how much they really are incentivizing quality over fee for service.

So this slide, I think, shows a, proxy for the growth in, in, in value-based care. So this is growth in accountable care contracts over time. As many of accountable care organizations are networks of physicians, hospitals, and other providers that give coordinated high quality care. And c m s designed the program to ensure that patients receive the mo most appropriate care at the right time.

ACOs are basically a tool for four value-based care. And as you can see they’ve, done fairly well. From a contract winning point of view over time, and I think their growth is, a proxy, an Im imperfect proxy for the growth and adoption of value-based care. A few other data points, as we, we’ve talked about with a couple of the panelists.

Aetna has said recently that they spend 75% of their spend on value-based care. Humana recently said that two-thirds of its patients seeking care are in value-based arrangements. And then Kaiser Permanente is a great example of what they call a payvider, where the, payer and the provider are, integrated and ultimately they, they’ve pushed that spectrum all the way up into the right in terms of value-based care.

But, so this is a, slide that I think hearkens back a little bit to the first slide. Where I talked about the wastefulness in the high G d p or high healthcare percentage of gdp. And I think it’s a little bit more hopeful slide. So Deloitte came out with a report last year that basically uses the numbers in terms of projected growth of healthcare spend, but they said that’s, overestimated.

And the reason it’s overestimated is because you’re, not taking into account technological advancement. You’re not taking about, you’re not taking into account the growth in, data sharing and interoperability and in value-based care. So their, report, which is I think more in line with how we view the world, is that there’s a huge opportunity to bring down these projected costs with the help of tech, with the help of novel protocols and value-based care with the help of biotech.

Innovation, et cetera to, ultimately make a dent in those G d P numbers and get the spend down. So on that relatively more optimistic note, would love to get into some of our value-based care experts. I’m gonna hear what they have to say. So Blake, would you mind giving us an overview of, what you’re working on at Care Signal and, some of the results you’ve had?

Blake Marggraff: My, my, my pleasure. And, thanks, Tom. That’s it’s, a hairy, task to try to boil down all of the trends in healthcare to five minutes. And I think if I were sitting on a call about agriculture or food, I’d be like you, really, you hit the perfect balance. So let’s zoom out to 30,000 feet and talk about the it stack.

That is around care signal. And that I think is decently representative of a provider side. It stack at least the big, points. So at the top kind of upstream is the concept of population health, figuring out what is likely to happen to whom in what general timeframe, right? It’s, just a super high level risk stratification.

And some groups are getting more and more granular. Okay? Now, downstream at the very end is the concept of telehealth or virtual care delivery. And I bet every single person on that call, not only now knows about that, has experienced that in some form or another over the past year. Okay? So you have, what’s happening with my population?

What are the rough trends? And then how am I delivering care, which is really the core capability of providers. And what’s missing is the puzzle piece in the middle, which is in a couple of words, remote monitoring. It’s how do you keep tabs in a more granular way than retrospective data analysis of claims allows from a population health perspective, how do you keep tabs on not just a handful of individuals, but on thousands, tens of thousands of individuals that warrant that kind of monitoring longitudinally.

And that’s exactly where care signal fits. And that’s exactly where I am to, to the greatest degree, even though it’s a small degree, qualified. To speak a little bit about how that aligns with the shift to value-based care. The concept in remote monitoring is exactly as Tom summarized that by investing in, grabbing more frequent glimpses into what’s happening for individuals over the long term, that you can just prevent bad stuff from happening.

A cool stat here, lots of different definitions, but if you define a rising risk individual as someone who, is immediately below the top 1% of utilizers, then literature have different, outcomes. But, the rough consensus is that rising risk population, that kind of two to 20% of the risk pyramid has about a 5% chance of bubbling up into high risk on any given month.

And you say, great, okay, 5%. But how do you allocate resources to invest in cooling off that population? And I’ll, wrap up here by sharing that the approach that Care Signal takes is as a compliment to the many, different device-based monitoring solutions that exist. Essentially capturing biometrics through wearables, through in-home monitoring suites as a compliment to that.

Care Signal offers what we call device list. Remote patient monitoring and the theory and thesis behind device list remote patient monitoring is that by asking patients in that 10 of tens of thousands of, patient scale the right questions at the right time, you can monitor with similar sensitivity and specificity and inform clinical outcomes that, again, match and in many cases are superior to what, different, much more expensive device-based monitoring approaches can achieve at scale for the long term for that population.

So I know that was, again, trying to boil the ocean there. Tom, where’d you like me to dive deeper?

Tom Bunn: Yeah I’m, curious about from a payer perspective, talk to me about your relationships with payers and, the distinction you’ve seen and are seeing. Versus c m s and, some of the commercial payers and, where you’ve seen adoption and where you’ve seen roadblocks.

Blake Marggraff: Absolutely. And it’s a, it’s an special impression question because you know of the, now about 30 large organizations that care signal serves nationally, most of them, about 65, 70% are large provider organizations. And of course, providers are defacto payers at the very least for their employees.

But, in terms of how we are working with, I don’t think I can name. So we work with a couple of the techs of the of the Aetna joint ventures as payers. And then we have a bunch of others of the top three, I think we have the big two. And I think payers lack one thing and they know they lack it.

And that is the relationship with the member, with the beneficiary. Whereas providers have a strong relationship and now are getting more and more into risk payers recognize that the greatest threat they have, the thing that would really deliver on the disintermediation risk by providers is they’ve never managed to have a trusting, healthy relationship, for lack of a better word, with their members who likes getting a phone call from big name payer.

So to answer your question, Tom, the way that we’re tackling that is is, almost leaning on payers to see the opportunity for relationship arbitrage. Payers have the money they can direct at least to, a great extent the innovation, including innovations like care signal that can deliver these financial returns for them through clinical improvement.

And if they agree to just go through the provider, leverage that provider relationship, they can avoid a whole lot of cost that would be incurred

Tom Bunn: otherwise. Great. This is interesting, Blake. I wanna come back with a few questions, but in the interest of time and get into everybody. Defer some of those till the end, but thank you very much.


Dr. Robbie same, question to you. How do you, rationalize simple’s market positioning in relation

Dr. Avi Gurwitz: to value-based care? I think far as population and patient and po the, available population that we serve is everybody. Everyone can use nutrition, whether it’s prevention or treatment.

There are three general. Nutrition areas that we, that are focused on. One is prevention and each insurer has a certain amount of prevention visits. And based on the aca, all prevention is deductible, copay free. So these are built in to patients benefits, but they don’t know they have them. And while it may be impractical for a physician to spend an hour counseling a patient for a more reasonable price for insurer and a payer, a physician can offset that conversation to a partner like us.

So that’s how we partner with on a larger level. There’s two other possibilities. One is M N T Medical Nutrition therapy. So you might have a diagnosis, you may have either used your prevention, but this is like a referral to pt. You get a referral, you try to approach it in a conservative manner rather than an expensive surgery or medication and see if we can make a difference.

And then the last is gestational diabetics, the special population that has a great impact on a lot of lives, including the baby’s life and the life there further. So those are the three sort of areas we focus on Now, as you can see in that circle it’s a team approach. Even though we provide the nutrition.

Nutrition alone is nice, but it works when everybody’s on board. The systems, the doctors referring us, the patients understanding the need for this. And then payers understanding the importance of nutrition and lifestyle medicine to decrease this, overwhelming cost and increasing costs of chronic disease.

Our goal is to align all this and to make it, especially using the prevention, make it free, essentially. Free for pretty much everyone because it’s a built-in service that they’re paying for but don’t know they even have it or use it. And so there’s no copay for the patient. The physician doesn’t take any loss in, revenue.

In fact, in value-based care, if their patient gets healthier, they take, they get an indirect cost savings and more money and, for insurance payers to see that they could have an decreased cost on this chronic disease with a low cost intervention.

Tom Bunn: Great. And what, sort of data do you think you need to, level up with the payers for them to, onboard you more, across their, environment

Dr. Avi Gurwitz: And I think look at looking at Blake’s slide and he all the randomized trials and publications they’ve done, we need that.

The problem is from day one, we started seeing patients and we’ve had to build up over time. We collect the data, but we didn’t have enough patients to actually run studies. Currently, we are engaging with academic medical centers to study either specific populations or populations as a whole to have third party input.

As it’s not just an industry provided study, but rather it’s a study done through a third MA party in the academic center. I think that, that, would be a powerful. Thing to bring to provide to insurers that payers and even health systems, in other words, yes, every lots of nutrition programs and everyone thinks they got it.

Nutritious scientists as vast and as controversial and of anything you can think of. But if we say we have protocols, we show, we institute them. This was the a1c, the blood pressure, the weight prior, and this is what it is after and a year down the road, which is both a la a lasting impact because we’ve left them with education and understanding.

That’s something that would have a great impact on the patient when they join the insurer, when they think about including us maybe as a more mainstream, perhaps providing more visits and the health systems who bring us on to get that value-based care savings.

Tom Bunn: Great, Dr. Avi. Thank you. We’ll come back for more questions to you as well at the end. Vishal, thanks for joining us. You, come across, you come at this problem in a different way working with large health systems and hospitals, specifically in the experience realm. As we talked the other day, distinguishing between value and experience.

How do you, parse out the differences and, how do you relate the two, which is how is experience related to value and what are some of the, key kernels of wisdom you’ve, learned about experience for value at Parkland and then soon to be Atrium?

Vishal Bhalla: Thank you, Tom.

I know everybody has said this. But I think it needs to be repeated that you, get what you measure and you’re incentivizing so there’s an incentive and therefore there measures for those incentives and then people are working for those. But if the wrong thing is incentivized or not, everything that needs to be incentivized is incentivized in the right priority.

Are you really making the difference that you intended to make? That’s the question. And so what I did at Parkland, what we did at Parkland, what I was able to help facilitate is really focus on an NPS equal and recommend the hospital. Though value-based purchasing is based on rate the hospital, right?

Vvp is based on how do you rate your experience as a hospital, I think will you recommend is the key, the other piece that, that, because, and I’ll explain why. There are, if we take vbp value-based purchasing for our healthcare system, there are four parts to it, right? I don’t know if, there’s value in just, it’s just in just explaining that.

But very briefly, there are four parts to it, and one part is patient experience. That’s only one part. The other part is, the clinical outcomes and then safety and efficiency. And if you were to look at efficiency, right? You’re so, each of those four has a 25% weightage in how you get reimbursed.

Okay? So the four are, once again, clinical outcomes, which is 25% age caps or patient experience, which is 25%, safety is 25%, and efficiency is 25%. And without belaboring the conversation too much. For example, efficiency is only measured by one indicator is your Medicare spend per patient. That’s it. And that’s 25% of the weight date.

In terms of patient experience, there are seven measures that include plus rate the hospital, right? They’re all around communication, whatever they are. But if you’re only measuring and incentivizing based on the patients who are responding, so you have a sales mix or a, patient mix of various socioeconomic and demographic backgrounds.

Okay? Just imagine that. So, let us say 60%, and I’m just going to take an example. Let’s say 70% of our patients are Hispanic, 50 plus age group. Let’s say 70% of our patients were that, but not 70% of the people who responded to the survey are of that socioeconomic and demographic profile. Now, we are actioning as a healthcare system, and if you layer it all the way up as a country we’re, actioning based on the information we are receiving.

We are not adjusting that based on the actual demographic profile of the number of people coming to see us. So if, individuals are not necessarily articulate in, in, in the language either English or Spanish, or they’re, some cultures are more clear in their needs, some are less, some are out of respect or whatever they may perceive, we’re not necessarily fixing in the ratio.

We’re not paying attention to the problems because we’re not hearing it because their voice is not allowed enough. We’re not adjusting for that. We’re not. And I think that is one, one part. The other part is the questions that are being asked. So, the, while there are many, questions being asked, we’re only incentivizing six questions.

So we were able to move the needle at part by focusing in on three of the six questions, right? So while it looks great on paper, and yes, we, we’ve improved and overall patients are happier because there’s a lot of correlation between what you work on and what the, net effect is. But it’s very, important for us to review that.

Are we measuring the right things? And then are we adjusting to, to fit our, profile of the people that we serve in the communities we serve? And then the last thing I would talk about is adherence. And we’ve done a lot of work on that. And so there, there are many articles that show that one of the biggest issues spacing, healthcare, and in that cost that you showed us on one of the graphs it would be interesting to see what, how many trillion of that is due to lack of adherence.

And I’ll, I’m gonna go from the 30,000 foot level to an individual patient perspective, again, with a persona. And I keep bringing this up in terms of this persona. So again, let us say I’m a first generation, 60 year old Hispanic male who’s a roofer, right? I’m a roofer. My provider doesn’t know I’m a roofer.

And so I have a medical condition, which my provider takes care of for me and gives me a prescription with some of a medication, which is very effective, but that prevents me from working on the roof. Am I going to take that medicine? No, I’m not. But am I gonna tell the provider that I cannot take this medicine?

No, I’m not, because he’s a position of authority and I’m not. And I’ll come to the solution next. But fundamentally what happens is I don’t adhere to my care and then I end up in the ed, right? And that feeds the cost up. If we are able to enable the providers or the healthcare system to care for the whole person and understand the dynamics around the person, then if there was a medication which was 60% effective and the provider gave me that medication, but that allowed me to be on the roof, that allowed me to continue my profession and care for my family, I would definitely take it.

And so there is this, dynamic where people in healthcare are so aligned with the purpose of serving the person in front of them that if, that person, they’re doing everything they can, the provider is writing the medication, the partner is giving them the medication for free, but the person is not taking the medicine that causes burnout in the provider.

And they’re like, why am I even doing this? And so adding that social aspect, what we did is we did two things, and this goes to Blake’s point in terms of remote monitoring. So with, Covid also, you had people with chronic care conditions who didn’t want to necessarily come into the hospital setting.

So we set up something called an RN clinic. And for some patients we were able to get some remote monitoring equipment, but for others we enabled it in their MyChart account. And so they were able to put in their. Vitals in the MyChart and the nurses would review them. We were able to set up thresholds so that if a patient is beyond that threshold, then the nurse calls them and then they’re calling them in.

So it becomes a pull rather than, I have a routine visit every month, I have to go see the doctor. And we are filling our waiting room with people who don’t necessarily need to be there. Meanwhile, there may be another patient whose cadence is different and they need to be there, but we don’t know they need to be there.

They don’t know they need to be there. And so what we have done, we have now played it out in three clinics. We have RN led clinics. So two things happen. One is that the patients are able to help input their data manually and the rn their thresholds, and they’re able to call the patient in as needed and otherwise you’re not needed to come in, keep up the good work.

The second part is that if the. Patient comes in, the RN can spend more time with the patient face to face and get to know that VI is a roofer, right? And so RN is operating at the top of her license, seeing most of the patients, and only escalating patients to the provider that need to be escalated. So the provider is also now operating at the top of their license.

And so the social determinants or health are being assessed by the RN with a 40, 45 minute conversation, not a 15 minute conversation that provider doesn’t have time for. And so the volume to the provider has gone down, but is more effective. And we are able to also show better healthcare outcomes for the populations who have signed up for the RN clinic.

What is missing is incentivizing, and that’s where the pairs come in and it makes sense for the pairs. And I don’t remember who talked about incentivizing. I think it was Avi, that if a patient is doing the right thing, we need to incentivize the patient. And again, go back to al the roofer who’s never had a massage in his life.

If he was to bring his weight down by two kilos, we give him a massage and now he’s hooked. And then you can now start doing incentives that make sense to the individual. And we can leverage technology on onboarding and let’s not get good on a rabbit hole. But fundamentally, it’s about those creating those personas.

So what we do, and I’m sure other areas do, and as entrepreneurs, you’re aware of the community health assessments. And in which zip code, what are the challenges, and therefore you can have really targeted messages and targeted incentives in a, in alignment with the value-based care.

Thank you

Tom Bunn: Michelle. Thank you. It’s super interesting how interconnected all of these tenants are. And in, in my mind, I was an underappreciated, many of these are underappreciated. And very interesting to see how, turning some knobs, one in, one tenant can drastically affect, others.

So very cool work you’re doing and, wished you all the best at atrium next week. Last but certainly not least, Dr. Dave Ahman from PVI Health. Dave, can you talk to us a little bit about what you’re doing in, particular I’m, I feel like you’re coming at this in a different angle than Simplex, for example, as they’re starting with a, chronic disease and, you have told me you’re going a little bit more granular, starting on a very focused acute or discreet condition and then moving outward from there.

Can you talk to us a little bit what you’re doing and your, strategy for that? Sure.

Dr. Dave Amin: Yeah, absolutely. Thank you, Tom. And it’s been also a pleasure to listen to all these subject matter experts and all of which I. Concur with and are in direct alignment with the work that we’re doing.

So much of the work that PVIS is doing today, sadly, is based on past failures where we’ve learned a lot. They say you learned more from your failures and your successes. That’s absolutely true. In my case, I take us back to the work I did in the Accountable Care Organization, where a very large focus was on taking care of the, whole person and, thinking about the risks of, for example, delivering chronic care management.

And so I want to speak to a fundamental of the work that we’re doing, which is one of the reasons that value-based care has. Had a stumbler too, especially in the system or provider space is that we, all dove into this and certainly I did when I was on the healthcare administration side without a very clear understanding of what our risks were.

So it’s one thing to say we’re gonna go at risk, and it’s quite another to say, okay, if you’re going to go at risk, what is the risk of your population? We didn’t know back in the day. I’m not sure that we do a great job at that today. And then even beyond the risk of a particular population. When I think about population health management, we get singularly discreet and we say, what is the risk for a particular individual?

So, Tom, when you say we’ve taken a, discrete approach that we’ve taken a discrete approach to this in, two ways. And so number one, the start of our philosophy and process is that artificial intelligence or machine learning ai, big data, whatever you want to call it largely is a technique that hasn’t had a great use case in healthcare.

At least not in my experience today. We’re still struggling with what does that mean? So we took the point of view that what if we could take risk stratification of patients to another level? What if we could develop a personalized risk stratification plan for every patient? Let me cite an example if, I’m c m s I’m going to look at two heart failure patients that both have diabetes exactly the same.

So they’re gonna get a risk score, risk adjustment factor, H c score that is going to be additive based on historical actuarial data. And yet the reality is those two patients look wildly different if you sit down and look at where the risk is for each one of them. One patient may have great social support great medication compliance, great supplemental insurance coverage.

The other patient may live alone, live in a food desert, not have supplemental insurance, wind up in the donut hole of c m s and not be able to afford their medications. That presents a far greater challenge. There are two wildly different patients so, we are using our platform to actually do that.

Personalized risk stratification. We can take in claims data, clinical data. Great. That is not the entire story. We’ll look at social determinants. We’ll take in external data sources like CDCs social vulnerability index. We’ve even started tinkering, around the edges of incorporating consumer purchasing patterns.

There’s a world of data out there that if it is processed and the right clinical questions are answered, has the ability to create a personalized risk profile for every patient down to the patient level. That can also be rolled up. And you can look at cohorts of patients. That’s what I call next generation risk stratification.

That is far superior to just looking at two heart failure patients that both have diabetes and say their risk is X because we know it’s not. And that’s where part of the failure. Of the, risk profiling within conventional value-based medicine lies. So once you can quantify risk, I think it follows that you n need to be able to take action against it and you need to be able to mitigate it.

And if you can do that at a discrete level or at the patient level, you’ve got a fighting chance of, actually managing that patient’s utilization and keeping them healthy, which is the goal at the end of the day, whi, which is the same as keeping utilization low. So that requires a technology infrastructure that actually allows you to mi mitigate the risk.

So we’ve heard a lot of these techniques today, remotes, whether it’s remote patient monitoring or whether it’s advanced communication with a patient, virtual first simple things like texting. And so developing that technology infrastructure then lays out a care plan for this patient over some period of time, or some discreet episode becomes unbelievably important.

And that care plan who needs the remote monitoring? It’s probably not every patient where they all need something a little different. So being able to tailor that to their unique risk profile becomes unbelievably important. And so there’s many techniques, and you’ve heard a lot of them today about that technology infrastructure that comes into play.

Then the question is, does technology alone solve the problem? No. I’m gonna posit if it did, we would’ve solved the problem. Technology doesn’t truly care for people. People care for people or human beings. So we, can’t lose sight of the human touch where patients feel like they’re engaged both with their providers, they’re engaged with the system.

I think somebody’s referenced that nobody truly feels engaged to their payer. Probably not. But restoring trust and building the relationship with their provider or health system is unbelievably important. That leads to a question of scale. How do you do that? I could assign some person to sit with this patient 24 hours a day.

That’s neither scalable nor financially feasible, but it can use technology to increase that reach. We can use asynchronous messaging. We can use remote monitoring, I think that Blake spoke to, to actually set off alarms. When people start to depart from the guardrails, we know it ahead of time.

This is proactive care not, retrospective care. It’s about anticipating and then monitoring and keeping patients within the guardrails. So we never lose sight of that scalable touch, or we shouldn’t, we should strive to, to use technology to make that outreach scalable. The last thing I would mention is that one of the challenges value-based medicine has had is boiling the ocean.

It we, started our journey in the realm of chronic care management. Wow. It’s hard for our. Payers, providers. It’s even hard for c m s I would su suggest sometimes to get their heads wrapped around what does that actually look like? That’s a a monumental task. This global care that encompasses just about everything that could be wrong with a patient.

We haven’t seen a lot of enthusiasm for that. What we’ve seen a lot of enthusiasm for, however, from both payers and, well from payers, employers, and in some respects, providers, is can you drill down into something a little more discreet that we can get our heads wrapped around? So let’s get back to bundles for a moment.

Okay. So a 30, 60, or 90 day bundle. Wow. This process I just laid out has to have a fighting chance of ensuring a better clinical outcome, which in effect drives cost. In addition to quality and patient experience for that matter, we’ve also had a lot of traction in the payer space coming to us and saying, can you do this?

But just prove your point with our heart failure patients? Absolutely. As a clinician, I would tell you that the heart’s connected to the lungs is connected to your diabetes, is connected to everything else, right? So we’re, happy to entertain the idea that we can go down a disease specific pathway.

What we’ve also heard from the payer space is, wow, if you can do it with heart failure, can you do it with diabetes? Could you do it with C O P D? So we’re looking at these discreet pathways that we all know what one point will converge because it’s a similar process, it’s just a different pathway, and there’s a little bit of overlap there.

But we’ve stopped speaking about globally taking care of people, even though we know that’s unbelievably important. And we’ve started speaking a little more along the lines of, Give me something that’s discreet and you can get your head wrapped around, we can get our arms wrapped around. We’ll go quantify the risk associated with each one of these patients.

We’ll go tackle that using this technology infrastructure. And that seems to have gotten a a pretty enthusiastic welcome. The last thing I would mention to the group here and to the folks listening in the audience, we’ve also taken a really hard look at the horizon of our customer. It’s unbelievably important because if I go to a payer and I say, this is good for your patients 10 years from now, that’s a non-starter because at that point, Quite likely that patient is on another plan and somebody else reaps the reward of that.

So we have to provide a, an roi essentially that is within the horizon of our customer, whoever that may be. Payers have a different horizon within the payer community. Medicare Advantage plans I would speak to Humana, have yet a different horizon than commercial. Medicaid has a different horizon still.

And then in the provider space they have their own horizon. They’re working with. Let’s face it, doctors don’t wanna lose their panel. They’re not looking to keep patients for a year or two. They’re looking to keep them for a lifetime or as long as they can maintain that relationship successfully.

And so we, take that focus on horizon very seriously. And when we’re pitching an ROI to somebody, that, that has to be a consideration. So I’ll pause there. I, just unloaded a whole lot and give you an inside look at what. Pvi does and, I’ll pause and take any questions.

Tom Bunn: No, that’s great.

Thank you. Dave. I know we’re pushing up against time. If you have to jump No worries. Either panelists or attendees. We might push on with some stragglers here for a minute, but we have a couple questions from the audience. But, real quick, just while I’m thinking about it, Dave, and I think it’s a question for everybody from a payer perspective, you mentioned risk stratification as a key obstacle that needs to be removed.

Curious from, the other folks on the panel, what you think the biggest obstacles are, both from a payer onboarding and from pro provider onboarding to get we’re talking about ACOs as a proxy up or, other proxies for value-based care across the country. Up. What, are those?

Dr. Avi Gurwitz: I think part of it, if I had to say, is that a lot of providers are saying, oh, another help way of changing things. More paperwork, more administrative task, more of another thing. We’ve heard HMOs, ACOs, we have heard mips, and so it’s like another acronym and then you know the, question worries, what if my patient doesn’t do what they’re supposed to do And I lose out on that.

And my business depends on the outcomes of my patients, that I may have some control but not full control based on my population. And. That would be an obstacle for, everything for, the provider, for an insurance company, it’s again, about the horizon. They have a shorter horizon than the physician’s horizon.

The physician’s horizon may say, listen, if I get this person to live a better quality life and a healthier life and a longer life, over the course of my having them as a patient, I feel like I’m I’m doing the right thing. I’m, making success. Payer may say, did I make return in a year? Because that’s a typical policy.

And so with people jumping policies, they wanna know short-term gains, and the physicians really focused on more overall healthy, long-term gains. And so that would, that’s an obstacle that I’ve come across.

Dr. Dave Amin: Tom, I’m happy to dive into, agree with everything obvious said, and it’s, a question of adoption. When I think about the. The obstacles to risk stratification I think it goes without saying that interoperability is obviously an obstacle, which may be going away here in July or may be getting more complicated.

I’m not sure anybody’s really sure yet, but certainly the interoperability integration and, I think the, relative lack of understanding on the part of, and I, don’t wanna pick on the payers here because I’ll pick on all parties, the relative lack of understanding of. What machine learning is capable of doing.

We haven’t seen it directly applied in many respects to this. We’re starting to, but we’re still conventionally doing things the old way. Let’s go look at our claims data, which is a 90 day retrospective look back. What is that telling us? That’s not even coming close to telling you what you need to know.

If it were we would’ve had far more success than we’re having. And so, while interoperability is one thing, it’s also the open mind which says, what other data sets can we pull in? And what data science teams with the life sciences focus can we pull in? What clinical questions do we need to answer?

And then how do we groom these, algorithms using these external data sets to tell us what we think we want to know or generate Insights is not always obvious where, a risk a four or five risk for the patient will pop up. So we’re not there. That’s in its infancy, but they’re, it’s, that’s, it’s getting a lot of attention.

Interoperability will help. But the, fundamental understanding that machine learning can be far superior if it’s applied properly than, conventional actuarial tables based on historical outcomes is, probably an obstacle too. I think there needs to be more education and more demonstrated success.

Again nobody, believes in science fiction. Nobody’s willing to bet a dollar if, unless they’re absolutely sure they can get a dollar 25 out of it on the ROI side. So it, it’ll it’s a challenge. It’s a good challenge and there’s a lot of really smart folks doing, work in this area, so it’ll come.

Vishal Bhalla: I would like to add one perspective to your question. We’ve talked about pairs and providers. Let’s also consider the perspective of the patient. Sure, please. And I think the biggest hurdle barrier is trust. We’re asking them to change behavior fundamentally, whether it’s, there are two parties, there’s the care provider party and the patient.

And the patient is also, has to be equally, if not more than 50% responsible for their health. And so in order to enable that, we need to enable changing of behavior. That’s what we’re talking about for everything that we have discussed today. And in order for that, there has to be trust and there has to be relationships.

So I, request to you all the entrepreneurs, please consider that trust and building that relationship on a one to one level. So that all of this will be scaled up. I think that is, key. And the other thing that I just wanted to mention, which, and Tom again, thank you for the quadruple aim slide.

And remember we talked that whatever is incentivized is worked on and measured What’s not incentivized is not measured. So while caring for the care team, the wellbeing of the care team is in the quadruple aim. Neither is it measured, nor is it incentivized, and therefore nothing is done about it except lip service.

And I’m sorry, I’m a little passionate about it, but I think if we don’t do that, so so you have the patient and you have the care provider, right? The two parties fundamentally at, that’s where the rubber meets the road. If the care provider is burnt out and the patient does not have trust, that’s where we are at.

And the solution is to please consider that relationship of both the, care provider’s flower blooms when he sees the patient do well and the patient does well when they can trust the care provider. So I think that is something I would just request you all to consider in your development. And you can definitely leverage ai coming from healthcare, the CRM systems, personal likes, dislikes, and what drives me, what doesn’t drive me, right?

There are many avenues and that, that, can be leveraged, including voice spots or stuff like that. But anyways, thank

Tom Bunn: you. Great. Thanks for that, Michelle. Looks like we have one question from the audience, and then, we’ll go on our ways here. But Jerry Dowel asks, what does the integration look like between the federal and state governments as states look to shift at least the Medicaid systems over to value-based care?

Someone wanna take a crack at that?

Blake Marggraff: That’s a beast of a question. It’s gonna depend on the state. It’s gonna depend on a lot of the federal policy that’s in pipeline, literally right now.

I, would, it’s a copout, but I would say a lot of that depends on the sentiment of the employers. After all a lot of dollars and outcomes are controlled. The third of dollars and outcomes at least are controlled on that side.

Yeah. Tom I’m, glad to put together thoughts for the person who asked that question and share some resources if that’s of interest.

Dr. Dave Amin: I can take a crack at it a little bit just based on some current experience. Tom it’s a great question and one of my great passions is what I view as the UN under underserved population or even some cases non served.

And we know that Medicaid is exactly that and we’ve had Medicaid expansion. We’ve had states, I live in one that’s not a non-Medicaid expansion state. And historically what’s been done with Medicaid is state or state Medicaid has contracted with, the payer space to deliver some kind of an H HMO solution which is not value-based care.

It’s in many ways just cost containment and doesn’t deliver the promise of true, care to the patients. Certainly not in any, what we would expect from a commercial or even a Medicare or certainly not an MA plan. We have gained some traction. Most recently with, a Medicaid plan, and again, I’m gonna go back to discrete states.

The Medicaid population’s unbelievably complicated for a variety of reasons. Socioeconomic status number one, job hopping inter interstate movement, going from one plan to another. When we talk about horizon now, we’ve talked about something far even, somewhat more restrictive. However, it is interesting that a state Medicaid plan reached out to us and said, what can you do for our heart failure patients within a 12 to 18 month horizon?

Because they’re killing our bottom line. And again, if we consider Horizon and we consider a discreet pathway of care we, have a really good chance at affecting something very positive for these patients over that timeline. Now, can I change the rest of their. 20 years. I, probably can’t unless we do manage to connect with them in that 12 to 18 months.

And it’s an amazing experience and we manage to build that trusting relationship that Vishall talked about or rebuild it where it’s willfully lacking in the Medicaid system. I think we’d all agree if we manage to do that leveraging technology is one thing but, always inserting that human touch in it to make sure patients feel like they’re cared for.

Hey if, we can satisfy the plan in 12 to 18 months that we’ve saved them money, if we can connect with a patient in a meaningful way, that’s at least a start. And it’s a great question that somebody asked and that it shouldn’t be lost to any of us. That I’ve often said if you can, crack the nut on the, on Medicaid, everything else looks easy by comparison.

And I’ll

Dr. Avi Gurwitz: hop onto that because Tom, one of your slides, when you looked at adoption of value-based care, Medicaid was literally almost flat line. Yeah. And. Dealing personally in our company with payers, which we deal with all payers cuz our go, our mission is to bring nutrition services to everybody regardless of socioeconomic, regardless of insurance, et cetera.

I would say that we’ve had the most difficulty with certain managed care Medicaid in the sense that they’re not seeing nutrition as a valuable therapy. Obviously, again, we don’t have yet the data, but we will, but we’re not even given the door to say this is a service that. It’s worth a try for you.

Maybe we’ll pilot, see a thousand of your patients. So the Medicaid population is, what we need the most to hit, but they’re the hardest to get through if we want to do our mission of not charging the patient, which is, which for those populations would be detrimental and impossible and have Medicaid pay for it because that their incentive is to keep costs low.

And while yes, they’re doing some version of value-based care, at least look into lower cost options to improve the these expensive chronic care patients. And they’re hard enough to crack. And I think Dave said it best if you get Medicaid on board. Everyone else is gonna follow, or usually Medicaid follows everybody else, but you will have gotten everyone else to follow.

And they’re, it’s a difficult, it’s a difficult payer to deal with and there’s a lot of managed cares in d in, one state alone, let alone many different states. And they all got their own philosophies and they all got their own agendas. And as opposed to commercial or even Medicare, it’s, these are, this is a payer that you have to fight for.

Vishal Bhalla: The one thing I just wanted to add briefly is you have the federal, you have the state, but also please do not discount the county because the counties like in Dallas the, county taxes, its residents to care for those that are not necessarily covered all through by the, between the state and the federal.

Tom Bunn: Terrific. I’ve kept you all later than I said I would, so I apologize. But thank you for your willingness to keep the conversation going. This has been fantastic from my point of view. I hope it has been for you as well. And it spawns some, new friendships or new collaborations to those in attendance.

We host these calls every month, the second Wednesday of the month at 9:00 AM central. And we alternate between a topic in food and ag and healthcare. So look out for next month’s topic on food and or agriculture, and we hope to, speak with you before that, but hopefully see you at that webinar as well.

So thank you all for your time again and, have a wonderful Wednesday. Thank you.


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