The Alignment Imperative: Bridging National Scale and Regional Execution in Value-Based Care

Speaker A: Foreign. Welcome to another episode of Benson. Today I'm extremely excited to have our guest, Nicole Bradbury, whom uh, I've known for a few years now and carries more titles that I can keep count. Nicole, if you can kindly introduce yourself.

Speaker B: 30 plus years in healthcare. You know, started on the payer side, spent half my career there, ran affordability for UnitedHealthcare. That kind of led to jumping on the provider side with my first startup, Rice Health. From there I've created Sunflower, ACO and Value Services Management and um, as well as of course I run the Florida association of acos and the Texas association of acos.

Speaker A: Uh, thank you for taking the time to join us today. The topic that we're going to talk about is something that's been on the back of my mind, especially lately. Nicole. One of the things that I've been thinking about and talking to some of the healthcare leaders that I constantly interact with is you have organizations that started very regional, very local in different markets and then are looking to build a national footprint. And then the flip side of the coin is you have national organizations that start on a, that traditionally have had a national footprint and then trying to build some local strategies specifically focused on value based care. And I thought you would be a perfect guest to talk about the dynamics around that. And you know, traditionally in healthcare we've always said that, or uh, before the advent of vc, the general assumption was healthcare's problems are universal and solutions are local. That was the general premise and general talk. But then I think with VBC as a vertical factor and AI and data interoperability as a horizontal factor, I don't think that is true anymore. I think we are able to create a more consensual approach to how we want to transform health care. So that alignment, how do we align this need to have a national scale for BBC but also have regional execution? How do we bridge the two, how do we balance the two? And that's what I want to kind of uh, dig into with you today. So let's start with that, right? I mean you've seen both sides, you've been part of national initiatives, you're running regional networks and regional associations of ACOs that are permitted to value based care. Why do you think that alignment is important now more than ever given everything that's at stake in the next three to five years?

Speaker B: Well, so I think the problem with health care has always been execution, right? So, you know, and I think the reason it is, uh, historically tried to be solved locally is because everything, you know, healthcare Was complicated and everybody wanted to do it different. It was very manual. There wasn't a lot of technology, there wasn't all the right incentives. Right. Because we just, in a fee for service system, we just had to do a lot of stuff. And the way we did a lot of stuff could differ by the local way that doctors got contracted, the technology they adopted, et cetera, et cetera. So I think value based healthcare, to your point, has really allowed us to look across healthcare and health care incentives and what needs to kind of needed technology and workflows we need to do to deploy to really execute well regardless of where it is. Right. Because the incentives are no longer your kind of your local fee schedule, the number of doctors in your, in your market, the type of doctors in your market is really about. We're aligning to drive medical costs down. And how do we do that? And we do that by aligning, right? We all have to align around the same set of incentives. You know, cost. It was kind of focused on filling beds and doctors filled on creating capacity, you know, because they were trying to get as many patients in as possible. And technology was all about selling technology. And now if we look at, you know, alignment, we say, okay, how do we align the same incentives? So they're all kind of going off the same goals. And to me, when you get there, then you get to good execution. So always been to me about execution. I think with the newer models and the volume of models coming out, it's even more important. I think, you know, a lot of the early successes were really, you know, I'd say 50% luck, 50% kind of, you know, which is rip luck in your wrist pool. And you know, maybe some had a little bit of advantage on the execution side, but now it's really, with all these models, you've got to be really good at execution. You got to have interoperability, you got to have good solid data. You got to know where your opportunities are. You know, I could go on and on and on, but you know, it's all about execution.

Speaker A: How much of a factor is the dynamic of the patient in this alignment? One of the things that I keep thinking about is I've always believed that the groups that tend to do well in local communities are the ones that focus on that. There's a little bit of a cultural convenience there, the cultural relevance, if you will. Uh, especially in New York, you know, we do a lot of work in New York. And one thing I realize is if I think about national large players versus local doctors, right? The Local doctors tend to create more value and impact with VBC because the patients tend to comply and come to align better with the local doctors because that's who they have the relationships with. Right? They don't like this, you know, uh, large entities coming into their communities and prescribing how medicine needs to be, uh, you know, served as not. What, what is your view on the patient's uh, impact on this alignment?

Speaker B: Well, I mean, think about large entities. Probably very similar to what payers were when value based healthcare started, right? They're, they were large. They're trying to look at populations, they're trying to create predictive analytics to say what percentage of that population will I make the most impact on not looking at what a doctor looks at, which is I can see every patient. And then the reason value based healthcare even exists is because the payers finally acknowledge they could never get past a 10, 11, 12% engagement, whereas a doctor should be able to get 100%. They should see all of their patients every year. And it's really about understanding how analytics can get the patients there at the right cadence, you know, for the right reasons, you know, but at the end of the day they should be still seeing and touching every one of their patients. So I think patient engagement is the absolute, you know, it's the reason, you know, value based healthcare exists. And there was a great saying that patient engagement, if done well, is the next blockbuster drug. And so that's at the kind of cornerstone of what value based healthcare is. It is local in delivery, but what national plants can do if they partner with the doctors is create solid, you know, workflows. You know, they can create support systems, but at the end of the day it's got to be delivered by the local team.

Speaker A: 100%. 100%. And we talk about the challenges to alignment, we talk about incentives, we talk about the ensuring that the patient is in the driver's seat. One of the other things that I think about is policies, right? Whether it is at the federal or state level, we've been closely involved with data interoperability. You've seen it, I've seen it. I think we are in a golden era of data, uh, uh, interoperability with TEFCA and all the CMS initiatives and whatnot. But I feel one of the things that I see as a challenge is that we have more policies than what is being governed or operationalized today. There's no dearth for policies. There's enough and more policies documented to the point where it's hard to even Pin what is the right policy for a specific requirement or use case? What's your point of view on policies coming out of the administration or the federal level versus what you see with your members at, UH, FLACOS or even at the Texas, uh, Association? How are they looking at these national policies that sometimes can be frictional to how they provide care to the patients in their community?

Speaker B: Well, I mean, I think that what's coming down to CMMI M I'm actually pretty excited about it. I think they've been thoughtful about listening to the ACOs and the other stakeholders to say, what can we do to really make these models better? How can we make successful doctors sustainable in these models versus one of the early fears was, uh, the better they got at managing costume quality, the less they would make because they got so good at it, they no longer would get the savings that they getting in original models. And so I think they've been thoughtful about that. I think they've been thoughtful about how do we pull specialists in specialists for you, uh, know, a large part of it kind of, you know, been left out. And so now with the CARA and the new lead model, there's ways to get them in. ASM is another way to get them in. Uh, you know, some of the mandatory stuff I think is good. It propels. But at the same time, there's enough of the carrot stuff out there to really get people excited that they can be successful in these things, you know, know, but they're not perfect. And with every policy there's always unintended consequences and, you know, and we have to fight through them and still look at the, the bigger and larger goal. You know, for instance, the fact that, that we still as a country are not moving the cost curve. You know, we might have some great successes in pockets of, you know, the country around ACOs and, and certainly have shifted some dollars from hospitals to primary care. But overall, you know, know, the, the percent of GDP for healthcare in this country is still going in the wrong direction. And so there needs to be some policies which I kind of see coming out this new administration with Maha that, you know, let's move more to preventive care. Let's figure out why we're in a sick care system and you know, all of that. So. And at the state level, you know, the federal, um, CMMI kind of drives Medicare, which really drives a lot because commercial tends to follow along. But where I think the big lagger has been is in Medicaid. And so, you know, with some of the policies at the federal Level, with the Rural Health Transformation Program coming down to the state level, I think you might see more and more of Medicaid embracing value based health care, at least I hope, you know, and I think that's really where kind uh, of state policy can really come into effect and state stakeholders, you know, so still early there, but hopeful.

Speaker A: You're actually right. I think we've seen more activity coming out of M CMMI and CMS than we did in the last 10 years. So that's definitely a very encouraging sign. And one of the things that's core to who we are as a company and something that you're prioritizing on a daily basis in everything that you do, which is that horizontal impact, that technology, data and the potential around what AI can be for everybody in healthcare, all the stakeholders in healthcare. I see that as a horizontal force. I see that as a deflationary force that can truly force alignment of incentives, governance and even ownership or accountability. Right. Is that something that you credit as a factor, kind of like a.

Speaker B: Well, I mean, I think you couldn't have value based healthcare without data. Right. And there's three prongs to that. There's data that lets us understand the opportunities, there's data that lets us build programs and drive systems success or failure within those programs. And there's ultimately, you know, what do those programs do from a cost and a quality perspective, you know, at the end of the day. And so, you know, data's getting better. You know, some of the um, holding on to data, you know, interoperability was never a technology issue. It was, it was people holding data, you know, hostage for revenue models and things like that. So I've seen some of that, you know, go away. And so data is getting better. Certainly the government, when they released all the Medicare data, spurred out when Todd Parks was in the White House. But um, but yeah, so, so data is king. AI I think is the most amazing thing that we're seeing now because I think, you know, let's start with the patient. The patient is using AI, so they're coming to their doctor armed with information that they never had before. You know, if the doctors don't get on AI, then they're, they're going to not going to have the right answer, not have all the possible answers, you know, but, but they don't want to be less educated than their patients walking in the door. So they, to embrace AI from that perspective and then from a, uh, and that's, that's the kind of the scary part, the clinical stuff that's coming out of AI, but from an administrative perspective, you know, engagement, like we said, you know, engagement so important to value based healthcare. But engagement is very expensive to do it right. And AI is bringing, you know, cost efficiency to that. The new access program really is looking at, you know, take the engagement, uh, pyramid and turn it upside down. Access is supposed to get that top layer of how can we get outcomes with using basically technology to get it to as many people as possible, but also use it as a driver of who's next, ccm, rpm, the next level of engagement, and then down to whose needs to come into the office and when, and then all the way down to the point of the pyramid, which is those people we can't get to that are in the home. What do we do, how do we. But AI is totally at that top layer. And then, you know, just, you can go on and on about how it's kind of AI is going to transform the world, much less healthcare, but it really is a, you know, once in a lifetime kind of pivot.

Speaker A: Well, 100%. In fact. I was reading this stat that on an average every single day there's about 40 million health queries going through OpenAI and ChatGPT, which is crazy. Like we've never seen that kind of a, uh, scale. But I think what you, you mentioned something that kind of is scary even from my perspective, Nicole, which is you said the issue with the interoperability was never technology. Right. One of the things that we are wrestling with at scale is today there's no issue around, um, data availability. Right. With all the initiatives, national and uh, state level, you can get access to data that previously we never did. So that's a great hurdle to overcome. But what you realize, especially in our world where we are processing millions of clinical documents every single day, what you quickly realize is there is a significant lack of standardization and contextualization of data. When you're dealing with that at all these points of care, the models and AI and any advanced technology can tend to hallucinate, can tend to misinterpret and misrepresent, you know what I'm saying? Because it's like data in intelligence out or garbage in is more believable. Garbage out because AI makes everything believable. So that's something that we've been very careful about is.

Speaker B: Well, I think it not only makes everything believable, but I think AI really wants, in a weird way, wants to please you. And so it kind of gets to know you. And I think at the end if it wants to tell you what you want to hear. So you have to be very careful to almost challenge AI to make sure that they're just not becoming an echo chamber for your, your own kind of beliefs and wants and, you know, whatever, which is a scary thought that they, it's almost human like the way that they, they do it. But there's actually um, a guy, I don't know if you know him, Brian Martella, that comes to my conference and he, he really talks about what you're talking about, which is kind of a little bit, you know, he's very enthusiastic about AI, but also talks about the caution side of it, the dangerous side of it. The kid that is such a tragic story that was talking to AI and really encouraged him to commit suicide. You know, just a horrible story. But you know, you could translate that to so many things in healthcare, they go wrong. And so I think, you know, just like we have hipaa, just like we had traffic, you know, rules, you know, when the first cars were invented, you know, there's going to be governance and oversight that needs to be built into everything we do, um, on the AI side. And I've already seen there's a company on kind of that governance side to make sure that whatever is coming out, there's someone checking, there's someone to make sure, you know, what's the database, what's that, that state is pulling from, what are the guardrails? And so I just think it's so in its emphasis that we're not quite there yet, but we've got to make that a part of every AI, uh, rollout.

Speaker A: And just like every transformational, uh, technology in the past, Nicole, it will take some time and it will normalize, it will eventually normalize. The one thing good about AI is that we are not going to roll back. I think the potential of AI has been exactly. So that's one aspect of it. I think it's a horizontal factor. What do you think is important for partnerships to win in this alignment imperative? Nicole? We've done our partnerships, we have multiple partners that we have engaged with to scale the work that we have done. And in many instances it works great as long as there's alignment of our own business goals and whatnot. In some cases it gets uh, a little frictional in terms of maybe there's an overlap in your capabilities and maybe there's a, uh, variance in market focus and whatnot. What, what is important from your perspective to get this large scale partnerships to help with that alignment?

Speaker B: Well, I mean, you're talking about from my technology, your perspective of how do you align with kind of some of these folks that are taking risks? Because I think, you know, I think everybody, you know, needs to be driving from the same set of uh, incentives. And so even you as a technology provider, I think somewhere in that contract and that partnership, you know, you should be aligned on the same goals. You know, some of, you know, I know that there has to be kind of a m monetization model that factors in, you know, keeping a business alive, but at the same time just because it's cost to deliver and roll out and provide. But I think the best partners are going to be those that figure out somewhere in that contract where there's alignment on success. And so, you know, if, if that comes together, that's where you create long term partnerships. I actually think on the technology side someone needs to create the rev cycle of value based healthcare, you know. Yeah, it just doesn't exist. And um, and I think that in and of itself aligns incentives, right? When the technology helps push, you know, the constant process improvement, the constant, you know, pushing on, you know, the, the contract is about meeting these financial goals as well as quality goals, et cetera. How does the partner, the technology partner, the solution provider, you know, participate in getting to those same end goals?

Speaker A: You're 100% right. I think a financial alignment and, and with VBC, it becomes a bit of a moving target, right? Because depending on how you're operating your uh, ACO or whichever be your VVC model, it can be looked as a revenue displacement strategy, ra, a revenue generation or a revenue enablement strategy. So that's kind of like depending on how you operate SEO. Thank you Nikol. Now let's look into the future, right? We're all excited about it. I am an optimist. I believe there's a great future out there, especially for the next generation. I know we've been uh, burdened by our current health system and like you rightly pointed out, the cost of care is in an uncontrolled spiral and whatnot. Where do you see five years from now? Nicole? What is your view of the future state of vbc and assuming that value based care is the most dominant model of care in the country, let's say 20, 30 or beyond. What do you see in the future for vbc?

Speaker B: I always live in a kind of ah, a um, bleeding edge entrepreneurial world. And so what I believe is going to happen in five years is actually the business I just launched, Navita Health. I really believe that we're moving back to a preventive health care system. I think all of these new healthcare modalities around cellular health, metabolic health, you know, peptides, hormones, supplements, all of this stuff which gets us out of a sick care, let's just prescribe or operate into a, uh. How do we look at ourselves as, as adopt preventative anti aging, longevity, you know, non chronic disease. How do we keep ourselves from getting chronic disease? How do we keep ourselves from getting Alzheimer's and dementia and these things that strip, you know, the quality of our life at the end of our life. How do we, how do we eliminate all that? And I do think all of these um, new modalities and protocols that are coming out and it's really about, and the business Navita is all about getting traditional doctors into delivering care. This new way, you know, kind of adopting functional medicine, preventive medicine modalities. Because until we do that, we're never going to move that cost curve. So it's new right now. Insurance doesn't really cover it. I think that's going to change. Um, I think elevate one of the new um programs is helping to kind of change as adopting lifestyle as prescription and you need engagement to do that. But if you do all those things, truly it's aligned completely with ayurvedase healthcare because you're keeping people out of the hospital. You're, you know, you're, you're keeping them home and healthy and happy and non sick. So that to me is the next uh, horizon at least.

Speaker A: I hope you're absolutely right, Nicole. I mean I've always believed that if you look at healthcare as an industry, just like every industry, there's supply and there's demand. There's never going to be enough supply for us to meet the demand of healthcare. The only way to balance this industry is to calibrate the demand. And the only way to calibrate the demand is through a preventive, proactive model of medicine. There's no other magical solution to this. So kudos to you, more power to you with Navita and we'd love to partner with you down the road on, on that journey as well. So yeah, I'm with you. I'm a big believer in preventive uh, medicine and you know, uh, it's something that we are working towards with our customers as well to see how we can rewire their models of care. You made a comment about reimbursement around preventive medicine being very nascent today.

Speaker B: Yeah.

Speaker A: How do you see that being a. Do uh, you see that As a challenge, as an opportunity to innovate. How are you working on that?

Speaker B: So I'm already seeing you know, with like self insured employers adopting, you know, some of this stuff, you know, I think it's going to probably start, you know, in a non equitable way which is with the executive teams and with, you know, there's so much um, cash paying patients on kind of the concierge medicine that you know, those are aligning. But I think they're, they're going out there and talking to kind of innovative, not the buca, but the other innovative kind of payers, TPA stuff to adopt some of this stuff. I mean Cigna Healthcare just created a cellular health line of service and they're, you know, all self insured and I think they're looking at how they can, you know, pay for some of the same stuff because at the end of the day it really does keep people healthy and out of the hospital and so. And the ultimate payer other than Medicare is um, the large employers, all the employers out there and once they start adopting it and then with Maha, um, with the, you know, trying to prove that some of these things work to get into the Medicare schedule, I said those are really good signs that they're looking at this stuff.

Speaker A: So awesome. Thank you Nicole. Like I said the very best to you and uh, we'll be rooting for you guys and uh, hopefully we'll partner in this journey as well. Before I let you go, I got to ask the most difficult question of this podcast, which is a fun question. Are you ready for it?

Speaker B: Yes. Yes.

Speaker A: Okay.

Speaker B: I hope I am.

Speaker A: If you were made the National Health Commissioner, I just made up that position for a day. Right, yeah. Where you could change anything in healthcare with no opposition, political or otherwise. What would you change? There's one thing that would change in healthcare.

Speaker B: Well, I would get rid of the current payment system and get rid of um, health, um, insurers and I would make it go direct to consumer and people had to budget for this stuff themselves. And all of a sudden you would drastically change how healthcare is delivered in this country.

Speaker A: Now this is where you and I are, ah, very well aligned. Nicole. When I decided on that fun question, I thought to myself, if somebody asked me that question, what would my answer be? And my answer would be, I would eliminate all the middlemen in healthcare.

Speaker B: Same answer?

Speaker A: Yeah, same answer. Let the provider and the patient, one provides care, one receives care. Right. Then the system will be much more simpler, much more affordable, much more accessible.

Speaker B: Go back to what insurance was supposed to be to mitigate the highest risk. And then we figure out how to pay for our healthcare ourselves. Yeah, totally.

Speaker A: That shows our alignment. Thank you so much, Nicole. Thank you for taking the time to join me on Wednesday this time. If you enjoyed this episode, make sure you subscribe to our channels. Episodes will be posted once a month with a variety of industry leaders and you can follow us on LinkedIn, Twitter and Facebook. As a garage, have a good one.