[S2E16] Dr. Ralph Snyderman: Fixing Healthcare While the Plane Is Flying - What Comes Next

Part of this is the intrinsic culture of how physicians have been trained. And this is something that you know the Duke Medical School and every medical school is responsible for. Are we training physicians to be thinking of proactive, personalized, preventative medicine? Or are we training them to deal with episodes of disease?

And I think that there is still a culture on the part of physicians to be ferociously independent, stay out of my sandbox, and I'm going to do things the way I did it before, which is really focusing on episodes of disease, because quite frankly, as a physician myself, it's it's fun in a sense to try to figure out the different the diagnosis and the treatment. And uh it it's it's very, very precise in terms of how you do it. It's much fuzzier to think about prevention, and it's much harder to see the impact of what you do.

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Well, so excited to be here on the Clearly Beneficial podcast today. Um my guest is a very special one, uh Dr. Ralph Snyderman from Duke University. He is the chairman emeritus, Chancellor Emeritus, excuse me, of Duke University, director of the Duke Center for Personalized Health Care, and a founder and a board member of a company called Zeal Care, which is involved in population health.

Welcome, Ralph. It is a pleasure to be there. It's good to see you, Vincent. Well, thank you so much for being here.

It's it's really an honor. So um let's start, you know, with a simple question. You know, in your opinion, you know, kind of what's the state of health care in America today? I think uh the state of healthcare is uh is in tremendous transition.

Uh during the time periods that I've been involved in healthcare, which goes back two, three decades, uh I've never seen so much change going on uh in basic fundamental aspects of healthcare delivery. Uh and um and I think that's an important and a positive thing. I I think we are in a period to some degree of chaos, but I think it is necessary and inevitable that we move from the care delivery system that we've had predominantly over the last 30 or 40 years uh into a new, more rational model of care, uh, which I'm sure we'll spend some time talking about.

Well, let's let's dive right into that. I'm I'm I'm all ears. I think what you're talking about is is fascinating because I'm sensing it as well. Um and so tell me what you feel are those those new innovations and new things that are that are currently kind of brewing.

Okay, well, let me let me just take it up a uh a little higher elevation and and talk about just very briefly the way things have been uh and then where I think that they're going. So when you mentioned that I uh that I'm chancellor emeritus uh at Duke University, which I'm honored to be. Uh but uh what what put me in that position is that I was the uh the chancellor for health affairs for 16 years, uh, and the the the founding president and CEO of the Duke University Health System, which is one of the first major integrated care delivery systems uh that was led by an academic uh institution.

So, from that framework, for a long period of time, I oversaw a large clinical delivery system uh that ranged from Durham all the way through a vast part of North Carolina, South Carolina, Virginia, parts of Florida, even into Singapore. And the way that we were paid, if we get to uh a major driver of what health care is, it it's it's what's paid for. Uh, you know, you know, what you get is what you pay for. And the way healthcare was paid for is what we call fee for service, that we got an amount of reimbursement for the service that we perform, you know, for specific episodes of service.

And the more intense, the more technical, the more you got paid, and actually the more margin that you got. And in running a uh a large care delivery system in which we took care of patients who had no insurance whatsoever all the way to insured, you ultimately needed to balance your cash flows so that you ultimately, at the end of the day, had at least enough margin to subsidize those things for which you got no reimbursement. So that was a fee-for-service system that led to a delivery model that had to contain and actually overweight to a degree, dealing with episodes of care and fairly high-intensity interventions for episodes of care.

What that has done over this period of time is through neglect of thinking about evolution of diseases, particularly chronic diseases, potentially preventable chronic diseases, that the uh there is an epidemic of chronic diseases in the United States. A prototypic one would be type 2 diabetes and kidney disease and heart failure, et cetera, et cetera. So, and that's also driven up the expenses of care delivery to a level that is pretty much unsustainable by our economy. The reason I say that we are in a very, very big transition now is that this has been well recognized.

We cannot afford the current way that healthcare has been delivered because it is too expensive and it is not doing what it needs to do, and that is not only treat episodes of disease, but prevent them, uh, mitigate them when they occur, and improve health. So there is now a move from this reimbursement system, which you know we've called fee for service, to payment for value and payment for continuity of care. But it's still a very small percentage of all care reimbursement.

So, you know, this is uh a work in progress. So the transition of care delivery is going to be massive, moving from this tremendously overweight emphasis on episodes of disease to rationally thinking about how do we anticipate an individual's likelihood of having a disease, how do we intervene if it occurs, how do we try to mitigate it most effectively? Thinking of care over time rather than episodic care. Well, I tell you what, I mean, as you're speaking, I mean, literally the fireworks are just going off in my brain because I'm really not sure which gem to pick up on, you know, from what you just you know said to kind of unpack all that.

Um, but the first one I'll go into is is it's kind of a kind of a two-parter in the sense that so I living in California, I mean, the the predominant one of the predominant health systems here in California, and they're certainly beginning to spread their wings beyond California, is Kaiser Permanente, for example. You know, so they they they are the sort of the classic, you know, um, you know, staff model um organization where you're in a capitated HMO arrangement where people are, you know, their people are, you know, the they get paid whether they see patients or not.

And and I think they themselves have struggled long term. I remember back in 2010-ish, when they began to launch this notion of well-being or wellness uh to the employer market. And the notion was if we focus on the health of our patients, we focused on the preventative side, you know, we're gonna lower long-term costs. I I don't know that that has played out for them as well because in in truth, because I don't know that, you know, there was a moment, there have been moments in time when the Kaiser Health Plan, for example, has been the lowest cost plan around, but even they aren't the lowest cost plan around, depending upon the day, right?

So I think there's been a challenge there. So I take it you're familiar with that organization and and and how that compares and contrasts or dovetails into what you've been saying. Yeah, no, I think that's uh, you know, it's uh it's very important. Uh and you're asking it is uh is exactly spot on, but so I I think it's uh it's a very important question.

You're correct. Kaiser Permanente and there are a few others, are kind of whole uh entities in which they're somewhat shielded from reimbursement on the outside because that they have their whole means of reimbursement. They have everything from primary care, you know, primarily primary care to access to specialty care. So you ought to think that Kaiser Permanente ought to be the model for developing value-based care.

Right. And I think they're capable of doing it, uh, and they have some fantastic people there. But I think with Kaiser Permanente, the problem has not been in the concept of more uh, let's say, holistic approaches to care based on the fact that the payment is the payment. So, you know, the there is an incentivization to try to minimize expenses.

I think it's been the execution, quite frankly. Uh you know, how do you go about if you have a system uh in which you're dealing with a population uh and what you're trying to do is improve health and manage cost, then the question is how do you do it? So if you get you know a level or two down in Kaiser Permanente, and you know, I I don't want to speak for Kaiser Permanente, I'm a total outsider, but I I know we've actually competed with them for a period of time when they tried to come into North Carolina.

Uh but I I know a lot of those people. I knew the former uh CEO and president, uh, we were actually on a board together. Uh I love the model. And I know that they just recruited a superstar from Duke, who was the head of our health system, to go there.

So I think, you know, I think they're they're off and running. But one of the problems with Kaiser Permanente is that even though they have many, many uh primary care practices, I think they will tell you that each practice is an entity unto itself. I mean, it it isn't as though there is an overall direction, or at least you know, when when I was much closer to working with them, that there would be an overall model of how do you actually, if you have the responsibility for population uh care management, well, how do you do it?

How do you do it effectively? And I think that you know may be uh part of our conversation today, because having that responsibility is a good thing, and having the reimbursement aligned with outcome is a good thing. The next thing is, okay, so how do we do it? You know, you know, now now that the the the dog has caught the bus, uh you know, what do you do with that?

So I think with Kaiser Permanente, they have the opportunity to be very big, high impactful leaders in this area. Uh, I think what they need to do strategically is really thinking how do we do this effectively? And then part of this is the intrinsic culture of how physicians have been trained. And this is something that you know the the Duke Medical School and every medical school is responsible for.

Are we training physicians to be thinking of proactive, personalized, preventative medicine? Or are we training them to deal with episodes of disease? And I think that there is still a culture on the part of physicians to be ferociously independent, stay out of my sandbox, uh, and I'm gonna do things the way I did it before, which is really focusing on episodes of disease, because quite frankly, as a physician myself, it's it's it's fun in a sense to try to figure out the different the diagnosis and the treatment.

And uh it it's it's very, very precise in terms of how you do it. It's much it's much fuzzier to think about prevention and it's much harder to see the impact of what you do. Well, one of the things Kaiser was very, very good at um when you know I was an active insurance consultant and broker, and I had some very large group clients, um, they were very good at reporting. I mean, if you had a population of more than 250 members, I can deliver a report that told you how many people had high cholesterol, how many people were pre-diabetic, you know, all the things.

And I'd sit there with my clients, I'd sit there with the Kaiser representative representing the data to the client. And so now we know this stuff. What do we do about it? And and and there was never really the I I love, I always just use this term, the last mile.

The last mile wasn't solved. You you've paved the road for me, but but I don't know what the destination is. And there was this this disconnect there. Um and and thank you for saying all that.

And and um it's it's it's just it just speaks to the culture of care that we've been facing in this country for many, many years. But let's now go to the other side of the equation now. When I think of value-based care, you know, I think that now we now we get into the world of incentifying physicians and and systems for doing better, for lowering the cholesterol of a population, for minimizing the type 2 diabetes of a population, for doing all these things. And I know CMS and Medicare, oddly enough, are the absolute innovators in this, right?

They've been fighting that fight for probably seems like 10 plus years and have come out with different models that work. And I I was familiar, I spent some time working with a with a company out of New York called Pearl Health that was in the Medicare ACO space. So I got deep into the weeds of how that works. And and it seems to me, it just, you know, to me, it just makes sense.

Why wouldn't I try to deliver value on the whole for my patients? Well, I think um to me, what is really exciting, and this is what uh I have been focusing all my attention on, at least for the the last 15 years, is, you know, to your point, if you have the capability of practicing population and personalized population health care to maximize the health, minimize disease of each individual, how do you do it? You know, how do you do it? And I think that most of the attempts, if you talk about what CMS has done, and I will violently agree with you that CMS now, uh with the leadership of Mehmet Oz, really understands what you and I are talking about right now.

You know, how do you start going and doing what you could do to practice much more rational, proactive, effective health care? And they do it through reimbursement mechanisms, and they support reimbursement of the things that will try to get you to a more rational form of delivery. But you know, that's so distant from okay, so how do you do it? You know, so what do you do?

Uh you know, what I've spent most of my time thinking about is if we were going to start with a blank canvas, what would we do? You know, if you given everything that we know now and all the capabilities we have now, what would you do if you had that opportunity? And there are a number of component parts. Number one, you need to have some understanding or some approach or a model of how care should be delivered.

You know, what is the approach to care? Uh when an individual sees a physician now, by and large, uh the physician is expecting the patient to uh to have a problem. That's the reason they came to see the physician. So the whole approach is you start with the individual's chief complaint, you know, why did this person come to see me?

There's something wrong, and then you do a different differential diagnosis, you figure out what it is, and then you have a treatment plan. So that is a culture trained to deal with episodes or some problem that the person has. That is necessary, but far from sufficient. You need to have, in addition to that, what is the mechanism by which, when you see an individual, when an individual interacts with the care system, that you develop some approach or a plan, a healthcare, personal plan for that individual that recognizes their current state of health, what are their risks, their immediate or longer-term risks, what are the things that they could be doing to mitigate the risk and enhance their health?

And then, you know, what is the plan to do it? So you have to start with what is the basic approach to care? The basic approach to care right now is reactive. We need a basic approach that's proactive and personalized.

And that's what I've been kind of banging the drum on, you know, since about 2002. Well, and and in our previous conversation, which I thought was was such a great point, was that, and you knew the numbers right off the top of your head. I mean, the percentage of people within a population that drive such a small percentage of people that drive the highest costs of care. Absolutely.

You know, a large for the audience, you know, I think, I mean, you know the numbers better than I do, but I would say, you know, the top 1% of claims represent, you know, 50% of the cost of care. I mean, is that about right? Well, I what I could tell you from uh from the experience that I've had and the data that I've seen, if you think of our healthcare expenses now of roughly $5 trillion, 50%, 50% at least half of it uh is related to uh 5% of the population. Uh 80%, 80% is related to 10% of the population.

And if you say, what are the drivers of those expenses, it's very heavily, you know, independent of things like trauma or transplantation of organs, it is multiple chronic diseases which are preventable, multiple complex chronic diseases. So if you think of it using your perspective, from health care expenses, because you could start it any way and you end up at the same place, uh, if you think of uh I want to solve the problem of Of health care cost, and I want to do it in a rational way that we're not denied care, uh, but we're improving care and rolling uh decreasing cost.

If you uh if you look at it from that perspective, if you deal with a small percentage of the population, you have the vast amount of cost, and even more interestingly, costs that are needless cost. You know, they're inefficient, they're they're related to the inefficiency of the care delivery system. So if you want a lower cost, you start with the end of the highest utilizers and you try to say, well, you know, look who are these people, what is their problem, and is there anything that we could do to actually improve the quality of their care and decrease their costs?

And the answer, Vincent, is a resounding yes. Yes, yes. We know that that is the truth. So if you think about, let's say, Kaiser Permanente or any uh any system where you have an opportunity for large population health care management, you you have to start with a different approach to care, which is proactive, preventative, uh continuous.

Uh, and you you have to start with that. You have to change the current approach to care, which is reactive, episodic, to one that is proactive, personalized. And there's a lot of literature on what that is. And you know, this is something that I've spent a lot of time writing about and thinking about.

But so that's that's one thing. But the second thing, uh a second thing that you need is that you need to align the care delivery system so that it allows the distribution of individuals within the system to the level of care that they need. So, you know, when I uh when we developed the Duke uh health system, I really visualized it as a uh as a distribution system. You know, we had this population of several million people, and then how do we develop a system that provides individuals where they are uh with the care that they need, with the level of intensity going all the way up to those people who would ultimately need to come to Duke Hospital?

And it would be a small percentage of that entire population. So you need to have a new approach to care, you need a care distribution system, you need to have a reimbursement system that rationally rewards uh good, effective outcomes. And then another big piece which has been totally neglected in healthcare, I would say totally, but very heavily overlooked in healthcare, is the need of the individual to participate effectively in their care. Oh, can I just stop you there for a second?

I mean, preach that. I mean there's but is it let me ask you this question is as you're talking, I I was I was kind of thinking about this. Sometimes the highest cost of patients are afflicted with an illness that is let's call let's just say no fault of their own. It's not a lifestyle choice.

They get they get brain cancer, they they are they get diagnosed with something evil. And they've done all the right things, never smoked a cigarette in their life. You know, they they they've done everything right, and yet they still are afflicted. And I think sometimes those tend to be the the saddest yet most sometimes the most costly things.

Because there's there's the population that's chronically ill from a lifestyle choice perspective. It's it's obesity, it's eating the wrong foods, it's any number of things. But I feel like, you know, targeting the folks, and it's got to be on a multitude of levels, right? And I think people just need to have that someone grab them by the hand and show them the way, right?

When you're diagnosed with something bad, I mean, like yesterday I was on a phone call with a physician, my father-in-law was diagnosed with something, and he asked me to be on the on the phone during the visit with his doctors, so I could hear be a second set of ears on it. And it's treatable, all the good things. But he is now a patient, right? And so it's the thing where people get into this patient mindset that they're gonna be the system, then brings them in and doesn't take care of them per se.

They just become a cog in the big wheel. So, how do you address the need to calm the patient from a medical diagnosis and treatment protocol perspective, but also that someone is there to help them? Okay, I mean, that is so important and it's spot on. And you know, what I would say is if you that need ranges from individuals who, as you say, uh develop a glioblastoma or, you know, or whatever, uh, to individuals who develop uh type 2 diabetes and early chronic kidney disease.

And um uh, you know, I think uh we need to have a system that recognizes that full range. But you know, the concept is that when an individual has a clinical situation, uh even if it's of no no fault of their uh the uh of their own, as far as we know, let's let's say an individual individual develops cancer. And I it's so funny because I was just talking about this today, to you know, these are things that we actually work on. And that is uh individuals who have a uh diagnosis of cancer, uh, and their therapy is very complex.

Sometimes it has surgery, radiation, chemotherapy, uh, and the ability from the time of diagnosis, let's say the diagnosis of breast cancer in a woman, diagnosis, the life has changed at that moment. Boom. I mean, it it is very difficult and devastating. And then over the next six months or a year, the life has changed in that there are likely to be therapeutic uh interventions that need to be addressed.

How does this person, how does this woman navigate that? Currently, it is piecemeal, uh, it is uh, you know, I feel, given what we're capable of doing, sometimes barbaric in the lack of support uh that they are given. And you say, well, whose fault is it? It is it is it the health system's fault?

Well, you you depending on how you look at things, you could say, of course it is. But from the health system side, says, you know, we we get reimbursed for these kinds of things, and there's a whole bunch of things we'd love to do. But, you know, quite frankly, you know, Vincent, I'd love to do it. I just can't afford to do it.

And and that is actually the truth. I'll I'll I'll digress a little bit. When I was, you know, running this uh massive operation, uh, we developed a program called the Cancer Survivorship Program, knowing the difficulty of women navigating breast cancer therapy. So compared to what you normally went through, we gave this individual a coach, a survivorship coach, and then developed a plan that spanned that entire time with all their appointments, what they needed to do, uh, if they had chemotherapy support for nausea, vomiting, hair loss, et cetera, et cetera.

It was one of the most beautiful things that I've ever seen. And here, you know, I was running the place at the time. The problem is we couldn't afford to do it because everything came out of our nickel. I mean, we had to pay for, we we we got reimbursed for none of this.

So that shows you the tight linkage between what is better medicine, more compassionate medicine, and better outcomes because you get compliance, much better compliance, uh, if the individual uh actually shows up and do does all the things that they do. But the health system has not had the frame of reference to do it this way. You know, life is a journey and a continuum, and we ought to be helping along the life continuum. And in that life continuum, as you said, what the patient needs to do in many instances is at least as important as what the health the health system can deliver.

So what I have kind of had the the epiphany of uh is that there is a vast aspect, component of health care that has been neglected. And that is how do we develop the support systems to engage and enable the individual to do what they need to do to get the greatest benefit for their care delivery. No, that that is such such important stuff to say, and and everybody is responsible for this. So, but what's also interesting is there was a feature on CBS Sunday morning last weekend talking about a company in New York, again, run by a bunch of you know millennials in Brooklyn, um, you know, that that that that started, and their their their mission is not to do any of that, right?

Their mission is to help someone, you know, navigate their insurance bills and navigate, you know, the hospital. So I mean, while that's an important thing, it's also another stressor for a patient because that you throw that into the middle of this need for compassionate stewardship through a care journey. And it's the people have to absorb a lot when they when they're diagnosed with something. And it's it's just the the nature of this.

And this is where I want to pivot back to CMS for a second, because the Center for Medicare Sciences um services. Um what they're doing in forcing the hand of hospital systems and physicians to play in the value-based care sandbox, I think will ultimately have a trickle up or down effect, depending upon your perspective, on the systems as a whole. Because systems have to operate, you know, it's not there's no there's no unlimited source of funds, right? Employers are getting sick of paying premiums at the level they're paying.

Paying a thousand bucks a single for a single employee to be on a plan these days that cannot go to two thousand bucks a single in the next five years. I mean, I don't know where the revolt starts, but it will start. So this is such an interplay of so I would say uh like you're you're obviously your comment starting with the population of CMS. Focusing on value really trying to derive that point.

Um I mean you're absolutely right. And um CMS uh is is actively trying to develop funding mechanisms right now to support these concepts of continuity of care and even patient support systems. And again, I'll I'll mention that Mehmet Oz uh is very familiar with the things that we're talking about and has bought into it. And he understands, because he and I have talked about it, and I've written some papers about it, the importance of having these systems that enable individuals to, in parallel to the care delivery system, to do the things that they need to do.

They have recently come out with a new uh they're doing it now with with you know more with carrots than with sticks. Uh there's a new funding opportunity called Access, which will start in July, that actually provides funding for these uh essentially care delivery programs that um have a continuum over time, these care delivery patient support systems that pay for coaching platforms and uh uh let's say patient support uh systems. Uh but you know, but I think what is necessary uh is to, well, you know, I think the changes are going to be incremental in getting uh reimbursement mainly from CMS and then from insurers, from self-insured insurers to self-insured employers.

You know, I think uh a big driver can be CMS. Another very big driver, big drivers that have a big stake in this game are the large self-insured employers. I agree. Because they can, number one, they they have a vested interest in everything we're talking about, the best outcomes, the best health at the lowest price, but not sacrificing price for health.

So if you say that if we do it the right way, it's going to be less expensive, I could tell you, yes, that is true. That is true. So self-insured employers are in this, uh, the federal government uh is in this, uh, and then you need to develop the reimbursement mechanisms, but then you have to go back and say, okay, so how do you do it? Because if you try to develop that innovation from inside a care delivery system, uh it's hard to do.

And you mentioned Kaiser Permanente, uh, which I think that they are focusing more and more. So, you know, given this large capability, how do we get it to work? And again, this is just my biased opinion. I think part of the problem is that if you're dealing with so many independent physicians that are trained to do things differently, you need to train, you have to change the culture of what we expect from care delivery.

So I think that uh the reason I said that we are tremendous transition and somewhat chaotic is that everybody recognizes what you are really emphasizing that we need to change the way things are being done. Everybody recognizes that. But the question is uh it, you know, it's like uh if you are in a 747 and you have to fix it while you're flying, it's not the easiest thing in the world to do. So um the question is, how do you go in the transition from this heavy fee for service episodic approach to care to a more proactive, value-based uh approach to care?

Uh well, it's healthcare is this thing to me, you know, there's not an industry with more smart people, all right, across the gamut of care delivery, management, you know, scientists, researchers, business people. All these smart people still can't figure it out. And that that wasn't a question, that was just my own bias of a statement, right? Um, I want to wrap up.

We have about five minutes left. I want you to spend a little bit of time if you know, sharing a little bit about the work that you had mentioned to me in our previous conversation that is being done with one specific population. I you you can I'll leave it to you to name the names. I won't name the names, but there's a one large section of one state in the union where some innovative stuff's going on, and I'll leave it to you to fill in the blanks.

Okay. Well, I uh, you know, I you know, you talked about Brooklyn millennials. Uh I I grew up in Bessonhurst, Brooklyn, so I get straight to the point. Um so uh, you know, you could fix the system, and the system will have to be fixed uh from where it is right now.

And, you know, how do you most effectively get that transition? Or you could start from scratch and say, if I were going to build it, you know, what would it look like? Uh I feel comfortable uh in saying that Alice Walton uh became familiar with what we were doing. Uh, you know, generally, the approach to care, which you give different names, you could call it whole health approaches to care.

She came to visit me uh in in Durham at Duke probably five, six years ago. We instantly became very, very good friends and colleagues and uh Sympathico. Uh and Alice uh is a person of action. You know, she's uh the youngest child of Sam Walton, and people said she was the most like Sam Walton.

So, you know, you don't get to be Sam Walton without actually doing things. So uh she made a decision uh starting in Bentonville, Arkansas, uh, to create the infrastructures and capabilities and actually start from as much as you can with a clean slate uh to develop these whole health value-based approaches to care. Uh I uh am a founding member of a board of an institute that she stood up called the Heartland Whole Health Institute in Bentonville, which uh has a number of people, and I'm sure to the people who uh who are listening to this, uh they'll recognize uh some of the names.

But uh Todd Parks is you know more on the insurance side, very uh very creative guy. Uh Toby Cosgrove from Cleveland Clinic. Uh so it's a uh a group of people that are on the Heartland Holt uh Health Institute board that conceives of strategically what are these models of care look like? What are the different components?

You know, what are the different elements? And it goes from I know we're running out of time, you need to have number one, so what is the approach? What is the workforce that has uh that's going to contribute, and physicians who are thinking this way, what does the care delivery system look like? And then who are you gonna do business with?

Uh and uh so this is one of the more exciting things that I've seen. So in Northwest Arkansas, Alice has worked with the Mercy Health System, Cleveland Clinic, uh to develop an integrated care delivery system in Northwest Arkansas. Um and um, you know, she and uh, you know, I was with her. We we met with CMS and other people, uh, developed funding to do a very large program uh in Arkansas taking these general concepts and dealing with high utilizing uh individuals to see if these proactive whole health approaches uh actually work and save money.

So I think there's a tremendous amount of uh exciting uh initiatives being done uh initially in Northwest Arkansas Center in Bentonville, but the entire northwest portion of the state, but then this uh project uh for uh chronic diseases with that's going to involve the entire state of Arkansas uh with uh support from uh from Arkansas CMS and from the Alice Walton uh charitable foundations. Now that's that's what what I love about what you're saying is it's it's a it's not just a a city of Bentonville, one small, it's it's a regional play.

It's a statewide play. It's something that if it's scalable, you start to be able to multiply it in other other places around the country. And I think that's where the problems have have always subsisted, you know, you know, persisted, is that someone solves a problem, a big problem in a very micro way and doesn't know how to scale it. And if you're able to take this to scale in in a small city like Bentonville, but also the rural areas in the region and and throughout the state, that's when you have impact.

And now other states will look at that and go, hmm, that's interesting, or other innovators will start to. Say, I want to do that here. And I think that's that's great. So that was kind of like that.

Exactly right. I mean, that that's exactly why we're doing it. Uh, we're putting together, you know, my I started my career as a scientist, so you always have a model and a hypothesis, and you have to test it. And anything that you do is either incomplete or wrong.

So, whatever we're doing, hopefully it's incomplete, not wrong, uh, which is which is what I think it's going to be. But the whole point is to set this up as the best working model that we could have that people will look at, recognize, and improve upon, depending on where they are. But the idea is to take this fresh look, uh, essentially from the top down. If we have the opportunity of developing a new approach to healthcare, what does it look like?

And uh, you know, through Alice's uh leadership in many ways, uh, we're starting to do this in Arkansas. Oh, that's that's fantastic. So, no, thank you for sharing that and and thank you for being transparent about that. So um thank you for being here.

It's it's I really have enjoyed this conversation. I've enjoyed your perspective uh around all things, and um I look forward to staying in touch and uh um you know keeping our relationship going. Absolutely. I love what you're doing, and thank you for allowing me to be a small part of it.

Well, thank you again. This podcast reflects the personal views of the host and guests, not their employers or sponsors. See you next time.