Inside the Rural Health Transformation Program w/ Dr. Tim Ferris, InterSystems

Speaker A: Welcome to Healthcare Rounds, the podcast where we speak with healthcare executives, operators and innovators about the business, policy and tech forces shaping the industry today. My guest is Dr. Tim Ferriss, Vice President of the healthcare practice at Intersystems. Tim has held leadership roles across some of the most influential health care organizations in the world, including Massachusetts General Hospital, Mass General, Brigham, and the National Health Service in England, where he served as National Director of Transformation. Today, he works with health systems around the globe on some of the healthcare's most pressing challenges, including interoperability and care coordination, digital transformation and improving access to care. So today we're going to discuss the future of rural health care, why interoperability remains so elusive, lessons from transforming the nhs, and what healthcare leaders should be paying attention to over the next decade. So, a lot. Tim, welcome to Healthcare Rounds.

Speaker B: Wow. Thank you for that generous introduction and, um, it's a pleasure to be here.

Speaker A: Before we get into it, I was looking at your background and I know I put this into your introduction, but very few people that we've had on this show have senior leadership roles in a major U.S. academic medical system, uh, ACO, Pop Health Organization, NHS serving 50 plus million people, health tech incubator and healthcare technology company. And so I've been wanting to have you on for the, for just the. Simply the diversity of your experience. But then as we were kind of winding up and getting ready to record, we were talking about my previous experience at Dartmouth, um, in their PhD program, and you were talking about your early pioneer experience. So before we get into the questions, and we're going to start with rural healthcare, but just tell me a little bit about that, um, experience with pioneer ACO back in the day and maybe some of your early lessons. I think that that would be well worth hearing about.

Speaker B: Well, um, thanks for raising it. And um, you know, it has been. I've noticed that and listened to your earlier podcast about why value based care hasn't, um, really, um, gotten the traction that we all thought it would 10, 15 years ago. Um, uh, let me just say a couple of things about my experience. One was that, um, boy, there is nothing that galvanizes change like signing a contract that puts you at risk for tens, if not hundreds of millions of dollars. Um, and I just remember the board meetings at Mass General and Mass General Brigham basically telling the leaders who are like, top of their game in fee for service medicine that we've got to think differently about how we deliver health care. I just happened to be the instrument present at the time to lead that. Um, but it was really the senior management's um, decision to A allocate resources and, and B, put a foot in two canoes. You know, the classic analogy where we are trying to drive revenue in a fee for service system and at the same time we are trying to, for populations that we have been attributed to us, we are trying to be more efficient and take care of them, um, in a more efficient way. What's amazing to me, and it's sort of similar story to the Massachusetts story around getting everyone insured. Massachusetts got up to 99% insured. Um, uh, is that it worked. And it worked better than um, I think most people understand. And let me illustrate that with two points. If you look at um, what the state of Massachusetts, because they required providers to take risk, um, their ranking on states in terms of the cost of medical care pre and post, and the widening gap between the projected expenditures on healthcare and, and what Massachusetts, uh, ended up spending. There's tens of billions of dollars difference between those. And at the same time, Mass. General, Brigham, the population health programs and the taking of risk has been accretive to their bottom line. Wow, that's sort of win, win, right?

Speaker A: Exactly. Yeah.

Speaker B: Um, and so when, when people discuss, you know, well, why hasn't it taken it off? Taken off, I would say the problem is in Washington because, you know, there was this, uh, very highly cited paper that came out which was a New England journal paper about, you know, have these ACOs been successful? The federal Medicare ACOs. And unfortunately the press and even the writers of that article came um, to the wrong conclusion because they said what they measured was 1.5%. There was a 1.5% annual benefit. And, and they said, ah, it's modest, you know, it's not making a difference. Oh, wait, wait, hold on. Healthcare inflation over the last 40 years has been 5%. General inflation has been 2.5%. The problem in the cost of healthcare is not the absolute cost. It's the annual rate above inflation that is the problem. And a voluntary program cut that difference in half. And it was just getting started. Uh, I call that a massive success. Like, well, can you imagine a public policy program that actually removed half of the problem of health care cost inflation that was voluntary, I mean, and it was accretive to the bottom line of the participants. Like, why isn't that the law of the land across the United States? I just don't get it. I just don't get it.

Speaker A: Um, so, well, for me, um, as one who toiled in a lot of that data, um, at the time for me the issue was always the physicians themselves. And in that ACO model was there enough of a benefit? Especially not for the mass generals, not for those organizations, but for some of the, let's say more rural organizations, ones we're going to be talking about or ones that weren't quite as just overall advanced and just kind of back in the envelope looking at the numbers and saying, okay, we had shared savings, we're going to distribute this. Some of this is going to go to tech, some of this is going to go to infrastructure and, and the rest we're going to share with the docs as like 500 bucks.

Speaker B: Yeah.

Speaker A: And when you get down to it. And so that was always my issue. I've been a fan, people have heard me evangelizing this model for eight years on this program and for longer before. But that was always the rub for me. Like is that enough of um. Because I get the so called paradigm shift in thinking about value based, you know, volume versus value and that kind of thing. But at the provider level was it enough for to change behavior just in terms of the shared savings alone? And I don't know that anybody has really sufficiently answered that. I mentioned to you, um, before we got started that Elliot Fisher is going to be on again this summer and I'm sure I'm going to ask him this question.

Speaker B: Yeah.

Speaker A: Um, because I, last time he was on several years ago, I didn't ask him this question. But I don't know. What are your thoughts on that?

Speaker B: I guess what I would say is um, for large organizations, large provider organizations that are pushing the boundaries of um, um, let's just say um, antitrust, um, the populations they cover, their market share is a significant fraction in their region. I think 100% of them should be at risk. I just think the problem, and this is to your point about are the doctors getting their share of this? Um, I think that model breaks down when you have smaller organizations that have much smaller margins and you um, and the inherent instability as you move away from that scale and get down into smaller populations, that model of attributed population and savings against the projected costs of that population, um, becomes trickier and trickier. So my, I guess my response would be we, we have a solution that works but it, it doesn't apply to everyone. It just applies to the, to the big integrated delivery systems and every one of them should be at risk, um, uh, in the same sort of way. But, but there are different solutions for the small and medium practices, uh, that are in safety net populations and in rural um, places because honestly it doesn't make sense. Their margins are so tight um, and the percentage of their revenue that they've got to spend on the infrastructure to do that population health. That's not fair. Um, it's fair to do it to the big ones and not only fair but it's the right thing to do. Um, but we need a different approach and I've got some ideas about that approach when we talk about the rural um stuff because uh here the underlying financial um resilience can't sustain taking risk and therefore we need a way to uh, manage populations that is efficient and effective but not reliant on the, the wherewithal of the providers in those rural places because they're underwater both financially and from a demand perspective. Um, so we need a different solution. I think that solution, or let's just say I think we could generate that solution from what is contained in the rural health transformation um, initiative.

Speaker A: Well we are going to get to that but I think implicitly in what you're saying is things like the aimed ACO investment model, um, and I forget what it was called before that but things like where the government is really trying to put some money into these smaller systems and in subsequent models maybe those haven't been quite as effective. Right. For uh, a variety of reasons. Um, but again it kind of comes back to and I think of geez, just recently we had um, uh Don Calcegno uh from ah previously with Advocate and one of the themes that he kept coming back to is there's no really one size fits all around all of this stuff that you know as you say Tim, maybe for the big systems it should be mandatory or those that have you know, substantial market share own their markets. Right. But in the maybe the mid sized markets or maybe in the rural that that kind of model two sided risk, heavily incentivized, um, you know just, just doesn't work well. So well let's turn to rural health care and one of the questions that I think that listeners of this show and I said this before we got started, I think primarily healthcare executives, probably not the consumers that are listening have a general idea of the problems in rural administering healthcare in rural settings. Right, right. Um, let's talk about technology, let's talk about um, uh absolutely resource allocation. Physicians want to, and other professionals want to be located in these areas like this whole host of things. But what do you think in your experience is kind of maybe misunderstood. Um that really getting beneath it that people just don't understand what really you know, not only why is rural health care so important in this country, but what we're missing, what we're misunderstanding.

Speaker B: Uh, I, uh, think one of the things that I, that I, that I perceive is that we are allowing our rural health providers, we're basically starving them and we're allowing them to go under. And you know, I don't know if you've seen this, but if you look at a table of the OECD countries and the number of acute hospital beds per 100,000, uh, the US as a country is in the bottom decile. But rural areas are at the lowest point on an international comparison scale. What that means is that the basic services that people in urban and suburban areas just know that they're there and they can depend on are simply not there in very large swaths of the United States. Um, and knowing, just personally having relatives who live in very rural areas who are two hours from a medical facility, um, and hospitals, rural hospitals in this country have been closing at a steady clip since 1972 I think was the peak. Um, and uh, and there doesn't seem to be any, um, effort to stem that, uh, before this Rural Health Transformation Program to stem that, um, trend. Uh, and I have to say I'm not sure the Rural Health Transformation Program is going to stem that trend either because they get most of their funding from the delivery of care to Medicare and Medicaid patients. Both of those payers pay below cost. Right? And so it's the suburban and urban hospitals that have commercial patients that subsidize the care of Medicaid and Medicare patients. And so my big take is that in the big picture, we are losing critical services for, uh, rural America. And no one seems to be sounding an alarm bell. Now of course, the Rural Health Transformation Program was catalyzed because with the current administration's cuts to Medicaid, the rural hospitals, the rural states, you know, their advocates said, hey, wait a second, this is, this is going to accelerate what has already been a, uh, you know, a um, process that is not helping the people of our state and the rural regions. And so this is a, the Rural Health Transformation Program is a five year stopgap. But I'll just say it's a five year stopgap, but there's a cliff at the end of it. This is not ongoing funding for the delivery of care. In fact, the Rural Health Transformation Program, for all of its benefits, and I am a big fan of, is not going to solve the sustaining rural health care problem. Not at all. I think, um, and we'll hopefully get into it. I think we can do a lot more with technology to deliver services to rural patients. A lot more. But as the silver tsunami, as our population ages, the need for acute hospital beds in rural areas isn't going away anytime soon. And yet we are losing those beds. So I don't want us to get confused by the fact that yes, there's an opportunity here with the Rural Health Transformation Program to literally transform the delivery of care in rural areas. Uh, an opportunity that, that I'm, I'm, I want to make sure we pick up on and, and um, and take this opportunity. But that other problem still is still there. It's not going away. We haven't fixed that. We've just put it off a little bit.

Speaker A: Have you ever driven across country?

Speaker B: I have, yeah.

Speaker A: You know, I think that that many people, I'm just going to guess, probably haven't had done that exercise. I. But when you do that, you realize that we're really just kind of a. Yeah, we have big cities, but it's, it's one small town after another.

Speaker B: Yeah.

Speaker A: And it's not just in, you know, so called flyover country in the middle. I mean it's everywhere. Go through New Jersey, go through, you know, Illinois, go my own state now of Arizona. Yeah, right. I mean it's so, it's just one of those things. I think that if more people did that and experienced. Look, this is really what our country is. It's a connect. Yeah, we have big cities, but it's a connection of small town after small town after small town. Um, I don't know, I think maybe we pay closer attention to it. But I want to get back to. Before we get into a little more about the Rural Health Transformation Initiative, can you just kind of set the stage for everyone? Because we're not all policy wonks and just kind of what is, you know, you said, okay, five year stop gap. But what are the nuts and bolts of this project or this demonstration and what's it trying to accomplish? Just to kind of help us get our bearings around what it is that we're talking about.

Speaker B: So it's um, $50 billion for 50 states for five years. And so you can do the math, you can divide it up and interestingly enough, um, ah, so, and all of the states, the states had a very short time to submit their responses to an rfp. All of the responses, the RFP and all the responses to the RFPs are on the CMS website. Um, you can uh, look through all of them. There are some great AI based summaries of all of them. Um, and they go after a bunch of things. They go after um, uh, chronic illness of course, as it should, um, mental health and um, maternal and infant services. So on the clinical side the proposals had to address those areas. On the um, uh, wanted to address interoperability to make sure that um, providers of health care were able to speak to one another. And I need to say, I just said something that I need to correct which is providers of health care. No, providers of health and social care. Because social determinants of health is a big part of this and we need to connect both the health care providers and the social uh, services. Um, uh, to make sure that people who are eligible and need those services are connected to those services. It's interesting for me to come from England where I spent three years where social media, social services and healthcare services are explicitly part of the same program and funding system and they are much more connected than here. It's wonderful to see the US making progress to connect the social services with the healthcare services because we all know about social determinants of health and, and food and housing are um, uh, as good if not better predictors of health as whether or not you're on the right hypertension meds. Um, um and so it's great to see that explicitly acknowledged um, in the funding that's about the sort of interoperability piece of. Also talked about remote monitoring and AI. So what more can we do to get remote monitoring into people's homes so that they don't need hospital beds, um, so that we can monitor m for um, uh, changes in their status, their health status, uh, acute changes, uh, and, and in what ways can AI again required to be part of the responses, um, be used to enable, um, home based monitoring, um, and the systems of interoperability for the delivery of care. And then um, those. Oh and then of course the workforce. And you mentioned this in your opening remarks. You know the workforce is a major issue in rural areas. Those wonderful clinicians of all people delivering services, um, are generally overwhelmed and under resourced and they are heroes. Um, but heroes, even heroes need support. Um, and so how are we going to support um, the rural health care workers, healthcare and social care workers and um. Oh boy, you'll remember the name of this group, but I'm blanking on it. There's this wonderful program in the southwest where gps groups of gps can get online with specialists and present their tough cases and you know, form basically form a virtual community around where you know, I could walk into the office next door if I had a question at Mass General and, or, or meet someone in the hall about something that I really needed an answer to. But if you're alone in a rural area, who do you talk to? Um, where do you get your support? How do you get help on difficult issues? Um, AI will be a, ah, solution there. Almost every doctor in the United States has now used open evidence. Um, I find it spectacular to use, uh, almost magical. Um, and so there's some making sure that our rural clinicians have access to high quality decision support tools. That's going to help, but also helping them be part of virtual communities where they can be connected with each other and with specialists in urban areas. So workforce support was the, another pillar of the, um, of the transformation program.

Speaker A: It seems like things like the community, the, the virtual community that you talked about, it seems like the workforce support things like tuition, um, reimbursement or, you know, wiping out student loans. It seems like that those home monitoring applications of AI, these, they're not easy, but they're easier to address in this rural model. What I can never seem to get my arms around is delivering babies. What can we do? Regardless of whether it's part of this initiative or not, what can we do when people really do need physical access?

Speaker B: Yes.

Speaker A: And that seems to be one of these. You know, you get broadband in, you get all these things. Right. Yeah, but, but how do you, how do you wrestle with that? How do you solve that particular problem when you need that physical, um, whether it's an operation, delivering a baby, whatever that may be. But they need to have hands on care.

Speaker B: Yeah. So, um, so I think of the needs in three categories. The digital data category, um, and all the infrastructure that goes with that. The physical, uh, structures like an obstetrics unit and an or, um, where you can, um, um, have a cesarean section emergently if you need one. And the workforce. And in the physical, um, I also include diagnostic tools, uh, you know, ultrasounds, CT scans, MRIs. In Boston, there's practically an MRI scanner on every block. Um, but I was just on the phone with someone, um, in Georgia and they were talking about driving an hour for an MRI scan and calling me and saying, tim, do I really need this? Um, and, and, you know, my answer was actually, yeah, you do. Um, and so, yep, you're gonna, you're gonna drive an hour. Um, and so, uh, I was gonna,

Speaker A: I was gonna add chemo or other kind of infusion services, things that you need to have on a regular basis. You don't want to be driving an hour or two or force people to, uh, drive these long distances for those kinds of things.

Speaker B: That's right. Although interestingly, I'll tell you, uh, one, um, solution that um, I help support in the nhs. So there's several small islands off the coast of England, um, and some of them have rural hospitals with cancer patients. And they actually used drones to fly the chemo, which was made at the main mainland hospital, across to the hospital, the rural, um, location so that patients didn't have to leave their island home to get their chemotherapy.

Speaker A: Yeah, very cool.

Speaker B: That's a creative, yeah. Isn't that a creative solution? It's very cool, yeah.

Speaker A: Um, so how, how, I think I have an idea of the bones of the program. But how from your perspective, at the end of all this, at the end of this program, how are you going to judge a success? What are you going to be looking for to say? Because right at the onset you said, tim, um, it's not a panacea, uh, not your word, but it's not going to solve everything. But what are you going to be looking for as success measures?

Speaker B: So one of the things we learned during the pandemic is we do not have great real time views of, of the health of our population. We get state reports usually a year after, you know, they analyze the data and blah, blah, blah. And um, and by that time no one's really that interested because it's, uh, it was a year ago. Um, and what I would like to see is the infrastructure necessary to give our state health departments, public health departments, near real time status on things like gaps in care. So I always use the same example. Um, the number one cause of preventable morbidity and mortality in the United States is cardiovascular disease. And we are, as a nation just lightly better than 50% of people eligible for secondary prevention are getting it. That's terrible.

Speaker A: Yeah.

Speaker B: Right, yeah, yeah. But you know, we've got all these hies in, you know, New York and Texas and Montana, Ohio, like most states have some, some are more fully developed than others. But most states have health information exchange. There's no reason those states couldn't be reporting real time gaps in care. Right? So think about that. What if we knew in, uh, the particular regions in Ohio where secondary prevention is low for whatever reason, we could focus our attention there, but we could do that. Uh, so you asked me what would be a measure of success? Knock it out of the park. Success would be actually at five years, lowering preventable morbidity and Mortality from cardiovascular disease. That would be home run.

Speaker A: Amazing. Amazing. Yeah.

Speaker B: But even if we were just had the measures in place so we knew what we needed to do and where we needed to do it, that I would take that as a victory as well. And I don't want to be dismissive because all the cancer folks are, um, I'm hearing them in my head right now saying, dude, what about us, Tim? What about cancer? Yes. So cancer screening. We should know in real time who's eligible for cancer screening and do outreach to them. And so whose responsibility is that? So that's the kind of thing in the nhs when I was across the pond, the nhs, it was the NHS responsibility. Whose responsibility is it to tell Joe, uh, Smith, who turned 60, that needs a colonoscopy, uh, who lives in rural Oklahoma, Uh, I don't know that I can point to whose responsibility that is. And because we don't allocate responsibility in this country for the delivery of preventive services, um, we don't do very well at it. But the Rural Health Transformation Program has embedded in it that the payment and the development of the technology which will make all that transparent. Not, of course, not disclosing any individual patient identified information. But for example, and here I'll just do a little plug for inner systems. Our unified Care record health share technology, which underlies 11 of the state's health information exchanges, has the capability of having everyone in the state get a app on their phone that gives them from all the different locations of their records a unified care record that says, oh, by the way, you're due for these immunizations or you're due for colonoscopy, or ah, you have diabetes, which is ah, an equivalent risk factor for coronary cardiovascular disease. You should be on a secondary prevention lipid lowering agent. Um, all of that would be possible and not very expensive to deliver. Like it all could be automated through the infrastructure that this transformation program is paying for. But we have to want that, that has to be our goal. Um, uh, in order for that to happen. Um, it's certainly possible, but. Sorry, that was a long answer.

Speaker A: No, it's a great answer because in my mind it's getting to that sort of state level policy, national level policy. Right. And especially if you're tying together these health information exchanges or have the ability to do that across states, because there's a lot of people, I mean, think about Medicare population. Okay, now I'm being quite stereotypical, but think about those that spend part of their time, uh, in New York and then part of their time in Florida. I have relatives like this. I say I'm being stereotypical, but I have plenty of relatives like this. Or, um, you know, a lot of people here in Arizona, they spend a lot of time in California in the summertime as much as they can because it's so flipping hot.

Speaker B: I hear it gets hot there in the summer. Yeah, yeah.

Speaker A: So, so it. And I can. All at the same time, I can see, you know, your roots in Massachusetts and where, where you were doing all this early work at acos. Very advanced in my mind, as a state, um, in a lot of different ways. And on the policy side, um, you know, as you said, MRI machine, maybe too many MRI machines. Right. But, but, but, but there is this sort of advanced nature. And then there are some other states too, that you wouldn't think about. I mean, there's some elements of Arkansas that have advanced, you know, really advanced care. Right. So there are pockets in certain places. But do you try to execute this or implement this at the, at the state level or can something like a, uh, rural transformation initiative, maybe. I'm answering my own question here, is that maybe you can set the goals nationally and have the incentive set up nationally, or however you want to talk about that. And if one of those goals is reducing cardiovascular disease mortality and morbidity, it's sort of like a national framework or goals around that, that states. And maybe you incentivize them with bonuses, more money if they do better. Right, Those kinds of things. Um, I don't even know where I'm

Speaker B: going with this question, but it's interesting because implicit in the RFP and the evaluation of each state is whether or not they are actually making gains in health. It is actually. I shouldn't have said implicit. It is explicit. It's interesting now that you say this, I hadn't thought about this, that they didn't actually say cardiovascular disease or cancer. They didn't. They didn't call out any particular disease burden. Um, they did call out mental health and, um, maternity care, but they didn't set any goals. They just said improve. But. Because every state is starting from a different position, both infrastructure and current performance. But just the idea. I mean, you know, I'm sure you've seen the. This, the Commonwealth Fund, state by state, their annual state by state comparison, and they rank the states. And, um, what's interesting, I'm just reflecting on this now, is that, yes, we've had that for 20 years or more, but we've been watching the states, and mostly the states that are Doing well, stay up at the top. And the states that aren't doing well are still at the bottom. This opportunity with the Rural Health Transformation Program actually gives us the opportunity internally within the state to set some targets and then in a rapid cycle measure whether or not we're making progress. Like that's something that the uh, Commonwealth Fund report doesn't do. Right? Uh, it's an exercise that doesn't have an effector arm. This is trying to build an electronic digital effector arm for the delivery of public health, of preventive services that serves a public health beneficent.

Speaker A: So I'm wondering. And um, I might as well just throw out my interview guide at this point. We're 40 minutes in and this is way better discussion than maybe the questions that I was going to ask you, but the implications for me on state level public health programs and we can lament at the national level, kind of where we are right now, a lot of these issues came to, I mean people have known about them for years, but Covid and all of that brought a lot of these issues to light. Now with some of the cuts, um, and what's been going on nationally, I wonder, is it going to make it harder to implement? Because I feel like you need to have a robust state public health program to be able to corral all of this. Um, I don't know. What are your thoughts on that?

Speaker B: Well, um, the first thing you need is the. Just. You need to have the ambition. You need to think we could do more, we could use this funding to do better. Um, and then you need. And this I experienced being in the government in the uk, you need alignment. And I'll just say like any, and I don't mean to use the word pejoratively, but like any bureaucracy or set of units within a bureaucracy, the state, you've got Medicaid and you've got, you know, the hie, which is a nonprofit associated with the state but not part of the state. You've got, um, the health policy, um, group under the governor. You've got, you've got different pockets, they have different interests. And getting them aligned around a, um, uh, direction, um, is a real challenge. I've talked to some, uh, state, uh, uh, Medicaid and HIE directors just in the past month. I've talked to quite a few in fact. And um, they talked about the challenge of getting alignment with all their stakeholders and partners. Um, and I empathized, uh, with that. I keep coming back to, okay, how can people not be aligned with the number One cause of preventable morbidity and mortality. Like just that one thing. Like, let's go after one thing. And if you had to pick something, you would pick cardiovascular disease because it's the number one thing. The number two thing I would say is adolescent, um, mental health. It's on everybody's minds. Um, there's a real opportunity here to, um. Several states are thinking about bed allocation and capacity for mental health beds. Um, I love that it's a huge need. When we had patients in the emergency department of Mass General, every single patient, we just calling all over the state looking for a place that had a bed. Um, uh, why in 2026 do we have to call? Like, it asks somebody at each place, like, there's got to be a better way of doing that. Um, meanwhile that patients wait for days in the emergency department. And that's not. We shouldn't be doing that to our adolescent, um, uh, population. So I hope you can hear in my voice some. There's an opportunity here. But we've got to, We've got to have. We've got to pick some goals and we just have to drive after them and get everyone aligned around those goals.

Speaker A: Can some of these. Or, uh, can you think of. Because I know the answer is yes, but can you think of any examples where. In the private sector, where, you know, Mass General, Brigham, say, for example, or where institutions have done a good job collaborating, partnering, whatever word you want to use to accomplish some of these objectives through their own CNS or through the health Information exchange? Like, can you think of any examples where. That's where an institute. You can say, well, yeah, Kaiser did this with, uh, you know, Sutter or something? I don't know. I'm just making that up. But can you think of any examples of where the private sector has done well by focusing on a goal like that in cardiovascular, um, disease mortality or even, um, partnering on the rural side?

Speaker B: You know, I know there are great examples, but I am. But I'm coming up empty right now.

Speaker A: Uh, uh, most people are going to be listening to this, but if people could see your face, you had the same kind of quizzical thing like, like I was saying. I know. In fact, I feel like I've written about these, these things. But there aren't any sort of bellwether, banner case studies out there that people can point to. I know they've been, They've. They've been happening. But you know, as things are in this country, we always tend to look to the, the private solutions which, yeah, I You know, we're getting close to the end and I just, I have to ask you, Tim.

Speaker B: Yeah.

Speaker A: Um, which you've probably been asked a million times before, so I apologize. But simply because you took this detour in the uk, um, what are, you know, misconceptions that people think about the health service over there? And are there any, you've talked about some of the lessons and things that we can learn, but are there any kind of misconceptions and are there things about that system that you think that we can port over to the US system that would work? Well,

Speaker B: a couple of misconceptions that even when I was on the board there, before I went over, I still didn't know until I got there and actually had responsibility for it. One misconception is that, um, people here tend to be. It's either got to be total cost of care value based or it's fee for service. And the NHS is total cost of care false. The NHS has a mixed model in which they pay for some services, fee for service, a lot of services, fee for service. Why would you pay a, ah, fixed cost for a variable service? They don't do that. So they actually allocate money according to volume. Um, and a lot of people who are on the total cost of care, value based care, think that is the solution. The fact is health care, the delivery of healthcare services, some of them should be fee for service and some of them should be, you know, total cost of care, population, health. It's just that it appears as though administratively, it's just too complicated to do to simultaneously either when you're receiving the payments or if you're doling out the payments. But I wish we could come to the realization here that if it's not one or the other, which is how the debate usually goes, it's both. It's both. Um, that's thing one. Thing two.

Speaker A: Can I just interrupt you one second with thing one? Yeah, we definitely do that here. We definitely do that in these conversations about value based care. As if it's a transition to 100%, right? It's this transition to everything is going to be this new model, right, Whatever that is. But what you're saying is it's both.

Speaker B: It's both.

Speaker A: And we, and we need to get our arms around. So for instance, maybe it does make us, uh, make sense to do bundles with hips and knees and certain procedures. Right? And that's one value based approach. Maybe it does make sense to pay for care coordination in certain instances in the oncology models or in, um, in rural care. Right.

Speaker B: Or fee for service, for preventive services. Like, the more the better. Like we should pay more if you do more. Right, Yeah. I mean, it's not like people are going to abuse. Go. Go back for more colonoscopies.

Speaker A: Right, Very true. I'm due for one, by the way, so. David made me laugh, so I'm sorry I interrupted you.

Speaker B: So 02 or thing 2.2 is just that, um, people think all the data is available, um, and that it flows. Not true. The, um, gps are in a separate contract and they use the fact that the NHS and the government does not have access to their data as a negotiating tactic for their pay. Um, and the BMA, which is the doctor's union in the UK, um, for all the GPs or for all the doctors. But the GP unit of the bma, British, uh, Medical association, um, is doing a serious disservice to the health of the country by blocking access to GP data, um, which was borne out, um, uh, during COVID when the Health Secretary, um, uh, unblocked it because of public health powers. And so for two years the country had access to all the data it needed. And that's why you saw such extraordinarily great research on Covid come out of the uk, because they had everything. Uh, but as soon as the public health emergency ended, the, um, gates were closed. And, um, there is a path to undoing that I worked on there. I never completed it. Um, but, uh, I did try to convince serial health ministers one of the best things they could do for the health of the country was to unlock access to GP data for public health purposes. Um, and, um.

Speaker A: Uh.

Speaker B: So again, there's sort of a mythology around universal that they've got it all, uh, set up in a beautiful way. Not quite.

Speaker A: Well, it's very frustrating that. And I get it, politics is one. One, uh, thing that politics is supposed to, I guess, achieve is allocation of scarce resources. Right? We elect people to. And healthcare is a scarce resource. And so almost by its nature, healthcare can be political, but it feels just so overly politicized in this country. And I don't know what the roots are of that. Um, but I bring that up because there's almost this, oh, UK healthcare. Oh, Canadian healthcare. Oh, well, what they're doing over in Sweden doesn't apply over here. And the reality is all these systems are different. You can't just say, oh, it's universal and that's the way the rest of the world does things. There are a lot of different models.

Speaker B: Um, can I put a plug in, please. I wrote a paper, a New England Journal policy paper about lessons from the NHS that the US should learn. Um, and I published it last January. Um, uh, January a year ago. Um, and, um, so I made a bunch of points about misconceptions about the nhs, but also things that we can learn from the NHS experience. Well, um, if your listeners are interested in learning in more of my thoughts

Speaker A: about that, I feel like it's in the distant past, but I feel like I've seen that paper, so I'm going to go back and reference that. Um, Dr. Tim Ferriss, this has been great. Um, thank you. I feel like we've scratched the surface. I'm telling you now. I'm going to ask you to come back because there's more that I'd love to talk about. Um, any other final words before I give a sign off?

Speaker B: Thank you for doing this. We need more discussions on this topic, on this set of topics, and you're a great medium for getting that word out. So thank you, thank you

Speaker A: and, uh, thanks to everybody for listening. Um, and thanks for, um. First, for spending time with me and Dr. Tim Ferriss. If you're in healthcare and found this conversation valuable, please follow Healthcare rounds on Spotify or Apple Podcasts so you don't miss future episodes. And if you have a minute, please leave a quick review. It helps other people find the podcast and all of our episodes as they will be on your favorite podcast platform, are also available on darwinresearch.com I'm John Merchika and we'll see you next round.