Tales from the Trenches™ with Aneesh Chopra, Co-Founder and President of CareJourney

Speaker 1: (00:09)
Hello everyone and welcome to tales from the trenches. I'm Steven Collins. I'm the CEO of matter. We are a healthcare technology incubator and innovation hub built on a belief that collaboration between entrepreneurs and industry leaders is the best way to develop, uh, healthcare solutions. Today's program is part of our tales from the trenches series, which features accomplished healthcare entrepreneurs, sharing their learnings and stories and takeaways from their journeys. We have a great collaboration with village MD to produce this series. Uh, for those of you who aren't familiar with them, they are a Chicago based company. That's innovating in value based care, operating in 10 markets, and they work with physician practices to implement true value based care, uh, models. Our guest today is Anish Chopra. Anish is an extraordinary entrepreneur and a technology leader. Who's played a, a key role in designing the United states' relationship with healthcare innovation and data.

Speaker 1: (01:15)
Uh, he was the first ever CTO of the United States serving under president Obama from 2009 to 2012. He previously was the CTO of the state of Virginia under governor Tim Kane. He's the author of innovative state, how new technologies can transform government. And importantly, for this conversation in 2014, he started a company called care journey, which is a digital health company on a mission to make healthcare data more useful. Uh, he also serves as a senior advisor with the Albright Stonebridge group, uh, which is a consultancy chaired by former secretary of state Madeline Albright. Our moderator today is Mike Roberts, the chief technology officer of village MD. Uh, Mike joined the company in 2016 and he and his team, as I said, are, they're truly at the heart of enabling value based care solutions and allowing the, uh, village MD to scale Anish. Thank you so much for joining us today, Mike, thank you so much for, uh, not only joining us, but facilitating the conversation and I'll turn it over to you to kick things off.

Speaker 2: (02:24)
Awesome. Thanks Steven. Uh, excited to be back. I think this is my, my second time. I certainly look forward to today's dialogue. Uh, frankly probably, uh, the best part of my week. At least that's what I'm hoping for. Anish. How are you? It's good to see you.

Speaker 3: (02:36)
No, no pressure my man, but yes, we're gonna have a great conversation. Great to see you as well. Thanks Mike.

Speaker 2: (02:40)
Yeah, of course. So I've gotten to know you over the last four or five years reasonably well. Uh, and I've just been blown away at the level of passion you have for disruption in healthcare. Uh, but I'll be Frank, your journey. Uh, that's gotten you here thus far is quite unique. Um, and as you've seen a lot relative to the, both the private and public sector, I'd love for you. Just maybe to describe a little bit about that and what's led you here.

Speaker 3: (03:04)
Well, I'm generally a, a, I'm passionate about problem solving Mike. That's my, you know, when I was young, my dad's college buddy, uh, uh, launched a kind of a technology company from a farm in India, came to the us as a graduate student, became an expert in telecommunications. Uh, the switch from analog to digital in many ways, got lucky. And after he successfully sold his business, he decided to get into the problem solving business and went to India, uh, with a penny a year salary to say, I want every family to get access to phones. At the time India had 300,000 telephones, uh, telephone lines on a country of 300 million people. And if they simply accepted the Western technical architecture, it would've been a multi-billion dollar journey and they never would've gotten there. And it would've been huge political debate about taxes and market forces.

Speaker 3: (03:57)
He actually found a way to solve the problem through innovation. He built a brand new Denovo technical network as an open stack, the government funded, the engineering, built some of the intellectual property and then open sourced it to a new marketplace of entrepreneurs and innovators who could build the last mile. And within a decade, they had every single rural village connected to the phone network. And that was in the 1980s. Uh, Mike, I believe in this generation reigning in healthcare inflation to allow for American reinvestment for the industries of the future is the issue of the day. So it's not just because we wanna fix healthcare. It's good for society. And I deeply care about, uh, improving health outcomes for every American. There's also an economic competitiveness. I want the economy of the United States to thrive and the two are highly correlated. If we can constrain the rate of healthcare inflation, we can reinvest in the industries of the future. And that formula will be how we compete over the next 50 to a hundred years. And so I'm motivated to solve problems and grateful that for the chance to do so in what is obviously a significant, uh, sector of the us economy.

Speaker 2: (05:08)
Yeah, me. Yeah. Uh, actually I didn't know that about, uh, your, your family. So that's one thing that was just, uh, really exciting to hear. Thanks for sharing that. Uh, I, I know why you, you think the way that you do, I think in many ways as you described that, um, so one of the aspects that, that one part of, uh, how you've been both innovative and entrepreneur, uh, in terms of your, your path has, hasn't been limited to just the, the, the public or the private sector, but you've sort of interwoven the two, which from my view is so incredibly important as we think about the change that you just described, which is not about, you know, lowering the GDP of healthcare. Of course, that's one of the outcomes, but it's also about a competitiveness in the global economy. Um, maybe if you can describe a little bit more specifically about some of those twists and turns along the way that sort of led you to this level of passion that you do have

Speaker 3: (05:56)
As it relates to driving to, to innovation and change. So you, you take that weird turn outta college and you end up at Morgan Stanley as an investment banker. So you're like, how does a public policy guy with an interest in healthcare show up as an investment banking analyst, you know, uh, out of, out of college. And, and the reality is I wanted to understand capital markets because they're a uniquely American muscle in terms of bringing about new ideas. And so I was on the healthcare team, but my colleagues on the tech team took a little old company called Netscape public. So I'm dating myself, Mike, I'm a bit older than you. And so Netscape going public was this sort of watershed moment. There's this thing called the internet and it's gonna change everything. And sort of, I got, I got religion about this thing called the internet and it was gonna change everything.

Speaker 3: (06:42)
And when I went to graduate school, the Kennedy school, I decided to focus my master's thesis on how we can apply internet based technologies to the healthcare sector. I then took a more traditional job out of graduate school, where I joined the advisory board company. Many of you were members of the advisory board. Uh, we, we felt like it was a cute little happy Oasis for best practices, research, and a place for us to think. And I kept asking the leadership team, we gotta focus on the internet. We gotta focus on technology, even though our members hadn't been asking. So I got permission to write one study. We took it around to get member feedback, and there was a lot of interest in how we can use these new technologies to solve problems. So I spent that time at the advisory board, we were blessed with a company that was growing.

Speaker 3: (07:26)
It went public. I was on managing director. What have you? And that gave me some freedom to then get into the government where I served, uh, focused on healthcare it, but at the state, uh, level. And while I had a broader mandate to look at transportation, innovation and educational, uh, technologies, I was passionate about that healthcare it component and witnessed sort of stage one of health interoperability with HIEs and all the rest. And then as I went into the Obama administration, we were just obviously with the recovery act all in on three things in healthcare, making sure that we digitized the medical record, making sure that we open up as much data as we collect in government and regulate. And then obviously the, uh, sleeper cell, uh, making sure that we can actually focus on driving, uh, uh, payment reforms to reward the use of these technologies for the betterment of patients, uh, outcomes, financial and, and quality.

Speaker 3: (08:26)
So I've been in and out of the government and I would say I'm in the private sector and I will wear a private sector hat, but I'm skirting right up to the edge of the government as we'll go through today's discussion, believing that the public private interface has the highest leverage for impact in the, in, in this journey to, to modernize the system. And we're gonna do our level best to maximize the value of that public private H I call it handshakes and handoffs, where we've got relatively bipartisan views on this set of issues, standardizing data, opening it up, regulating the EHRs, the data systems and moving to value. Let's maximize those, you know, where we all agree and maximize the impact, um, neighborhood by neighborhood. So that's, that's the journey, Mike it's, it's trying to find this sort of technical muscle as an innovation fuel and applying it to our sector.

Speaker 2: (09:16)
Uh, fascinating, thanks for sharing. And I do wanna get to a lot of what you just said, especially as it relates to the last five years in our journey. Cause I think the level of this hand shaking that you are seeing between public and private sector is at an all time high personally. And I'd love for, for you to apply on aspects of that before doing that, though. I'd love to go back to your time, uh, in the white house and on Capitol hill. Yes. Just an extraordinary thing for, for me. Uh, and for us, I think more broadly to be, be talking to the first chief technology officer of the United States of America. I, that's not lost on me, but that's also my title and just happens to be at village MB. That's very different than these two are sort of very different. Um, so I'd love maybe just to describe the magnitude of what that sounds like and how that translated in, in the day to day of actually having that role.

Speaker 3: (09:58)
Yeah. So, uh, president Obama had a unique passion for this subject and I just happened to be the first to fill in a vision. He already laid out, which was of belief. First of all, he had a philosophical view that changes bottom up, not top down, let's just start that I don't mean to make any political statements about one being good or bad, but that was his philosophy. And by saying, I want bottom up change. There was a natural need to leverage technology, data and innovation to reach the larger population in ways that you just couldn't in traditional organizing. And so he had an intuitive sense that we're gonna take advantage of these new technologies. And frankly, as he was walking into the white house, a sense that the policy implementation up until that point likely wasn't maximizing the value. And he'd seen it firsthand in his campaign, which is a microcosm, but maybe we hadn't seen the fruits of it.

Speaker 3: (10:53)
So, uh, I was on the transition team because, uh, Virginia had kind think of it like minor leagues to the major leagues I was in the governor's cabinet. So you might say, oh, look, we have CIOs and their technical people, and they can implement, you know, change and they buy servers and they make systems work. And so we, we had a professional, uh, CIO and some states were experimenting with putting a person like a CIO in the cabinet. The role in Virginia was a little bit different. They didn't want the engineering team to kind of make policy changes. They kind of wanted the engineering team to just execute the job and do it really well. But they wanted a policy advisor to say, as we were making decisions on regulation, investing in programs, implementing, uh, policy that we took full advantage of all that we could.

Speaker 3: (11:41)
So we weren't leaving, uh, uh, capability on the, on the table. We were maximizing the value. So I, my, my, my, the joke with governor Kane was that I was CTO in, in kind of conceptual terms. I was really chief collaboration officer. And so when president Obama named me, he did a couple things structurally, uh, it had nothing to do with me. I'm a nobody, but he, he, he created this role as an assistant to the president, which means it reported directly to president Obama and these two policy councils that were critical to healthcare reform, the national economic council and the domestic policy council mostly were made up of members of the cabinet, but a few staff members. And he put me as principle for black about a term on both of these bodies. Again, I could never tell the experts in health policy, how to maximize incentives and figure out where the math is on, on expanding access.

Speaker 3: (12:38)
But I could be a little bit more swimming in my lane. Here's where the technology data and innovation implications are if we twisted this versus that. And that was the role. So the role was wake up every morning, identify the priorities that the president laid out, execute the te the horizontal muscle of, of technology, data innovation, and then flywheel as much as we could. And as you could imagine, you know, Steven is such an awesome recruiter of talent. He brought Todd park, my successor, really the most important thing I did when I left the administration was making sure Todd was my successor. And I frankly think that was the greatest gift of the administration to have Todd cause you have an execution arm who can scale up some of the experiments that we ran in the first term, but that idea carried forward in the Trump administration.

Speaker 3: (13:23)
Actually, he had handed this sort of role to, to kind split the role, Jared Kushner, his son-in-law had a piece with the office of American innovation. And then, uh, he, he had a, he had tasked a, a more proper, uh, chief technology officer. And then, and my point in saying, this is that we had a bipartisan view. And now of course the BI administration is, you know, embracing, uh, these same muscles as it goes about its work. We just saw this week, the Senate confirmation for the science advisor, my old buddy, Dr. Eric Lander, who who's made sort of the same philosophy bedrock into the role he's gonna play, uh, in the administration.

Speaker 2: (13:56)
Yeah. So that, that's amazing. I quite, quite fascinating always to, to hear more about that, um, maybe going from that as this, I would argue Genesis of, of many of the, the changes that are coming to fruition today. So we've seen, um, info blocking rules. We've seen the standardization using fire. We've seen opening up a data. The things that you're mentioning may maybe talk a little bit about like how that actually happened. Cause it, it didn't happen right away. Things needed to be digitized and then people needed to get their head around it. People needed to. So it it's, it's a journey to get there, but, but I'll be honest. It does feel like the flywheel is starting to turn pretty quickly on these things.

Speaker 3: (14:34)
You know, so I'll, I'll step back and give you context, which is the us has a very unique policy approach to technical matters. We rely on industry consensus before we dictate regulatory action and where there's industry consensus. We can scale it up through regulation, but where there's not consensus, we face a sticky wicket, which is how do we standardize something when the industry stakeholders don't want to now in the recovery act, I'm just gonna give you a tail of three markets, banking, energy health, all three of which had digital transformation on the agenda. In the energy sector, we were installing these smart meters into everyone's homes. Think of them as electronic health records, but for your, your, your energy consumption patterns. Uh, on the banking side, we were digitizing, uh, checking accounts and we were enabling, uh, data sharing so that you could use a mid.com to access your bank and all three digital transformation.

Speaker 3: (15:39)
Uh, we saw three completely different frameworks for how we would get to standardization in the banking sector. We never had to write a rule. We have rule making authority there's information, blocking authority in banking, never wrote a rule. Why? Because the industry self-organized, and even if they didn't want to have quote unquote disruptive tech accessing the banking systems, the norms in that sector are that they've worked together and they standardize and begrudgingly if they didn't want it, but they did it. They've opened it up. I remember vividly, uh, J JP Morgan CEO, Jamie diamond, one day cut off mint.com claiming a cybersecurity risk. He got a call from the regulator the next day, Richard Cordray, who said, do you want me to issue this rag? Are you gonna fix this? And in fact, it was true. They went from screen scraping technology, which, you know, Mike is a security threat and they upgraded to this sort of oof, 2.0 technical standard, uh, that allowed for safe, secure sharing by, by the way, the same anchoring technology to the smart on fire, uh, regulation.

Speaker 3: (16:42)
So banking, self-organized the energy sector. We put a small amount of money, maybe 10 million. And we facilitated. What we didn't wanna do is you have a Chevy volt in Chicago charging in your home, and then you drive across the way to Indiana and they chose a different technical stack and it was incompatible. So you couldn't charge the volt because somehow Tesla got in and made a proprietary Tesla connector. So the industry got a bit of a jolt, but that one time funding was enough to get over a thousand stakeholders over the course of several years, agreeing on 20, 30, 40 technical standards, that seemed simple, but they engaged and they scaled that they never had to replenish the 10 million health Siva said it best at hymns. Two years ago, Mike, when we regulated the EHRs, we said, what is the minimum data set? We can get you to launch on day one, let's get the meds list, the problems list, maybe a few other, uh, definitional things that were structured and say, Hey industry, this is the minimum data set.

Speaker 3: (17:47)
We published it in 2010. Mike, you should self-organize and fill out the medical record by 2019 or 18 or whatever the date was when she stood on the hem stage to announce the rules. She said, I'm doing this because she said something like you made me do this. The industry didn't add a single variable of data above the minimum data set. Now she said, we're gonna have to move. You've made me become quote, unquote, big government. We're gonna regulate you. And, and, and so now we've got by grudgingly in many ways, uh, a requirement to get to the entire medical record over the next three years. So now there's a flywheel, but really only after rule making and, and heavily contentious debates about this. And so a really interesting dynamic across the three industries where I was involved in digital transformation to see why healthcare so far behind consensus making.

Speaker 3: (18:46)
Yeah, I'll give you one more final vignette. I'm gonna just say thanks to Dr. Bud tri a physician who serves as the chief technology officer at apple, because if apple health, when they launched chose an apple process to extract the data, they might have convinced a lot of the vendors just to go with the apple way because you don't, you know, you can't have a, you know, your card now has to have apple play in it, you know, whatever. Uh, so they could have done that, but they chose to embrace this very early, uh, smart on fire technology before really it had any traction faster, frankly, as you know, Mike than the rest of us that are in the interoperability space. If apple doesn't do that in 20 16, 17, whatever the dates were through something called the argon project. I don't know if we would've made as much progress as we have now, because that forced everyone towards one common connection point that was open and substitutable. And here we are building on that initial consensus, uh, roadmap. And I will say thank you to epic. Thank you to Cerner, thank you to all scripts for participating in this, um, industry standards, effort, maybe a little bit too begrudgingly, a little bit too late, but we made it and now we're here and we're working together.

Speaker 2: (20:02)
Yeah, that's that's great. Great description. Um, maybe to, to double click on one thing that you had mentioned relative to, it took the lag time between 2010 and 2019. Um, and what, what SEMA said, and I, I remember that as well, um, is you made me do this. Um, do, do you think structurally between public and private, we have the, the right set of, um, from a techn standpoint, features in place, uh, be, be it, be it, you know, whatever that structure might be or, and if not, what do we, what do we need?

Speaker 3: (20:31)
So we, we still have this bizarre world where everyone's data sharing requirement is its own thing. We need a technical standard for prior authorization. We need a technical standard for prescription drug pricing. We need a technical standard for, it seems like we've got this litany of technical standards that we need. When in reality, we need one reusable framework, smart on fire, and we need to make it work. And any data element we need needs to map. So I'm trying my best Mike, to get all these good intention well-intentioned stakeholders who are moving in lots of different directions to say guys, 21st century cures act is law. The land information blocking are the rules of the road. Let's fold everything on top of a common stack and reuse as much of the infrastructure as is humanly possible. We don't need five years and we're in the middle of this right now on public health reporting.

Speaker 3: (21:26)
We don't need a five year journey on a technical standard for a separate public health reporting system. We wanna reuse the same infrastructure that village MD can tap to bring patients on board and to manage their conditions as we would need to report COVID positive cases to the authorities and that concept of reuse and building off of a common open tech stack. I think that's a, still a mental shift. We've gotta get more of the industry, uh, to embrace. And we're seeing it right now in addition to public health on price transparency. So everything has to be its own technical standard, no fold in one team, one stack.

Speaker 2: (22:04)
Yeah. Yep. Fascinating. So maybe just to pivot a little bit towards how does this ultimately get funded over time relative to these innovative changes? We we've, we've talked, um, a number of times about innovative payment models and, and this, this sort of convergence on, on taking on more and more risk as a provider and, and really focusing on managing the total cost through the lens of treating people better. Um, the, from my view, you know, the work that CMI has done and, and, and the work coming out of, uh, sort of your, your, your, you know, where you live is just quite transformative and I'm not sure that everyone maybe necessarily understands all of it. So if you can maybe just describe and give your perspective. Cause I think it's so fundamental to change the dynamics around what the funding levels look like over time is pretty dire. If you don't sort of make these type of changes like yesterday, but at least we're making 'em I, I think now, so maybe just describe your perspective.

Speaker 3: (22:56)
I, I'm not here to scare anybody, Mike, which I think you teed me up to sort of scare people, but let me, let me just say the Medicare trust fund is running out in the not too distant future. Okay. Or it's gonna fall into the, into the red. So we, we have to, uh, find a way to reign in healthcare inflation. The world is divided into two camps. I'm in the religious movement that believes we can actually accomplish that mission objective by delivering better care at lower cost. We actually, we actually have enough inefficiency in the system swirling that if we rooted it out, we can come back better, faster, stronger I'm in that religious't okay. But the other camp is like, oh, look at the fodder over there. These nice, happy people are running experiments. We know the answer to this question slash the rates.

Speaker 3: (23:41)
These people are paid too much. Okay. So door number one, let's just call it the sort of evil door. It slashed the rates, go through another round of balanced budget, act all over again in pain, pain, pain, and we're all disaster land. Okay. Door number two, the happy land, the hand of collaboration, the hand of working together. It's how can we it, do we believe all of our neighbors are getting the best possible care at the best possible time at the best possible rate? We know the answer to that. It's it's no. And, and, and what's powerful about this moment is if we can tune the rules of the road, we can, uh, put the spirit, the entrepreneurial spirit of the country to work on how to route people more thoughtfully through the system. Do we bring them in earlier for preventive services? Do we monitor them more actively while they're home?

Speaker 3: (24:34)
Or do we wait for them to call us when they're in need and then try to manage them in a better way at the time they call? I don't know. I'm not smart enough to figure out which mixture of the portfolio is gonna be more preventive, uh, better monitoring, better action in real time when they show up. But I know that good people are gonna work on it and, and may the best teams and approaches win. So what we're doing right now is we're, we're, we're experimenting with, how do we, uh, arrange the business model? Should the us government like Medicare advantage, write a check that says, Hey, you, you, you, you take on the responsibility of this patient, take the check and you manage it. We've had a decade or so of experimentation and early results clearly suggest it's better for patients to get more supplemental benefits.

Speaker 3: (25:23)
They get better care, but at a price, they give up their, their original Medicare benefit. So now the question is, is there a Goldie locks, if we've got unmanaged fee for service, where you can kind of do whatever you want, but you don't really access the services you need in the timely manner where you have to switch to ma where they can manage it, but you gotta give up your benefit. Is there a third option? And I think Mike, I'm more bullish on direct contracting or a version of it that the BI administration will iterate on that emphasizes health equity, whatever the formula will look like. If we can allow individuals to retain their Medicare benefits, but to participate, maybe even opt in to a risk bearing network that can help them navigate more thoughtfully and without taking away their choice of doctor, maybe we can actually move, uh, a model that, that, that can scale across the entire country.

Speaker 3: (26:18)
So we're in, not even, you're not even in the first name we could turn to you and Mike, what's your experience in this? You're like, yeah, I've been live for three weeks. So , I don't know yet. We're not there yet. So no pressure on you, but I do think there's a huge, uh, bet that capitating primary care and networks allowing you a lot more freedom to pick and choose what you want to pay a premium for what you might wanna discount and to engage patients in a way that a passive Medicare benefit just doesn't do, might we do a much better job I'm bullish and I'm again, wearing my care journey, entrepreneur hat, I'm here to like monitor all the data that flows through the CMS system to track what's working. And what's not, and to scream at the top of my lungs, if there seems to be an emerging strategy in a given market that needs to scale.

Speaker 2: (27:04)
Yeah. Yeah, no. Awesome. So let's, let's spend some time there cuz we haven't gotten to the entrepreneurial side of what you're doing today and, and where you've been focused. Uh, one of the areas I should say, you've been focused in the last several years. Um, but it really, my, my view is and full disclosure MD as a customer. But my view is, um, you launched the company with the belief that it was at this grandiose level of being globally competitive through, um, uh, you know, better policy, open data, better standards, et cetera. And this was, this was how you personally and, and your team was going to try and impact have the greatest impact. Um, and so when you talk about the open data sets and the reporting and the visual analytics, all the things clearly important, but I think it's really, really sustained from, from this sort of, uh, perspective that that's really much bigger than that. Having said all of that. Maybe just describe a little bit about, uh, you know, how care journey has, how you started it and how it's changed over the course of the last seven years as more of these things have actually come to

Speaker 3: (27:59)
Fruition. Yeah. So my view is, and I felt this then, and I feel it now the Medicare claims database, which is not beholden to any vendor, it's not proprietary. It hasn't been aggregated through clearing houses. And other means it is an open resource and buried in that database are the keys to learning what populations are getting great care, which ones are getting not so great care. Who's quarterbacking that care, how can we scale it? It's in the database base. It was illegal in the Obama years, you know, coming into the Obama years for anyone but an academic researcher to touch it. It was too sensitive. Not only was it sensitive, it was seen as privacy for the doctor because you, you could look up any doctor in America and find out exactly to the penny, how much Medicare paid by the way, highest paid doctor in 2015, when the wall street journal took the data set and published it 11.1 million, that's a lot of ENM visits for a doctor by the way, by the way.

Speaker 3: (29:04)
And that was, it turned out part B drugs as the driver will get into that later. So the theory was this resource should be made public, but it's so sensitive for privacy reasons. You can't just like put it on the internet individual patient level detail that we had to have a gating function. And the market, I felt in 15, 16, 17, when we were thinking about this, uh, a business model, I thought there were really two theories of the case. We'll call one, the rent seeking theory and the other, the democratizing theory. And that meant, Hey, I wanna be in the data business and I'm gonna acquire data from every which way from Sunday, I'm gonna clean it up, normalize it and make it the easiest database to access. But man, that's an expensive thing to do. So I'm gonna have to charge a lot of money for someone to be able to tap it in order to, to, to, to get insight, which largely meant the incumbents, big pharma stakeholders that may not have been as motivated to drive the change would've been, it's like a sort of inverted problem, which is the very people who are gonna have, it may not be the ones that are gonna lead the revolution, uh, and the people that would individual doctors, physician networks, startups, they don't have the capacity to fund a massive data project.

Speaker 3: (30:22)
So I thought, is there a business model that allows for a little bit more democratization, a little bit more open, uh, philosophy and our, we settle on the theory that to solve the competitiveness issue, we need a village to succeed. We need all scripts to succeed. We need Oak street to succeed, not just to name my friends in Chicago. We need rush health system, uh, uh, system for health to succeed. We need the stakeholders to succeed. We just know that in all of their teams that are on team reform, they would like to tap the data set to learn about their, their markets. So how can we do something that works? And the answer was reusable, uh, library of insights. And so our philosophy was let's build one open, uh, uh, scorecard for every doctor facility, network market, and then syndicate. So you may compete vigorously with some of the names I mentioned, but you're both, if you're care journey members, you're gonna access the same information and hopefully compete on how you use the information.

Speaker 3: (31:25)
And that may result in more surgical refinement of strategies. So we're not waiting years and years to determine whether that one intervention actually made a difference. We can't wait the 17 years from, uh, bench to bedside that we've seen historically in change in healthcare that needs to be 17 weeks . Uh, and so we've gotta do a better job, so that that's the philosophy. I'm grateful that more data sets are being added to the open domain, Medicare advantage encounters, Medicaid encounters. And so we will start to the dream is, uh, the bipartisan lower healthcare costs proposal that never went final, a called for a kind of a commercial version of the CMS data cloud, where we'd have like a commercial of, uh, cloud and a, a government cloud. And we could tap both clouds in order to, to make sense of it. I'm looking forward to that day and I'm working hard to bring that vision to life.

Speaker 2: (32:16)
Awesome. So maybe let's spend a little bit of time. We've got a number of entrepreneurs on the call. Um, and, and I, I have to imagine part of what's going through their mind is we've got all this, uh, policy, uh, disruption happening and this flywheel has started and I've got my business that I'm starting or growing and, and hopefully gonna be a successful business. As you think about the opportunity that exists for continued disruption. How, how do you think about where that opportunity comes from? How as, as a, as a sort of individual or a small set of individuals that are trying to disrupt and be impactful? Um, obviously funding is one thing, but it's not all about funding. I, I, I know for a fact, it's not all about funding from, and we've talked about this. And so just tell me a little bit about like, how, how do I, how do I be successful in the current state as an entrepreneur from your

Speaker 3: (33:01)
Standpoint, H hug a risk bearing physician with love? My, my, my sense is physicians were trained in medical school to think broadly about the patient's needs. And then as we got into the business of medicine and the data sharing was hard, it could only do with what they had in their, in their hands. So if the patient only came to them for back pain for this one acute episode, but they didn't have a lot of the context around what they tried in the past, who they visited, what was diagnosed, what was not, you, you, you didn't have the full picture to be able to make thoughtful determinations the idea of hugging a risk bearing, uh, physician is that, uh, those are the folks when given access to information are the ones that are spitting off, all the things they would do if they had, they think if they had the chance and that could splinter off into management service organizations or networks, uh, um, it could mean niche services.

Speaker 3: (34:01)
Like I'll be the remote monitoring team to support you. I could be the telemedicine on call service that has the specialists ready for you. If you need a quick consult. So you don't have to have a referral out, but you could just get the answer. There are litany of use cases yet to be born and entrepreneurs on this, uh, webinar. We hope will run hard and fast at each of these niche problems, because it's going to be thousands of niche solutions. We're not gonna have the one startup to rule them all. No offense, Mike, uh, that will just be the answer to the nation's healthcare conundrum. There will be many, many component parts. There may be a few systems integrators that have figured out which of the best of those that are there to bring 'em to scale, but really there's so much wide space for improvement.

Speaker 3: (34:46)
And as, as Todd might have said on the webinar, I gotta double check Steven. But what he used to share publicly was that, you know, it's not that there's low hanging fruit in this move to value. It's like on the floor, you're stepping on the fruit down the street, right? It's just, there's so much, you know, relatively straightforward stuff. I'll give you one small example. We've put out this billion dollar innovation challenge before I left the white house. Uh, it came outta the innovation center and we put out this, Hey, who's got an idea. And you know, hundreds of people applied for grant funding. What have you, the Y M C a submitted the program they've been running for years called the diabetes prevention program. And they said, look, we, we, we think if you are pre-diabetic and you enroll in our course, you'll lose the weight.

Speaker 3: (35:29)
You'll keep the weight off and you'll stay healthy, avoid full-blown diabetes. We funded a trial, maybe 7 million bucks on whatever the number was. And, uh, 5,600 patients, uh, enrolled. And the actuary said, whoa, four to one ROI. People that enrolled in this program lost 5% of their body weight, never got full blown diabetes and kept it off. We should fund this everywhere and we could include a pay for outcomes. You don't, you get paid something for enrolling in the class, but if you get the weight loss, the doc, the Y M C should get paid more. Wow. 2018, every doctor in America with the stroke of the actuaries pen had the ability to score to, to, to, to, uh, refer every single Medicare patient to the Y M C a it's 2021. How many pre-diabetic Medicare fee for service patients have get, have been given the $600 voucher to get the clinic forget whether they actually got the benefits of it just even started thousands out of a base of millions who are eligible, how many seniors are aware that, uh, uh, that they even have this option, how many physicians are aware they could prescribe it, it's in the Medicare program, funded trial scale, right?

Speaker 3: (36:54)
So entrepreneurs are gonna solve that problem. They'll be, you know, lead gen for Y M CS that can connect them and they get paid a nickel for the, whatever. We'll figure it out. That's what we need more entrepreneurs to run towards.

Speaker 2: (37:08)
Yeah, that's awesome. One, one of the things that you had mentioned about the current administration, but I, I think we all, it all resonates with, uh, at least those that, that are, have a passion about healthcare is, uh, the, the efficient and the equal access of care. So be it, uh, in the rural areas of America or in the, in the dense population, in the urban, urban areas of America, there are plenty of, of, uh, healthcare deserts, uh, that exist in many forms and fashions. Um, and I know you have a particular passion as it relates to both, uh, the public and private sector in terms of that being addressed. I'd love for you just maybe to riff a little bit on that. Um, given that I do think that there's disruption opportunity in that space as well.

Speaker 3: (37:46)
If you live in an economically distressed neighborhood, you are a third less likely to be enrolled in an ACO than if you lived in a wealthiest neighborhood. The very people we need to bring care coordination to fall through the cracks, why either the physicians, they rely upon don't enroll, uh, in these models were worse. Their patterns of utilization fall through the attribution formula. And so structurally the very people we need to provide care coordination for aren't in the program, and we need to learn why, but that's not a reported widely reported, you know, statistic. It, it, it sort of, you know, now with the Biden team asking for these sorts of reports to be published, we're able to see more of this. And our team is running a lot of this. So my view is we have a paternalistic view of value based care, which is get the doctor to enroll in the model and all their patients come with them.

Speaker 3: (38:50)
I think Liz Fowler has said, uh, the CMMI director who's currently in charge. I wanna move to more of a consumer facing version, which is we want more people to participate. I believe the future will be some mixture of risk adjustment, or incentive tied to recruiting folks that may not have stable PCP relationships to come into your networks to manage their care and to coordinate it so that we accomplish the mission. Objective, think about the dual eligible seniors. And, uh, oh, Hey Esther. I see a question from Esther. She's my, uh, fairy godmother of, of good energy. And so I, uh, she's posed a question in our chat. We'll get into that hopefully in a minute. But, uh, my point here is that we have to find a way to drive, uh, more encourage recruit ethically and morally individuals into, uh, into these, these models.

Speaker 3: (39:50)
And I, the reason I'm excited about the Biden version of direct contracting as they iterate is it will naturally likely include an equity component in whatever form. Maybe there'll be a one time fee adjustment. Maybe there'll be a risk adjustment. I don't know exactly how, how the math will work, but the good news is we should have people working to recruit folks from the underserved communities, rural and urban, ethnically diverse, and to bring them in and they could retain whatever rights they have, which is to see any doctor they want, but to have an overlay, I call that overlay Mike, a health information fiduciary. And if I were to go back to what is care journey I wanna serve as many health information fiduciaries as, as possible, we should have a massive map marketplace who compete to advise consumers on the very best decisions they need to make on their healthcare journey. Yeah,

Speaker 2: (40:43)
Yeah, no, I, um, so, so well said, and couldn't agree more relative to the concept that you just described there, especially towards the end. Um, maybe just pivoting a little bit to a few of the questions that are coming in. Um, cause I think they're pretty relevant to, uh, this discussion as well as, uh, clearly, uh, you have some, some deep expertise, some of the questions are around, um, when you started describing fire and smart on fire, um, you know, there's been apple sort of helped, uh, push us to where we are today and, and, and I would argue, and some of our questions are around, how do we, what does the next sort of leap look like? What is like, how do we actually make it go forward and maybe describing some of the use cases or, you know, even to some extent, what, what is the, what, what is it and what is it not, I think would be helpful for, for the group to

Speaker 3: (41:25)
Hear. Yeah. So Mike, I think everyone that's been in healthcare data for a decade or more has lived in the world of interfaces. I want to connect to you and share information. And for them, this whole move to fire is like, what's the big deal. We're just translating from English to Spanish. I've already got an interface. It talks HL seven B two. Maybe that language is a little bit arcane. And so we're gonna clean it up with a new language, big deal. So anyone out there is looking at this, like what, why is this an issue? Well, that's like the 2% of the innovation is a common language. That's in a modern internet, you know, uh, architecture, but 98% of the change is removing from interfaces to substitutable apps.

Speaker 3: (42:17)
That means one connection reused many times versus one connection per use case. Now there are many companies and I love everybody who will say no, no, no, no. Make the one interface to me. And then I'll subdivide. And so there's sort of a, kind of a clue of this, which is like pick the one connector to rule them all. And it'll, you know, we'll have a, a sort of a, a connector, uh, efficiency play. My view is that the road we're on is really about when I build an app, what are the resources I can access to do my job? And so now that we've got this architecture of substitutable applications, not only can you connect to apple health or Android, but a village MD wants to build a, uh, a consumer facing app, you ride the same exact rails, no interface required. Ideally no registration required.

Speaker 3: (43:14)
We'll get back to that on the policy side. So now we have a safe, secure internet based application architecture that allows for any, with no barriers to entry so that we can all compete for consumer's voice. Now there are limits in terms of what data I can pull. I can't really get much in the way of cancer stage. That's not a thing. So we, we can get, uh, structured data, we'll have raw notes, but over time we can iterate and say, how do we wanna communicate social, uh, uh, determinants of health? May maybe we wanna have a little bit more structure around food insecurity and here's how you flag it. Okay. So there'll be iterations on what the supply of data will look like from the proprietary data models into the open data model. Think of it like a Roku channel where, uh, we're gonna add 20 more channels in the next three years, and we should decide what channels do we wanna add a cancer channel?

Speaker 3: (44:06)
We wanna add a, you know, whatever, uh, uh, orthopedics, uh, uh, device implant, channel, whatever. Then we need to expand the uses. It's not just the consumers that wanna log in to apps. Uh, doctors wanna log into apps, health plans wanna log into apps. My health information fiduciary might wanna log into apps. So we've gotta create governance at the application registration layer that is scale from, uh, traditional, uh, business to consumer to B2B. And so if we think about these as, as, as, uh, knobs and dials, we can adjust, we don't need to have a whole new debate for 10 years for what fire 2.0 is it's an ever evolving price, transparency rules coming. Where's the command that says get price for back surgery. Well, what's the command? What are the definitions? And then what would the response be if I asked? So we're gonna iterate that way. And Mike, the answer to me is we've got to continue to build consensus on the same open stack. We don't wanna have a public health data stack over here. Uh, you know, a, a price transparency stack over here, the, you know, clinical data stack here, we've added complexity. So my, my objective is re reuse, add more resources, expand the governance, and we can standardize off of the regulated, uh, substitutable applications that the information blocking rules is gonna scale between now and, and next December.

Speaker 2: (45:37)
Yep. Um, uh, I com complete the way that I think about it is it's all about the democratization of, uh, the data and the connections such that the innovation can happen really at the point that it needs to happen closest to be it, the physician, the nurse, the, the patient whomever. And so I, I'm really excited about where it's going. Um, maybe a co well, let me, before I get to that, uh, you mentioned something just now relative to, um, what's happening over the course of, of the next year. I mean, I think these things are, it's so easy to just say, oh yeah, that's just happening now. But I, I think some of these things are so seismic in terms of the impact that they can have relative to open data across the, uh, the, the, the sector that is healthcare. Maybe it's just described, like, what is that? So people have an understanding of, of really what's what's to come. Uh, as we think about open

Speaker 3: (46:22)
Here, here's the quick timeline last month in April, every doctor had the right, has the right to give a list of their patients, to the local hospitals, even the ones that you don't have privileges in to say, if you see my patient, you gotta send me a notification. That's now a right. And if the hospital refuses you as a physician, they can be licensed and sanctioned out of the Medicare program, which is essentially a death sentence to say, policy makers are serious. Hospitals must share real time notifications to doctors. One that's live already two July of this year, every government sponsored plan, Medicare medic, Medicare advantage, Medicaid, healthcare.gov. They har they will have to provide the same consumer facing patient access API to not only include the claims data that they've been generating. You know, when you, the residual of all the, the encounters, but actually all the clinical data that they've been collecting, the lab values and others package it up and make it available to a consumer.

Speaker 3: (47:27)
No, again, no fee, no registration required. Just, just a, an open source process. Then as we evolve into 2022, uh, CMS is expecting EHR vendors to ship the smart on fire protocol no later than December of 22, but it's already getting rolled out. Now that has two fundamental features that I consider to be to your words, seismic one, it empowers physicians who purchase these EHR systems to select any third party app that meets the smart on fire protocol, a village sponsored app, and install it natively in their EHR without having to go through a huge third party fee gateway app store. The doctors have rights to install apps on top of the EHR. As they've purchased. Number two, we introduce a new technology, which to me, is the ballgame and is taking the single patient, uh, fire payload and aggregating it at a population level called bulk fire or anecdotally push button, population health.

Speaker 3: (48:37)
This means every data sharing contract from next fall on will be negotiating bulk fire rights. Here are the list of patients I would like to pull out of your EHR. Here's the list of patients like to pull out of your health plan system? Here's what resources I can access whenever I want. Here are the resources you can act, and we're gonna update this every 90 days or yearly. Just that's it. A, B, C go. That's the data sharing no more months and months of waiting for interfaces and security reviews. It's like, this is the machine. The machine can do this. Let, if we agree to negotiate this data sharing terms, execution of that should be super straightforward. That is what excites me, because most of the waste in our administrative systems today are gobbling up all this random data, trying to make it common and consistent for whatever purpose you're you're looking to do, scoring on quality, looking for cost savings, whatever the issue is that's coming.

Speaker 3: (49:36)
And if we get our act together, now we can demand that the payers and providers implement this, like who's the apple health for this bulk fire application use case. It ain't gonna be apple. So who's gonna step up to represent, I say, village MD or someone else in the matter ecosystem should step up, right, Steven. So that's what we're gonna do. We're gonna bring this new muscle to life thoughtfully, uh, so that we have the information that we're gonna need to be successful. Now, there are other rules that are coming price transparency rule across the next, uh, 12 months, uh, implementing the good faith estimate. So doctors have to know what the anesthesiologist fee is and others to like send it, send the, the pre-bill to the plan, to get the, um, estimates. And so we're gonna have more quote, unquote shopping potential in 12 months as also we will payers have to talk to payers, and there are other use cases that are coming, but these are, these are big building blocks. The single consumer fire to bulk is the biggest that I'm focused on.

Speaker 2: (50:36)
Awesome. So maybe I'll give, uh, one, I have two questions. Let me start with, let me go back to payment models. So you, we, we talked about this innovation coming through the lens of CMI relative to the newer program that is currently DCE, but think about payment models in commercial plans or PPO plans, things that are happening, um, sort of more broadly for, for the, for the broader population, um, albeit you know, moderately healthier, but that's still really dense population. What, what kinds of innovation, what kinds of changes, uh, do you think about that area of, of the healthcare domain? Would you see coming, or would you hope you would see that that would happen?

Speaker 3: (51:12)
I, to me, I think the digital front door virtual telemedicine concierge chassis is ripe for scale in this consumer, sorry, commercial, uh, value based care, uh, model, because it would encourage, and in fact, recruit, uh, partners who are going to compete to earn your trust, to bring you in early for consideration and triage you, the ideal scenario is we went down the narrow network road, and there's a future for that when you can't afford anything else, the real magic is can we improve navigation in an open choice world? And the large employers in Medicare are actually, this is, I saw an email about Amazon Berkshire Morgan Stanley. I tell you nothing beats the common challenge of driving value based care on an open network. You can't constrain choice. You can't limit with prior ath. Can you introduce a more actively engaged opt in, uh, approach if it works for CMS DCE, it should carry over philosophically into commercial PPO.

Speaker 3: (52:22)
And so that's why I'm very excited about this. And I think the CMMI team Liz has said, she wants to collaborate with employers in the next generation of models. So that is where I'm, I'm eager. And I didn't, we learned something new for the first time, very briefly, Mike, 15% of original Medicare patients estimated have a retiree plan sponsored by their employer. So there's an interesting nexus, which is how do we get employers to route their retirees into a village, uh, MD, uh, direct contracting entity, no, no pressure anybody else, but I love you. And I love the team. It can be anybody Schmit, MD, whatever. And, and, and, but we could do that, right? We could, we could encourage retirees and employers to participate and then carry the learnings into their commercial offerings as they go. It, the roadmap is in front of us. Mike, I'm so excited. We're gonna bring the country forward together.

Speaker 2: (53:16)
We are, we are. So let me ask my, my last question. I'm gonna bring it back to entrepreneurship. Um, as, as hopefully people can tell, uh, we were very fond of each other, but that said, I didn't know you when you were 25. Um, and, and I would love for your perspective on if you went back to the 25 year old version of a niche and had one piece of advice to give him, what would you say?

Speaker 3: (53:37)
So 25 year old, a niche thought we could accomplish a lot more, a lot sooner. And I think 20, you know, 48 year old Anish would say, uh, change takes time. And so you, you know, you may be enthusiastic and excited and you can see impact, you know, in, in days, weeks and months, but we're gonna have to see impact in years. And so you might wanna plant more seeds that are baking for a multi-year change than to hurry up, hurry up, hurry up. And, and that's, that's been a, a challenge for me. I see ed Simko, former HHS CTO, uh, uh, on the Q and a love it, love that we have this bipartisan spirit and ed is raising the same question, Mike, you, you know, maybe we could in iterate out on here, which is, um, you know, the 25 year old Anish may have also had a little bit of a, a lack of market sensitivity, which I didn't quite appreciate.

Speaker 3: (54:30)
There's all these, you know, entrenched interests with, with, with Byzantine economic models. And so the obvious but why don't we just do the obvious, well, there's many structured things. And so Ed's describing an example where even the government itself is sort of entrenched with some of its, you know, overspending on relatively average to not so great, you know, capabilities. We've gotta get a culture of, of, of agile and modern frameworks in place. So 25 year old, should've been a lot more market sensitive about, uh, how to understand, uh, uh, the, the, the Byzantine nature of the market and, and to find ways to, to work, uh, unwind some of that to, to drive some of the change. But we're here now. We're gonna make a great deal of progress and I'm grateful and hopeful we can do more of it together. So thank you for the chance to join you today, Mike.

Speaker 2: (55:16)
Yeah, same here. And just with that, I want to thank everyone for participating. Great questions. Anisha's always a pleasure. I really appreciate our time. I look forward to connecting again soon.

Speaker 3: (55:24)
Excellent. Take care, everybody.