Medsider: Learn from Medtech and Healthtech Founders and CEOs - Demystifying Value-Based Healthcare – A Physician Expert Explains All (with Real-World Examples)

Episode Date: July 17, 2016

CMS has an objective to shift 50% of all reimbursement services from fee-for-service to alternative, value-based methods by 2018.  And bundled payment models, according to Dr. Dan Mazanec, will be the principal driver of this transformative initiative. But the topic of value-based healthcare can be pretty confusing , right?  Comprehensive Care for Joint Replacement.  Medicare Access...[read more]Related StoriesSubstantial and Sustainable – 2 Words That Medtech Companies Should Get Used ToSocial Media Best Practices for Marketing Medical DevicesAre Medical Device Models the Key to Building a Lean Medtech Startup? 

Welcome to Medsider, where you can learn from experienced medical device and medtech experts through uncut and unedited interviews. Now, here's your host, Scott Nelson. Hey there, ladies and jents, it's Scott Nelson, and welcome to another edition of MedSider Radio. If you're new to the program, MedSider Radio is where we learn from MedTech and other healthcare thought leaders through uncut and unedited interviews. Just a few quick messages before we get started with this particular. episode. First, if you've enjoyed these interviews over the last several years, please head on over to iTunes and rate our show. It's pretty simple to do. Once you're in iTunes, just click on the write a review button. You can then check the number of stars, preferably it's all five,

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Okay, so on to today's episode. CMS has an objective to shift 50% of all reimbursement services from fee-for-service to alternative value-based methods by 2018. That's a significant percentage. In bundled payment models, according to Dr. Dan Mezzanick, will be the principal driver of this pretty transformative initiative. But this stuff is kind of confusing. You know, you've got programs like the comprehensive care for joint replacement, Medicare Access and CHIP Reauthorization Act, MIPs versus APM. I mean, the list goes on and on. So how do you begin to understand it all? And if you're a leader within your med tech or biotech organization, how should you begin to

prepare your company for the future. So to help answer some of these questions, I invited the aforementioned Dr. Dan Mezzanek to join Medsiter Radio. Dan is currently the chief medical officer for Dorsata, but prior to joining Dorsada, Dr. Mezeneck was the associate director of the Center for Spine Health at the Cleveland Clinic. Board certified in internal medicine and rheumatology, Dan led the development and implementation of the spine care path across the entire Cleveland Clinic health system. Here are a few of the things that we're going to cover in this interview. How did the original concept of bundled payment model start and what was the original intent? Two early examples of bundled payments from the 80s and 90s.

The shifting financial risk in health care and why care coordination will be so important. With the Medicare Access and CHIP reauthorization Act, or otherwise known as macro, what that means for health care, and really more specifically, the two paths to reimbursement for physicians, MIPS versus APM. Those are the two paths that we'll cover in this interview. And in regards to really this overarching concept of bundled payments and reimbursement, what are the top two to three things that MedTech companies need to consider right now? All right. So without further ado, let's get right to the interview. Dan, welcome to a Medsider program. I appreciate you coming on.

My pleasure. Let's get right after it. CMS has an objective to shift 50% of all reimbursement services from fee-for-service to alternative value-based methods by 2018. I know you, wrote recently in one of your pieces that bundled payment models will be the principal driver of this disruptive or transformative initiative. And so let's kind of start with that and then we'll dive into some other topics along the way. But can you kind of provide an overview of the original concept for bundled payment models? How did the start and maybe what was the original intent? I think you go all the way back to the early 80s, at which point the CMS, Medicare, Medicaid,

reimbursement to hospitals and physicians, was entirely cost-based. So there was no cost control. If you went in a hospital for an appendectomy, the hospital essentially passed all the charges, the lab tests, the nursing care, the room, et cetera, based on whatever they were charging directly to Medicare got paid. And what Medicare was seeing was a tremendous increase

over a period of just a few years, I think, the costs, Medicare costs to reimburse for that type of care had increased more than 50 percent, I think it was approaching 80%. So in 1983, Medicare introduced so-called diagnosis-related group or DRG concept,

which said, we're not going to pay you for the hospital for individual costs. We're going to pay you by diagnosis. So they came up with about 500 different diagnoses. And, for example, an appendectomy.

Now the hospital got a fixed amount of money, which obviously kept the exposure of Medicare or CMS. and it forced hospitals, effectively forced hospitals to bundle all those charges associated with that procedure. And if the hospital was successful and came in, the actual cost of the appendectomy was $2,000, the hospital had a $1,000 profit or margin. On the other hand, the hospital was at risk if their costs obviously exceeded that figure. I think that was where the original concept of bundling comes from. Medicare essentially made hospitals.

all their charges for a set fee. And clearly the original intent of the program was to reduce cost. Later, and not too much later, and for all fairness to Medicare, they added really the phrase preserve cost and preserve quality. And now I would say as bundling has evolved, now I would say that they're not only controlling costs, but they're actually improving quality in a so-called value-based system. Other than BRG, some physician groups, a good example is the surgical global package.

So sometime in the 90s, Medicare started paying surgical fees in a global package. So this is not the hospital now. This is the surgeon. Would get a set amount of money for all the care associated with a procedure, beginning with the first day in the hospital or the first pre-op day through the surgery and anywhere from 10 to 90 days afterwards. That model is still out there today, and so irrespective of how many visits a person had to make to the surgeon, the surgeon had to take the person back to the operating room. There was a single set fee in our so-called global fee for that set of services by the surgeons. That's another example of bundling.

Those were two early examples of this concept associating all the costs of a so-called episode of care into a single-old. figure and essentially shifting some of the risk or taking the risk away from the Medicare system or CMS and shifting it to the providers or the PRG. You mentioned this notion that, you know, this was early. I think that's what maybe is most surprising, as I hear you explain, sort of the origins of bundling, and that this concept, it's not necessarily new. I mean, you mentioned that it really started in the early 80s, whereas we read so much about it in today's headlines, and there's so much focus on it, it's really not necessarily that new of a concept. It's been around for 30-plus years. Now, having said that,

before we get into newer models, like the comprehensive care for joint replacement, CMS has changed bubbling quite a bit over the past few years. Can you quickly kind of highlight that for us? There are really two trends, I would say, that CMS has focused on in the last several years, and really these trends were accelerated with Affordable Care Act in 2013. But the two trends really are folding physicians costs into the hospital as well. So, as I said, DRGs reflected hospital costs, but they did not include professional fees for the physicians caring for the patient in the hospital. The new bundling model, all the fees involved, the anesthesiologist fee,

the if involved, the surgeon's fee, the physician's fees tend to be now incorporated in the same bundle with all the other hospitalization related costs. The other major trend is the definition of an episode of care, which for DOG purposes was related to a single period in the hospital. Now the episode of care really extends through the hospitalization into the post-acute phase of care. So really going up to 90 days after discharge. So for someone hospitalized, for example, a total knee replacement, that episode of care begins with admission into the hospital and extends after discharge into rehabilitation and any post-acute care all the way out to 90 days.

So the bundle now involves a whole continuum of care and involves both the doctors as well as the hospital or health care organization. The other aspect of bundling is that this has now been applied to outpatient care. DRGs related to inpatient experience. Now outpatient care in a variety of models is being bundled as well. Again, the objectives are the same as with DRGs, obviously control costs or reduce costs and incentivize quality and drive more integration of care that relates to quality as well. but really forcing health care organizations, providers at multiple levels to coordinate care within these bundles. A couple of those points that you recently mentioned are part of that comprehensive care for joint replacement program, that CCJR, that acronym that we often see, correct?

That's correct. What's different about there, there's some differences, but basically that program briefly is for people, for patients who are going to have either knee or total hiprople. replacement surgery. And this program actually is just being introduced and the rules were just rolled out literally this year. But this program involves 800 hospitals. Unlike some of the other bundling projects, which you could look at as pilots or experiments, so to speak, the CCJR or comprehensive care for joint replacement program is mandatory for these 800 hospitals. As I said, for hip and knee replacement, which is a big ticket item. You know, there's 400,000 hip and knee replacements a year. Hospitalization alone is probably upwards of $7,8 billion, and there's a lot of variability

and costs. So what CMS has said is all the care for your joint replacement from Dave admission through 90 days, meaning the surgeon, the hospital, the physical therapist, the home care, the rehab facility if required all of that care is bundled together and a targeted prices set based on historical data and the total at totaling up the costs is done sort of after the fact but if the hospital or this organization comes in under target they will get some obviously there's incentive there they get some money back or give back on the other hand if their costs of providing the

care throughout the whole spectrum of care exceeds the target, then there will be a penalty in the hospital or organization will have to give money back. So it's really bundling of multiple providers, physicians across a whole continuum of care. The goal is to obviously reduce cost, and it will certainly drive better coordination of care that certainly should if the organization expects to be successful. Sure. That's why, you know, this concept of reducing readmissions for hospitals is so important because that's such an expensive event for, you know, if a patient is going to be

readmitted into the hospital and as part of that 90-day window, as you mentioned, it can be so expensive for the hospital. They're going to miss their economic targets. Is that right? That's absolutely right. So what the health care organization has to do is in the hospital, it certainly has to, make sure that complications are avoided. I mean, drug replacement, a big complication is DVT, a blood clot in the leg,

very common after knee replacement, less so after hip replacement. But managing people in the acute hospital to ensure that you minimize those risks and getting them out of the hospital these days, you know, get out of the hospital anywhere from one to four days, depending on whether it's a hip or knee. And then in that post-acute space, avoiding re-hospitalization, unnecessary care, the post-acute space is one that's been somewhat overlooked in these bundling packages until recently because, and it's an important one, because that's where 40 to 50 percent of the cost of that total episode of care resides, and that's the portion of the continuum where I think

it's fair to say somewhat uncoordinated care. People would kind of pick where they want to go for their rehab, but this really will force better care in that post-acute space, whether it's home care or in a rehab facility, and it's the place where the hospitals also have to focus if they're going to be successful economically in this new reimbursement model. Got it. And you said, just to confirm, you said 50% of the cost is going to be in that post, that acute post-care phase, correct? Depending on the nature of the procedure, for example, hip replacement, just, it's to contrast with hip and knee, hip replacement surgery, very little rehab is needed. Most people have a hip replacement and are kind of rehabing themselves at home.

They may need some home care, but that's a lot cheaper than having to go to a rehab facility for a week or two, and that's more common after a knee replacement. So I would say that post-acute space is more costly after a knee replacement than a hep, but it's upwards of at least 40% of the cost of some care of the cold, episode of care can be tied up in that post-acute space. In terms of the economics and the financial risk, that's a whole other shift that's happening because of some of these changes, right? That financial risk is shifting now to a different party.

One of the issues, you know, is that for a health care organization to a hospital, they traditionally have had less control over what happens after discharge. And even within the hospital, I mean, again, going back to joint replacement, some hospitals, you know, depending on the surgeon has had pretty free reign in terms of choosing the hardware, so to speak, the prosthesis for the hip or knee. You know, you may have six orthopedic surgeons choose six different brands of hardware at considerable variance in costs. One of the things hospitals are now doing is negotiating harder and agreeing, getting the surgeons

to agree on using brand A rather than brand A, B, C, and D, and to save money in the hospital that way. There are ways to control costs that the hospital are beginning to exercise, but the idea of managing that post-acute space where you may have physical therapists who don't work at the hospital who are in private practice, you may have a rehab facility that's not necessarily within your system. It's a little harder to control and coordinate the care in the post-acute space. And that's where the information highway, as I like to call it, the electronic medical record sort of serves as a backbone because these handoffs, the so-called handoff from the hospital to the rehab facility or to the home carriers or to the physical therapist, transferring information and keeping communication open between the surgeon and the therapist after discharge is critical to success in this new reimbursement world.

I can definitely see the importance of, you know, that health IT would play in solving for some of these, you know, these care coordination challenges, especially post-procedure. So let's talk about that more specifically. How there are a couple things that come to mind when we really focus on that point of health IT being able to help facilitate or overcome some of these challenges that hospitals and other health care providers will encounter. I think really this is, and we'll talk maybe more about some of the other. some other aspect later, but I think in terms of these models, the bundling model, for example,

information, again, the information highway is what's going to be the glue, meaning the EMR, that will really hold together these various components of that episode of care. So it really has to be, you have to have all the providers in the loop so that you can track and record data, events, provide practice, clinical decision support within the hospital, hospital and after. So I mentioned the blood clots, you know, there's good evidence-based medicine that needs to be built into a smart EMR that helps clinicians make the right decisions in the hospital to keep those complications down and reduce the length of stay, which is very, the length of stay is a critical cost driver. And then the EMR has to be able to guide the post-acute care,

the home care nurses, the rehab doctors or providers in maintaining continuity of care and avoiding errors in those handoffs, the repository of information, whether it's the drugs the patient is on, or what the other comorbidities are, whether it's diabetes or hypertension, that need to be managed to avoid those visits to the ER or re-hospitalizations in the worst-case scenario are really glued together by the EMR. For example, one of the things that attracting the Dorsada was the fact that Dorsada is kind of a unique information technology company in terms of building very user-friendly interfaces that sit on top of the EMR and really engage clinicians,

because one of the things that we certainly have seen in the post-acute space is that some of the documentation requirements and in the hospital as well are unwieldy, and the decision support isn't there. CEMR has to have a user-friendly interface, so to speak, to engage the clinicians, to collaborate, to cooperate, and really ensure the best possible outcome. I mean, I think the other thing that I would say is that there's likely going to be a significant role for telemedicine in the post-acute space.

So there was just a study looking at telemedicine from the standpoint of behavioral health, and people just discharged after a heart attack, a myocardial infarction. This study showed tremendous benefit in terms of reduced re-hospitalizations, reduced ER visits, and a almost million dollars saving in this particular study costs as a result of those reductions based solely on a telemedicine intervention in patients who had just been discharged. So I think telemedicine will be used to help manage the post-accompetence.

acute space increasingly to provide better care, but also to save money. And that's going to be critical, obviously, in the new health care world. And on that note, you mentioned Dorsata, where you're at currently. I would encourage, if you're interested in these topics, if you're interested in learning more about them, Dan posts quite frequently to the Dorsada blog that's D-O-R-S-A-T-A-Dorsata.com, and just go to the blog. You'll see it there in the top portion of their navigation on their website. I would encourage you to check out a lot of those posts. They're really, really good, very informative. And if you're thinking, well, this stuff is great, but I don't really use it that much,

or maybe I don't have necessarily an interest, I would encourage you to take a step further because if you're at a med tech company, you're in customers are most likely hospitals or health care providers, right, in general. So this is the kind of stuff that they're thinking about, right? This is what's on their radar. And so if you can speak to them intelligently about what matters to them, you'll probably be a lot more effective in communicating. So I would definitely encourage you to check it out.

So, Dan, before we move on to a couple of these other programs that fit under this bundling sort of umbrella, anything else to add that you think is worthy of mentioning with respect to the CCJR, the Comprehensive Care for Joint Replacement Program? Again, I think the thing is it's mandatory. It's being rolled out all across the country. I think there's 67 different geographic areas, and it's going to be interesting.

It's certainly going to drive. better coordination of care and between not only hospitals and surgeons, but again, this whole post-acute base. I mean, I think this certainly for surgical care is really where reimbursement and CMS is going, and it's going to be the way this whole concept of value-based care in that world is going to be pursued. Sure. And I can see how some of those changes that you mentioned in regards to the episode of care, the fact that almost every single stakeholder in terms of a healthcare provider's stakeholder is going to be incentivized to hit these targets. I mean, you can see kind of all of these pieces, all of these puzzle pieces sort of

beginning to fit together. And I think, you know, most people that are listening to this audience are, you know, are in med tech or biotech. And I think it would behoove everyone to kind of consider all of these different puzzle pieces and how you can best serve them, you know, moving forward in this kind of new era of not just bundled payments, but also, you know, value-based care. So let's move on to a couple other programs. One is the way of the acronym is Macra,

but it's the Medicare Access and CHIP reauthorization Act. That's a lengthy program name. Macra. Macra, yeah. Go figure that it's confusing to actually say. Can you kind of cover that and maybe start out with sort of the two paths to reimbursement for physicians under this new program? So the macro law is the law that was passed, I think, in late 2015.

and it could have been early January, that really replaces these whole SGR, sustainable growth, Medicare, the fix that every year there was a panic in December, January, and Congress had to pass a patch law to fix this law. So this is the new law, 900 pages, that really rewrites the reimbursement rules for physicians in American health care. It's really based on three drivers or values. One is that reimbursement is going to be based on value, not volume. Again, so it's moving away from the fee for service.

The more procedures you do, the more you get paid to the value-based model. It has a strong emphasis on IT, and the focus shifts from just process in IT to performance. And then it, again, much as the CCJR funding concept, it really fosters movement towards integrative practice. So it identifies two paths to reimburse. There's two ways doctors will be paid. You'll be in one of these two groups. One is the so-called MIPS or merit-based incentive payment system. This program is going to affect 800,000 doctors. So probably it's estimated 85 to 90% will be under the MIPS model, which again is called merit-based incentive payment. The other model, which exists now and is, I would still look as more of a pilot, a test that is being done across the

country in various practices, is the so-called advanced alternative payment model, or APM. And for example, CCJM is an example of that. These are programs, the accountable care organization is one, a patient-centered medical home would be another. These are, again, I think it's fair to say pilots where CMS is saying, you know, we're going to reorganize care, saying a patient-centered medical home where there are multiple specialists, physicians, social workers, behavioral specialists, nurses, nurse practitioners who will provide care to a population of patients. And again, coordinated care, you might say, with the same goals of reduction in cost and improvement in quality. But these are the two paths to reimbursement.

under the macro law. And most physicians will be dealing, since most physicians are not in these pilots, will be dealing with the so-called MIPS program, which again is incentive-based. And essentially, and it sounds complex and it is. The physicians will be scored in four categories that will essentially determine their reimbursement. One is quality, and that's 50% of your score. Quality measures, which now there's a myriad of them, actually one good thing about MAC, one important thing about MACA, which is certainly good from the physician's perspective, is reduce and standardize to some extent and give physicians some input in the selection of these quality metrics. One of the major complaints of physicians is that there's just so many quality metrics they have to report on,

and they differ from payer to payer, and there's an effort to standardize those and reduce the number. But 50% of your score is quality. 25% of the score is based on what's called, and I don't like the name, but it's advancing care information or ACI. And this is a big change. This program, ACI, replaces meaningful use, which we can talk about if you want, but meaningful use has been a program that CMS has had for the last several years to essentially incentivize the adoption of electronic health.

records in physician practices. And it has succeeded, 80 to 90% of physician practices now have electronic records, but the program itself was widely disparaged and not in dislike by physicians. Sometimes instead of meaningful use, it's been called meaningless abuse, largely because it focused so much on process, on, you know, what percentage of prescriptions are sent electronically and did you hand the patient to printed after-visit summary. It really wasn't focused on what clinicians might consider the important outcomes of quality. But this is a shift.

That program is replaced by ACI. And then 15% is on clinical practice improvement activities and cost 10%. So the big change with MIPS is some changes in the quality metrics, and then certainly a major change in this so-called advancing care information. And those are going to drive how you are reimbursed. program is budget neutral. So at the end, there will be program rolls out in 2017, and by 2019, the data will be in, and physicians will, the reimbursement will be adjusted upward or downward by as much as 4% in 2019, and I think by 2020, it's 7%, which in a Medicare payer environment is a huge amount of money. So there will be winners and losers, so since the program has to be budget neutral,

and efficient high-quality practices that can provide coordinated care will presumably succeed in this program. I suspect that we'll begin to hear a lot more about these programs come 2017, especially in 2018 and 2019 when some of these penalties come to fruition is probably the best way to describe that. So that's really good information. And so with some of those changes like the Advancing Care Information Act, as well as kind of the two different reimbursement pathways, physicians, or four physicians. How will that, in your opinion, affect solo or smaller physician practices? When this was published a month or so ago, maybe six weeks ago, that was the immediate reaction

was a lot of outcry about smaller and solo physician practices. So practices, solo physicians or practices up to seven, eight physicians, in the law itself, in the 900 pages somewhere is a table that CMS itself projecting that 87% of solo practices face negative adjustments and reimbursement totaling up to $300 million. So CMS in the document is actually predicting that the losers, so to speak, will be the small groups and solo practices. So from their perspective, this is really to be successful with this program, if they're going to participate, and there's a risk that some physicians will just, in that category,

will say, you know, I'm taking early retirement, I'm not going to see Medicare patients, I'm going to do a concierge practice or whatever, but which obviously has implications for health care delivery, since many solo and smaller groups are in rural areas or underserved areas, and there's a real threat that the access to care could be compromised. But the alternative for those practices is to really, what this program requires and what they need to do is to develop the capability to collect this information in terms of quality to demonstrate the ACE under the ACI or the advancing care information that they, to acquire the technology to meet the requirements. Essentially, it means building and acquiring the technology to meet all the reporting requirements. and that's the objection of the smaller practices, that that's expensive and difficult, and there's some truth to that.

But if they're going to succeed economically, they need to be able to do that. And that's another area, actually, where I think a company like Dorsada can help with the kind of clinician smart technology that we're building. I'll ask you about that next, Dan, before we get into the last three rapid fire questions. But for those interested in learning more about Dorsada, I would presume that you could just direct them to dorsata.com, that's d-o-r-r-s-a-t-a-com, correct? Correct, correct. Yeah.

And the way I would explain Dorsata, and feel free to step in, I think it's, what you guys are doing is really unique. It's you sort of sit on top of a traditional EMR, I think, because everyone that's probably going to be listening to this is encountered a health care provider that complains about their EMR, whether they're using, you know, CERN or Epic, those are probably the two primary players. But I personally, I think when you and I first talked, I mentioned this, but I personally have never come across a health care provider that's actually enjoyed working with their

EMR. So that's one of the reasons I think you guys are onto something there with the electronic medical record, you know, these dinosaur products are a significant factor in physician burnout. It's very hard to find physicians who, you know, are happy working with the medical records. So, you know, at Dorsada, trying to build a technology that really thinks the way the clinician thinks, documents and provides sort of seamless clinical decision support. You know, you have happier physicians, happier patients, more productive physician, certainly economically. You give time back to the doctor and the patient because the patients don't like a record where you're clicking away and standing at a computer screen. So the Dorsat interface is really very slick. And these are some of the

things that when I left the clinic tracking me to Dorsat. I think, take a look at the website. Yeah, sure. And if you're not an ideal customer for Dorsata, I would definitely encourage you to take a look at their blog. It's highly informative, the trends that are happening right now within healthcare. So regardless, you know, definitely check out Dorsada.com and at the very least, learn a little bit more through the articles that Dan post there. So Dan, just to summarize, if you can, I know you're a healthcare, you're a physician yourself, you're the health care provider, but if you can, let's pretend almost like we're sitting down for dinner. I'm someone in MedTech, maybe a senior level executive at a MedTech. company, and I want your opinion on what I should do, you know, are there a couple things that I should consider do moving forward in light of some of these, you know, these major changes, whether it's the CCJR or the BACRA program? Do you have any, you know, can you give me maybe two or three insights to summarize our conversation? The first thing is, you know, whether you're a provider or whether you're involved in a health care organization or really at just about any level, or if you're a manufacturer of health care technology, or health care hardware. You need to be aware that the bundling of services along the entire continuum of care involving all providers,

not just physicians, but physical therapists, is really the direction that is TMS is taking to really reshape care along the lines of value, meaning cost, quality over cost. And that from the health care organization standpoint, having robust, clinician-friendly and smart health care IT is the glue throughout this process, that throughout the continuum, anyway, that will facilitate meeting the demands of the terms of reporting just on the outcomes, on the important elements of care provided,

and at the same time, improving efficiency and quality, and it's critical. I mean, I would look at health IT in this whole thing as the backbone of the, bundle really that ties it together. And I think that that's, I think that's really my primary message. Very good. Let's finish off with the last three rapid fire questions. Now, the questions are rapid fire. Your answers don't necessarily have to be the same, you know, in the same fashion. But let's start out with number one. What's your favorite nonfiction business book? You know, I would have to say, and it's not a new book, and it's really relevant to what we're talking about, it's redefining health care by Michael Porter. You know, Michael Porter is

a Harvard professor, economist, whose book, I think it's probably now close to 10 years old, and I've actually gone back and reread some of it, really embodies the elements of the whole revolution in health care redesign. Many of his concepts have been adopted, adopted in the Affordable Care Act, have been adopted by CMS, and it's really a critical, very important book from the standpoint of the business of health care and redesigning health care. The title of that is redefining or redesigning? Redefining health care. Correct.

That's great. I've never heard of that. That sounds like an interesting reason. He wrote a paper, which was actually a seminal article in the New England Journal of Medicine, published, think back in 2009 or so, I think it was something like a strategy for health care reform. But if you read that article, it's almost like a roadmap for the direct. that CMS is taking health care in this country.

Got it. Very good. So second question, is there a business leader that you're following right now or one that is inspiring to you? I'd be very provincial. As you know, I was at the Cleveland Clinic for more than 30 years. And I would say that the business leader that I would reference is actually Toby Cosbro, who was and is the CEO at the Cleveland Clinic. I mean, he's a heart surgeon who became CEO maybe, I don't know, 10 years ago. But amazingly insightful. an innovative CEO, visionary. I mean, I think he, from the health IT standpoint,

he was several years ahead of the game, certainly from this whole focus on value-based care and on patients first. I mean, a lot of this is business. You can't forget that the center of it all is the patient. And Toby, just to give you a brief example, several years ago, recognized that access to care. It was a big problem.

I mean, it's not that that's a new, idea, but his answer was somewhat disruptive. He said at the Cleveland Clinic, there's a huge organization where people sometimes were waiting two, three months for an appointment. He basically said literally almost overnight, we're going to offer same-day appointments. If you call the Cleveland Clinic before noon, you get seen that day. And he said, this is the way it's going to be and make it happen. Wow. And I mean, it was a very, I can tell you from my perspective, as a lot people said, what, it's impossible. We can't do that. How are we going to do this? But the bottom line is, I think, the last time I heard it, I know it's much higher now, there were more than a

million same-day appointments scheduled since he instituted this a couple years ago. So, tremendous, I mean, just a very out-of-the-box, savvy, innovative CEO. That's great. I think most people are probably familiar with him in name only, but that sort of anecdote that you just shared is pretty cool. It gives us a better feel for kind of his style in terms of running the Cleveland Clinic. So last question for you, Dan, is when you think about your career in health care, if we had the opportunity to kind of use a time machine and rewind the clock, is there a piece of advice that you tell your, you know, your 30-year-old self? Well, when I reflected on a question like that, you know, I think about my own career.

And, you know, I started out as a board-certified internist, a rheumatologist practicing arthritis care, probably about when I was 30 or 32. And then an opportunity came along. I don't want to say out of the blue, but was asked to become involved in spine care, non-surgical spine care, and that led to becoming the director of the Center for Spine Health at the Cleveland Clinic, until I left really probably for 15, 20 years. And then in the last five or six years at the clinic, I was basically asked, because to some degree nobody else wanted to do it, to become involved in building care paths, which is kind of what we're talking about, building a clinical pathway and then enabling it in the EMR,

So I got into sort of the health IT area that way. And what I would say, the advice I'd reflecting on all that, I'd say you just have to be open to change, opportunity, be flexible. I would have never guessed 30 plus years ago that I'd be working for a health IT startup as I am now. It was really a matter of being flexible, willing to take on challenges and not be locked in a box and be inflexible. And I think that's probably the best advice I would give myself.

Yeah, that's good stuff. Well, I can't thank you enough, Dan, for coming on the program. As I wrap this up here, I'll have you hold on the line. But, again, for those listening that want to learn more about the topics that we just discussed, I would definitely encourage you to check out the Dorsada blog. I'll link to it in the show notes for this particular episode. But dorsata.com, that's D-O-R-S-A-T-A-com. Click on their blog and Dan posts articles fairly frequently that are really,

really good. It's not a boring read at all. They're actually really, there's just really informative. He's got a knack for explaining things in an easy to understand fashion. And if you've got an interest in Dorsata, just check out their product. It was pretty cool. It really would help us out if you go to iTunes and give us a rating that just helps in terms of raising the overall visibility for this radio podcast. So that's it for now. But again, thanks for your listening and attention until the next episode of MedSider, everyone. Take care.