Christopher J. White, MD, MACC, MSCAI, FAHA, FESC, FACP of Ochsner Health gives a provocative talk on the importance of value-based care in a stormy economic climate for healthcare systems in the United States. Watch the Post-Lecture Interview with Dr. White Here.
Well, good morning everybody. I hope you're enjoying your breakfast this morning. Um We would love to welcome you to the second annual Georgia Heart and vascular symposium. Thank you all for being here with us. But before we get started, I would like to recognize that this program is provided by Georgia Heart Institute with the generosity of grants and sponsorships from our industry partners and you can find our partners in the Ian Ballroom next door. The planners have disclosed any financial relationships with commercial interests. Our speakers who have relationships will disclose them in their presentations to claim cmemoc nursing and other continuing education credit for our program. Please take our evaluation. You have instructions in your tote bags with instructions on how to download our mobile app, which is it will give you quick access to take the survey and also see what's happening. Check out the agenda, check out our speaker bios and if you need help with that, we have a help desk right outside at our registration station. If you have a question for the presenters today, please hold until the Q and A segment. Online viewers feel free to type questions into the chat and we will read them aloud and now I'll give it to our host, Doctor Habib Si. Ok. Well, welcome everyone. Um It's great to see um, old friends, many old friends and current friends. Um We're really, really excited with the second annual Georgia Heart and Vascular symposium. Um Many of, you know, you might ask, you know, why do this symposium? There's so many symposia out there. Um But we felt it was really, really important uh within the state of Georgia to have a forum where we come together, we talk about the la latest patient centric care and as you'll see in some of our live cases today and all the discussions, it's all about putting the patient, the family in the center of it all. Um I also wanna thank um many of the folks here that have helped make this wonderful symposium come together yesterday. We had an amazing session with our emergency medical services folks. I think we had about 100 and 50 people. It was a session that was completely dedicated to a key component of health care delivery, which is the emergency component. Um you know, as, as I think about uh where we stand in cardiovascular care. It, it's such an exciting time with the developments in pharmaceutical biotech research. Um But ultimately, it's about what we learned about compassionate patient care. And as you'll hear from our CEO in a minute, these are sort of the core values of our organization, our deep interdependence um bringing your excellence stewardship and really compassion. Um So, with that said, and without further ado, I, I wanna describe to you what these next two days are gonna look like, right? We're gonna kick it off with an amazing keynote address shortly. Um And we're gonna talk about cardiovascular quality. Um And then we're gonna have live cases. We all love life cases. We're gonna have three simultaneous live cases including for one of the first times, a robotic mitral case. Um and then another percutaneous mitral case and oh and also a coronary case. We do do coronary still, but um uh it's gonna be really fun. Uh We have an amazing ep session. A shock session. Tomorrow will be a focus on prevention, women's heart, heart failure, vascular disease. And we'll have a really nice jeopardy session run by Jamie Burkle who chairs our education committee. So um let me now ask um our Ceo Carol Burrell to step up and um say a couple of words, Carol, come on up. Good morning. Ok. The way we do things at Northeast Georgia Health System is we're always trying to continuously improve. So let's try that one more time. Good morning. Yes, I got it. I love it. Well, you're gonna hear this probably multiple times, but I wanna say it myself. Thank you for joining our second annual Georgia Heart Institute symposium. So we are really excited this program was launched last year as many of, you know, and we're thrilled that you're back here. Um, again, you'll hear this over and over continuous improvement. I think you'll see today and tomorrow being in more, more impactful than it was last year. Northeast Georgia Health System has a long history of heart and vascular services. We're an organization that's over 75 years old. Our first heart and vascular services started 65 that's 65 years ago. And I'm sure in today's time, that would probably be considered pretty minimal, whatever that was. But I think that's an example and displays how we're constantly improving and being better tomorrow than we are today. Now, Georgia Heart Institute has a team of more than 80 cardiologists and advanced practitioners. We're in more than a dozen locations across the Northeast Georgia region. And again, as I said, being better tomorrow than we are today, we're very focused on continuous improvement. And I know that Dr Sami and all of the Georgia Heart Institute team is very much focused on that. We continue to build on our foundation of expertise and innovation all while being focused, laser focused on the number one reason and that's our patience. Now, what does that mean? That focus means embracing change, encouraging new ideas and fostering groundbreaking approaches in each and every day. It's our daily work because you have to start with the basics to be able to improve. It's also a team sport. And so for all of you in the audience today, we appreciate your, your thoughts, our internal team, those of you who have outside perspectives, please bring those ideas and help us to embrace that because we re the important thing is that we are changing lives throughout the Northeast Georgia region and the state of Georgia. So again, thank you for the making the commitment to be involved. I hope that you walk away tomorrow with an idea and a perspective and something that will encourage you to do better tomorrow than you are today. Thank you. And I wish you the best take care. Great. Well, Carol, thank you for those uh words. And um let's go ahead and get the session kicked off. Um Maybe before I uh I'll introduce our keynote speaker. I'd like the panelists to each introduce themselves because you're all here to support uh the discussion around um Chris White's talk. I'll start. So, um I'm Brian Steins. I'm the Chief financial Officer for Northeast Georgia Health System and I'm on this panel because I just assumed doctors wants something from me. Ok. I'm Spencer King. I'm a Professor Emeritus at Emory and uh I guarantee you he does. Well, I won't go into what people might spit. My name is Manesh Patel. I'm chief of cardiology at Duke and Co direct the heart center. Hi there. I'm Karen Gersh. I'm a new, I'm new to the area just here. A little over a month and a half or so. I'm a cardiothoracic surgeon and specialize in mentally evasive or robotic assisted cardiac surgery and also thoracic oncology. Interestingly enough. So, uh Vena Thrane cardiac surgeon, um chief of cardiovascular surgery at Piedmont uh in Atlanta, Georgia. Fabulous. Well, uh as you can see, um this sets up our, our keynote speaker here very well. Um who's uh a long term friend and, and really mentor for many of us in many ways, Chris White is currently professor and chairman of Medicine and Cardiology at the Arner Clinical School. He's also medical director of the Centers of Excellence and service lines and medical director of Value Based Care. Um And as the system chairman for cardiovascular diseases, Ner Chris graduated A O A from Case Western Medical School in Cleveland in 1978 completed residency and training at the Letterman Army Medical Center in San Francisco. And following a very active military duty service, he joined Oser in 1988 at the time serving as director of the Cath lab. So Chris his vantage point uh not only as what I just described but also as a internationally renowned investigator and thought leader is going to be really critical as he shares with us his uh thoughts about improving the quality of care in cardiovascular medicine. Chris, thank you for joining. Thanks, Aib. Can we you need to raise the podium or get a stool? Um So, yeah, so all what Habib said is all bullshit. I'm gonna try. Yeah. Are we to warn you about this? Can we, can we? Yes, we are being recorded and we're gonna have to. All right, we're, we're gonna have to keep it clear. You can start now. Hey, Spencer, can you step up? I'm, I'm going to spend the next 20 minutes telling you things you don't want to hear. I don't have a lot of good news for anybody. Um There is a little bit of light at the end of the tunnel like there's hope. But if you don't get this message, uh you're in big trouble. So um we're going to start with, I don't have disclosures. So if the power goes out and we lose everything, this is the only thing you need to understand from the entire talk. And that is that everything you plan to think about dream about gonna do tomorrow should make value get better. And the way you make value get better is you improve your quality, you improve your service, you improve your access and you do that by reducing cost and cost includes complications, dis utilities, anything that makes it difficult for your patient centered care. So when you think about a plan or a strategy, you wanna plug those features into this to make sure that everything you do incrementally continuous improvement is making the V go up. So it's no surprise it shouldn't be uh that American health care is very expensive, not only very expensive. How about twice as expensive? Twice as expensive? We spend twice as much money as our European counterparts. Who I think most of us who would think over the last 25 years of globalization of health care and cardiovascular care would agree that the Europeans are certainly our peers, if not in some ways leading uh health care. So we we're paying this premium for health care. Now, that might make sense if we offered a superior product. But I'm going to show you that perhaps that's not the case. So this is the cost of a diagnostic left heart catheterization in the United States. And again, it's 2 to 3 times as much as around the country. Now, why is that? Well, at Oxner, we use gold plated catheters and, and so that explains that, but I'm not sure what you guys use in Northern Georgia, but there's a unexplainable reason for this increase in cost. Again, these are outcomes and the United States is distinctly separate from the rest of the curve when we look at a lot of health outcomes and disparities in this country. And then this is a scorecard where number one is good and number 11 is bad. And what you can see is the United States has an awful lot of elevens. Uh We actually rank at the bottom, but you're paying twice as much as the, as the best uh health care system for what you provide. Why is that? Well, number one, our patients can't get access. Right. I don't know how many of you were involved in clinic access and patient scheduling. It's a big focus for me. And one of my problems is people don't have a method of payment. So if we don't have a margin, we don't have a mission. I'm a 501 C three. I take care of my community, but I can't go broke doing it right. And so because we don't have adequate health care insurance or ways to pay for our people's health care, we tend to not provide a lot of health care, particularly to folks who can't pay for their health care. And then the other thing that's happening in the pandemic has accelerated, this is there's just a ton of bankruptcies going on in consolidations. There's a heart hospital in New Orleans that went bankrupt. A heart hospital, how does a heart hospital go bankrupt? One of the parish hospitals, county hospitals went bankrupt in our region. And of course, you know the story about the academic medical center at Haneman going bankrupt. So why is it that they can't keep their doors open? Well, this is the reason and that is that reimbursement continues to dwindle. We are under relentless constraints and relentless costs and reimbursement. And so this is the curve and I I guarantee you the pandemic has accelerated the shift where the growth of our expenses has exceeded the growth in our revenues. And frankly, for those of you who are not mbas, that's a bad thing, right? That's a bad thing. Hard to keep the door open when that happens. And this is just a projection of what that looks like where in 2021 2022 many institutions have become uh loss leaders in driving their health care. And once again, no margin, no mission. So as Yogi Berra said, when you come to a fork in the road, take it. So many of us talk about having 1 ft in the canoe of value based care and 1 ft in the canoe of of profit based care or productivity based care. And when you have 1 ft in each canoe, it's kind of tough to keep your balance. And so this doesn't work. You cannot navigate both of these paths unless you're willing to put orange stickers on the foreheads of the patients that you don't want to do anything to. Right. So your managed care patients all get orange stickers and the people who pay you to do things to them don't have stickers and you can figure out what to do if you don't wanna do that, trying to just practice good medicine is difficult to follow either a, a value based care and a volume based care. And by the way, let me tell you that the vast majority of the physicians in this country are paid to do things. They're not paid to think they're not paid to consider they're paid to do. And so what do you get when you pay doctors to do something, you get things done. So we all know we have to change. The problem is nobody wants to. And the reason they don't want to is they're kind of wed to this productivity method, which is so easy to count. Right? We can easily count RV us billings collections, those are very easily counted. Savings. On the other hand, are very difficult to count and very difficult to attribute. So this is how most of us approach change. We think it's a good idea. We just want you to go first. So this is that AC C was in New Orleans uh last two months ago. And so this was one of the talks that was given. Uh the picture is pretty bleak. Gentlemen, health care is changing. Hospitals are going broke and we all believe that open arteries are better than closed arteries. So we're done. So I'm gonna talk to you today about improving value by decreasing, low value care and decreasing the variation in the care that we provide most of us can agree that whenever you look at a process and there's a ton of variation in how that process is conducted, that nobody's figured it out, right? Because if you figure out how to do it right, people will gravitate toward that one method. But when you see a lot of variation, it means people haven't figured out the solution to the problem. And so these are just some examples of what low value care and high value care look like. For example, I don't know about your hospital, but we have a hospital with a lot of interns and residents and very junior staff, hospital, medicine doctors. And when somebody comes in with acute corner syndrome instead of listening to their heart every day, they just do echoes. Well, we're capitated for that. So every echo that's done is a cost to me. I have to hire people. I have to buy machines. I have to read those echoes and then I pay the doctors to read the unnecessary echoes. It's a perfect storm for losing your shirt. We know that routine angioplasty and stable ischemic heart disease isn't a good idea. It doesn't mean never just means it's not routine anymore. Annual stress tests. I spend more time telling my patients, I'm sure Spencer does too because we had weaned them to annual stress testing. If you got a stint, you needed to check your engine once a year. Right. With a stress test. Well, it's been about 15 years since we learned. That wasn't a good idea. I spend more time telling people why they don't need the stress test. My patients want the annual stress test and I have to talk them out of that and it costs me time and I don't get any revenue for that. So the drivers of low value care obviously fee for service. If you pay for something, you get it. But also there's a problem in managed care patients and caregivers believe that doing more is better. They think that doing something is better than doing nothing. And they just don't understand the harms or the costs that go along with unnecessary care. A stress test that isn't needed that's indeterminate. That leads to a cath lab visit that leads to a 50% led stenosis that somebody looks at has an ocular stenotic reflex and says, let's put a stent in that the stent causes the dissection and then we go from there. So there's a lot of uh hidden costs. So how do we get away from low value care? Well, one we use evidence. We try, we use eminent which are guideline based documents which are helpful to us. And then eventually and more and more you will see in your practices that payers will just stop paying for low value care. I want to talk just briefly about quality. So I'm a big fan of beauty pageant quality. You know, I I, we work very hard at us. News and World Report. It's an absolutely worthless thing to do. But we really like the color of that gold shield hanging all over the hospital. We think it makes a difference. It doesn't. So many of you may not have heard of the Lowe Institute. Uh I had not Bernie Lowe was a absolute visionary pioneer uh cardiologist back in the day and he established this Lowe Institute as 501 C three which accepts no funding from external sources and actually measures our quality. Now, I saved your guys the embarrassment of showing your numbers. So I'll show mine. Um but basically we rated on, on equity on value uh uh as we perform and this is what our value looks like at auction or we get an A uh uh for the measures and we get A B for the efficiency. And you can see that we're doing pretty well for stars in many of those procedures. But look at that carotid stinting number. I do carotid stints. I think the reason we score poorly is we're in a lot of trials, right? So the trials are not, are trying to prove the method. And so that's what I tell myself when I look at this slide and again, when we look at value, you can see that uh our cost efficiency is high. I would encourage you to look at your data and to see where exactly you land on this, these uh assessments because it can help you focus your work. So variation is a difficult testy subject with physicians. There are two kinds, there's unwarranted variation which is random unexplained variation without any evidence to support the best practice. And then there's warranted variation where we typically say we put a brain in it, meaning that any pathway that we recommend shouldn't be followed more than 75 or 80% of the time because patients will have unique features that require deviation. That's good medicine, we should do that. So, warranted variation is good unwarranted variation should be uh discouraged. Again, overutilization. First, we're gonna run some tests on this machine to help pay it off. Sound familiar. Yeah. So this is a great example. This is uh uh C MS data on vascular ultrasound, diagnostic ultrasound and peripheral vascular intervention around the country. And if you look at the top left, there's bend organ and you can see that there's a significant reduction year over year in vascular ultrasound and peripheral intervention. But then you look down at the bottom at mcallen Texas, for example, where you see a 40% increase and a 30% increase in intervention. Now, we all know the reason for this is that the patients with peripheral vascular disease in Texas are completely different than the patients in Oregon, right? No. So if the patients aren't different, why do we see such variation in utilization? So this is coronary stents and and Don Berwick has outlined how much money we're wasting on unnecessary tests. And I don't need to explain this heat map to you in California. All I need to show you is the heat map. Why is there such dramatic variation in the use of stints in California. Why? What explains that? So when you do quality improvement, it's not only important to know what the right things are, but you have to do them the right way. And this is just an example of a study that showed that following indications from guidelines and following dosing uh of of drugs were both important independently that if both were low, you had a lot of events, if both were high, you had the best improvement. So it was important to couple them together. One solution didn't maximize your outcome. And then this is a paper that just amazes me. This is from Connie Hess. And she looked at a year after people had peripheral intervention and in a year after only 61% of patients were discharged on a statin only 67 on aspirin. What, how does that happen? How do you let somebody go home after you put a stent in their leg without an aspirin? It doesn't make any sense to me. Bad medicine. So I don't know how many of, you know, Michael Lewis. Michael Lewis is a New Orleans boy. Um uh he's written books, he wrote, he, he, he did the Blind Side. You may know him for that, but this is the best book he's ever read written. It's called the Undoing Project. And it's about two psychological economists, Amos Tversky and Daniel Kahneman. And they basically explain how physicians can know the right thing to do. For a group of people, statins or aspirin but often fail to apply those standards to any specific individual. They find reasons to make exceptions. And their student Lewis Goldberg took it further looking at uh algorithms uh to take care of uh patients. And he compared things like looking at GIX rays. He looked at what the algorithm would do and what the experts would do. The algorithm by the way was written by the experts. The algorithm beats us every time the algorithm wins because it doesn't vary, right. The algorithm is very consistent. The experts vary and the variation is what damages the quality of that outcome. So these, this is from auction, this is Rich Melania and chip levee. Uh two really bright guys, you know, I I hired them because they were smarter than me. Now, they won't let me forget it. Um But anyway, these are a CS uh C MS core measures and, and you, you're familiar with this list. We've been doing this for years. And as the chief, you know, when I'd look at this, I was my buttons kind of popped. We were in the 90% for most of these things. Uh really quite good. Well, Milani, the spoil sport, noninvasive guy that he is um suggested that what would happen if we got 100% on all of them? What if we did? Perfect care to which I said, well, that's not gonna happen. The interns are right in the end with the orders. He said, well, I can write a computer program and it'll generate the orders and we can compare what the computer program, computerized order entry does compared to what you do in real life. And we'll see what happens. So he did and this is what happens. So perfect care. Meaning 100% on all of those things was increased six fold with the CPO E with the computerized order, as you might imagine, the algorithm worked. But what we didn't anticipate was a significant survival advantage. It makes a big difference if you get all of those things, right? Or whether you get 90% of them, right? And so it was really eye opening to see how important this was, which led now to us for a number of years using these algorithms for almost all of our cardiovascular admissions. So we do have a lot of choices. We can embrace the change, we can do nothing. We can oppose the change. The future is this providers that cling to our broken system will become dinosaurs quickly. Reputations based on perception and not better outcomes will fade. Maintaining the current cost structures, particularly post pandemic when we've lost federal funding, nursing is more expensive than ever before maintaining our structures in the face of this transparency and falling reimbursement is just gonna be untenable. And organizations that fail to embrace this value agenda will not be able to compete with those who do. Well, I'm saying this to a room full of folks, caregivers. I'll include you all in this and, and this year thousands of you are going to die from stubbornness. No, you won't. Right. Ok. So I will offer these solutions. You need to identify low care, low value care opportunities. I will venture to say to Habib's point. I'm sure you're doing coronary cases today in your cath lab. Some percentage of them will be lesion preparation with atherectomy devices. That absolute have zero comparative evidence of benefit but significantly increased reimbursement for you and increased cost. So why do you do those things that don't have evidence to support them and you do them routinely and you believe that they work very well. Professional societies will continue to issue guidelines and as practice documents, some payers will stop paying for more and more low value care, identify reduction opportunities and pathways. Look at cat lab management management strategies. What's your first start time? I thought my first start time at ox was really great. Turns out not so turns out we don't really get started at eight o'clock in the morning even though we bring in a team at 6 30 to get ready to start at eight o'clock in the morning. And then the final thing I'll say is there's a huge opportunity for physician preference items and vendor consolidation. We were using 14 vendors knees for knee replacement surgery. Uh Three years ago, we're now down to three vendors and next year we'll be down to two and I'll show you the savings in a minute. There are four or five vendors of drug alluding Coronary stents. The difference in the value between each drug alluding stent is the color of the box and how it pleases you. Blue is your favorite color. That's the best one you like green. Ok. We're gonna use the green one, but the patients don't do any better, right? So these are the savings in 2020 they're increasing, but you can see cardiology saved almost $2 million predominantly in commoditized areas like drug stents, peripheral vascular things, guide wires, other things you can get together and decide it doesn't really matter what drug alluding stent I use. Let's go get the best price. I do not need anyone in my system to use a cheap device. We are referral doctors, right? We're not gonna use cheap knees. We're not gonna use cheap stents. We're not gonna use cheap anything. But if you tell me what your favorite is and I can make a volume commitment to a vendor for 90% of our volume. I can get you that price. Pretty, that device pretty cheap. So all I need you to do is tell me your favorite. I don't care how much it costs. What's your favorite? I'll get it for you cheaper than we're paying for it now. So early adopters will reap huge benefits. Uh going forward outcomes will improve reputations will also and you'll see increased referrals and volume. Again, the currency of health care is still going to be patient volume. Though you want large patient volume, you want to manage that volume well, by managing these costs, providers will maintain economic viability. Even in continued reimbursement cuts and cost-effective physicians will be sought out as partners of choice. You'll want to work with them and we will enable them to expand across their regions. I wanna final slide is I wanna remind you that pop health is not our enemy. Pop health is not a specialist enemy. They are the funnel that can bring you the appropriate patients to make a difference on and that's how you get good outcomes is a big funnel. So good selection and then good outcomes from good doctors. Thank you very much for your time. I appreciate it. You know, that was um absolutely. Um This is my, you want to turn this mic on for us. Can you hear me? Um That was Chris. That was absolutely um a remarkable talk. Um I'm kind of still stuck at watching the babies here right now. Yeah, it looks like my two year old. Um So the thing that draws 100% agree with you. Consolidation is a great thing and I'm not sure we have a lot of device to device comparisons. At least for me as a cardiac surgeon. I do a lot of stuff in the catheter valve work also. Um, and we've had completely, that's been an area unlike Coroner Sting where we've had really no device to device comparisons on a grand scale. Um So we're struggling with that a little bit, but at the end of the day, it's evidence and I'm, and I'm struggling, I do a lot of research trials. I'm struggling on how to generate evidence. I have to be honest with you on one side, if it's industry sponsored, where a lot of it is, um it is potentially fraught with what industry wants the results to be. The primary end points are that way if it's NIH, well, you know, only about 2% of the studies are actually going to be N I supported or A H A supported. How do we gain I get it? How do we gain this? Because I'm struggling right now, how to bring value in um for whatever product we're using or idea of a philosophy of how to manage someone when I'm not sure how to gain that evidence anymore. To me, that's the biggest problem I can't change until I have evidence. And I'm having struggling with how to, you know, garner the evidence. So I'll tell you, we have 50 49 hospitals in our system just last week. I was asked and, and we have a valve that we use 90% of the time again, not because of evidence because experienced surgeons have told us this works well. I'm fine with my experienced surgeon telling me they're gonna focus on one device because they know what they're doing. Right. So, if they all use 90% of this device, I'm fine with it. I had two requests for two different valves that were double and 75% more expensive than the valve we're currently using from uh from two different heart surgeons who, who actually had a behavioral problem when I told them. No, wait, wait, wait, wait, wait, wait, wait, wait, wait. That, that seems like an anomaly, a cardiac surgeon. I don't know how many of you have Children say that Children are Children or grandchildren that are about two years old. And you've tried to tell that kid, no, that's about the reaction I got from these surgeons and then said, well, I don't mean to hurt your feelings, dumbo. But if you'll just provide me a little bit of evidence, I'm happy to spend more money to take good care of my patients. Right. So if some valve is out there doing something better for my patients, it costs more. We're going to buy that valve. They weren't able to provide me any evidence. It was just their preference and they wanted to waste a bunch of my money, a bunch of our money on an unproven thing because one of them wanted to be the first one in the state to put this valve in, right? Cool. Some vendor came and said you could be the first one in Louisiana, which you know, being the first in Louisiana is kind of like being the first in Mississippi kind. Well, let me um let me just bring in one of the reasons I asked uh Brian Stein is to be on, on the panel. Is that um right, this is, this is a team sport and I think you laid out uh you made a case, Chris for collaboration, ultimately, collaboration and looking at that matters which is value. So Brian, you've worked in a number of different healthcare systems, including ours for a number of years. Um Give us your perspective as a CFO when you hear that and uh you know how well just tell us what we as the physician leadership community can do to improve value from your perspective. Yeah. Thanks. Thanks for the question. Doctor Sandy. Um I would say two things I'll work in reverse order. I really like what you talked about in terms of gathering the physician leadership and champion um uh getting down to a couple of implants, devices, et cetera. So we did this recently at Northeast Georgia Health System and I don't know which vendors are out there in the audience. So I'm not going to say who it was, but we went down to dual source on a particular um device that we use and we cut our price by 75% $2.2 million just on one initiative. And we've done that in a number of different, um, service lines throughout our hospital, but it has to be physician led. So here's, here's what will never work. Your Chief Financial Officer walking into a group of physicians and saying this is the device, this is the implant that you're going to use. Um, you will get a two year old reaction if, if that happens. Um And, and that's never good. The other thing that I would just like to double click on, I think you almost went past it too quickly. The very beginning slide where you define value because everyone likes to define value as reducing cost. And that is one part of the value equation. So I'll pick on my uh uh robotic surgeon down there. Um First conversation I ever had with her and doctor Sloan guy is um I need $800,000 ok. That sub Chief Financial Officer that doesn't scream value. Um help me understand. But then in sitting down with these robotic cardiovascular surgeons, we can improve access. We can um lower cost because the time spent in recovery in the hospital is exponentially decreased. And that adds value to mention that as the Chief Financial Officer, it's only a matter of time before I'm on that table. Look it up and I want to make sure that uh I get the right care of the right ca uh place, you know, right cost, et cetera so that I can recover quicker. And so it that adds value. And so you as providers if you're going into your Chief financial Officer's office and talking, make sure you bring in all of the elements of value and not just cost because there is, there are other variables. So that, that's great. I think Manesh Patel um has a comment to make and he co directs the Duke Card and Vascular Institute as well as his Chief of Cardiology. And then after that, I think uh you know, one of the things we're doing with this symposium differently is we have a floor moderator who arguably has the strongest mic in the room. So it's Greg Giuliano. So Greg and one of my colleagues has a question. So man, I just gonna say two things about that experience for, for vendor or device management. We went through the same process. One thing that was um pretty interesting. We had our organization do, which is called the shared savings program. A certain portion of the savings is going to go back to the group that's using that because there's a tension between innovation and savings quality and innovation just like I want to be the first one, but somebody has to make a decision on which what matters. And then the second thing is what comes in, we standardized which devices are coming in by the same value proposition access. So it's not just that there's 17 things we're gonna all sit in a room that, that's one point I wanted to make on that. The second thing I think I'll just say is, um, there are going to be disruptive things in cardiovascular care that are going to change the value that we're not touching. I know yours is probably thinking about when you can manage a population's lipids in a different way, you're probably going to change your outcomes faster. And so we as cardiovascular providers have to start thinking about how do we integrate with that, especially when things that can give you like in cloer an injection every two, twice a year to get your LDL down, but it costs money and it's got these cost issues. So we have to think through that. So um Greg, yeah, so we got Jamie Burkle uh who, that's right up his alley as head of prevention here. Um is gonna ask a question, Chris, thank you for a great presentation. Uh So C MS has been talking about this for years, right? Uh Moving from RVU based care to value based. So if you had a crystal ball and you were able to predict the future, how do you see healthcare systems changing this perspective over the next 5 to 10 years? So I think C MS is going to lag significantly because there will be they're a political body and they will be a lot of pushback and So I think there's individual, institutional, individual benefit to pursuing this value equation. You can take on more managed care lives, you can take on more risk, but you're only willing to do that. If you have a group of physicians that can work together and you want to couple that with primary care and specialty, right? You can have all these primary care guys. But if everybody, they refer to cardiology gets an angiogram, you're spending a lot of money. So I do see institutions getting ahead of C MS because it will be to their benefit. But the physicians to the points being raised, it must be physician. L we can't be drug along and until the docs understand the equation and once they do, I don't have that much trouble, but I spend a lot of time laying the groundwork. You have, they have to know the why. So Spencer may be a question for you as we end this session or this portion. Um I mean, as the past president of the AC C you've seen over decades now, the change in way value based care has been determined. What's your take on the future? What are we going to need to be able to do that maintains keeping the highest quality care minimizing costs. Is there some magic things that you can foresee that we should be doing? I think Chris is dead on. Uh with most of what he said, I did want to raise one question that bothers me. Uh, there's this, the performance measures and the score carding uh, that affects uh, cost. As I understand it, some insurers want to reward a higher scorecard. I chair the New York State Cardi Advisory Committee and we look at all this sort of thing and so risk adjustment I'm familiar with, but I'm also familiar with the fact that it may not be uh completely accurate. And the example I'll give you is that uh if, if you do angioplasty and you do it and uh very high risk patients, they are risk adjusted for sure. But you get some mortality out of that if you do absolutely simple patients and never touch anybody that's gonna die. You get a very high score. If you are innovative and pushing the envelope and taking the patients that the surgeons turn down, you're screwed. And so that's just one example of uh not to criticize the fact that we need to judge value, but we need to understand, you know how we're evaluating the value. So you're absolutely correct. Spencer and risk adjustment fails at mortality, right? So you quickly run out of the risk adjustment when the dead bodies pile up. So, but my answer to you is that's the 20 or 25% warranted variation, right? So, so I do believe, I believe that we don't understand futility. Well, and we take an awful lot of cardiogenic shock patients to the cath lab with the impala that her DNR the next morning. Um So we that has been a knee jerk. Just go do this. So to your point though, there are patients who benefit, right? And so are we need to get better at the high acuity patients who benefit and make them that 20% of areas? So that heart team group uh some somehow that needs to be improved too. So that that feudal patient, it does not go this way. Patients referred to surgery. The surgeon says sts score is 10. We're not going to do you. Uh, interventional cardiologist, will you do it? And they say, oh yes, I, I'll give it a shot that you're the only person who can help this patient. So guys, I know we're, we can keep doing this for hours, but we're going to go ahead and move to the next session, Chris, this is very provocative and I, and I actually really think we should spend more time on this value portion of it because in the future, I think this is going to drive all the innovation that we do.
