Don Calcagno & Terry Williams – Value-based Care Through the Lens of MSSP

Today we hear Advocate Health’s Don Calcagno, Senior Vice President and Chief Population Health Officer for Value Operations and Terry Williams, Senior Vice President and Chief Population Health Officer for Partnerships and Strategy who provide insight into Advocate’s participation in the Medicare Shared Savings Program and share with CHESS President and host, Dr. Yates Lennon, the successes that have been achieved along with some of the lessons learned.

Well, Don, Terry, thank you for joining us on the Move to Value podcast today. Glad to have you. If you don’t mind, Don, we will let you start and just take a few minutes to tell our audience a little bit about yourself. And then Terry, you go next and the role you play at Advocate Health.

DC: All right, thanks Dr. Lennon. My name is Don Calcagno, I’m currently the Senior Vice President, Chief Population Health Officer for Value Operations for Advocate Health. I also serve as President of Advocate Physician Partners, which is a large, sophisticated, clinically integrated network in the Chicagoland area. Personally, I’m a lab tech by training, completed my schooling in 1992. I have an MBA as well from Northwestern Kellogg and I’ve been with Advocate for quite some time in various roles from lab tech to others. But I’ve been a vice President, Operations, Senior Vice President on OPS and I’ve been either the President or a Senior Vice President of Population Health at Advocate, Advocate Aurora Health since about 2015. So thanks for having me Dr. Lennon. Look forward to the conversation.

Glad to have you. Look forward to it. Terry?

TW: Hi, I’m Terry Williams, Chief Population Health Officer with focus on partnerships and strategy for Advocate Health. And in terms of background, I was Chief Strategy Officer at a couple of health systems for about a decade as well as started Population Health at one of them that we’ll talk about a little later today and I’m also responsible for looking at how we can tie together the academic enterprise and some of the innovations that are happening there into what we’re actually doing in population health. So, to give you one example, there was something called the EFI Electronic Frailty Index that was developed in the School of Medicine. It’s the single best indicator we have found for predicting future utilization. And so, we use that to we think really do some unique work in our population health work by incorporating that measure.

Yeah, familiar with the EFI and I think you just opened the door for a couple more podcasts right there in that one, one statement. So well, one of the things we wanted to do today with you all is to talk a little bit about the MSSP program and Advocate’s participation in that. I know we look forward to hearing about some of the successes as well as the challenges that you all have and are facing. It’s interesting the program now is what, 11-12 years old and NAACOS just recently at their fall conference released some stats and I’ll read some of those to you. So since 2012, ACO’s have saved Medicare 21 1/2 billion dollars in gross savings and 8.3 billion in net savings. So that’s since the beginning of the program. For ’22, It was the sixth straight year that ACO’s delivered net savings to Medicare. 84% of ACO’s in 2022 saved Medicare money and almost 60% of them were in two-sided risk arrangements. So when you think about where this program started and when it started, it sounds like success right, we’re moving in the right direction. With that backdrop though, I would love for you all to talk a little bit about Advocate’s participation in MSSP specifically and maybe start, Terry, if you don’t mind, start with the story of the Southeast which would be Atrium and Wake Forest and their journey up to ‘22 and then Don you do the same thing for the Midwest and then we’ll tackle ‘22 as Advocate as a whole.

TW: OK sure. So the journey for in population health being a really committed journey started 10 years ago in the southeast with Wake Forest, Wake Forest Baptist, which is now Atrium Health. Wake Forest Baptist is part of advocate Health and at that time that was highly unusual for an academic Medical Center to say they were committing to a value-based journey and but there were some thought leaders there that and and I believe that that was what we wanted to do and I was enthused about that and so we stood up a program for the first time. Part of the other unique history here is we decided to partner with a organization that you’re familiar with the cornerstone which is set up a company actually that company was CHESS to help guide physician practices and hospitals in the region and beyond to go on a journey to and value based care. There were not a lot of good road maps although you’ll hear in a minute from Don Advocate really has had an even longer history and has been doing some amazing work even well before this. But a part of what was stitched together was not only a pop health team, but we said we want to be very intentional on how we work with the Wake Forest Center for Aging, the Center for Alzheimer’s, we have a unique division of public Health Sciences there that does some of the largest studies around the world. The Sprint trial for example in blood pressure control was coordinated out of Wake, you might have seen that announced on the news a few years ago. So we said let’s we want to bring all that capability together and see if we can go on a journey and really a journey that I consider an academic journey because you’re rigorously using data clinical insights to drive change. So that’s the history with Wake Forest Baptist. The other three areas in the Southeast in terms of their history all came forward and I’m talking about in Charlotte for example in and in in Georgia is that those population health efforts started about five to seven years ago with different leaders that kind of had a vision for where this needed to go, and in fact the largest ACO in North Carolina is in Charlotte and is collaborative physician alliance. And so there really are some thought leaders spread across two or three states that we brought together to make the Southeast region and then have come together with the Midwest region through our when our we came together about a year ago. And it’s just made a really amazing team in terms of experiences, clinicians, administrative folks that just have a lot of lessons to share with one another. And so that’s, that’s the history that brings us up pretty current to today.

Okay. Thanks, Terry. Don?

DC: Yeah, great. Jump right in. And first one, say thanks for having us on your podcast. You know, the move to value is one of the must listen to podcasts that I have. So, I appreciate the opportunity to actually be on it. As Terry said, great history in the Southeast and then in the Midwest as well. So in the Midwest, Advocate Aurora Health has had this incredibly rich history on value based care that really predates everything back to the 1980s. For those you old enough like myself, you remember that the 90s everyone thought everything was going to be capitated. Well, in 1995, Advocate physician partners, which you’ll probably hear me slip and call it APP, was formed. And really that was an inflection point for Advocate Aurora Health. So at that point, we first started as a messenger model where we brought our physicians together, helped them get good rates with payors. But early on, we morphed into a clinically integrated network a CIN, so much so that we had some discussions with the Federal Trade Commission in the early 2000s that landed with the FTC consent agreement.

Those are always fun.

DC: Always fun, but it’s really a good spot because it did help us flush out what a CIN should be. But because of our history, we’ve been taking financial risk since the 1990s. And by that, I mean commercial HMO capitated risk, but then really in the early 2000s as we were morphing into the CIN, we started implementing pay for performance and we kept expanding our metrics. So, our metrics started as primary care, HEDIS, ambulatory, but then we moved to specialists, and we added hospitals, we brought in evidence based medicine, we brought in post-acute. So, our history really is wrong, becoming a clinical integrated network focused on improving quality metrics across continuum with the sound belief that doing good quality care is going to reduce total cost of care. When the ACA came along was being developed, we actually kind of jumped ahead of it for better for where’s a PP launched a commercial ACO with the largest payer in the market, Blue Cross Blue Shield, Illinois. At the time, it was one of the first commercial ACO’s in the country and it again, it was even before the ACA launched with MSSP. But really at the end of the day, we’re going to continue to lean into healthcare transformation that we’re talking about MSSP today. But there’s commercial ACO’s, there’s Medicare Advantage, there’s other CMS Innovation Center bundles that we’re super excited about. And as Terry pointed out, when our organizations come together, it’s just the capabilities from both of us come together. We’re really gonna drive and really focus on helping people live fully.

Alright, So that gets us up to 2022. And let’s talk a little bit about the ACO, the Advocate ACO footprint if you will and recognizing Don and your story of for the Midwest. I mean we’re obviously focusing in on a somewhat narrow portion of patient lives in value-based care as we talk about MSSP today because you all have value based agreements across Medicare Advantage and commercial and I’m sure even direct employer offering. So, we’re, we’re narrowing in on MSSP today. But so how many traditional Medicare ACO’s are there were there in 2022 across the Advocate footprint. How many patient lives were covered in those ACOs?

DC: So in 2022, we have 8 active affiliated MSSP ACOs. And I say active now because we do have 3 predecessors that are no longer active. Of those ACO 6 are MSSP and they really range from Track B, which I think everyone’s aware is upside only to enhance, which is the most risk we can take. And the way you get to 8, we also have two ACO reach programs, one professional in the Southeast and one global in the Midwest. When you look at the lives, if you just add them all up across the current active ones, we have about 270,000 lives across all of those, if you include when we’ve had the inactive ones, we’re about 350,000 lives. So quite a bit. And to your point, Dr. Lennon is talking CMMI, but we’d be remiss if we also didn’t talk about the fact that when Advocate Healthcare thinks about value-based care and Pop Health, we have 4 clinically integrated networks CINs across several States and collectively we’re managing 2.3 million value-based lives.

Yeah, yeah. Thank you for pointing that out. That was that dawned on me as we were having that conversation that we really are looking at a narrow slice of value based care work in the enterprise today.

TW: I think one of the reasons, though, that it’s an important slice to look at is because there is a similar set of rules across the country that allow people to see how they’re doing. When you start moving into the commercial space, everything can, the rules can vary so much by state that it’s really hard to see how you’re doing. And so I think some of the as we use MSSP as an important measure of how we’re doing for our teams, it’s helpful that we know that there’s kind of a consistent rule set. Now, there’s also some wrinkles and maybe we’ll talk about that later in terms of how baselines, when they’re, when they’re set, how they’re reset that, that. But in general the rules are similar, quite similar.

Yeah. The other thing we can talk about for just a few minutes if you guys are open to it, if Don, I think you said two enhanced MSSP’s I believe and then there are two ACO REACHs? those offer some benefit enhancements which for patients and patient’s families. I think just as important when I think about the skilled nursing facility waiver, these risk programs in the CMS and CMMI models offer some benefit enhancements to patients and their families that get them closer to being on par with some of the benefits that are offered in some of the Medicare Advantage programs. I know in our experience, we have found the skilled nursing facility waiver to be a crowd pleaser for patients. And like I said a couple times already, their families, because they’re often times looking at a loved one who is at high risk of a fall, needs skilled care but doesn’t qualify for the inpatient stay. And so you’re almost waiting for a disaster to happen to get the patient to the care they need. And most of the MA plans do have that three-day waiver, the waiver of the three day stay prior to a SNF. So I don’t know if either of you want to take just a minute and expound on your thoughts about how the CMS and CMMI programs can bring maybe even some parity to offerings to MA.

DC: Yeah. You know, one of the things I’d call out and it builds off what Terry said as well is one of the things I fundamentally believe is CMMI programs, MSSP specifically, too many organizations kind of treated as a side hustle versus the way we like to approach it is it’s kind of a life cycle. And in in that you you’re not just doing it because hey, all the cool kids are doing, but you’re actually getting in, you’re learning, you’re developing capabilities and to your point, you can advance from upside only to maybe a little downside to maybe a lot of downside, right. And that’s really how I’d encourage folks to think about it. This is not a one and done. This is not a side hustle. This takes commitment to actually pull off, but to your point, traditional Medicare the way some of the benefits are lined up doesn’t really support value-based care and that’s why there’s some waivers or safe harbors within the regulations so that we can do things much like you discussed the SNF waivers been incredibly valuable you know getting around the three night stay rule and things like that. So, I do think there’s probably opportunity for even more waivers as the programs advance. But I also realized you know it’s going to be a slow methodical process to get there.

TW: Can I maybe give one other example on how we’re really intentional trying to use the talents in a broad way to help drive innovation and and I love your words Don that it’s not a side hustle. It’s core to what we think is necessary to be transforming for the future, and that is so a few years ago, the Wake Forest School of Medicine Center for Aging was in a study called D Care, funded by PCORI that’s specifically looking at how to provide care to patients with dementia, which is a huge and growing issue in this country. A lot of the issues include what happens to the caregivers, often people at home that are taking care of those patients. Well, that study just was releasing its actual results in 2023, while the study and Wake was one of five places in the country that was very much involved in the study with a high degree of patients and providers participating. CMS worked closely with those results over the last couple of years and with PCORI and just announced in this summer the new guide model from CMMI which is the division you know as you know that really creates these new models. Well, because we’ve been so seriously working on this, we will apply to be in the first wave, which is a pretty high bar and is actually going to create funding for caregivers at home. They’ll have an annual payment for some respite time when they need to recharge their batteries at home. And after we’ve done the first wave in one of our markets, we’ll then roll it out across Advocate the next year. And the number of patients and families that are going to be dramatically, positively impacted because of this model and including funding to the for where they haven’t had it is going to be dramatic. It will be many tens, 10s of thousands, but that’s an example that only through really intentionally tying together the research, being a part of the innovation engine, using that to be first into some of these programs. You don’t do that if this is a side hustle, right? You’d kind of wait until others have tried things out and get around. And we said no, we feel a responsibility we’ve got, we’ve got talented people. Let’s really use it to drive innovation.

Absolutely. Yeah. It’s, it’s interesting. You brought up the GUIDE model. I’m just sitting here with an inbox message on that that program, and I think our philosophy at CHESS has always been that MSSP is the foundation that’s where you begin. It’s the beginning of your journey and continues to be the foundation of your journey. So that’s great. Well, let’s talk a little bit about your outcomes. What did you see across the various ACO’s in the Advocate footprint in terms of your outcomes? And if you want to talk in aggregate or individually where you sell pockets of great success, feel free to take that approach as well.

DC: Yeah, I can jump in here. And first, I just want to thank all the outstanding engaged physicians, our clinicians, our teammates, the leaders. I mean we’re blessed to have a lot of folks working very diligently to improve the health of our patients that we’re privileged to serve. And what’s cool about is along the way we’re also helping the change the healthcare industry through these different payer models. So a big kudos to the team taking care of the patients. When you zoom out, you see across the six Advocate affiliated, MSSP, ACO’s, in 2022, we actually generated $128.2 million in savings and along the way we improve quality and lower total cost of care, so 128.2. So that’s quite a bit of money and we’re pretty excited about that. But I’ll tell you what I think is more exciting is we generated over 3/4 of a billion dollars in savings since the program started. Well, you rattle off some of the stats that NAACOS said. Really moving the needle and we feel we’re a big part of leading that. The reason that excites us this is, you know, you talked to me and Terry and our teams, we are so committed to demonstrating to the nation that a transformational health care model that focuses on population health management can improve quality while avoiding total cost of care. So we see MSSP as proof point to that while early in the journey to us, it’s just like, hey, this is a real possible point.

Yeah, awesome. Terry, anything to add to that?

TW: Yes, I think that one of the other things that we see because we have a common rule set is our ability to work across our 8 ACO’s to share lessons. You have a common language, you had a common rule set and there are innovations happening. Sometimes it says, you know in the home, sometimes it’s how we’re reducing ED admissions or having some type of specific type of work with patients that are diabetic for example. And as we figure those things out, we are really intentional to spread those across the organization. We’ve only been as a total new Advocate Health for the last year. But the level of collaboration and the drive to really not worried, we’re not worried about who gets credit, we want to make sure that when we have new things that work that we spread those so that others can benefit.

Yeah, that’s great. Well, let’s talk a little bit now about some of the successes like in particular like where did you see things that maybe surprised you that were wins that you perhaps didn’t see coming or did you have some challenges that maybe surprised you as well and you didn’t see coming? Can you talk a little bit about that? Because with eight ACO’s I’m sure you had different thoughts about what happened in your different markets across the Midwest and the Southeast.

DC: Yeah, we can jump in on that and Terry and I can tag team it for sure. And I think what you just said Yates really hits it on the head is and it builds off again what Terry was just saying, right. We have actually the opportunity because we have these eight different ACOs, 6 different MSSPs that we can learn things in, in different areas and it’s about hey, if something’s working somewhere, how do we quickly learn and adapt that and scale that and all that. So staying fairly high level when we look at it, we did see basically we saw in some areas strength and claim based quality measures, hospital admissions, sniff utilization, condition management, but in other areas we saw those as exact opportunities as well. So, so you know you could say it’s a little bit of a mixed bag. And when we look at it, if you zoom out at the macro level to me if you can boil it down to this, that accurately identifying your chronic disease patients, enrolling them in chronic disease programs to better manage their disease, that’s the opportunity. Well, I believe our care and Advocate is top quality in the country. I think as an industry we all have the opportunity and I am a firm believer the reason I’m passionate about this space is if we do that well, we will see a reduction in emergency room visits, we will see a reduction in hospital admissions et cetera because it’s that disease equality that really drives this kind of stuff. A second thing I would say is, and you’re seeing this across the country, it’s just that that opportunity to help patients convalesce at home instead at a skilled nursing facility. And make no mistake about it, there’s times that a SNF, a skilled nursing facility, is absolutely necessary and we want our patients to be there if that’s the right place for them. But if they’re there, we also want them to be there until they’re convalesced and recovered to a point to be discharged. We don’t want them to stay longer than they should and one of the things that’s pretty cool for us is we are blessed at Advocate Health to have a very advanced post-acute home care program that we can help our patients recover at home, sometimes skipping the SNF altogether, other times starting up the SNF and advancing all care as well.

TW: The thing I’ll add a couple more thoughts. One is that the commitment to Health Equity and Advocate Health is extremely high and so that means that as we’re working with patients having intentionality to connect them with other resources that affect the social drivers of health is really important. So there have been systems built so that there’s closed loop referrals that are going to help patients get connected with other resources in the community. We also have a network of where we work with community organizations and faith organizations, several hundred of them, to help them be more intentional of providing for care and resources that people need for their lives. And then as you saw heard in the D care example around dementia a minute ago, that entire program was about how do you help people that have dementia to be in a home environment, successfully taken care of. And so that that work, of course, we have people that have to come into the hospital, and we want to provide and do provide exceptional care when they’re there. But we really have a drive to keep them in a venue that can actually work well for them so that they don’t have to have admission unless absolutely necessary.

Yeah, that’s really important. That hits home for me. My dad died of dementia. In his last six months to a year, he managed to stay at home thanks to my mom. But watching her as the caregiver is a grinding process on a caregiver and so being able to support those patients and their caregivers is going to be critically important and keeping them at home is ideal. Well, in spite of a lot of successes that we’ve talked about today, it appears that over the last few years the number of participants in ACO’s meaning providers or provider groups has really plateaued. There was a sort of a rapid increase and then several years ago plateaued out. What do you all think about why that might be and then what can be done in the future maybe to increase participation because to hit that goal of all lives in value-based agreements by 2030 for traditional Medicare, we’ve got some work to do. It’s not that far away.

TW: So I’ll jump in. I think making the journey attractive is key for some of the organizations that are still sitting on the sideline. As you’ve heard from Don and I, we have a deep commitment within the organization and among our leaders that we are. We are on this journey and we don’t have to be coaxed off the sideline. And yet the programs need to have enough predictability and understandability in the rule set that some people that maybe don’t haven’t gotten their feet wet yet could feel comfortable jumping in. Also think that that some of the there’s been some challenges around benchmarking at times that I think may dissuade some folks from getting in because they either feel like that process is not quite figured out or it’s unpredictable enough that they feel like if they did all this tremendous work and yet it didn’t show up because of a methodology that they felt wasn’t quite figured out then that can also be a big dissuader. And then the other thing that I think maybe has been affecting some of the ACO participation to be plateaued as you mentioned is there’s been quite a bit of private equity participation jumping in to participate. A lot of it’s been in Medicare Advantage, but the some of these entities are really running towards providers getting them to sign up to be a part of a program and maybe there’s a shorter term time horizon on what how they’re wanting to perform economically. And I think CMS has taken note of this and in fact has changed some programs. You would have, some would have noticed that the direct contracting model which had a lot of private equity entities jumping into it, that CMS did not believe that was good for health in the country and that there wasn’t a long term time horizon. So when ACO reach came out, the rules were dramatically changed to really make sure that a certain phenotype of committed provider was who was let in. And so I think that this sort of race on the front lines to get physicians to jump in, if you start, if the private equity entities actually start taking apart some of the local networks that people might have used in their ACO, that will make them hesitate on do they have an adequate network to actually participate in a program. So those are a couple of things that I’ll highlight. I’m sure Donald add a few more.

DC: Yeah, I 100% agree with Terry on that. And the other thing if you, if you think about those people sitting on the sidelines or you know in my view people aren’t fully committed, more of the side hustle approach. When I talk to my peers across the country, one of the questions that ultimately comes up is, is there value in value based care? And I think what they’re meaning is do programs like MSSP create a win, win, win meaning the patient the payer, CMS in this case and the provider right. Because what we’re really talking about is change management and it’s hard enough to do change and things are perfectly aligned. If things aren’t aligned then you’re going to find it very difficult to accomplish what you want. And so I’m very optimistic on it. I think the response to this, if you think about MSSP is yes, there is immense value and possibilities in there. But much like the benchmarks things that Terry was talking about, there’s things that happen from time to time in CMS and CMMI that, yeah, basically make it a little difficult to want to be in there because they’re not practical or rational. And I’ll give you one example. CMS, who is the one that puts together MSSP requires physicians to participate at the 10 level, whereas REACH, which is the CMMI program and by the way, you can only be in REACH or MSSP, you can’t be in both. REACH requires you to be at the 10 MPI level, meaning the position level, so practice level versus physician level. So if you are a large IDN much like us where you have your employed physicians under a single TIN, you’re forced to choose am I doing MSSP or REACH? So prior to the integration with the Southeast and the Midwest, Advocate Aurora, we wanted to do REACH because we feel so committed to Health Equity. It literally cost us hundreds of thousands of dollars an immense amount of time. creating a work around to enable to put a subset of physicians into REACH. So, we’re committed enough we did it, but I would have to bet across the country there’s IIDNs that said Nope, not doing that. So I think the point of it is be it CMS or CMMI or I’ll even bring in the commercial value payers, right. It has to be a benefit to all stakeholders. It can’t be a win lose situation, but it also has to be very pragmatic and practical. Healthcare is hard enough without that because otherwise I mean it’s hard enough just to do change management without those things. So completely agree I remain bullish on the whole thing that I do believe value is here and we’re gonna continue plowing towards it. But again be it our commercial payers, or CMMI, or CMS, we need to get better at some of those details.

TW: One of the things when people are joining new programs are contemplating and this is also involves in life you’re joining some new you know club or opportunity to sign up as you’re a lot of people try to figure out and how’s it going to go, how predictable is the journey. And I know that we experienced this year even though the 128 million that was saved was very significant and I think really the largest group of funds saved in the country of a family of ACOs. But there was unpredictability in some of our markets where we actually thought the savings was going to be much higher based on the interim reporting that we were getting during the year. And so again, we’re very proud of those results. But if we would have used the interim results from a few months earlier, we would have predicted even more significant savings. And again, we’re committed. So we’re moving forward, but there are entities that if they had a year or two of predictability, especially if their results were built into their budgets and their budgets roll up to public reporting and bondholders where they could really feel like that they were hung out to dry because of the big gap between interim reporting and what was the final reporting. So that that’s a pretty big factor. I think that may be affecting some from jumping in because if those entities then tell five of their friends or their, you know, fellow organizations, you can see how that might make them skittish.

Yeah, exactly. Another example of that, Terry, you’ll remember back to 2016, I think it was in year one for CHESS and Wake Forest in Next Gen and that rebasing occurred midyear and just wiped out all the savings in year one. So I can see where people might run for the hills when those things happen more than one year in a row.

DC: Yeah. And I would just, I just pile on to what both of you are saying is think about BPCIA, right? We’re all in it and CMMI changed the rules. Very few people are in it anymore and we’re still reaping the repercussions of them changing the rules. So again back to the point of this is, I think Terry used the term predictable, this has to be predictable because changing rules midstream is not going to give people confidence to invest in the resources that need to be invested.

That’s right. And then if I think back to the waivers for just a minute that we spoke of earlier, there’s we’ve talked about the sniff waiver fairly exhaustively, but there’s a cost sharing waiver and there’s the post discharge home visit waiver, there’s a handful of different waivers. They tend to be administratively very burdensome. And I think it’s aimed at avoiding or preventing abuse or waste. But it creates significant administrative burden where you look at what’s required to operationalize some of those waivers, and you just walk away and say we can’t do it. I mean it’s just the values just not there. So, as we wrap up, this has been very interesting and really appreciate you guys taking the time to spend with us this afternoon. But one last question. So how do you see health systems provider groups, Terry, you’ve talked a little bit about private equity already, but working with organizations like CHESS, value enablement entities, to really further the goal. How do we work together to further the goal that Medicare has set of all Medicare lives and value-based arrangements by 2030?

TW: Yeah. I think that especially if you look around the country at the entities that are highly committed and they believe there’s a philosophical belief that they want to lead in this space and that there’s a responsibility to innovate and create models that can be helpful to others that’s probably a lot of the people that are currently in. The people that are not yet in have a variety of reasons, but some of it is generally either because they’re not sure how they would do it or there are concerns about, and then just to be clear, you have to say you’re not just living for the fee for service model. I’m sure there are some organizations that are really, really still committed there. But let’s assume that if you’re going to have all Medicare patients are going to be in an APM by the year 2030, as you said and we’re at, you know, in the 40s in terms of penetration now, that still means we’re not yet halfway and so a lot of change is in front of us. I think that means we have some uncomfortable organizations that are going to need to get on the playing field. And it seems to me that an organization like CHESS is kind of an ideal partner to come alongside, help make the journey more sure footed, make it clear what needs to be done, learn lessons from others, don’t, you know, step in holes that you’ve already learned lessons from. And so I, I really think that there’s for the, the people that are not yet on board, that there’s really a lot of wisdom in coming alongside a partnering organization to help in that journey.

DC: Yeah. And I totally agree with everything Terry just said and I would just add, we’ve said it multiple times, but CMS pushing folks into APMS by 2030, payers, if you talk to them, want fee-for-value, employers are demanding more value. I mean at the end of the day healthcare clinicians and providers are absolutely gonna have to get to value. Now to the point Terry just made Advocate Health in both of our regions spent decades developing capabilities be it Wake, Atrium, CHESS, APP, right. We have a lot of scars and hard learned lessons. What is fortunate for folks now is you don’t have to learn those lessons again. I mean this is to me where a company like CHESS, it’s a turnkey solution to help you get in because you’re gonna have to get in. So to me, taking advantage of those opportunities is is definitely something people should be looking at.

TW: The one other thing I’ll add, I agree very much with what Don said, is that we talked about the benefits of the value based journey for improving care models for patients. One of the other things that I know is implicit for all of us, but I just want to say it explicitly is these models are better for providers. You know to move from kind of the fee for service treadmill to start looking at populations, panels of patients, and handling them in a more sophisticated care team model where the physician is still involved but they understand what the care team is doing and they have helped empower that. I think this this has to be one of the major solutions to this labor challenge that we have both with physicians and nurses in this country. I don’t I don’t know how it is navigated without advanced team team-based that move care to new locations and expand the definition of care team. So back to Don’s win, win, win proposition, we believe this journey can be and should be a win, win, win proposition. Doesn’t mean it’s easy and you do need some smart people. And of course, coming along someone like CHESS to help on the journey is wise. But it’s so fulfilling in the in the people’s lives that we’re seeing changed. Some of the stories we get from both patients, providers and their families are really amazing and make it all worthwhile.

Yeah, they truly are. Well, thank you gentlemen for spending some time with us this afternoon on the Mood to Value podcasts. I’ve enjoyed it very much and I’m sure we will reach out to do this again.

DC: Thanks for having us.

TW: Thanks.