EP409: 3 Really Cool Innovative Primary Care Bright Spots and a Few Notes for Policymakers and Payers, With Larry Bauer, MSW, MEd

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[00:00:00] Stacey Richter: Episode 409, "Three Really Cool, Innovative Primary Care, Bright Spots, and a Few Notes for Policy Makers and Payers". Today I speak with Larry Bauer,

American Healthcare Entrepreneurs and Executives You Want to Know Talking. 

Relentlessly Seeking Value. 

Today, we are talking about innovative primary care teams, and by way of Larry Bauer, my guest today, bringing you three inspiring case studies. Much can be inferred from these case studies as much from how they are alike as how they are different.

It is wildly important at the same time that it is wildly underappreciated how different local markets are. I love how Cody Kunrat put it on LinkedIn the other day, he wrote healthcare is not a 4 trillion market. It's 500 some odd interconnected markets ranging in size from 1 to 50 billion. It is not a singular problem.

Each market is driven by unique third party payer incentives with unique patient cohorts. Before you figure out the next great idea, seek to understand the underlying health, economic revenue cycle, service provider, contracting and cash conversion processes that undergird it all. That is how to truly disrupt health care.

Or said another way, if you're part of the community, if you are already caring for patients in that community because you're a doctor or another clinician, you probably have the best shot at truly and in meaningful ways helping patients in that community. This whole statement is a really uncomfortable truth for most people in private equity and anybody else who wants to find the easy button to fix health care with some big ass, scalable, rapid fire bulldozer approach.

It's also a very uncomfortable truth for any national payer looking for one model or one point solution to roll out in a broad stroke to every one of these. 500 some odd interconnected markets that Cody mentioned. One size does not fit all here. And leveling out patient outcomes and care is hard, grueling work that requires local market knowledge being rooted in the community with relationships to succeed.

You got to get a little closer to the ground. Policymakers, please take some notes here. And you too, self insured employers, payers. So many universal lessons are embedded in these three examples that Larry Bauer, my guest, shares today. But bottom line, and rounds of applause required, you go. Oh, you doctors and nurses and other clinicians or mission oriented teams who take it upon yourselves to find ways to address the problem of human suffering in your local area.

Stay tuned for an upcoming show with Jodilyn Owens, where we dig into this whole dynamic hard. I'm talking about the dynamic where some barbarian at the gate, i.e. some venture funded startup, has gotten money, in some cases lots of money, while there are community based organizations out there who are doing amazing work.

Really helping patients in the community, improving outcomes and cutting costs and struggling, scrambling for every penny they can manage to get their hands on. So that's in the future. Talking about today, though, we're going to cover the bright spots when you get a really creative and committed PCP primary care team who is part of their own community and who wants to do better by patients locally and got some money to attain that goal. 

Today, as I said earlier, I am talking with Larry Bauer, who has been working with Innovative PCPs and other docs for decades. All three of these case studies that Larry describes on the show today concern frail elderly adults, and this is on purpose, this using of the same patient population for a couple of reasons. One of them is just to highlight that the same population in different geographies is not the same population, and therefore the solution set is going to be different if we're going to reach out and care for them.

The second reason for selecting three solutions that all pertain to frail elders is that this group is notoriously expensive and care is notoriously poor. Everybody has a story about how their frail elderly family member or friend died a bad death or did not finish well, as Larry Bauer put said. It's a patient population at the mercy of this industry and unable a lot of times to advocate for themselves.

So solutions here solve in a way for the worst case scenario and might be a great starting point for anybody contemplating how to help other patient populations, too. The three innovations we discussed today are number one. Dr. Dan Hoffer and Susie Johnson in their transition program in San Diego, helping those at the end of their lives to finish well.

This is a capitated program. The number two bright spot we talk about is Dr. Ken Coburn, who along with his team created Health Quality Partners in Pennsylvania. This is a nurse navigator program and it is paid for by a CMS grant. And the third example we talk about today, the third bright spot is the brainchild of Dr. Alan Chip Teal at Full Circle America with a program to wire up patient homes so that the clinical team could monitor what was going on in the home, intervene in case of emergencies, as well as organize community services. This program is paid for by the patient or the patient's family. But, point of note, it is 10 times cheaper than a nursing home.

I do ask Larry Bauer, by the way, how to best walk the line between right sized care and not enough care, i. e. the whole death panel counter argument to some of this stuff. I think Larry's answer was elegant. You're going to need to listen to the show to hear it. My guest today is Larry Bauer, as I have mentioned four to six times already.

He is a social worker by training who has been at this, as he says, for a very long time. He created a not for profit called Family Medicine Education Consortium over 30 years ago, and it became a platform for bringing together very talented and capable family physicians and some general internists.

This gang has been really redefining and recreating primary care, which is a great way to sum up the three programs that Larry Bauer will talk about today. 

My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. 

Larry Bauer, welcome to Relentless Health Value. 

[00:06:36] Larry Bauer: It's wonderful to be talking with you, Stacey.

[00:06:38] Stacey Richter: This conversation is at two levels. The top level here, it's a case study for policymakers. But at the same time, end of life care is, let's just say has room for improvement in this, in this, in this country. So if we're talking about end of life care, if we're talking about the situation that many of the frail elderly find themselves in this country, do you just want to give a brief overview?

[00:07:05] Larry Bauer: What happens to frail elders in our country, they're, they're facing a, a couple of major challenges. First of all, quite often they're isolated. They may have family. If they're lucky, they have family members living nearby. They are isolated from their neighbors because of their health conditions. They can't get out and walk.

So they end up on their own. That's number one. Number two is they are facing an uncoordinated health care system, if you're a frail elder and you have two, three or four or more chronic conditions, if you don't have a good family physician or general internist to coordinate your care, which most do not, You are going to be bouncing around between emergency rooms, urgent care, subspecialist visits, and all of that care is uncoordinated.

There's great confusion, and it's difficult to navigate an uncoordinated system, and particularly if you have mobility issues, and transportation is also an issue. You're really in a difficult situation. I think as most people know, in the last three to five years of one's life, about 80% of all of the health services you will utilize from a cost point of view happen.

So you become a very expensive patient. You get a lot of unnecessary care quite often, and unnecessary care leads to bad outcomes from time to time. People end up dying. I've seen it said through the British Medical Journal that medical error is the third leading cause of death in the United States, and that's from, a lot of that is from uncoordinated and unnecessary care.

So you really face a daunting future trying to deal both with your social isolation. At a personal level and the uncoordinated care delivery that you're receiving. 

[00:08:57] Stacey Richter: You listed three things there. The first thing that you mentioned is just the isolation. It becomes harder and harder to be able to manage when you don't necessarily have family nearby or neighbors who are able to help you. Number one. 

Number two, there's a terribly uncoordinated health care system in this country, as you said. You can be bouncing around. Nobody knows what anybody else is doing, or probably even more strikingly, or more impactfully. Nobody knows that you were supposed to have the follow up visit, or you were supposed to go into hospice, or palliative care, or whatever, and then... It doesn't happen. 

And then thirdly, it gets expensive really fast and the consumption of services increases and anytime you increase this, the consumption of services, you increase the potential that the care is unnecessary or unwarranted, which increases the potential for harm. And just, it needs to be said that as people near the end of their life, these three things become more and more predominant.

But it could certainly be not elderly people who are in this situation. In fact, I just heard a horrible story the other day about someone with cancer who was transferred to a skilled nursing facility and half the orders didn't show up and her pain meds weren't ordered. And so here she is, and it's Friday at 5:45.

So here she is in terrible pain without any of the support that she was supposed to have had. 

[00:10:25] Larry Bauer: Yes. For people who are frail and elder, because of their mobility issues and sometimes because of their mental capabilities in terms of remembering things. It makes it worse. 

[00:10:37] Stacey Richter: You have had the privilege of working with three very creative and innovative primary care physicians, primary care teams who came up with three kind of very different solutions or different ways systems to deal with or to help those.

Nearing the end of their lives. We'll go through all three. They're interesting in their difference, I would say. So let's talk about the first one. 

[00:11:06] Larry Bauer: Sure. The first one is a family physician by the name of Daniel Hofer, who is in San Diego in the Sharp Steely healthcare system. Dan believes anytime one of his frail, elder patients, people who are, as I say, they have a number of chronic conditions, they're approaching end of life, but they're not at end of life, but in that last window, any of those who end up in the hospital is a failure on his part and his team's part.

So, he takes it really very personally that people should get the best proactive primary care to help them live the life that they're capable of at end of life. It's called the Transitions Program. He and a nurse by the name of Susie Johnson worked together over the years, over the last 15 plus years now.

They have a panel of anywhere from 200 to 250 patients. They have a team oriented approach and it is very proactive. As soon as people are assigned to their group and they're functioning in a capitated system so they're able to identify people who are approaching this window of their life, they go out and they meet with them and they have the conversations about the patient's family's life goals and they work with them and they work with the primary care physicians who these patients may have.

And if they have subspecialist physicians, which people quite often do, they have a cardiologist, they have an endocrinologist, et cetera, because of their chronic conditions, they will coordinate care with them. So what people experience is proactive care. They don't believe in waiting for something to go wrong.

If they know that, for example, somebody has congestive heart failure. You can pretty well map out what's going to happen over the next few years if you have congestive heart failure. You're going to have a series of what I call crashes where your cardiovascular functioning is diminished. You're going to end up in the emergency room.

You may or may not survive that event. But if you do survive that event, after having spent a few days in the hospital, you will come out with some diminished capacity. And this just cycles through. They get a little better for a little while and then they have another event and another decline until they finally reach the very end in their personal demise.

So what Dan and his team have figured out is don't wait for the emergency. Go out and proactively identify the potential problems and address those. And what's really remarkable is they've essentially eliminated the need for hospitals with this population of people. This population of people, this cohort, is in and out of the hospital, in and out of the emergency room, in and out of urgent care.

And if you can eliminate that, it's an incredible improvement in the quality of life for the patients. It's much, much cheaper. Everyone is happier. And, and it's just a better way to go. And as I say, if, if a patient of theirs ends up in the hospital, they take that personally. So they work very hard. And their data is very clear that, as I say, they've been essentially able to eliminate the need for hospitals.

[00:14:27] Stacey Richter: We're talking about the transitions program. It's in San Diego. The patient panel is 200 to 250 patients as you said. It's within a capitated system. And do you want to, what does that mean exactly? So, so there is a provider organization who is already getting capitated payments. And once someone graduates into this program, Dr. Hoffer and Susie Johnson and team take over the coordination of their care. Is that kind of how it works? But all these patients are capitated to begin with. 

[00:15:01] Larry Bauer: That is correct. Incapitation means that you don't have to bill for services. It's prepaid, if you like, by the insurance plan, which is part of the Sharp Steely system.

So they have their own incapitated system. You typically will have your own insurance plan. And so any money that you save by delivering the best care possible is money that you can invest in your programs so that you're able to deliver the best possible care and not worry about what happens typically with the fee for service, RVU driven, relative value unit driven payment system.

Where you're really not able to do proactive care. So it, capitation really allows the transitions program to function well and they're actually making money by delivering the best care possible. 

[00:15:51] Stacey Richter: You said that their PCP, their original PCP is also part of this mix. So it sounds like this unit kind of comes in and coordinates everything, but the original providers are still in place, or does the, is Dr. Hoffman now the new PCP? 

[00:16:07] Larry Bauer: No, he does not become the new primary care physician. He, he and his team, they are the coordinators of care. So they will pay attention to the big picture. Not that the primary care physicians wouldn't be trying to do that. But quite honestly, the primary care physicians are trapped in their office, so to speak.

Dan and his team, you know, home visits, that's where they deliver their care. They're out in the person's living room, following up with, so what happened with your visit with your primary care physician? What happened with your appointment with the cardiologist? What are the medicines that you're on now?

So they're really looking at the big picture, filling the void wherever that may happen. 

[00:16:46] Stacey Richter: I understand why they would regard it as a failure to keep patients out of the hospital because once someone is admitted to the hospital, it tends to be, I don't know, a cascade of activity. Some of it very important, but then it can certainly go off the rails.

For example, I just heard a story the other day about a cancer patient who was days away from death and everyone knew it. And there was all these tests being done. Luckily this particular patient had family who came in and put a halt to it, but like that hospital probably would have, you're dying and you're getting jammed in an MRI machine.

So how do you know, are they also in contact with the hospital? How does that work? 

[00:17:24] Larry Bauer: They are in contact with whomever they need to. And let me just say, Stacey, I think people don't really understand the deleterious effect of being hospitalized if you're a frail elder. So if you're lying in a hospital bed, and you're not up and moving around, you lose 5% of your muscle mass each day that you are hospitalized.

For a frail elder, who's generally weak to begin with, After a day or two or three, they've lost significant muscle mass, which means their ability to walk is compromised. The other thing that happens is from the mental capacity, when you are hospitalized, there's been some very good studies, you end up with what's called hospital acquired dementia.

People lose cognitive functioning as a result of being hospitalized when they are frail elders. So, keeping people away unless they absolutely need to be there is a powerful intervention. 

[00:18:25] Stacey Richter: As you were talking about Dr. Dan Hoffer and Susie Johnson and their team, you said repeatedly how the care team is taking personal responsibility for their patients, which in and of itself is certainly nothing to be proud of.

They just heard a really sad story about Greg Master's son who died in the ICU, who's a young man, because of a trend that people are calling NMP, Not My Patient Syndrome. Where no one is really taking ownership for a patient or for that patient's care. Okay, so just the first example here, as you just described, is this transition program.

It is a program for those nearing the end of life, three to five years. It's within a larger capitated program. Give me our second example here. 

[00:19:14] Larry Bauer: The second example I'll talk about is led by a general internist by the name of Ken Coburn. Ken Coburn. Who's in Doylestown, Pennsylvania. He created something about 20 years ago.

The name of his program is Health Quality Partners. They address the same issue. Frail elders, particularly those who are socially isolated. They have trained nurses who go into the homes. They get to know the patients. They're there also to coordinate the care. They will contact. the patient's primary care physicians and subspecialty.

What they've discovered is with this support, people live longer. At the same time, they cost less because they have less need. It comes back to the proactive, coordinated primary care. There's less cost even though the person is living longer. The patients and the families are very satisfied. The docs who are involved are supporters of the program.

So, Ken and his team have done a fabulous job, a little bit different kind of model. They are not in a capitated system. They started off trying to get the insurance companies to pay for their services, which didn't go terribly well. The insurance companies typically don't want to pay for extra care as they would think of it.

So they got a grant from CMS and they were part of a demonstration project that included 15 innovative programs across the country. They were the number one performer in terms of health outcomes, in terms of managing costs. CMS canceled the other 14 programs after a period of three or four years but continue to support the Health Quality Partners Program. So it's a remarkable achievement what they're able to, uh, to do again with coordinated care. Health 

[00:21:06] Stacey Richter: Quality Partners, this is mainly nurses going into homes and it is funded by a CMS grant. So there's not necessarily any particular given provider organization that has much to do with us.

We have Dr. Kenneth Coburn, as you said, kind of doing this as his own company, maybe? Yes, yes. And he works with local providers getting paid by CMS. 

[00:21:32] Larry Bauer: That is correct. I believe now they have managed to contract with some insurance companies now that they've demonstrated proof of concept. But it's always a struggle when you're relying on the insurance companies for your life support, so to speak.

This should be something, if we had a well orchestrated, well supported primary care system in the United States, this would be a core service that would be well funded. But until we get to there, you sort of, as Ken and his team have done, you sort of patch together your funding sources. 

[00:22:05] Stacey Richter: Yeah, I could see how Medicare Advantage plans would be.

A fan of something like this. I would think so, yes. Yeah. I had a conversation the other day with Andreas Mang that really supports what Health Quality Partners is doing. Andreas from Blackstone, who is going to be on the podcast coming up in September. But one of the things that they are doing is along the same lines as, as Health Quality Partners, although this is for commercially insured patients.

They are providing a nurse to be hip to hip with especially oncology patients and they have found that by doing this they not only improve patient outcomes but also costs go down because, do you know this, Andres told me something, he said that a number one reason for hospital readmissions is dehydrated chemotherapy patients.

Patients who are on chemotherapy and then become dehydrated because they can't keep anything down and they haven't gotten their anti nausea medications, right? So if you have a nurse who's helping them, then this doesn't happen. Again, this is not a frail elderly person. He's doing this with commercially insured patients, but it's just one example after another about how patient care.

Can go up and costs can actually go down like there is a cake that we can keep and eat here. Okay. So give me a third example. 

[00:23:27] Larry Bauer: Sure. So up in a lovely little New England town called Damariscotta, Maine. There's Alan Chip Teal, a family physician. He was in a three physician practice in this little town.

Alan, like Ken and like Dan, also considered it a failure when one of his elder patients would end up in a nursing home or a hospital. And so he developed a program called Full Circle Health. He wrote about it actually in a book called "Alone and Invisible No More". He created a program where the patients who signed up for his service, he was in a three physician practice, the patient signed up for the service, a team would come out to the patient's home, again these are frail elders, and they would install electronic equipment in the home, cameras, microphones, and that was all patched through to Dr. Thiel's practice. 

So that the practice could be vigilant and pay attention to what was going on in the patient's home. So if they fell, or if they were in distress of some kind, or if their food was running out, or whatever, he had a person monitoring this electronic connection. The intriguing thing is how they paid for this.

So they charged a fee to the patient of about $500 a month. Now this was a few years ago when I visited with them and saw this, so I'm not sure what it is now, but it was $500 a month then, which may sound like a lot of money. So that's like $6,000 a year. The cost of a nursing home for one of these people is about $5,000 a month.

So it's considerably less expensive, and not only the patient, but the patient's family, their extended family, would contribute money to offset that cost. Why would the children do this? Because if you have a parent who is in decline, and you're living in another state or another community, You could tune in to them in their home, so to speak, and stay in touch with mom or dad to see how they're doing.

So they were, they, they didn't have to move their parents into their home or their community so that they could take care of them. Because Doc Teal was looking over their shoulders, so to speak. And making sure they got the best possible care. The other thing that Dr. Thiel did is he organized the community services.

So the EMTs were aware of the people who were, quote, in distress. The Meals on Wheels was organized. In all of the community services that are available, and in most communities now there are quite a few services that are there to available, they're just not very well connected to the individual people who are in need of those services.

Through the Full Circle America program, all of this was coordinated, and once again, it cost less, people lived longer. 

[00:26:30] Stacey Richter: In this third example, it's a direct to consumer example, and if a family has the wherewithal to pay for it, then there's a number of companies who are trying to do this, and this is their new business model.

I think what, what sounds a little unique here is that number one, it's an MD who started it and he started it within his own community. So it's not just the tech, it's also the organization of community resources who are able to enable these elders to age in place, as they say. 

[00:27:04] Larry Bauer: It really becomes comprehensive care.

I think that's very important when someone is a frail elder, particularly if they have a number of healthcare issues, you know, it takes a village to take good, good care of people. And Chip just did a great job of organizing that at the community level, and it was just a very well received program.

[00:27:24] Stacey Richter: I have a bunch of questions for you, but let me start with this one.

The patients that are in these programs, so in this last example, the patient obviously has to opt in, right? You're putting cameras in their house, but in some of these other ones. I could certainly see that there would be a concern. You're, you're putting people in programs to keep them out of the hospital and you certainly can envision the counter argument.

I can hear it in my head. Are we denying care? Is this a death panel? Like they need to go to the hospital and now they're not going to go. If cost containment becomes a huge driver here. So how, how do these programs address this? 

[00:28:01] Larry Bauer: I think the way they address it is the number one goal is not cost containment.

That's one of the outcomes. The number one goal. Is that people have the potential for the life that they're capable of, of having a full life or what I call finishing well. For our society, we in many ways have abandoned particularly frail elders and everyone's on their own to finish well. The core issue for the three examples that I've given you starts with what I call the physician's philosophy of care.

They really want the best life for their patients and that's what's driving their innovation. The cost issue, we, we're living in a society where if you can't show the cost benefit, you're not going to get, have financial support for your program. So quite often, unfortunately, I think the focus becomes on saving money, but the real goal for these physicians.

[00:28:59] Stacey Richter: Yeah, and it's interesting just kind of reinforcing what you hear all the time in the marketplace. More care is not necessarily something that is better care and or something that all patients want. I. e., you know, you're giving people all kinds of tests for things like I just I'm thinking right now of my almost 100 year old grandmother who had a heart valve replaced, who had diabetes and her doctor kept insisting on giving her nuclear stress tests, which seriously, right? What are you going to do? Like operate on her heart valve? And then every time he would tell her her artificial heart valve was failing and then she'd be in the ER six times afterwards because every time she had a chest pain, she thought she was going to die.

Like this is not health. 

[00:29:44] Larry Bauer: Well, it's not the way people want to live. It's, and if you think from the point of view of human suffering. The hospital, it's not a pleasant experience, quite honestly, if someone has a problem with reducing the number of hospitalized once themselves and see what it's like. And as I mentioned, when people end up particularly frail elders who don't have the physical resources, the adaptive capacity to deal with the call it an insult of being hospitalized and what that does both to your brain and your body.

They just need to get closer to that experience before they pass judgment on its value. 

[00:30:25] Stacey Richter: Obviously, across the country, we would want to be encouraging these kinds of programs, right? Like, if only every community could have an offering like this, I don't think anyone would disagree. We'd all be in much better shape as a country from both a finishing well standpoint. I love how you put that as well as just from a cost standpoint because this is definitely one of those examples where a right sized amount of care is certainly better than way too much. Why don't we have this going on just given the benefits?

Like what is good policy? What does it look like here in order to encourage stuff like this? 

[00:31:07] Larry Bauer: At the core of this, I've given you three examples, and there are more out there. There are a lot more. But three examples where the physicians, particularly the primary care physicians, using their philosophy of care.

And their concern for the well being of their patients were the drivers of the innovation. And I think one of the core mistakes that we made from a health systems point of view, from a policy point of view, is we don't trust the physicians to come up with and to apply the solutions. That's something that we really need to take a look at.

The physicians, when provided the opportunity, will do the right thing for the most part. Yes, there is occasional fraud. There are some bad players from time to time, but mostly the docs are in the business because they want to help people. And when they're rooted in a community, they want to do what's best and they want to build what will work with the resources in their respective communities.

Number two is you can't have a cookie cutter approach. These are three examples of how it's done in different communities. There's many more examples out there, and we need to make room for that diversity of ideas and responses to the problem, the challenge of human suffering with this population of people.

[00:32:24] Stacey Richter: You listed two must haves for policymakers to be keeping in mind. And number one, to recognize that physicians were the drivers here. We'll have a separate conversation about this over the summer, but it just seems weird to me. It's like, if not the clinicians, then who? Private equity? And we think that the who else has a greater proportion of people looking to do the right thing for patients.

So, to be continued. But, so that's the first must haves. And then secondly, this can't be a cookie cutter approach that we have to make room for people to meet the needs of their communities because the healthcare is local as we often hear. If I'm a policymaker, I'm thinking about quality metrics right now, I'm thinking about some of the financial incentives given to, for example, Medicare Advantage plans or et cetera.

They don't feel very local to me. And the other thing that I'm thinking of is that these quality measures tend to be, and I talked about this at length with Dr. Rishi Wadhira, they're punitive, right? Quality measures tend to punish those who don't have the financial resources to game the measure. Sorry to be cynical.

So the money is taken away from the delivery organizations really that most need the money and are usually the ones caring for very vulnerable. Patient populations, I'd think a better way to do this would be to empower those poor. I mean, poor financially, as well as from a quality perspective to really empower these healthcare delivery organizations, you know, how do we offer assistance so that they can actually.

And then hoping that they figure out how to do better all by themselves in a lot of times quite challenging circumstances. What's your take on this? 

[00:34:12] Larry Bauer: My take in general is that if you trust the physicians and the clinicians, if you trust them, you hold them accountable, but you trust them. You're going to have a different approach to metrics than if you are worried about the gaming and the misuse of resources if you don't trust people.

And I think part of the challenge for us is that the policy people are not close enough to the ground. They are not connected with the people like Dan Hofer and Ken Coburn and Chip Teal. They really need to be present. It needs to become a partnership. The primary function of policy is not to find fault, particularly in these kinds of services.

The policy is supposed to be a more empowerment. Holding accountable, yes, but empowering the, the clinicians to do what they're trained to do. 

[00:35:08] Stacey Richter: Speaking of empowering physicians and giving them the room to innovate, you were telling me in an earlier conversation about Alan Dobson, who went to the state of North Carolina and saved 300 million.

Yes. From what I understand, with an investment of only $10 million. And this was called the Community Care of North Carolina. And from what I understand, 10k was given per doc, the idea being give them enough money to implement their local solution. 

[00:35:36] Larry Bauer: That's correct. You've got it. 

[00:35:37] Stacey Richter: And from also what I understand, each group came up with their own solutions.

They were wildly popular and also very different. So it sort of served to underscore these communities are just very different depending on the Demographics of that community, urban versus rural, the needs of that community can be so different that almost any solution that isn't built based on the problems that it's trying to solve can easily wind up being a solution looking around for a problem.

And the problem that the solution is solving isn't one that that community actually is struggling with. 

[00:36:12] Larry Bauer: Yeah, that's, that is very true. 

[00:36:14] Stacey Richter: Larry Bauer, is there anything I neglected to ask you or anything that you would like to add or underscore? 

[00:36:20] Larry Bauer: Start with the outcomes. The goal of healthcare is to improve the health of the population.

I think from a policy point of view, understanding that's the goal. And building incentives at the local level. And I see this more as a statewide initiative rather than a federal initiative, but really creating incentives that work to challenge the delivery system, challenge the docs. Challenge the hospitals, et cetera, to work together to deliver the best health to the population.

That is a fundamental change that I'm hoping that we're moving towards in this country. 

[00:37:00] Stacey Richter: Larry Bauer, if someone is interested in learning more about your work, where would you direct them? 

[00:37:05] Larry Bauer: They can take a look at the webpage of the Family Medicine Education Consortium or They can contact me directly, Lawrence, L A U R E N C E dot B A U E R at gmail. com. And I'm happy to talk to anybody and happy to share information, particularly about the innovations. That I've learned about .

[00:37:28] Stacey Richter: Larry Bauer, thank you so much for being on Relentless Health Value today. 

[00:37:31] Larry Bauer: It's my pleasure. Thank you, Stacey, for what you're doing. It's awesome work.

[00:37:34] Stacey Richter: Hey, could I ask you to do me a favor?

If you are part of the relentless tribe working hard to transform health care in this country, I don't need to tell you that we need as many on our side as we can you. The most vital thing that you could do to help expand the reach of this show is to leave a rating or a review on iTunes or Spotify and or share this show with colleagues or decision makers.

Personally, I cannot appreciate it more when I see the reviews. Thanks so much for listening.