EP413: The Intersection of Healthcare Waste, Value-Based Care, and the Potential Rising Power of PCPs, With Will Shrank, MD

You can listen to the episode here.

[00:00:00] Stacey Richter: Episode 413, "The Intersection of Healthcare Waste, Value-Based Care, and the Potential Rising Power of PCPs. Today I speak with Dr. Will Schrenk.

American Healthcare Entrepreneurs and Executives You Want to Know. Talking. 

Relentlessly Seeking Value 

My conversation today is with Will Schrank, MD. Dr. Schrank led the evaluation group at CMMI. He has spent time in the private sector, first at CVS Health, then UPMC as chief medical officer of the health plan in Pittsburgh, and then as the chief medical officer for Humana.

Now, he is a venture partner at Andreasen Horowitz and doing some consulting for CMMI. We start out this conversation talking about waste in health care. In fact, Dr. Schrank was on a team who did a study about waste in the U. S. health care system. I will link to it in the show notes. In that study, it says estimates suggest we have upwards of a trillion dollars of waste a year.

There's two main groupings of said waste, turns out. The first is in administrative failures. There's three subcategories here. Fraud waste and abuse, administrative complexity, and pricing failures. Then there's the clinical failures side of the waste house. There's three subcategories here as well, and they are failures in care coordination, failure in care delivery, and then low value care.

Dr. Schrenk digs in a bit on each of these in the interview that follows, but I have to say, I go in fast for the now what. Great that we know where the waste is coming from, because gotta know the problems to solve for them. But really, what's the best way to solve for this waste? You know me by now. So I, of course, point out immediately that someone's waste is someone else's profit.

So that's a wrinkle. And it's a really rough wrinkle because now you have groups lobbying to basically protect the waste. As just one example, what are pricing failures after all, if not someone else's margin? Thank you. Major spoiler alert here, but Dr. Shrank says one sort of broad stroke solution is aligning incentives with higher quality care, paying for the longitudinal patient journey and paying for outcomes.

If you do this, then at least the clinical failures side of the equation could improve. The implication here is that if the incentive is to be accountable for value. Which is, you know, numerator, quality, denominator cost, then the supply chain has an incentive to reduce its own waste because effectively at that point, it's coming out of their pocket as opposed to somebody else's will this resetting of the financial model happen overnight?

That was a rhetorical question that we all know the answer to. Commercial payers are slow to change and all but the best employers have been historically, at least busy making. Extremely lateral moves and going nowhere fast. Few seem super inclined to reward and pay for what they care about rather than just negotiating a price.

I sort of say this to Dr. Schrank and he says, yeah, true enough. I'm paraphrasing with a lot of creative license right now, but he says, let's reset our expectations with reality. We've actually come a pretty long way, baby, and not a particularly long time if you consider the whole value based thing really only started not that long ago, relatively speaking.

So there will be problems to overcome and bumps in the road. We should expect that. And we haven't had the time to work them all out yet. I think a couple of other interesting insights. For me, one was a little sidebar we go off on about the power that PCPs might find themselves wielding if they can gang up and harness it.

And this is kind of starting. We'll see if it goes anywhere. I recently heard a story about a bunch of employed PCPs who went to their health system bosses and asked to stand up in a PCP, an advanced primary care practice. Able to coordinate care, et cetera, do all the things that at this juncture we know are the right things to do for patients.

Now, they got shot down. Bam with the backhands from above. I hope those engaged and activated PCPs quit and start up their own thing. Maybe they will. PCPs getting together here could be a way to solve for waste, if they can gang up and harness it. And that's actionable if you happen to be a PCP or are looking to continue to employ them moving forward, the potential rising power of PCPs might cause some health systems to rethink some of the choices they are making, i.e. the choice to employ PCPs as RVU referral machines. PCPs better than anyone can see the harm inflicted by the business model that forces a drive by PCP level of care. Moral injury is at an all time high, and in addition, just, I just saw that study recently that showed to do all the administrative work of a PCP these days, it would take longer than 24 hours in a day.

If you're a self insured employer, I'd also kind of take note of this because it also could be actionable for you. Someone who would know told me recently that if enough employers demanded some value based accountability, some advanced primary care going on, even a dominant Consolidated health system would listen.

So there seems to be some alignment here between employers and PCPs. If these groups can come together and collaborate. In sum, we have a waste problem in this country. Aligning incentives might be one way to curb that waste. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group.

Will Schrenk, MD. Welcome to Relentless Health Value. 

[00:05:53] Dr. Will Shrank: It is great to be here. 

[00:05:55] Stacey Richter: So let's explore this topic. Can we cut healthcare waste and lower cost while actually improving patient care? Maybe the best place to start is talking about this word waste or wasteful spending. Could you just categorize what this waste tends to consist of?

[00:06:11] Dr. Will Shrank: I think it's really important to have a standard framework for how you think about waste because you are correct that many people think about certain features but not necessarily the whole set of potential sources of waste. So the Institute of Medicine came up with a definition and it's been reused by a number of organizations over the last 12 years with six categories of waste.

The overall definition is Dollars or effort being spent that doesn't meaningfully improve cannot be thought of as oriented around improving the health or the experience or the outcome of the patient. The six categories, three of them are focused on health care delivery and three are focused more administratively.

So the health care delivery, one is low value care, providing a service that would not be considered appropriate for a patient, something that is, it would not be indicated for a patient. The second is failure in care delivery. The right care isn't provided to a patient at the right time. And the third is around failures and care transitions, which is a place that we know there are huge challenges around patients moving from sites of care.

And the other three categories are more administrative in nature. One is fraud, waste, and abuse. Another is pricing failures, which is something that we spend a lot of time thinking about here in the U. S. is administrative complexity, which really is a result of the complexities of the fragmented billing system we have in the U. S., whether it's prior authorization or coding. A lot of the work that's just focused on documentation or authorizing a... treatment rather than actually delivering care. So it's really a pretty broad definition of waste. And there's a lot of what we do in health care can kind of ultimately fit into many of those categories.

[00:08:00] Stacey Richter: And I can definitely see that there, it's not like there's a bright line either in a lot of these categories, which I'll recap in a sec. Like, it's not clear what is appropriate care. Especially when some of these things take potentially years or even decades to accrue, right? Like if we didn't do the X intervention, then this outcome would or would not have happened.

So as you said, you need a standard framework though to even start conceiving of this because if everybody's just bandying about this term waste and no one's quite clear what that means, it. You can't come up with a solution to a problem that you haven't clearly defined, so you could at least consider it a start.

And you had said that the definition is dollars that don't improve health or outcomes or the experience of a patient. You gave six categories of said waste, starting with the care delivery, grouping. We have low value care that's not appropriate. We have failure in the care delivery system, i. e. botched surgeries or whatnot.

Then we have the third, which is failure in care transitions, lack of coordinated care, etc. So those are three biggies. And then we move into the administrative area. We got fraud, waste and abuse, FWA. We have pricing failures. Is the market actually dynamic? Then administrative complexity, which we talked about actually at some length with Dr.

David Schenker in a show last year. If you're just going to quantify what all this adds up to, what's your take on what these six things 

[00:09:38] Dr. Will Shrank: total? We went through a pretty rigorous exercise in 2019. I was working with a couple of colleagues at University of Pittsburgh and at Humana. And we published a review in JAMA where we assessed the published literature and also government reports to try to.

Come up with an estimate for each of those six categories and rolled them up. They're relatively rough estimates. But our estimate was that somewhere in the order of 750 billion to close to a trillion dollars in the U. S. is wasted every year on care that meets one of those six categories. To put that into context, that's more than we spend on defense.

That's more than the GDP of most countries, of virtually any country. It's more than a quarter of the U. S. health care spending. It is really an astounding number. And as we think about the total cost of care in the United States, we think about an affordability of health care and the impact that health care costs is having on our economy more broadly, and the extent to which health care costs are really kind of squeezing out opportunities to invest in other things that potentially could offer more value, certainly more value than the waste.

We are wasting so much money in healthcare. If we could just do a better job of figuring out the right way to create incentives and infrastructure and strategies and tactics to reduce waste, it would alleviate a huge amount of stress on our healthcare system and on our economy in general. 

[00:11:08] Stacey Richter: It's a pretty sassy number here, this 1 trillion.

Yeah. I would almost say that dollar amount in and of itself could beg the question. Why existentially does this amount of waste exist if we have a functioning market driven healthcare system? So is one potential conclusion that we do not actually have a market driven healthcare system or that we have a market driven healthcare system, but some parties are a whole lot better at it than others?

Because I think the one thing that doesn't get talked about maybe enough is that obviously It's not like that waste is plunging off the side of a cliff and sinking to the bottom of the sea like some kind of lost treasure here. Like we have a trillion dollars that's going into somebody's pocket. Our waste is their profit.

So what we're discussing here really isn't, you know, cutting the fat off a pork chop. It's literally preventing someone from taking money that they have been taking. And do you feel like that is actually the heart of this, that we're prying dollars out of somebody's hand and that exponentially makes this harder to do?

[00:12:10] Dr. Will Shrank: Yes, so certainly one person's waste can absolutely be another person's profit. There's a pretty good explanation for all these sources of waste, and it's very much aligned with how the incentives are structured in the U. S. Healthcare system. You can come up with a pretty good explanation for every one of those categories of why it happens.

There are incentives to promote waste in every one of those categories. Whether it's the payment models themselves, whether it's the fragmentation and the sort of adversarial nature of payers and providers, whether it's the way the government protects monopolies for patented products, you walk through each of those categories and you can come up with a pretty clear answer.

Thank you. explanation of why it happens. And I think the good news is that evidence has been published to suggest that we can reduce waste in each of those categories. We estimated how we would reduce waste if we were able to scale successful strategies and in particular in the care delivery area.

When you look at the some of the evidence that's come out of these progressive value based models that have really taken off over the last 10 years. There's pretty compelling evidence that we can meaningfully reduce waste through aligning payment models with producing the outcomes we want to produce.

And certainly it doesn't happen instantaneously. But over time, as you build the right kind of infrastructure and you really transform care delivery models, Be more integrated, less fragmented. A lot of these sources of waste should be able to be addressed. I don't think we'll ever have a waste free healthcare system.

That's impossible to fathom. But I think we're seeing evidence today of approaches we can leverage, whether it's new payment models, whether it's transformed, integrated delivery approaches, whether it's leveraging technology in new and better ways. That we can reduce waste in a really important and meaningful ways.

Just recapping what you said there, there is either hypothetically or proven or both ways that some of this waste can be reduced. And you mentioned reducing the fragmentation that Causes a whole host of issues that if care is not integrated, then, you know, patients slip through the transitions of care in a kind of big, bad, expensive way.

You talked about solving for the adversarial nature of payers and providers. I could also say solving for the incentive that both of them have, which is another thing that you mentioned when you said the system has incentives to create waste and there are any number of examples actually where either through vertical integration or through kind of the symbiotic desire to raise.

The price of care, both payers and providers actually win. You talked about the government protecting monopolies. So there's a number of reasons why this whole thing happens, which we've probably had 50 shows on. So not to delve into those, but you mentioned solving for this could be new payment models, for example.

And I'm sure other things as well. Do you want to just dig into that a little bit, like either from a hypothetical or from a proven standpoint, what leverage do we have right now or frameworks could we use to think about cutting out this 1 trillion that's not accruing to better patient health? 

Yeah, there are a couple different ways of looking at the transition from fee for service to value based care over the last 11 12 13 years.

Some would argue that during the this time period, I think we set very aggressive goals largely to signal to the sector that there is an inevitability that there's going to be a dramatic movement towards value based adoption. We also set these very audacious goals that we haven't come close to meeting.

So, you know, there was Secretary Burwell talked about a 100 percent adoption of value based care in a relatively short time frame, which was probably unrealistic, although I think a useful message at the time. And some would say it's moved slowly or that we haven't gotten the results we had anticipated.

And that a lot of the models that CMMI have tested haven't been scaled, that there have been incremental benefits and changes, but they haven't been able to scale the majority of the models that have been tested. That is not my read of where we are in the movement towards value based care. My read is that over 12 years ago, value based care was a nascent concept.

We, I think, naturally, through a lot of With spaghetti at the wall, we tried to encourage a really a wildfire of innovation and test a whole host of models. There's some certain themes that are really kind of, kind of coming through during this time period. We're learning that the shared savings program, which is the largest, it is a scaled model.

It's available for any provider in the fee for, in the traditional Medicare program now represents about 40 percent of traditional Medicare. And that program, year over year, we're seeing more and more savings. The last time it was measured, I believe it was about 1. 6 billion dollars in savings. And the overwhelming majority of participants are saving money.

And those numbers are all improving every single year, in terms of the amount saved and the proportion of providers that are in the savings. There's not a switch you flip to be able to deliver higher quality, lower waste, better value care. You got to work at it. And I think we're starting to really learn those lessons around how to do it.

The Shared Savings Program is the best example. I think across the CMMI models. Similarly, we're starting to see really important themes about the success or the utility of having better primary care. and leveraging total cost of care models as the framework for driving better care at lower cost with bundled care underneath.

And when all this work started, I think there was more of a throw a bunch of spaghetti at the wall. I think today we kind of know what the payment model of the future is. It's a model where we have a total cost of care primary care oriented model with bundles underneath a nested model and you know, back to your question, what are we learning?

How are we progressing? That's where all the evidence is coming from through those models around how to reduce waste, how to deliver better care, better outcomes and lower health care costs. You bullish. From what I'm seeing in the marketplace, you know, we yes, we don't have 100 percent participation and value based care.

But in Medicare, we got over 50%. And if you told me 12 years ago, we moved more than half of the Medicare market. A lot of people have been very excited about that. We've seen massive transformation in how care is delivered, integration of physical behavioral health, complex care case management, leveraging data in new ways to risk stratify and be more proactive in managing patients with complex conditions.

I think there's just a lot to be excited about. in terms of how these models continue to progress and how we're learning. Which is a fair statement. I just finished reading Dr. Robert Pearl's book, Uncaring. He basically wrote a whole book about just how physicians slash medical culture in this country really can inhibit change. There's a whole culture that is really tough to move for a number of good and really bad reasons, frankly. It's an interesting read. And Because of that, I do feel like there is a lot of focus on the negative, just how slow going this is. And anybody who wants to find a problem can always find a problem.

And sometimes it's easier to talk about the failures of the journey than what the successes may have been. At the same time, if we're saying that MSSP, the Shared Savings Program, has netted 1. 6 billion and we're staring down the face of a trillion dollars worth of simply waste, using cost savings as a success metric there may not be the best way to go.

No, I think that's right, but I think it's important to think about that in the setting of the counterfactual. We've built a backbone of extraordinary waste on a fee for service chassis in the U. S. healthcare system. We are not going to fix that waste problem on a fee for service chassis. The places where we're seeing evidence of improvement...

or where we're aligning financial incentives with the outcomes we're trying to produce. I wouldn't, I'll be first to say that this is not easy to change culture, change behavior, to manage change. And there is not a simple switch to flip, but I think we're getting better at it. And I think that's the right direction for us to head.

And I think that those who argue that we're not going fast enough, or this is not what it was cracked up to be, give me a better alternative. I think many of them would say it's actually all this value based. stuff and all of it's, you know, the consultants, I just saw some very cynical posts where someone wrote the consultants have made more on value based care than what we've managed to save.

So there, there certainly is this cynicism, but to your point, you look at like we had Larry Bauer on the show talking about three bright spots where frail elderly patients are getting really good care as opposed to the really bad care that you frequently hear about when you even say the words frail elderly patient.

And all of these examples that he talked about were built on a capitated model or on a model that facilitated patients getting coordinated care and there being clinicians who were not worried about what code they were going to. Put in the computer when they help the patient's behavioral health or help the patient figure out how they're gonna get transportation or help them access community services or whatnot.

So viscerally and intuitively, the points that you're making makes sense. 

I would just encourage folks to take a good look at different primary care models that are managing the health of vulnerable complex seniors. You take one good look at a senior focused, team-based fully capitated. Really patient centered model and that is the care you want your mom or your dad or your aunt or your uncle to get.

You're not going to want your aunt or uncle to get care from the local primary care doc that is focused on having your relative come into the office as frequently as possible and to bill as much as they can for each individual visit. You're going to want somebody that can help manage pharmacy, that can help manage, you know, the complexity of the pharmaceutical regimens, that can help manage social issues, that can help manage the sort of complex care across multiple specialties, that can help manage it.

God forbid someone needs oncology services that can help navigate the complexity of those kinds of services. That is what primary care and that's what the healthcare system needs to be. And that doesn't, it just never has evolved in a fee for service arrangement. 

[00:23:14] Stacey Richter: Here's, I'm not sure if this is a counter example or, a reason why in certain markets, if you are a provider organization in the community, this is actually really hard. We did have Dan O'Neill on the podcast. He's a provider organization in California and he cannot get ahold of his payer. You know, he's trying to be value based and no one is helping. Payers are completely not interested.

The payers or the IPAs themselves are maybe engaged in value based contracting, but they're paying all of the physicians fee for service and then just scraping up all the value based incentives that are out there because turns out the physicians are pretty good. And despite the fact they're not necessarily getting, you know, in air quotes, incented, they're still able to deliver the benchmark level of care. Then I also had a listener write in the other day that she asked her payer for some kind of incentive to provide a value based, more longitudinal program. And the payer told her, and this is a local nonprofit payer that in quotes, all fee for service is high value care. So why would we give you more money?

So like, this is the environment that some provider organizations are living in. What's your I advice there, if anything.

[00:24:37] Dr. Will Shrank: It is challenging if in particular if you're in an, if you're taking care of a higher proportion of commercial, younger, healthier patients. I will say though, and if you look at sort of the Medicare Advantage market as a bellwether, increasingly you're seeing primary care providers and communities really align more with the payer taking more risk.

And together, working to commoditize specialists and health systems. And if there's a warning to providers out there, I think it's, if you work in a health system, you're a specialist, and you're not figuring out how to be part of a broader population health management strategy. There's a path to being really deeply commoditized in a relatively short amount of time.

If the sort of primary care value based model continues to propagate, I think it's gonna. 

[00:25:30] Stacey Richter: Can you dig into that a sec? You said that if you're a specialist, subspecialist, and you're not figuring out how to integrate within a population health based approach. I'm taking it, working with some of these advanced primary care groups who are really mining data and really thinking through referral patterns, etc.

[00:25:50] Dr. Will Shrank: Whether it's as a sub cap, whether it's as like a center of excellence, source of bundles for high performing primary care. Like if you're a health system and you're just, you think you're just going to kind of continue to squeak out margins based on the number of beds you have. And a steady stream of patients coming in for large, you know, often preventable hospitalizations.

I think you should think differently because we're going to keep getting better at taking care of things in the home. And we're going to keep getting better at keeping people out of the hospital for re for admissions that don't need to be hospitalized or for social reasons. And I think if you're a hospital, you have to be deeply aligning with primary care and thinking about how you manage populations in the area, the region that you operate.

In a lot of ways, I think that's a better model from a longer term perspective, a better model of care. You have health systems that are deeply aligned with their communities, with community based organizations. That they really think about improving the health of a, of a local region. It's a really appealing model for driving better health at lower cost.

It's not really what we're seeing across the country with relatively few exceptions. The places where you're seeing real movement towards population health prioritization and a focus on managing the health of a local community is these risks. you know, fully capitated primary care organizations that are really changing the model around how they care for seniors in an, in a, in an area.

[00:27:18] Stacey Richter: So heard what you just said about how, despite the fact that there are some very successful advanced primary care groups, comprehensive primary care groups who are producing some pretty great outcomes at maybe even approximately the same cost. I do sometimes think to myself that. The object of the game could equally be having the same cost being cost neutral if you're producing far better outcomes and a far better patient experience.

I wouldn't consider that a fail by any stretch. But despite the fact that this whole idea of advanced primary care, comprehensive primary care becoming just Fairly inarguable at this juncture, you also just said that we're not really seeing hospital systems embrace this across the country. What is being embraced across the country, if I'm just going to make probably a slightly unfair broad stroke here, is that health systems bought up all the local PCPs and are rewarding our views to those who refer early and often inside the health system and reduce network leakage and you know, all the typical things that a fee for service, a hospital is gonna do to drive up heads in beds. Are they just going to continue doing that until they can't anymore? And is that a good strategy? Like, what's your advice to a health system who may have PCPs coming to them who are saying, because it's a much nicer, less morally injurious, less burnout y model for PCP as an individual to have a smaller patient panel, a team that supports them, etc. You hear over and over, it was just a summer short with Dr. Scott Kennard where they transformed a practice and then somebody came in and tried to untransform the practice and it was basically mutiny on the bounty with clinicians. Like they were like, I am not going back. This is so much better. So you do have PCPs kind of rising up to a certain degree, asking their employer, can we do this? And then I have heard several examples where the health system employer was like, no.

[00:29:29] Dr. Will Shrank: If I were to guess, if I were to be finishing my residency in July of this year, I guess I would have just finished my residency. And I had my choice of working at oriented primary care organization associated with a local health system here, or working at a local CVS in an Oak Street clinic, obviously that hasn't that transition hasn't happened yet, or one of the many sort of burgeoning new primary care models.

I don't think that's a hard decision for me. I would probably unquestionably pick a model where there's better technology to help me, that there's a team around me to help manage the complexities of the patients that I care for, and where my incentives are really aligned with the reason I went to medical school and chose to be in a primary care doc in the first place.

I, you know, I'm betting on the fact that's where younger doctors hearts and minds are. I think it's hard to change some older doctors, of course, who have made a great career taking great care of people and whose intentions and motivations are nothing but good, but for whom change is hard. But I think we're, you know, we're gonna see a new generation of provi, of primary care providers that are and excited to participate in these new models.

[00:30:43] Stacey Richter: So, the message to some of these maybe old school health systems is maybe not today, but you're going to have a terrible time recruiting and retaining primary care doctors in the future if you continue along this path, so it's going to be a bit of a generational shift what you're going to get. Yeah, I think so.

You know, caught in the compactor. I mean, look, if you've got United and Humana and CVS all hiring, literally, man, they're all going to be hiring many hundreds of primary care docs in the years to come, there's going to be a lot of competition for primary care talent. And I think you're going to see primary care docs getting paid more and more of a premium.

And I think they're going to be calling their shots. And I don't imagine that they're going to want to be in an RVU oriented, you know, volume, premium kind of setting. Yeah. 

And speaking of clinicians finding their voice, obviously we just had, because it's all over the news, the UHC utilization of this algorithm to deny care and not letting clinicians override said algorithms.

So patients who needed care as per their clinicians were not able to get it. I'm taking this whole thing actually as good news because there was a huge outcry, enough of an outcry that there was a change. So between that and the rest of this conversation, it almost feels like PCPs and other clinicians almost have two choices that may be potentially viable.

One is speak up because enough voices who are pointing out some really egregious. stuff could actually get listened to, but if not, there's the opportunity to vote with your feet. It almost sounds like if primary care physicians have a choice where they want to work and where they want to go, that through the power that is afforded in that equation, it holds everybody accountable to patient care, assuming that the PCPs, and I think we can assume this by and large, that the PCPs are thinking of their patients and are patient oriented. I think that's right. Well, thank you. Dr. Will Schrank, thank you so much for being on Relentless Health Value today. 

I just really appreciate that you're trying to shine a light on some of these challenges we're having as a healthcare system, as we're trying to make changes.

Changing the healthcare system is hard. We saw a couple things that changed really fast during the pandemic, like, like virtual care. Adoption, but for the most part, these cultural changes are really hard and I love that you're engaging in these conversations, trying to get people to think about it, to talk about it because we need to get more and more energy and alignment and focus if we're going to see real meaningful improvements.

Can I just read you some of the reviews that we got on iTunes recently? They make my heart so warm. I just want to acknowledge these individuals who took the time to write reviews. Here's the first one. It's from jspeaks1987. He wrote, RHV is my weekly go to for smart takes on VBC, value based care. I have recommended this podcast to literally hundreds of people, including from on stage at our recent customer success summit.

Anyone who cares about the sustainability of our health care system owes it to themselves to give Relentless Health Value a permanent spot on their playlist. Always smart, often provocative, scrupulously fair. I like that. Scrupulously fair. It's well worth a listen. Thank you so much jspeaks1987.

Here's another one. And this is from Happy Gilmore 80. I know who you are, Happy Gilmore. RHV is an amazing podcast and sorely needed in the healthcare community. I tell everyone about it. I am a recent listener and have learned so much from episode 399 and 400, which are the manifestos. Episode 410 was packed with knowledge, 407 was great, etc.

Let's start a hundred RHV communities across the U. S. where we implement small experiments so change is grassroots and ubiquitous. Then the status quo will concede. And yeah, for sure with that, if anyone is interested in creating a meetup or something in your local area, reach out. I'll try to hook you up with others in the Relentless Tribe.

Here's the third one, and this is by Miriam. Thank you so much for this, Miriam. Miriam says, I scoured the podcast world to find a healthcare industry podcast that offers intelligent, relevant, clear information and dialogue. I found it. Stacey and RHV cover the U. S. healthcare industry across all sectors while managing to go deep within those sectors.

Most importantly, RHV highlights how all of those sectors interact, supposedly with the patient at the center, while performing as businesses that are really driven by capitalism. Miriam says she never misses an episode. To the three of you, thank you so much. It's actually reviews like this that keep me and the team going over here.