A Better Approach To Population Health w/ Mark C. Clement | Executive Feature
May 09, 2024
CareTalk: Healthcare. Unfiltered.
Population health flips the usual model of US healthcare on its head. Instead of waiting until patients get sick and then billing on a fee-for-service basis when they seek care, population health is proactive.
It addresses the root causes of disease in the community by focusing on prevention and the social determinants of health.
It sounds great in theory, but is anyone actually doing it?
TOPICS (0:54) Tracing the career of TriHealth President & CEO Mark Clement (5:31) What is population health? (7:13) The Triple Aim in Healthcare (11:34) Perverse incentives in the healthcare system (15:52 )Transforming Healthcare for the Better (24:00) Addressing health disparities and challenges in the US (27:36) Cradle Cincinnati and reducing infant and maternal mortality (32:08) Building community coalitions for health equity
🎙️⚕️ ABOUT CARETALK EXECUTIVE FEATURES Caretalk Executive Features is a series where we spotlight innovative companies and leaders working to advance the healthcare field.
🎙️⚕️ ABOUT MARK C. CLEMENT CEO, TRIHEALTH In 2016, under Mark’s leadership, TriHealth began its journey towards population health because they saw that the healthcare system was broken and that it was up to them to get care right. Mark’s vision for providing better care, health, value, and experience is the basis for a more human approach to healthcare, designed to keep people healthy rather than simply helping them access treatment when they’re sick. This shift in approach has transformed healthcare in Greater Cincinnati and established Mark and TriHealth as the vanguards for adopting and effectively implementing the population health model.
Through Mark’s leadership and a concerted effort to improve access, TriHealth has been able to direct 70% of its caseload to the outpatient setting (compared to 55% for the next closest health system), ensuring consumers are always within 10 minutes of TriHealth facilities. Areas that were once healthcare deserts now have access to state-of-the-art care.
🎙️⚕️ ABOUT TRIHEALTH TriHealth operates 5 hospitals and over 100 other ambulatory, post-acute, and other sites of care throughout the Tri-State region of Ohio, Kentucky, and Indiana. The organization also operates the largest corporate health and fitness program in Greater Cincinnati, the largest not-for-profit hospice in the region, and major teaching programs, including nine residencies and fellowships.
In 2016, TriHealth began its journey towards population health because it saw that the healthcare system was broken and it was up to them to get care right. TriHealth has made a steadfast commitment to delivering better care, better health, and better value.
Population health flips the usual model of US healthcare on its head. Instead of waiting until patients get sick and then billing on a fee-for-service basis when they seek care, population health is proactive.
It addresses the root causes of disease in the community by focusing on prevention and the social determinants of health.
It sounds great in theory, but is anyone actually doing it?
TOPICS (0:54) Tracing the career of TriHealth President & CEO Mark Clement (5:31) What is population health? (7:13) The Triple Aim in Healthcare (11:34) Perverse incentives in the healthcare system (15:52 )Transforming Healthcare for the Better (24:00) Addressing health disparities and challenges in the US (27:36) Cradle Cincinnati and reducing infant and maternal mortality (32:08) Building community coalitions for health equity
🎙️⚕️ ABOUT CARETALK EXECUTIVE FEATURES Caretalk Executive Features is a series where we spotlight innovative companies and leaders working to advance the healthcare field.
🎙️⚕️ ABOUT MARK C. CLEMENT CEO, TRIHEALTH In 2016, under Mark’s leadership, TriHealth began its journey towards population health because they saw that the healthcare system was broken and that it was up to them to get care right. Mark’s vision for providing better care, health, value, and experience is the basis for a more human approach to healthcare, designed to keep people healthy rather than simply helping them access treatment when they’re sick. This shift in approach has transformed healthcare in Greater Cincinnati and established Mark and TriHealth as the vanguards for adopting and effectively implementing the population health model.
Through Mark’s leadership and a concerted effort to improve access, TriHealth has been able to direct 70% of its caseload to the outpatient setting (compared to 55% for the next closest health system), ensuring consumers are always within 10 minutes of TriHealth facilities. Areas that were once healthcare deserts now have access to state-of-the-art care.
🎙️⚕️ ABOUT TRIHEALTH TriHealth operates 5 hospitals and over 100 other ambulatory, post-acute, and other sites of care throughout the Tri-State region of Ohio, Kentucky, and Indiana. The organization also operates the largest corporate health and fitness program in Greater Cincinnati, the largest not-for-profit hospice in the region, and major teaching programs, including nine residencies and fellowships.
In 2016, TriHealth began its journey towards population health because it saw that the healthcare system was broken and it was up to them to get care right. TriHealth has made a steadfast commitment to delivering better care, better health, and better value.
Population health flips the usual model of U .S. health care on its head. Instead of waiting for patients to get sick and then billing on a fee -for-service basis when they seek care, population health is proactive. It addresses the root causes of disease in the community by focusing on prevention and the social determinants of health. It sounds great in theory, but is anyone actually making it work? Welcome to Care Talk Executive Features, a series where we spotlight innovative organizations and leaders working to advance the healthcare field. I'm your host, David Williams, president of Health Business Group. And my guest today is Mark Clements, CEO of TriHealth, which puts population health principles into practice. Mark, welcome to Care Talk. Well, thank you, David. It's great to be with you today. Outstanding. Well, I want to hear a little bit about your background and your role at TriHealth. Well, terrific, Dave. And again, once again, thank you for giving me the opportunity to participate in this podcast and tell Tri Health's story. So again, my name is Mark Clement. I've had the great privilege of being a part of this organization for nine years. Actually, this month I'll start my 10th year as president and chief executive officer of Tri Health. My story is a little bit unique, at least unique for folks that do what I do. I actually grew up in Cincinnati, Ohio. I was born in one of Tri -Hell's hospitals. My father was a practicing primary care physician who completed his medical school training at University of Cincinnati and then went on to complete his residency at one of our hospitals. My older brother, also a primary care physician, practiced at one of our hospitals. I never dreamed that I'd come back to my hometown, Cincinnati, having spent most of my career. in Chicago, Boston, and upstate New York, but had the opportunity to return to Cincinnati now a little more than nine years ago. And it really has been, you know, the privilege of my career to come back to my hometown and be involved in such important work that is underway at Tri Health. And that work is really about transforming how we deliver care, as you refer to using population health. financing and care models. Well, Mark, you know, you have an impressive resume and then with your pedigree of being born at the hospital and all the connections, I would hate to have been the other guy that, you know, who was up against you for the role. So well done of really locking it in. Thank you, David. So, you know, Cincinnati, I haven't spent too much time there. One of the things I remember about is when they were promoting Cincinnati as like a great hub. an airline hub. I remember somebody it was maybe Delta or somebody that had like said Cincinnati instead like to go there rather than somewhere else. It has a you know, it has like a nice aura around it. But but tell me a little bit about like greater Cincinnati and what the Tri Health vision is for it. Yeah, well, you know, greater Cincinnati. It's it's located in southwest Ohio. We serve what we call the tri -state area, southeast Indiana and northern Kentucky along with southwest Cincinnati. population approaching 2 million residents. I like to say having lived in Chicago, raised my kids in Chicago and Boston, Cincinnati, and those are two obviously world -class cities. Cincinnati really offers pretty much everything that those world -class cities offer, but everything is so much easier. Traffic is easier. It's easier to get around town. And we're blessed with a really, really good healthcare system. And we like to think that Tri -Health is kind of leading the way with the healthcare system here in Cincinnati. And hopefully we'll get into that in just a minute. No, that sounds great. I remember we've done some work in Ohio, some of your other cities like Cleveland, and they have very different characteristics. And I think Cincinnati's got a well-organized employer group, among other things. And I think with P &G, haven't been headquartered there, if I'm not mistaken. It has a real kind of a civic identity. to it that maybe punches above its weight. You know, it really does, David. Actually, I met with an employer, an employer group or the employer group. There may be multiple, but just last week to talk about, you know, the imperatives around health care transformation. And you're right, Cincinnati is blessed with having a number of Fortune 500 companies based corporately here in Cincinnati, whether that's Fifth Third Bank or Kroger's or GE Aviation. all based here in Cincinnati, among others. Good, but let me ask you the hard, what was gonna be the hard question, but is more, I think, up your alley is, I mean, what is population health? Well, you know, I think most, you know, most experts would agree that, you know, our current healthcare delivery system, which is based upon a fee for service financing mechanism or fee for service payment models, is broken in many ways. You know, Human beings, as we all know, operate in their own economic self -interest. And when you create financing systems or payment models that incentivize volume, you're going to get more volume. And that is historically how we have reimbursed or financed health care in our country. It's on a fee -for -service payment basis. And so... you know, the incentives around a fee for service payment system are to encourage, you know, more volume because that generates more revenue, which improves the economic prosperity of the organization. It also, I think, unintentionally, and these are unintended consequences, unintentionally promotes fragmented episodic reactive care. So when we think about population health, you know, I think most... experts would agree that it is a fundamentally different approach to how we both finance and deliver care. It's less reactive and more proactive. It's less a sick care system and more a health care system by evolving the underlying incentives that reward health systems and providers like Tri -Health for the right things, and the right things are prevention. early detection, better management of chronic disease, ultimately to deliver on what Dr. Donald Berwick, who founded the Institute for Healthcare Improvement, coined the triple aim and then he went on to expand that to the triple aim plus. Triple aim is better care, better health, better value, and in enhanced practice and work environment for physicians and team members. Can we talk about a little bit about sort of what's wrong with fee for service to begin with? Because, I definitely hear you and this makes tremendous sense about getting paid to keep people healthy and so on and so forth. But in other parts of the economy, it doesn't seem to be such a problem to pay people for what they're doing. So I'll just give an example. So if I have my car and I take it to the gas station, I pay them for however many gallons of fuel they put in my tank. And yeah, I probably, maybe I should get my oil changed more frequently or... keep the tires at the right pressure and all that kind of thing. But for some reason, it seems to work out, okay, I go and I get the maintenance more or less when it's recommended, I fill the car up and we're all happy. But somehow in healthcare, it's not okay to pay doctors for what they're doing. They're just, you know, somebody came to their office, they treated them, they should be paid. So why does that mess us up so badly? Yeah, well, you know, I don't think fee for service is ever. entirely, at least in my career and as far out as I can see, I don't think it's fee for service is going to go away. But what we are seeing increasingly is that value based incentives are being placed on top of fee for service to create incentives to deliver on the triple A. So back to your analogy, I go and I take my car and I need to, you know, the wheels changed. you know, what's wrong with competing on price relative to tires. Yeah. And, you know, in some cases in healthcare, you know, there's nothing wrong with that. But the aim isn't, you know, to just change tires or to, you know, stitch up a laceration. The aim is to improve the overall health of individuals and populations. And if we've got a payment system that only rewards you know, care that's provided in response to disease and illness, then, you know, acting is a, you know, in an economically rational way. Why would, I'm going to be a little provocative here, why would a health system want to keep people healthy if they're only getting paid when they're sick, and they're not getting paid to keep people healthy? And they're only getting reimbursed when folks are sick or injured or ill and show up in their emergency departments or in their physician offices. Population health is really about rethinking those underlying incentives and realigning the behavior of health care providers, physicians, health systems like ours to both cure and respond to disease and illness, but as well, proactively work to cure. to detect disease earlier, to prevent disease in the first place, to provide care in the least costly part of our integrated health system, and ultimately to improve health and drive down costs. We know that our system of healthcare in the United States is the most costly healthcare system in the world. We pay more, we spend more for healthcare in our country than any other nation in the world approaching 20 % of our gross domestic product. And yet we know that our outcomes lag many, many, many countries around the world. Whether it's Canada just across the border to the north, Great Britain, France, most European countries, our life expectancy is below Canadians. life expectancy, it's below most of Europe's life expectancy. Infect mortality is higher in our nation than most Western countries. Access to healthcare is more limited in our nation than other nations around the country and around the world. And yet we spend more than any other in the world. And I would argue that a big part of that is the perverse incentives that are unintended but nonetheless exist. in a transactional financing system that doesn't hold providers accountable and that doesn't really reward the right things or all of the right things. We were involved in some population health level efforts in Detroit some years ago. And, you know, one of the approaches was to try to reduce the number of unnecessary emergency room visits. Problem was the hospitals in Detroit, if they weren't getting those emergency room visits, they're going to go out of business. So it wasn't even that they didn't want to keep somebody healthy. It's just like they're going to be gone. They don't have people coming in. So someone's got to take policy at a different level for that to be able to work. Yeah. So TriHealth, let's talk about TriHealth. And what is TriHealth's approach to population health? Well, it's been a very intentional, it's been very deliberate. And it goes back in many ways to the creation and the founding of TriHealth now more than 25 years ago. TriHealth is the product of a partnership, a merger between two... tertiary care hospitals that came together, Good Samaritan Hospital and Bethesda, Bethesda Oak, which had a satellite hospital called Bethesda North. Those two organizations came together, they were independent hospitals operating independently. They came together in the mid -90s to create TriHealth. And... Tri -Health has grown rapidly since, but their vision, and I've been in healthcare long enough to remember, you know, risk-based contracting, and capitation in the 90s, and that's when Tri -Health was founded. And it was really the first foray into population. What I would argue was the first foray into population health, really modeling payment arrangements around what we've seen in Kaiser, which has been a kind of an HMO model for... nearly 100 years. And the vision of Tri -Health then and continuing to today was to really transform the way in which care is delivered for the better. And so in the ensuing years, Tri -Health expanded from a two -hospital system to a six -hospital system. And when I arrived in Cincinnati, and as you know, you know, in the early 2000s, because of, I think, a lack of big data and ability to really successfully manage care, there was a kind of a reaction to in a rejection of risk -based HMO closed panel health plans. And because in many ways, you know, managed care in the 90s was, was, was, you know, provided through what were called gatekeepers and it was preventing care more than it was managing care. It was, it was, you know, serving as a, as a, as a gatekeeper to care. And it didn't really work very well. May have saved some costs, but it did, it created all kinds of access issues. Fast forward, you know, to 2015, I arrived here in Cincinnati and our board and our management team and physician leaders went through as you would typically do with. with new leadership team, a planning process, and we returned to our roots and our original vision of transforming healthcare for the better. And at that point, we were a burgeoning integrated delivery system, more than just six hospitals, a nascent ambulatory network, a large employed physician group, post -acute capabilities like hospice and palliative care. And so we made the decision rather than doubling down on what we knew was a broken healthcare delivery system in our country, finance through fee for service. We recognize that things are very different today than 170 years ago when our oldest flagship hospital, the Samaritan Hospital was founded. And the way we carried our mission out 170 years ago and that mission was to improve the health of our community. It was through you know, reacting and curing illness and disease because that's all we really knew. Well, a lot of advances have occurred in that 170 years, you know, ranging from technology to medical practice to advances in the genome, as well as big data. And that big data now allows us to understand the health of our nearly 600,000 patients that we care for. So we made the decision to really transform and lead the way locally and really emerge as a model nationally for transforming healthcare for the better. And I'd love to tell you a little bit about how we do that. No, that sounds terrific. Population health has become a popular term. And actually sometimes you go to a conference like HIMS, you might see it all over the place. And of course, that's naturally led to some misunderstandings. And are there particular things that you would say that people misunderstand about population health? Yeah, I probably several. One is it's it's it's it's not an initiative and it's not just a change in your contracting. It is a fundamental change in in your for want of a better word, your business model, your care models, your financing system, the culture of your organization. the culture of your physician community. It is a fundamental change in how you do everything that you do. And so when we embarked upon this journey, and I guess maybe the other misconception is that if you, because there's been a lot of high profile examples of this, if you embrace population health, You you you imperil your organization financially. Right. Many organizations have gone down this path and have been unsuccessful financially and have reversed courses. And I can tell you that that's not necessarily the case if you approach it accurately as we believe we have. We've never been stronger financially than we are today even at a time. when our industry is experiencing very significant financial challenges. I think we may be the only health system in greater Cincinnati that's continuing to operate profitably, that hasn't been downgraded by the credit rating agencies. We're gonna achieve a 3 % plus operating margin this year. We're growing market share with the leading healthcare provider in this market on many fronts. And at the same time, more than 50 % of our patients, or roughly 50 % of our patients, nearly 300 ,000 of the 600 ,000 members of the community that we regularly care for in our primary care practices and in our service lines, nearly 300 ,000 are in some form of value -based payment arrangement. And we can talk more about those in just a moment. Great. But the way that we've, well, go ahead, I'll pause here. No, I was gonna say, I do wanna talk about some of your initiatives, but I wanted to mention that this concept of population health and the related topic of social determinants of health has really gone even beyond the Don Berwicks and other healthcare thinkers, right up to the White House. And in fact, the White House, if I'm not mistaken, this year actually released a playbook to address social determinants of health. And I wonder how does that... Something that's right. How does that kind of contribute overall to population health, to this notion of population health, social determinants, population health, White House involvement? What does that do? Yeah, yeah, yeah. And you're right about that. The White House has released a playbook, but it's more than just the White House releasing a playbook on social determinants of health, which is I think maybe a bit of a wake -up call for our industry. It's not a wake -up call for us. It's something that we've... been dealing with since the very, you know, outset of our journey around population health. We know that social determinants of health, and this is as well reflected in the playbook from the White House, social determinants of health, whether that's food insecurity or housing insecurity or lack of transportation or wealth inequity, socioeconomic disparities. that contribute directly to health outcomes and to health inequity. For example, we know that food insecurity alone is responsible for as much as a 15 % increase in chronic disease. And 100 % increase has contributed to a significant increase in mental health issues for new moms and infants. And it is much as a 58 % increase in the risk of death. And then the list goes on and on and on about these health disparities. I can tell you here in Cincinnati, the distance in a six mile distance in two neighborhoods, Mount Adams, which is literally a half a mile from where I'm speaking to you from versus lower Price Hill on the west side of Cincinnati. Life expectancy. diverse by 26 years from, you know, roughly 60 years life expectancy and lower price price hill to, you know, 8586 years of expectancy and those are health disparities. And those, you know, really troubling outcomes are the result of food insecurity, housing insecurity, socio economic differences. And so We've developed a playbook of our own to really address those because we know we will never be successful in improving the health of our community unless we are helping patients to get to their physician office visit or to get to one of our hospitals for a procedure. We know that moms and families will not raise healthy kids if they don't have food. So we've created eight free food banks. We provide thousands of free rides to our patients every month, every month. That's not year, every month. But I would say even beyond the White House playbook on disparities, CMS has developed innovative financing, alternative financing models for the Medicare population. And one of those is an affordable, not affordable care, but... It all started with the Affordable Care Act, but it's an accountable care organization. It's called ACO REACH, Accountable Care Organization REACH, which really focuses on and rewards health systems like TriHealth for addressing social determinants of health and health disparities. We have about 25 ,000 traditional fee -for-service Medicare patients that are in ACO REACH. We have probably another 50 ,000 Medicare Advantage patients that we care for through value-based payment arrangements. Pretty much every Medicare patient we care for is in a value -based payment arrangement. And we get rewarded for addressing, economically rewarded for addressing those social determinants of health. Mark, I had been doing a little research in preparation for this interview and you just made it even starker than I had understood about the disparities between two nearby neighborhoods. And I know you see it, you see it some in Boston, you see it in New York City, one zip code compared to another. You had mentioned earlier about how the US health system doesn't perform and you're comparing life expectancy here with Canada or Europe. But what you're seeing within your own community is you've got like basically, not to say anything negative, but you've got like, Guatemala level, that's right. Public health on the one place and you've got Japan level or, you know, richest part of Singapore level on the other. So that's that may, I don't know, that's unique to the U S but you know, how do you, how do you address that? Cause it's not, it's not the same kind of initiative you would do in that 86, you know, life expectancy neighborhood compared to one that's at 60. Yeah. I think you put your finger on, you know, an important factor here. which is driving a lot of these health outcomes. If you look at every other one of those nations that we've used as a kind of a reference point, whether it's Europe or Canada or Japan, what's the big difference between those countries and the U .S.? The big difference is universal health access. We still have, and we've made, I think, encouraging progress with the Affordable Care Act. to close that gap, but we still have 30 to 40 million Americans that don't have the same access to healthcare that you and I have because we receive employer-sponsored health benefits or we receive Medicaid or we receive Medicare. There's still a gap and a very significant gap of millions of Americans that don't qualify and they fall through the cracks and that's a major contributor. And that's, in my opinion, that's a real failing in terms of health policy within our country. So we do what we can do. And TriHealth is a not -for -profit organization. We care for every patient in need, irrespective of their ability to pay, whether they have insurance or not. And we give back hundreds of millions of dollars in free care each year. That's what our mission's about. And we work very hard with other community organizations to address those health disparities. I can give you several examples. Yeah, no, that would be good. So, I mean, so on the one hand, you know, free care, I can understand that. Some of the things you described before, you know, giving people free food, rides, it all makes sense economically. It's also something you would expect, you know, governmental organization or. you know, others to do. So I think it's kind of dramatic of what happens when you really get tasked with, you know, population health overall. But do tell me about some of these, and you told me about certain things, but I'd love to hear, you know, some of the areas that you look to as real successes, you know, once you've done some examples would be great. And if you care to share anything that hasn't been as successful that you've tried. Sure, sure. Well, you know, like every organization, we're a work in progress. We've got lots of success. We have we continue to have challenges and I'm happy to talk about both because, you know, what are they it's been said that if you don't confront and acknowledge your, you know, your challenges, your problems, you're never going to solve them. You're never going to fix them. So we're very open about what you know, what we do well and what we need to do better. Well, let me give you a couple of examples. It, you cradle Cincinnati. So, so fifth, actually, even before I arrived in Cincinnati in 2013, you know, it was recognized tri health, Cincinnati children's, which was recognized as the, you know, the number one children's hospital in the country. We have, we have deep relationships with Cincinnati children's. and so in 2013, we came together with Cincinnati children's other healthcare providers within greater Cincinnati. of foundations and funders to create an organization called Cradle Cincinnati. And we came together because we had an alarmingly high rate of infant and maternal mortality, particularly in the African -American community. And we created an organization called Cradle Cincinnati and funded it and it continues to operate. And through programs ranging from safe sleep post -delivery to prenatal... through prenatal care to better nutrition and a number of other things we were able to drive down avoidable, preventable maternal and fetal deaths and are continuing to do that. No longer leading the country, it was the worst city or at least close to being the worst in the nation, made encouraging progress there. I will tell you that as well, We have through other partnerships, we've established eight or nine free food banks in our patients and we place these in areas of our community and in our facilities that care for a disproportionately large percentage of patients that are at risk for these social determinants of health, food insecurity. We as well, we built, spent about,$35 million building a major ambulatory campus in an area that I was quoted as referring to as a medical desert because there weren't, and it's on the west side and it's bustling. It's been in operation for about a year and it's grown rapidly and we've closed that gap in access to care. we've, you know, we, we established probably 15 years ago, what is now the largest, free healthcare center in Ohio. It's on the West side in a socioeconomic economically challenged neighborhood. That same neighborhood that I referenced as a life expectancy of 60 years. and, and a number of other things, what I will tell you is, you know, work, where can we, you know, where can we perform better? we, we are standing up. It actually the only adult health care system in this region. We're standing up a center for health equity. Actually, it's being stood up as we speak. We'll be investing roughly $4 million a year in resources that are aimed at doing three things. One is to continue to strengthen our culture, make this an organization that fosters trust and a sense of belonging on the part of our diverse community. So a very robust DEIB focus to make this, you know, to continue to be the culture that, and the organization that our community trusts, because we know that trust translates into compliance, confidence, and a willingness to come and receive care and to accept the advice of physicians. The second is internal performance improvement around our own. disparities in care and we do have disparities in care. We five years ago began collecting what we call real data, race, ethnicity and language data for every patient. So today, about 99 % of our patients, 98, 99 % of our patients, we have that demographic information. So we can, we can, disaggregate information around race and around ethnicity performance data. And we know where there's opportunities to improve our clinical performance around those demographic subsets. And then the third area of focus of our Center for Health Equity is building community coalitions like we did with Cradle Cincinnati. To, you know, to... to address the life expectancy gap, for example, that I touched on a moment ago. And we're forging partnerships with other like -minded community organizations to do just that. We've got a lot of work to do in Cincinnati. That sounds great. Well, Mark, my last question for you is if you wouldn't mind providing advice to other health systems that maybe didn't start so steeped in the population health side of things, but how might other health systems move toward a population health model? You know, for us, we recognize that moving into population health was not something that you could dabble with, that you needed to make a decision to really be all in. And that decision was made on the part of our board and our leadership team, our physician community in 2015, 2016. And I think many organizations, healthcare organizations, colleagues of mine, friends of mine are just dabbling with population health. And what we've learned is that you have to be all in. And all in means that you really have to fundamentally change the way in which you think about how you're delivering care and how you're financing care. And get out of that place, you know, you've heard the metaphor, no doubt, of having a foot in both canoes. Right. And I would tell you that we no longer have a foot in both canoes. We're all in the population. But it's taken us nearly a decade. The second thing that I would suggest is find an execution partner, because this is really hard work. And it will require a fundamental change in care models, in your culture, in financing systems. The third thing that we've learned and that I think has enabled us to be successful in this transformational journey is don't go too fast. Don't take on risk before your organization has built the infrastructure and demonstrated the competency to manage risk. So we were five years into our journey. before we began to take downside risk. We were, you know, the focus of our, you know, the changes in our payment systems were really around upside shared savings, around ambulatory pay for, or excuse me, pay for performance in the ambulatory setting. as well as delegated services like care management. And before we took any downside risk, and we now have risk for about 200 ,000 of our 300 ,000 value -based payments, and have never had to write a check because we built the competencies and assessed our readiness to take risk before we negotiated risk -based contracts. And... And what we've learned is that it's important that you synchronize the transformation around care, care model change along with financing model change. Because if you move too aggressively to change your care models and you move more care out of your systems before you're getting rewarded for it with value based payment arrangements, you'll put the organization at financial distress. If you move too aggressively with your evolution or transformation of financing systems. and take too much risk before you can manage it, you'll put the organization at financial risk. So you really have to perfectly time the change on both the financing and the care model redesign sides. Good. Well, easier said than done, and I'm happy to get that extra word of wisdom in there. Well, that's it for the latest episode of the Care Talk Executive Feature Series. My guest today is Mark Clements, President and CEO of TriHealth. If you enjoyed this show, which I'm sure you did, please leave a rating and subscribe on your favorite service. And Mark, thanks so much for being my guest today on Care Talk. David, it was a lot of fun. Thanks for having me. My pleasure.