Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Payment Evolution in Healthcare with Chad Mather, MD
Moving beyond typical discussions of value-based care, Dr. Mather reframes the entire conversation. "Value-based care is financial innovation to solve important healthcare problems," he explains. These problems extend far beyond cost control to address clinician burnout, prior authorization burdens, care gaps, declining profitability, and health equity. For surgeons planning their careers, understanding this broader context proves essential.
The discussion dives deep into why procedural bundles like CJR and BPCI have limitations despite their promise. "Bundles are a building block," Mather notes, explaining their volatility problems and how they've made value-based care appear to be a "joints and spine initiative" rather than engaging entire practices. He then explores the complex world of condition-based bundles, global risk, and capitation models, illustrating why the shift from fee-for-service feels like "entering a dark forest" for many surgeons.
Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation and other areas. My name is Doug Lundy, host for this podcast series. Joining us today is Dr Chad Mather.
Speaker 2:Dr Mather is an assistant professor and vice chairman of practice innovation in the Department of Orthopedic Surgery at Duke University. He's a core faculty member of the Duke Margolis Center for Healthcare Policy, as well as the Chief Medical Officer of Optum Specialty Care. He went to medical school and residency at Duke University, did his fellowship in sports medicine at Rush University Medical Center and his master's in business administration at the Duke Fuqua School of Business. He is a health services researcher and a decision scientist with focus on economic analysis, health preference measurement and personalized decision making. His clinical practice focuses on hip arthroscopy, including both FAI and extra-articular hip endoscopy.
Speaker 2:Dr Mac there, welcome to the podcast, sir. Thanks, doug, it's great to be here. Thanks for inviting me. Yeah, chad, great to have you on. So, chad, when it comes down to when we're really looking at changes in payer models as we move into the future, we're going to discuss changes in payer models, as you and I had discussed. I don't know anybody that's going to be better to talk about this than you are. So can you tell everybody kind of what your other job is besides being a hip arthroscopist at Duke? What else do you do for a living that makes you such an expert?
Speaker 3:in this.
Speaker 2:Don't be humble, tell it all.
Speaker 3:Well, thanks, doug. Yeah, I feel like this is a topic I spent a lot of time thinking about. You know, it was a passion of mine before I even went to medical school and and and. Then, you know, as a resident, it became more interesting to me as this became more and more of a focus of the profession and I knew I had this interest and and so further developed it. I was lucky to meet you in the Washington Health Policy Fellows Program. That's where I learned a lot about the advocacy side of it, how the you know, how the sausage is made and so on, learned that there's the you know the regulatory side as well as the legislative side. Didn't even know those types of terms existed for that program. So that really gave me a great foundation for how to be actionable in the space.
Speaker 3:I spent my early faculty years, in the first several years, doing what I would characterize as the work in the components of value-based care, things like shared decision-making and patient report outcomes, so on and so forth. But as we built these really cool prototypes, I realized that this was never going to reach scale until we changed the payment model. And that was about the same time. I was going to Fuqua and there I took some great classes about organizational innovation and we came up with this concept the practice transformation unit that you had mentioned there in the bio and the purpose of that was to accelerate value-based care through development of innovative care models that would illustrate what that future looked like and the doing further experiments in the components of value based care. But then, when we're talking about today, payment models change. The payment models was also fortunate at that same time for the Margolis Center to kick off, so we had this great new health policy center at Duke and passion for that, and during that time we spent a lot of time working with Kevin Bozic at Dell and the three of us the Margolis Center, us at Duke, ortho and him at Dell working on condition-based payment, and that was really really had a lot of momentum there.
Speaker 3:And then and this is about maybe about four years ago I started feeling like we still had so much yet to answer. We had so much momentum and hope in North Carolina where we had some new leadership at our main payer, blue Cross, blue Shield. There was so much hope that we were going to be the epicenter of value-based care. And then in a moment he moves on and I realized that the limitations of a single state being able to answer these questions and that's what that's what led me to opt in that in Dan Murray, I mean, having great, great leaders is really important. I mean that's really what allows us to create things that solve these kinds of problems. And so you know, those two things that led me there.
Speaker 3:That, with one of my main goals was to learn, was to. I saw this landscape of 20 markets that we're in and said you know, we could solve this problem 20 different ways and learn from people solving in different ways. And so it has been the last four years doing a lot of learning like that and observing what's going on. So, yeah, you're right. I'm glad you asked me to again to come do this podcast because I can give you a chance to share all I've learned across our landscape in that time.
Speaker 2:Yeah, that's fantastic. I mean you're the right guy to talk to about this and, for folks who don't know, can you explain what Optum is and what your relationship or what your position in Optum is about?
Speaker 3:Absolutely so. That's usually how I start these talks on the future of orthopedic financing is kind of level setting that there. So you know, optum is a health services organization. It's a health care delivery organization that's part of United Health Group, no-transcript, an able hospital-based health systems, and that's one of the things that drew me to it.
Speaker 3:Optum is made up of a few big entities. You have Optum Insights, which is a data analytics arm. You have OptumRx, which is a big pharma arm, and then OptumHealth, which is the primary delivery piece, and then within OptumHealth you have components that are specialized, like Optum, behavioral Care, urgent Care, so on, and another section. Then you have the multi-specialty or primary care groups, ipa organizations and networks that all take substantial amounts of risk and heavy value-based care. And then you have SCA Health, which originally was an ambulatory surgery company, now evolved into a specialty alignment company. And that's where I formally sit, which is really the best of everything, because SCA still has a lot of its smaller company culture. It's, as I like to say, closer to the cellular level of healthcare. Sca, because it runs surgery centers, is only one step above that. So it's a wonderful place to work with a beautiful culture, and yet you know we're part of this big organization from a resourcing and learning standpoint, so it really is a. It's a. It's a wonderful job and very fortunate to be able to work there.
Speaker 2:So if we were in a deposition right now, the attorney would say I'd like to submit, Dr dr mather as a subject matter expert in this area. So clearly you are all right. So what?
Speaker 2:I'm asking everybody, as best as you can, within the concepts of reality before you get too far out on the edge and you start going I can't do that within the next 10 years, 20 years, however far out you feel comfortable doing. Where do you see payer models going? So my residents now who are just starting my PGY, ones who still have five years left with us here and then a year of fellowship and then they're going to get their job and pass their board and all that, so they really don't get up and spin it and cranking for probably another eight to 10 years and then they're going to do another, at least another 10 years of that. What do I tell them? This is what pair models look like that.
Speaker 3:Yeah, that's great. I love that. I love that framing. You know, I think the best way to start to answer is to take a moment to better define or at least renew the definition of value-based care. I get that question a lot.
Speaker 3:We're at this point now where people are saying what is this? And I get that question a lot, and so I've thought a lot about it and the way I like to define it and I would especially for young people is that it's value based care is financial innovation. It's using financial innovation to solve important health care problems. You know, the first problem that we envisioned solving was, as I mentioned earlier, affordability. I got really more passionate about this when I realized it could solve clinician burnout. No question that it can and should solve our prior authorization and UM burden that we face. It can solve the gaps in care that we have. That's where we used it to build a whole person musculoskeletal care model. It can solve declining physician profitability, and Dominic mentioned why that's important. And then what I think I've discovered most recently it can solve and I'm passionate about is health equity. So, especially for young people, I would suggest they look at it from that lens.
Speaker 3:What problems can we solve by innovating in the way that we pay for care and in 10 years. I think some of it depends on how well we do with that. I mean, are we just shifting the margins around, creating just different winners and losers, or are we truly solving those problems? A great example that's very tangible is exactly that Prioroth, um space. If taking more meaningful amounts of musculoskeletal risk and managing that can alleviate that burden, then value-based care has a future. That's 10 years. Those are the types of things that we try to focus on is tangible improvements in the patient experience, patient outcomes and our own experience that value-based care can solve. That's going to define the future.
Speaker 2:Where do you think let's just go to bundles then?
Speaker 3:Yeah.
Speaker 2:And I know they're coming out. So BBCI and CJR are nearly defunct. Now the federal government's come out with TEAM transforming, whatever the rest of that is. I'm not council chair anymore. What do you think about bundles? Are these the rest of that is? I'm not council chair anymore. What do you think about bundles in the? Are these the wave of the future or are these just a flash in the pan?
Speaker 3:I think bundles are a building block. Well, the mistake we we, as orthopedic surgeons should not make is to see those as the stopping point, but they were. They were a beautiful construct for us to learn. What things we did learn is if you put risk in a section of the delivery model, then you can get results. You know, bundles brought risk to the post-acute phase of care, and we see improvements in both outcomes as well as affordability in that arm.
Speaker 3:The problem with bundles, though, is and this is why I challenge a lot of surgeons to think about they're built for the clinician, that's how you want to manage care, that's how you want to manage financial risk is in a cell that you can control the bundle, the episode. The problem, though and it's on a classic insurance, if you're taking a risk on something too small, it's very volatile, and so it's thus the benchmark pricing problem that has befallen bundles and, I think, will continue to. Just based on the structure, you know, you have one reference group that you might price that, that bundle, at, and then there's a different group that you actually take care of, and that crushes the whole model. All the all your good work, you work based on the volatility of that benchmark price. So if bundles do have a significant future on a large scale, we've got to solve for that.
Speaker 3:The only way I know to do that is to expand the scope of the risk that you're taking and so that you absorb effective volatility in that way. So the other problem and this is so important, doug is that bundles have made value-based care appear to be a joints and spine initiative. Right, right, right, and that is a problem for the practices, for our practices more than any, because it splits them apart. And now you've got, okay, we're generating money here, we're maybe distributing it, and there's tension around that versus things that everybody can be involved in. So that's my other problem with bundles is they're too narrow to involve everybody.
Speaker 2:Yeah, wow, you almost stepped into narrow networks on that one. So you're talking really specifically about procedural-based bundles bundles around total knee arthroplasty, total hip arthroplasty, spine or proximal femur fractures. If you want to get into CJR and well, not CJR, ppci what about the stuff that Kevin Bozick's been talking about, carl Koenig's been talking about in terms of condition-based bundles, more or less, and you can even take that off into decapitated care if you want.
Speaker 3:Sure, well, that's where I started. That was my first jump off point was condition-based bundles and I thought that that was the solution. But when we would, we'd make progress and I could hear the you know the sausage being made, if you will, and it was almost like I could sit. I could feel the house collapsing under the weight of the details. And it's even even harder to define things like attribution. So another when I talk about payment models and I'm really focused on education, I'll go through the list of terms. You know that it's important to understand, to really engage in this.
Speaker 3:Attribution is one of the biggest and hardest ones. Attribution means you're responsible for this and then we, you know, pay you as such Procedural bundles. The attribution is so easy. Right, you did a procedure. I mean you did it. It's pretty obvious you did it. Attribution is super easy.
Speaker 3:In condition-based bundles the attribution is a lot harder and that's challenging there. So you search who's responsible for what and when, and then that affects the course of pricing and so on. So the details are challenging. The other problem with condition-based models they don't solve necessarily for the problem I mentioned about it being a joints and spine initiative versus an everybody initiative, and I think, the complexity of condition-based bundles. In my career we may only get through joints and spine and yet you know, that's only two thirds really of the opportunity that is out there. So those are.
Speaker 3:Those are some of the reasons that we've kind of decided to move away from or at least I think we should move away eventually from condition-based bundles. That said way the way that we're paid and the way we manage care are not necessarily the same. They have to support each other. But you can. You can have a payment model that is not a bundle and you can manage care as a bundle within that because it's easier. So the incentives and the things that we want to do within condition-based bundles, the focus on shared decision-making, patient-reported outcomes, the whole person care we need to do that and support that with the right financing model. I just don't know that the condition-based bundle is the one. Support that with the right financing model.
Speaker 2:I just don't know that the condition-based bundle is the one. Yeah, but under the procedural-based bundle I'm paid to do surgery.
Speaker 2:So if somebody comes in and not that anybody would do this but I'm incentivized to do total knee arthroplasty on somebody with degenerative knee pain, Whereas if I'm under a capitated condition-based bundle, if I'm on a capitated condition-based bundle, I should really only operate the people that, because we know that not everybody who gets a total knee gets better. So I should really target this total knee arthroplasty for the people who are specifically going to get better and offer less expensive care to the people where that's not going to help them. So what, you don't think that condition-based bundles help in that regard?
Speaker 3:I think they're a step in the right direction, they're another building block, but I don't think they can solve for everything and I do worry that the complexity of them is. I have a framework. I think about impact versus complexity, impact versus complexity and, you know, I think I worry that condition-based bundles, while they should do exactly what you mentioned, the complexity of administering them will prevent them from growing to the level that they should. And rather, we may look at other, like you say, capitated models, capitation, broader risk models that would create the same incentives without the complexities of definition, administration, attribution and so on.
Speaker 2:Okay. I can see that, so that's good, I like that. So at Optum there. So you guys, how many lives are y'all covering?
Speaker 3:So you guys, how many lives are you all covering, gosh? I mean in total, it's. You know I don't even know the exact number, it's, you know hundreds of thousands, millions of lives. You know mostly Medicare Advantage.
Speaker 2:Yeah, sure.
Speaker 3:Then we manage commercial as well, and so on.
Speaker 2:Yeah, and to your earlier point. I mean the bundles are, if the bundles are anything at all, the PPCI, cjr, or you can even put that into MACRA with the APMs and MIPS. If you want to talk about complexity, they have achieved that, wouldn't you agree? I mean anything the federal government comes out with. I mean you just hope your head doesn't explode as you're trying to read it. I don't know how anybody's supposed to get that done.
Speaker 3:There's also a one size fits none problem there too, right right Now. That, yeah, that we have. So I think you know models that allow for more. You know more flexibility. More you know can be, I think, can work better.
Speaker 3:Now I often say too that it's just the complexity sits somewhere, you know, I mean, in a condition-based bundle there's a lot of complexity on the payer side because they've got to administer all that.
Speaker 3:If you know, say, now the alternative side is something like you mentioned cavitation, where we're just paid a fee, we still have to figure out on the practice side how to distribute that money in a way that generates the incentives, right. We have to figure out who does practice side, how to distribute that money in a way that generates the incentives right. We, we have to figure out who who does what and when and how in order. And so I, I, you know, one of the things I I learned from a lot of my people I work with is we would talk about these, these condition-based bonos, at a high level and then they'd look at me and say, yeah, I get it, but how do I pay my people? So, right, right, yeah, right. So the complexity just gets shifted to us. But I would say I'd rather, as clinician leaders, be managing that complexity rather than have it being managed for me.
Speaker 2:Yeah, you just went where I was trying to get to. Whereas we assume the risk, then If we have in our group, in our university setting, in our hospital setting, we assume the risk on the condition-based mental health setting and yet pay us the capitated fee, we'll take care of the population and then we'll figure out how to pay people from that capitated payment.
Speaker 3:That's right.
Speaker 2:Wow, Chad, we're in the deep end of the pool here.
Speaker 3:I hope we can get to that point, but what we think is an in-between, that is, that balance of complexity and opportunity is just short of cavitation, which is still global risk. So it's just saying you're taking a risk on the whole MSK if you will, but it's still retrospectively, it's not prospective. So the difference between cavitation and global risk models capitation is prospective and, as we know from prospective bundles, it's powerful but it is disruptive, right, and it is hard to manage. And I you know your question about 10 years. I hope we can get to really effective capitative models in 10 years. We would be doing well if we did that in 10 years.
Speaker 3:Right, right, that's what we'd all like to get to, but it's hard, it's hard to. We're not used to that, as you know that we're used to do it. So you know RVU models and CPT codes and I do this work and I get, and I get paid right, like the. The fever service system is so transparent, it's so predictable because it's based on work and you understand work, right, and when you move away from that boy it is, it's dark, I mean it's it's. You know you're in a dark forest and trying to find your way and we have to be honest about how hard that's going to be.
Speaker 2:You know um so I think that's the most eloquent I've ever heard that said I'm not kidding. I mean I really, because I've been thinking of this whole time and yeah, all right, you just said it all. I was talking about consolidation. So at Optum, y'all have consolidated a fair amount. How does consolidation of the payer market? How is that going to impact us in the future? What does that look like?
Speaker 3:Yeah, yeah, I mean I think you know, I don't know, I don't, I don't spend a lot of time on that side of the house. Probably they would want me to comment on a lot on it anyway. I mean, from a from a, from our side you know, the clinician side, the, the, you know, the surgeon leaders side, I I think there is some benefit to some economies of scale. I think when you can move things state to state so you have payers that cross the states and you can say we did this great thing in Pennsylvania model worked great, let's take it to North Carolina. When you have a payer that can do that, a national payer that can do that, can transport those things, that does allow this to grow a lot faster At the same time, this to grow a lot faster at the same time.
Speaker 3:You know, competition is great and and competition drives innovation and um, and I think you, you, uh, you want to be in a place where there are multiple payers trying to solve the same problem, because we still haven't solved for it all. So there's some balance there, and so I guess if I was picking the perfect type of environment to drive payment innovation, I would say it's, it's, you know competition in the markets themselves with national relevance, you know. So. You know where there was where the same payer had a significant you know market share in a number of states, but maybe not a you know, a dominant share in any one single state.
Speaker 2:Yeah, it's. It's great hearing you say that, because when I was at resurgence I knew that dan murray was doing some really cool stuff in ortho carolina with the blues and we're like man, we want to move that down to georgia, down to atlanta, and uh, no, go buddy, it didn't. It didn't cross over state lines that's right, it's like what do you mean? Come on, dan, and dan was more than happy to share what they were doing in North Carolina, but the Blues wouldn't let us do it.
Speaker 3:That's right, that's right.
Speaker 2:Another question I had for you is and you learned this in business school, I am absolutely certain is that if you look, if you talk to the pundits, they say we pay way too much for health care in the US, that that is more than twice as expensive as other developed nations in the world, without any increased evidence of quality. So we're just super expensive, without any demonstration for that increase in cost. And you work with one. I certainly don't want to put you in a conflict, but you work with one of the big payers. Do you feel that stress that people are? Because whenever I talk to the folks inside the Beltway in DC, I feel that stress. Do you feel that stress that, man, our health care costs way too much. We got to find ways to deliver this less expensively.
Speaker 3:Definitely. I mean definitely. There's no question that when the risk is shifted to the clinician and you know that affordability pressure is real. But I'm glad you asked this question though, because this came up with recently. You know, one of my partners, one of our great clinical partners, said you know, I don't know about value-based care. Are we just shift, like I said, shifting the margins around, and is a patient ever going to see the benefit of this and so on, shifting the margins around and is a patient ever going to see the benefit of this and so on? And I said you know we should.
Speaker 3:We should, in our back of our mind, question whether they even want to spend less on healthcare. I know that might not be, you know that might be controversial, but but I think more what they want is more for what they are paying. You know the society wants more for what we're paying on healthcare. I think in this country we do value our health care a lot. I think we value our access to health care a lot. We value our health a lot, and I think we're just not getting enough for what we're spending. I might argue that that's actually what value-based care is supposed to drive. That's why I like to introduce it as solving these problems. Solving these problems. One of them is the cost of care, but I think I listed five or six right. So I would challenge that, and I think thinking about it in that way helps you understand what any stakeholder wants out of this.
Speaker 3:The other problem, though and one of my payer friends told me this was great insight he said I asked him is quality or cost more important? Because when you're selling, when a payer is selling a health plan, they can buy it on any number of things, and people want good health coverage, they want good care, right? He said that's not the problem. The problem that you know quality is important. It's not that quality is not important. Quality is harder to see. The cost of care. The premium amount is so transparent, right. You know what a few cents is. You know exactly what it means in your budget to pay this much more money a month. The employer knows exactly what that's going to do to their budget. When you show them what quality care is, don't know exactly what that means, right. And when you're trying to choose between things, everything from a quality standpoint probably looks similar, but the cost it's very clear to see the difference, so it's not about I think it being more or less important quality versus cost.
Speaker 2:I think it's about how easy it is to measure it and see it. All right, you brought it up. So I had lunch the other day with our vice chair of family practice in our system, yeah, and he was telling me and my diet partner that he, that his doctors, get bonused based of the diastolic blood pressure and HBA1C that's measured over the year on their captured patients in Epic. So how do you measure quality? That's a great measure, it's a nice, hard, objective number right. How do you measure quality in orthopedics, then?
Speaker 3:Yeah, great question, just off of pros or what.
Speaker 3:Well, the first thing I would say is that's the single most important question and challenge that we have to advance value-based care. I realized that in this last year that value-based care lacks a measurement system, especially in specialty care. The primary care space has the STARS system. They have this robust way of evaluating quality within their risk-based model. We have almost nothing evaluating quality within their risk-based model. We have almost nothing. And yet in the fever service world, we've got so many metrics that tell you how you're doing. And so I think the message I've been sending more and more is that we have to get to a measurement system that we build. We want to be building this. We don't want to have it built for us, which it is being built for us. We want to be building that, and we have to be serious about getting you something feasible, not just something perfect, but something feasible. I think that's I guess that's my main message is this measurement system is imperative. How we measure quality, then you know, I think with it varies. I think you've got to look at the stakeholder, I think you have to look at what's important, and there's measuring quality and outcomes, and then there's assessing performance within that system. Different things right.
Speaker 3:One of my favorite books is Dave Jessivar. I love that I heard him say recently. I really love this concept of resulting he talks about.
Speaker 2:Yeah, CEO at OrthoVirginia. Yeah, CEO at OrthoVirginia, yeah.
Speaker 3:CEO at OrthoVirginia about the result you get, the outcome. The hemoglobin A1C may or may not be related to the decisions you make. You may make a bad decision. They may have a good outcome and vice versa. Right? So we have to balance the outcome the prom with our ability to manage it. And that takes me to the importance of experience. Right, you know, I had another day at a personal experience healthcare and had a lot of those lately with my family. I am often so struck on how important a great experience is. I mean, it's something that has everything to you, right? I mean it connects you to the system, that connects you to your family. It is, it is so critically important and I know we don't it's not that we don't think it's important, but that's something we can control Right? I think a lot about when we measure performance and what's important about, about focusing a lot on on on the experience to healthcare.
Speaker 2:So the CG caps and H caps actually accurately reflect that or no?
Speaker 3:I think. I think, again, that's a step in a direction. I don't think they capture it completely. I think the way they're measured is questionable too, and the way that we use it as a benchmark, I think, is questionable too. I think, yeah, I mean, there's a lot, a lot of different ways of measuring. I mean, another way to assess experience can be the use of things that we know drives good experience.
Speaker 3:If you're using shared decision-making tools, if you are reviewing patients' problems, you're probably providing a better experience, right, and so that gets again into, you know, the things I can control as a doctor that I want to be measured on. I want to be measured on whether I look at their problems and talk to them about it, not how they interact with the receptionist. Now, that's important and I got to quarterback that Right. But that's the pushback you get on CG caps is. You know they got in traffic that day. They're already upset, forgot their coffee and I'm already going to lose, or they're, or what. I see a lot of this referred. They refer to me. They shouldn't see me at all. I can't really help them. They waited three weeks to see me. I'm I mean, I can't hard to save this one right. So, versus, have I used the tools at my disposal to create the best experience possible?
Speaker 2:so what do I tell my pgi fives? That are on their way out, getting ready to take their fellowships, and they're asking me hey, man, so in terms of looking for a good position, a good job, in terms of the future, in payer model, what do I tell them?
Speaker 3:Yeah, I love that, doug, because I think that dovetails a lot into what we look for in our practice partners. So one of the main things that I do at SCA Health is run a value-based care partnership model, and we primarily partner with independent practices but also health systems and so on. And so we think about who's the best fit for that and what's going to dictate future performance and so on. And so we think about who's the best fit for that and what's going to dictate future performance, and so on. And my answer to a lot of this is thinking about real performance versus ability to perform. And when I think about the ability to perform in any set of model, it comes down to the organizational effectiveness and culture.
Speaker 3:So what I would tell your PGY-5 is look for practices who have solved some difficult problems as an organization. That might be the most important thing. Problems might be top of that list or the most visible, but what has the practice organization solved together as an organization and is that problem something that builds for the future? So one of my kind of four big things to watch for or to solve for is how do we evolve the way we deliver care to be at the forefront of value-based care, to dictate what's going to be done versus react to it. And if we do it too far, we, we know we we're going to, we're going to bankrupt their practices. We can't completely change that payment model, but if we don't change it all, then we will constantly be playing catch it. We'll have no leadership in that.
Speaker 3:And so I think you know you, look at a practice who has, who has built for the future, without having to be paid for every piece of thing that they do, has invested right, and having to be paid for every piece of thing that they do is invested right. And development of capabilities for the practice. That's probably number one. I think that's number one. I think the other things to look for are, you know again, great leaders, great culture.
Speaker 3:I mean and that's part of that, of course, but I mean, when you're in an environment that's constantly changing, having you know your, your leaders are is critically important. And it's also amazes me I'm sure you see this too how much an organization reflects its leaders. I mean, isn't it incredible how quickly and broadly an organization will reflect its leaders, credible, how quickly and broadly the organization will reflect its leaders. So you know, if you have a leader that you in that practice that's, that is infected and they're not going anywhere. That's how the practice's culture is going to behave too, and so I I would be wary of that when you're finding a place.
Speaker 2:Yeah yeah, that's good. Those are great nuggets. All right. Last question for you. So you are now I am now appointing you as the secretary for health and human services. The Senate has confirmed you and the deal with this is you're actually stuck in this job for the next 10 years and what you do during this next 10 years affects the healthcare of our nation for the next 20 years. What are you going to get done in the next 10 years, secretary Mather?
Speaker 3:Wow, that would be an amazing opportunity.
Speaker 2:I'll sign up for that.
Speaker 3:But my employer wants what I might want. It could be similar or maybe a little bit different, but I think how I would answer that is I would continue to to advance the accountable care initiative. I think the I think having the risk in the hands of the clinicians is is the answer and, as as a you know, hhs and CMS and so on, important to remember that our role is to facilitate that right it is. It is not to be in that game. Role is to facilitate that right. It is not to be in that game, it's to facilitate it. And I think there's more that can be done to share learnings, to learn from what's happening where and so on, and really drive that, to listen to everybody that's involved and really share in a lot of those learnings.
Speaker 3:But I think, from a specialty standpoint, we have to figure out how to really get to meaningful risk. The accountable care initiative cannot end with primary care. It has to involve specialty care and in that role that's what I would focus on the next 10 years is expanding accountable care to meaningfully engage and involve the specialists. Right now I think the accountable care is transferring it to the primary care provider and then facilitating the interaction with specialists, but I'm talking about actually meaningfully transferring that risk, making the specialists accountable in those more type of global risk models. That's going to move care forward. That's going to drive affordability and really create something that feels different to our patients and, in this case, constituents, if you will.
Speaker 2:Well, if I was elected president, you'd be. You'd be my secretary of human services. All right, this has been absolutely spectacular. I really enjoyed talking with you, chad. So we have had Dr Chad Mather, who is the vice chair of practice innovation at the Department of Orthopedic Surgery at Duke University, where he's a hip arthroscopist. He's also a core faculty member of the Duke Margolis Center for Health Policy and the chief medical officer of Optimus Specialty Care. Chad, thank you so much for being on the podcast.
Speaker 3:Great Thanks, doug. It was great being here, always great to talk with you and see you.
Speaker 2:Absolutely, friend, and y'all look forward to futures in orthopedic surgery. Podcast on this podcast channel.