1 00:00:03,720 --> 00:00:06,980 It is so important for leaders at the top of organizations to keep learning, 2 00:00:07,170 --> 00:00:08,860 stay sharp, grow their networks, 3 00:00:09,290 --> 00:00:12,420 help our audience better do this in a more simplified, personalized, 4 00:00:12,480 --> 00:00:16,180 and meaningful way. Becker's Healthcare has launched my B h c, 5 00:00:16,690 --> 00:00:19,900 it's your trusted Becker's healthcare experience and more with content, 6 00:00:19,930 --> 00:00:22,260 connections, events, and learning opportunities. 7 00:00:22,890 --> 00:00:27,780 Join the community free of charge@www.my dot becker's hospital 8 00:00:27,780 --> 00:00:29,780 review.com, and we'll see you there. 9 00:00:33,410 --> 00:00:37,580 Well, thank you so much for tuning in to the Becker's Healthcare podcast series. 10 00:00:37,770 --> 00:00:41,620 This is Jacob Emerson, associate news Director in the Becker's newsroom. 11 00:00:41,890 --> 00:00:46,140 Pleased to be joined today by an esteemed guest, Dr. Robert Pearl, 12 00:00:46,800 --> 00:00:50,940 who is going to discuss with us consolidation in the healthcare industry and the 13 00:00:50,970 --> 00:00:54,020 rise of health services giants. Now, Dr. 14 00:00:54,020 --> 00:00:58,100 Pearl is professor at Stanford University's Medical and Business Schools. 15 00:00:58,450 --> 00:01:01,340 He's the best selling author, a Forbes healthcare contributor, 16 00:01:01,840 --> 00:01:06,140 and is the former c e o of the Permanente Medical Group. So, Dr. Pearl, 17 00:01:06,190 --> 00:01:09,860 thank you so much for taking the time to be with us on the podcast today. 18 00:01:10,710 --> 00:01:12,420 Thank you Jacob, for inviting me. 19 00:01:13,930 --> 00:01:18,270 So, so Robbie, appreciate you taking the time to be with us. Um, you, 20 00:01:18,270 --> 00:01:21,830 you've published so much of your thoughts on the topic of healthcare 21 00:01:22,110 --> 00:01:26,950 consolidation, and this is obviously such a rapidly changing area, as you know. 22 00:01:27,210 --> 00:01:31,990 So I wanna just start broadly by asking where you view our healthcare 23 00:01:32,090 --> 00:01:36,670 system today. We've got so much going on right now with the big players, Kaiser, 24 00:01:36,810 --> 00:01:39,910 of course, acquiring Geisinger to launch Rand Health, 25 00:01:39,910 --> 00:01:43,790 United Health Group being the largest insurer and owner of physicians now. 26 00:01:44,090 --> 00:01:46,670 And then the retail disruptors like Amazon and Walmart, 27 00:01:46,890 --> 00:01:49,750 really expanding their healthcare capabilities. 28 00:01:49,970 --> 00:01:53,630 So how should we be framing where we're at right now? 29 00:01:55,110 --> 00:01:58,630 I think of this as a conglomerate of monopolies. 30 00:01:59,430 --> 00:02:03,890 You're looking at five or six insurance companies 31 00:02:04,930 --> 00:02:06,610 covering over half of the nation. 32 00:02:07,590 --> 00:02:12,490 You're looking at hospitals that consistently are consolidating not 33 00:02:12,510 --> 00:02:13,930 to improve performance, 34 00:02:14,420 --> 00:02:18,370 which should happen in most economies of scale, 35 00:02:18,870 --> 00:02:21,130 but instead simply to be able to raise prices. 36 00:02:22,200 --> 00:02:24,820 We know that in the medication area, 37 00:02:25,330 --> 00:02:28,460 drug companies are definitely consolidated, 38 00:02:28,800 --> 00:02:32,940 all working to the same outcome of ever higher prices. 39 00:02:33,760 --> 00:02:38,580 And now we're starting to see the entry of private equity into the 40 00:02:38,940 --> 00:02:42,660 provider network. And their goal is, again, 41 00:02:42,800 --> 00:02:47,070 market control to raise prices. So far, 42 00:02:47,230 --> 00:02:52,030 I can't find anyone outside of a small number 43 00:02:52,130 --> 00:02:56,510 of groups like Kaiser Permanente that are trying to focus on opportunities to 44 00:02:56,630 --> 00:02:58,790 increase value and lower cost for patients. 45 00:02:59,530 --> 00:03:03,100 Yeah, absolutely. And let's talk a little bit more about Kaiser Permanente. 46 00:03:03,520 --> 00:03:07,140 You led the medical group side of the company for 18 years, 47 00:03:07,560 --> 00:03:10,100 so I do wanna ask you a bit more about Rise and Health, 48 00:03:10,320 --> 00:03:14,300 how you think that will go in the long term. Um, you of course, 49 00:03:14,300 --> 00:03:17,940 you wrote in Forbes a few weeks back about the conversations that you've been 50 00:03:17,940 --> 00:03:21,460 having since they first announced that deal. Um, and, 51 00:03:21,460 --> 00:03:23,900 and you've been speaking with a lot of healthcare leaders across the country 52 00:03:23,990 --> 00:03:24,760 about this, 53 00:03:24,760 --> 00:03:29,700 almost all of them asking the question that I just did of will it work and 54 00:03:29,730 --> 00:03:33,900 what is causing you some initial doubts on this acquisition? 55 00:03:35,820 --> 00:03:38,730 There are two aspects that are creating doubt. 56 00:03:39,660 --> 00:03:44,650 First problem that I see is that the acquisition was 57 00:03:44,680 --> 00:03:48,610 done through the hospital and health plan, half of Kaiser Permanente, 58 00:03:49,230 --> 00:03:52,170 not the medical group half or phrased differently through Kaiser, 59 00:03:52,430 --> 00:03:54,290 not through Permanente, 60 00:03:55,030 --> 00:03:58,890 and the knowledge about how to increase performance, 61 00:03:59,790 --> 00:04:04,690 how to become the number one quality organization in the nation according to the 62 00:04:04,730 --> 00:04:05,563 N C Q A, 63 00:04:05,990 --> 00:04:10,130 how to achieve access and service as 20 points higher than, 64 00:04:10,130 --> 00:04:14,050 than the communities around the medical centers 65 00:04:15,040 --> 00:04:16,660 for JD powered associates. 66 00:04:16,880 --> 00:04:21,340 How to have lower prices that resides in the medical group. 67 00:04:21,880 --> 00:04:26,740 And I can't quite see how this is going to change the current 68 00:04:27,380 --> 00:04:31,180 economic challenges faced by Geisinger. 69 00:04:31,840 --> 00:04:36,020 The second problem that I see is that Geisinger has a very mix, 70 00:04:36,260 --> 00:04:40,330 a hybrid payer revenue stream. 71 00:04:41,430 --> 00:04:43,760 Some is capitated, they have their own health plan, 72 00:04:44,260 --> 00:04:48,240 but a lot of it is coming through very traditional fee for service. 73 00:04:48,980 --> 00:04:51,360 And when doctors are paid, 74 00:04:51,870 --> 00:04:55,760 when hospitals have to perform with a hybrid model, 75 00:04:56,190 --> 00:05:00,840 they don't quite know what to do because if you do the things that are 76 00:05:00,850 --> 00:05:03,570 value based, lower demand, 77 00:05:04,320 --> 00:05:06,610 move to the outpatient and home arena, 78 00:05:07,930 --> 00:05:11,850 maximize care for patients with a chronic disease so they don't get heart 79 00:05:11,850 --> 00:05:14,090 attacks and strokes and cancer, 80 00:05:14,670 --> 00:05:17,130 you're finding yourself with half empty hospitals. 81 00:05:17,150 --> 00:05:21,250 You're finding yourselves without having the income that you expected 82 00:05:21,910 --> 00:05:26,890 before and making the pivot to something that is going 83 00:05:26,890 --> 00:05:31,810 to be purely value-based. I think that's gonna be very difficult for it to do, 84 00:05:31,970 --> 00:05:34,490 particularly as the competitors, 85 00:05:35,060 --> 00:05:39,770 university of Pittsburgh Medical Center and the University of Pennsylvania 86 00:05:40,310 --> 00:05:44,570 are acquiring medical groups surrounding them and trying to take market share 87 00:05:44,640 --> 00:05:45,430 away from them. 88 00:05:45,430 --> 00:05:49,970 Mm, that's a great point that yeah, as these, as the rise ant grows, 89 00:05:49,970 --> 00:05:53,130 they are entering a very highly competitive area. Uh, 90 00:05:53,130 --> 00:05:56,650 you just mentioned with U P M C as well. Um, we, 91 00:05:56,650 --> 00:06:00,100 we heard Greg Adams last week or a few weeks ago, excuse me, 92 00:06:00,100 --> 00:06:04,260 at AIPs 2023 conference, talking a little bit more in detail about this, 93 00:06:04,430 --> 00:06:07,700 about this deal, about how this isn't meant to be the, 94 00:06:07,720 --> 00:06:10,740 the replication of Kaiser Permanente in Pennsylvania, but, 95 00:06:10,800 --> 00:06:14,700 but like you just said, Robbie, uh, spread of value-based care, um, 96 00:06:14,810 --> 00:06:19,140 into other areas. Um, so a spreading of the Kaiser model. 97 00:06:20,000 --> 00:06:23,340 Um, we are of course, we're seeing non-health systems, UnitedHealth Group, 98 00:06:23,840 --> 00:06:25,620 CVS Elance slash Anthem, 99 00:06:25,850 --> 00:06:29,660 they're continuing to grow into non traditional, 100 00:06:29,660 --> 00:06:32,100 what they started as as insurance companies. Um, 101 00:06:32,100 --> 00:06:37,100 they're healthcare service giants now that have incorporated the insurance piece 102 00:06:37,100 --> 00:06:40,460 of the business, the care delivery side, and a heap of other services, 103 00:06:40,800 --> 00:06:44,700 of course. Um, so, so I guess the question naturally is, 104 00:06:44,880 --> 00:06:49,020 is this the model of the future for everybody? I. 105 00:06:50,480 --> 00:06:53,900 Do not believe so because to me, 106 00:06:54,120 --> 00:06:59,100 Kaiser Permanente is successful only because it has 107 00:06:59,100 --> 00:07:03,620 the combination of the insurance, the hospital and the medical group. 108 00:07:04,040 --> 00:07:07,700 And when you don't have all three of those fully aligned, 109 00:07:09,060 --> 00:07:13,620 I don't think you see a major change in performance. And as you've noted, 110 00:07:13,950 --> 00:07:17,380 given all of these changes in the healthcare world, 111 00:07:18,010 --> 00:07:19,740 what did the government, uh, 112 00:07:19,850 --> 00:07:24,340 published last week that by the year 2031 113 00:07:24,390 --> 00:07:29,060 healthcare will be $7.2 trillion, right? 114 00:07:29,160 --> 00:07:33,340 And a consumer is 20%. Now we can debate whether that's accurate or not, 115 00:07:33,840 --> 00:07:38,660 but that view that basically what exists today isn't going to turn 116 00:07:39,240 --> 00:07:43,460 the trend in the right direction. It's not gonna raise quality, improve access, 117 00:07:43,480 --> 00:07:46,180 and lower cost simultaneously. I don't, I don't, 118 00:07:46,220 --> 00:07:49,820 I maybe the future of the current incumbents, 119 00:07:50,080 --> 00:07:51,420 but as you mentioned earlier, 120 00:07:52,020 --> 00:07:56,580 I think the real future is going to come through the retail giants only because 121 00:07:56,600 --> 00:08:00,620 the people inside the industry aren't going to do what's needed. 122 00:08:01,120 --> 00:08:05,020 And there, what you see is you see the Amazons, the cvs, 123 00:08:06,080 --> 00:08:11,040 the Walmarts acquiring all of the pieces, a pharmacy, 124 00:08:11,480 --> 00:08:15,320 a delivery system, a home health system, an insurance arm, 125 00:08:15,820 --> 00:08:19,120 or they'll be looking to do it through self-funded insurers, 126 00:08:19,980 --> 00:08:22,920 and they're not gonna contract with all the doctors in the community, 127 00:08:23,100 --> 00:08:26,000 and they're not going to contract with all the hospitals. 128 00:08:26,060 --> 00:08:30,600 And they're gonna find centers of excellence able to do superior total joint 129 00:08:31,240 --> 00:08:33,680 outcomes at 40% lower prices. 130 00:08:34,100 --> 00:08:38,600 And this is gonna be the disruption in healthcare, not this year or next year, 131 00:08:38,860 --> 00:08:41,040 but somewhere in the five to 10 year range. 132 00:08:41,500 --> 00:08:45,800 And if you look at what every one of them is focused on Medicare 133 00:08:45,990 --> 00:08:48,890 Advantage, why? Well, 134 00:08:48,890 --> 00:08:53,490 it's possible we could debate the fact that it's has excellent revenue stream 135 00:08:53,490 --> 00:08:56,740 that's been talked about as being fairly high. 136 00:08:57,760 --> 00:08:58,900 But more importantly, 137 00:08:58,980 --> 00:09:03,340 I think they're doing it because it's the inroad to capitation, 138 00:09:04,480 --> 00:09:09,260 the only fully capitated program outside of a Kaiser Permanente that I'm aware 139 00:09:09,260 --> 00:09:14,060 of in this country, maybe Chen better or a couple of other primary care groups. 140 00:09:14,560 --> 00:09:18,620 But that's not the model that exists. Capitation, 141 00:09:18,740 --> 00:09:22,420 I think is gonna be the future for the employer, for the payer. 142 00:09:22,770 --> 00:09:27,500 It's a guaranteed cost with promised quality and service. 143 00:09:27,640 --> 00:09:31,580 It aligns the incentives to avoid heart attack, strokes and cancer. 144 00:09:32,160 --> 00:09:36,900 It allows people to focus on patient safety early, uh, 145 00:09:36,960 --> 00:09:41,180 access to care, to avoid complications and secondary problems. 146 00:09:41,580 --> 00:09:43,540 I think that that's going to be the future. 147 00:09:43,830 --> 00:09:45,620 We've talked about it for almost a hundred years, 148 00:09:46,080 --> 00:09:47,620 but I think that's actually coming. 149 00:09:48,000 --> 00:09:52,250 And if the government is right and healthcare costs reach 150 00:09:52,610 --> 00:09:54,210 19.6% of gdp, 151 00:09:55,160 --> 00:10:00,090 that will be the trigger that makes what has been a theory into practice. 152 00:10:00,880 --> 00:10:03,210 Yeah. So capitated is the future. 153 00:10:03,350 --> 00:10:08,170 The first tow dips into that pool has been the Medicare advantage realm 154 00:10:08,190 --> 00:10:12,770 for most of these companies. Um, but so, so it seems fair to say then, Robbie, 155 00:10:12,770 --> 00:10:15,890 that the traditional healthcare entities, let's say a health system, 156 00:10:16,470 --> 00:10:18,850 the ones that are most cozy with these retailers, 157 00:10:18,950 --> 00:10:22,210 are likely going to be the most successful moving forward. 158 00:10:24,600 --> 00:10:28,800 If you mean by that, an Aetna with cvs to me, 159 00:10:29,060 --> 00:10:32,480 you can call it Aetna, you can call it cvs. It's going to be in essence, 160 00:10:32,550 --> 00:10:34,760 very similar to Kaiser Permanente. Mm-hmm. , 161 00:10:34,760 --> 00:10:38,680 it has an insurance arm, it has, uh, you know, it acquired 162 00:10:40,220 --> 00:10:44,920 Oak Street, it acquired signify, you look at Amazon, it acquired one medical, 163 00:10:45,430 --> 00:10:48,040 this, this is the fully integrated model. 164 00:10:48,840 --> 00:10:53,240 I think that's duplicating where Kaiser Permanente has been successful. 165 00:10:53,420 --> 00:10:55,640 You know, if you look at the failures of Kaiser Permanente, 166 00:10:55,640 --> 00:10:58,440 and there've been five or six regions that have had to close, 167 00:10:59,190 --> 00:11:02,720 even though they're called Kaiser Permanente, that's not how they performed. 168 00:11:03,110 --> 00:11:04,400 They were in essence, 169 00:11:05,060 --> 00:11:09,080 fee for service models contracted with many physicians in the community 170 00:11:09,790 --> 00:11:14,720 providing the type of reimbursement at the delivery system level that encourages 171 00:11:15,020 --> 00:11:19,640 volume not value. So it's not what you call something, 172 00:11:20,110 --> 00:11:21,560 it's how it performs. 173 00:11:22,380 --> 00:11:26,960 And you can be Kaiser Permanente and fail as much as someone else, 174 00:11:27,540 --> 00:11:31,960 but I can't see how the types of massive changes, 175 00:11:32,580 --> 00:11:36,280 and I'm talking about 25% improvements in preventive services. 176 00:11:36,700 --> 00:11:40,720 I'm talking about 25% fewer complications from chronic disease. 177 00:11:41,100 --> 00:11:43,000 I'm talking about 15, 178 00:11:43,020 --> 00:11:46,760 20% lower cost while quality and services going up. 179 00:11:46,910 --> 00:11:50,960 When I was the CEO in Kaiser Permanence, that's what we achieved. Yeah. 180 00:11:51,060 --> 00:11:55,780 And so it's possible, but it requires that you have the right structure, 181 00:11:56,160 --> 00:11:59,220 the right incentives, and anyone who believes that simplify, 182 00:11:59,220 --> 00:12:03,260 putting a label on it is going to accomplish it, is going to be disappointed. 183 00:12:03,810 --> 00:12:06,180 Yeah. And I know you've written directly that the, 184 00:12:06,200 --> 00:12:09,740 the ones that are gonna be most successful here are those that, uh, 185 00:12:09,740 --> 00:12:13,900 disrupting healthcare, those that have the size, the national presence, 186 00:12:14,000 --> 00:12:18,980 and the willingness to accept massive risk among all these changes that are 187 00:12:18,980 --> 00:12:22,060 occurring. Um, but, but I did wanna ask you, Robbie, 188 00:12:22,400 --> 00:12:26,900 do you think healthcare regulators are prepared to take on this new 189 00:12:27,450 --> 00:12:28,283 environment? 190 00:12:30,450 --> 00:12:33,910 I'm not certain what you mean by healthcare regulators. There are a lot of them, 191 00:12:34,300 --> 00:12:36,230 obviously , uh, , 192 00:12:36,380 --> 00:12:41,070 they haven't stepped into stop hospital consolidation with higher 193 00:12:41,090 --> 00:12:44,790 prices. And it's been well written about by Zach Cooper from Yale. Mm-hmm. 194 00:12:44,830 --> 00:12:44,990 , uh, 195 00:12:44,990 --> 00:12:49,110 how much higher the costs are in communities that are consolidated versus not 196 00:12:49,350 --> 00:12:51,030 consolidated. Um, 197 00:12:51,700 --> 00:12:54,670 they've made some small steps in different locations, 198 00:12:54,690 --> 00:12:57,390 and there's obviously a lot of state regulators and other regulators. 199 00:12:57,810 --> 00:13:02,070 So I'm not sure that they're ready to handle the challenges of 200 00:13:02,520 --> 00:13:07,270 healthcare overall. Even Medicare that should be able to lead the way. 201 00:13:07,860 --> 00:13:11,710 It's these tiny steps. NIPS and macro. Yeah. 202 00:13:11,710 --> 00:13:13,830 8% here and 4% there. 203 00:13:14,100 --> 00:13:18,390 What you have to fundamentally shift the entire 204 00:13:19,150 --> 00:13:20,270 structure that exists, 205 00:13:20,770 --> 00:13:25,430 you have to have all your providers being capitated at the 206 00:13:25,670 --> 00:13:29,630 delivery system level, including doctors in hospitals. 207 00:13:29,970 --> 00:13:33,310 And the thing about these large organizations, remember Forbes, 208 00:13:33,310 --> 00:13:36,230 fortune 500 came out, I think two weeks ago, 209 00:13:36,650 --> 00:13:41,350 and of the six largest companies in the United States based upon 210 00:13:41,350 --> 00:13:46,190 revenue, four of them are in the space. Amazon, cvs, 211 00:13:46,340 --> 00:13:50,270 Walmart, and United, that's now the partner of Walmart. These, 212 00:13:50,320 --> 00:13:54,350 these companies have the resources to weather the transition. 213 00:13:54,770 --> 00:13:59,150 And I know that Becker's focuses tremendously on hospitals. 214 00:13:59,490 --> 00:14:03,950 The problem when moving from fee service to capitation for a hospital is 215 00:14:04,460 --> 00:14:06,790 that in year three or four, 216 00:14:06,790 --> 00:14:10,830 you're gonna have half of your beds empty until you get market share. 217 00:14:11,490 --> 00:14:15,750 And transitioning through that, I'll call it the next five years, 218 00:14:17,170 --> 00:14:20,650 bankrupts them. They just can't survive the transition. 219 00:14:21,270 --> 00:14:24,810 And I think that's why a lot of delivery systems, hospitals, 220 00:14:25,150 --> 00:14:28,530 health systems don't do it. They just can't figure out how they can, 221 00:14:28,530 --> 00:14:31,290 they can see the other side across the chasm, 222 00:14:31,310 --> 00:14:35,850 across the massive value valley. They just can't get there. 223 00:14:35,880 --> 00:14:37,290 They don't have a bridge to get there. 224 00:14:37,380 --> 00:14:41,250 These companies have the dollars to do it. Now, whether they will or not, 225 00:14:41,430 --> 00:14:45,130 that's a different question. Many of them are going to be publicly traded. 226 00:14:45,130 --> 00:14:49,130 They're gonna have shareholders. They're not gonna want to see the income drop. 227 00:14:49,420 --> 00:14:52,540 We're seeing layoffs in a few of them. So we don't, 228 00:14:53,020 --> 00:14:54,980 I don't think it's in any way certain, 229 00:14:55,990 --> 00:15:00,170 but I can't imagine that our nation will be able to tolerate 230 00:15:01,380 --> 00:15:03,210 7.2 trillion. 231 00:15:05,030 --> 00:15:07,210 That's 3 trillion more than today. 232 00:15:07,680 --> 00:15:12,570 Imagine what we could do that in this country to be able to change, 233 00:15:13,510 --> 00:15:17,250 uh, impact the social determinants of health, racial disparities, 234 00:15:17,960 --> 00:15:21,760 education every, almost everywhere we look, 235 00:15:22,070 --> 00:15:26,640 that money could be better spent than essentially getting the same healthcare as 236 00:15:26,690 --> 00:15:29,820 today simply for $3 trillion more. 237 00:15:31,520 --> 00:15:33,720 Absolutely. Well, you've teed me up perfectly, Robbie, 238 00:15:33,740 --> 00:15:38,040 by talking about our focus on hospitals for all the 239 00:15:38,720 --> 00:15:43,240 hospital and health system leaders listening to this all over the country right 240 00:15:43,240 --> 00:15:44,840 now. Your final thoughts, 241 00:15:44,840 --> 00:15:49,600 your final pieces of advice for them as they navigate this changing 242 00:15:49,600 --> 00:15:52,200 environment and they, they watch these companies, 243 00:15:52,200 --> 00:15:56,440 these health service companies look to dominate the entire healthcare spectrum. 244 00:15:56,790 --> 00:15:57,880 Your final thoughts for them? 245 00:15:59,280 --> 00:16:04,220 My first thought is they all should read Clay Christensen's book on disruptive 246 00:16:04,220 --> 00:16:06,380 innovation and ask themselves, 247 00:16:06,920 --> 00:16:11,640 why is healthcare going to be different than 248 00:16:12,340 --> 00:16:13,560 all these industries? 249 00:16:13,700 --> 00:16:18,600 And he has 20 or 30 of them that saw the same process 250 00:16:19,180 --> 00:16:24,020 of ever a higher cost without conglomerate value and someone being 251 00:16:24,020 --> 00:16:27,880 able to come in the marketplace and just disrupt it. 252 00:16:28,460 --> 00:16:32,120 Now so far, the incumbents have been so strong, and if you're an incumbent, 253 00:16:32,140 --> 00:16:33,280 you may feel strong. 254 00:16:34,020 --> 00:16:37,960 But that's why I think these retail giants are going to accomplish it. 255 00:16:38,590 --> 00:16:43,320 They're amassing all the things they need not to 256 00:16:43,320 --> 00:16:44,440 become another player, 257 00:16:45,410 --> 00:16:48,630 but to actually replace the insurers of today, 258 00:16:48,980 --> 00:16:53,550 replace half of the hospitals of today, replace half of the doctors of today. 259 00:16:54,750 --> 00:16:58,930 And once disruption starts my experience and I teach you say the Stanford 260 00:16:59,210 --> 00:17:03,450 Graduate School of Business, you never catch up. You will be gone. 261 00:17:03,910 --> 00:17:07,850 And that may be hard to imagine given the size of some of the industry players 262 00:17:07,980 --> 00:17:09,690 today, but if I were them, 263 00:17:10,330 --> 00:17:13,210 I would be looking to figure out how to do capitation, 264 00:17:13,870 --> 00:17:18,610 how to put together an insurance system with a hospital system with 265 00:17:19,180 --> 00:17:23,850 fully capitated physicians and other clinicians at the delivery 266 00:17:23,950 --> 00:17:27,810 system level. And I think the clock is ticking. You have five years, 267 00:17:27,870 --> 00:17:29,730 but if you don't start in the next one or two years, 268 00:17:29,910 --> 00:17:31,050 you're never gonna get there. 269 00:17:32,760 --> 00:17:35,650 Fantastic. Dr. Pearl, thank you so, so, 270 00:17:35,650 --> 00:17:39,250 so much for taking the time to be with us, to share your insights with us. 271 00:17:39,590 --> 00:17:44,050 It is just so fascinating to hear you speak and it's such an exciting time to be 272 00:17:44,050 --> 00:17:45,490 in healthcare. So thank you. 273 00:17:46,610 --> 00:17:49,400 Thank you, Jacob. I appreciate you inviting me today. 274 00:17:50,810 --> 00:17:54,230 You can tune into more podcasts from Becker's Healthcare by visiting our podcast 275 00:17:54,420 --> 00:17:57,590 page at becker's hospital review.com/podcast.