Judson: So Rick Rossin, you've spent nearly 40 years in various leadership roles in the healthcare system. Take me back to a moment, maybe a crisis or a breakthrough when you realized that you wanted to change how this whole system worked.
Rick: I think of, for me, it was, my first CEO role. We had. I'd come out of a health system in rural central California.
We serve Kings Fresno Tulare counties. My first CEO job was a small district hospital. We had, taken over or acquired, or. And what I found was that, the financial benefit of what that, what brought our system was dubious at best. They had on $12 million of net revenue. They had lost 5 million the previous year.
And when I sat down and looked at that, I realized that I could cut all the expenses in the organization and we'd still be upside down. And, I went back to my team and, really we dug deep into why we were there. Thinking about the people we were serving, the communities we were serving.
That we were serving poor, farm worker based communities for a reason, and it wasn't our prerogative to be able to move somewhere that would be more, affluent, in terms of the traditional way we thought about healthcare, finance. And, so we pulled our team together and he said, hey, what's working isn't gonna continue to work.
No matter how good we are at it, there isn't enough co. Cost to cut. And the only way out of this is to take a lot of risk and to really substantially grow the system. And so it was fourth and long and we just threw bombs. And that was probably one of the most liberating times of my career because I realized that the conventional wisdom of what we're trying to do in the healthcare system is, is going to hit a wall.
It hit our wall in that community very quickly. And what happened over the next three years is we tripled our net revenue. We grew access, we improved the relationship with the community's trust, and we saw a significant restoration, a belief in a local healthcare system. As we linked that together with other hospitals that we also acquired, we built a regional system and and changed the way we had traditionally thought about.
The model was that you try to get people to come to where your hospitals are. But we served, a disparate number of communities, many of which had lost hospitals over the years and realized that we had to drive a different strategy. And to me, this became the way I completely think about the whole healthcare system, whether it's in urban or rural areas.
And that is instead of trying to, get people to come and use the services we provide, how do we become, trusted partners in all the communities we serve? And it really allowed us to think about redistributing care in a way that, people needed it when they needed it, where they needed it, not what was convenient for us.
And that was transformational in terms of how we started investing in communities, building. Really high quality clinics and communities that had very little, healthcare access in the past. And, and what we saw was a dramatic turnaround. Our hospitals were on the potential to divest list out of our health system.
Yeah.
Rick: Because of their overall performance and the lack of, potential within the conventional way we thought of success and potential. Yeah. But in a, in two years, we basically became the most profitable part of our system. And and that was really driven by a whole transformation of community centered and person centered strategy of which our, we became a steward of that health and wellbeing in a community, and then looked to customize what people needed, where they needed it, and rebuild that foundation of trust.
So
Judson: I'm hearing you say you were presented with. An end point in the current strategy. Like it could not have gone on further, maybe expenses were climbing faster than revenue and you had a need to turn around financially. A hospital. I imagine that's not unique to just you and your situation.
Many healthcare financial leaders and operation leaders are probably facing similar things. What made, maybe I'll say it this way, have you ever talked to a colleague that didn't see it the way you did? And what allowed, what was it about Rick Rosson that came up with a reframing of the challenges that you were facing?
Rick: I think, yes, I have talked to people and they see this as just the way it is and they rationalize the way. That's how the system works, but. I think I had an optimism and a belief that everything could be different. And I realized that in healthcare, we needed to find our creativity and innovation to completely rethink rethink the business model.
Our business model has been very transactional. Our structures have been built, our financial structures have been built that way. Our delivery systems have been built that way. And we think about how do we get the most revenue for the services that we provide. And I think. As I look at industry and I see organizations like Apple who have very transactional products, technology, iPhones, iPads, computers, yet they have a very relational business model.
My relationship with Apple is complicated, but I have a lot of devices that tie in. Yeah. And it, and the ecosystem impacts the way I live and impacts my life. So they have found a way to create a relational business model. In healthcare. We have the ultimate relational business model, the human being.
Yet we try to drive this transactional model. And so I think if we think about our customer and how do we build relationship with that, how do we create trust? I think that can make a very significant difference of how we rethink how we provide, services. For example, when you look at utilization in a hospital, at a community-wide basis, and when you're looking at strategy, for instance, a small percentage of people in any given year are going to use your hospital, a very small percentage probably less than 5% for your inpatient services, which we would argue is the core of what we do.
Yeah. A little larger percent, maybe 20% for your emergency department, which is, was always seen as a front door or Yeah. Something else we did. But. I started asking a different question of our team, and that is, okay, we're relevant in the lives of the people that need us when they need us.
And with that comes a degree of trust in the quality of care they receive if we do a good job. And it also comes with a little bit of. Lack of trust and resentment in terms of what they perceive as a cost of care, how we bill, how we collect and things like that. And so the bigger question, the bigger strategic question is how do we as a business become relevant in the lives of everybody in the community, whether they need us or not?
And I think that strategic question drove us to completely rethink our whole business model. How do we think about customizing the services we have and are available to provide to what people need when they need it, in a way that brings them into relationship? Yeah. With our organization. So if it's, if somebody isn't sick, how do we provide education or wellness services?
Yeah. For those that are vulnerable, how do we make sure that social services are available and customized to them?
Judson: So I'm hearing you talk about a shift from. A transactional model may, maybe we would call that fee for service to a community model a, a relevance to communities. But you and I have sat in the CFO see it at different times of our life.
Other people listening may not have done that. So maybe explain to a listener kind of how those revenue streams changed in your mind as well, that correlate to your philosophy changes and how you made sustainability off those changes.
Rick: Yeah, so I think as a CFO, your primary interest is a financial sustainability of the organization.
And I think, my thinking about this began when I was A CFO and started looking at, how do we. How do we work through an income statement that doesn't work where we have declining revenues and increasing cost, and how do we rethink that? And for, from my perspective, it was really about how do we increase revenue models, because it's a lot easier to carve a margin out of a big stream of revenue than it is a smaller stream of revenue.
And so from a business perspective how do we grow revenue? At very rapid pace. So if
Judson: this is a hose is this the size of the hose or how fast the hose is? Is flowing water? I
Rick: think it's creating the size of the hose. Okay. 'cause the bigger the hose, the more water can move through. And I think the more you get involved in other services in the community, I think it expands your capability of creating value added services to people when they need it, where they need it.
And so for us in the Central Valley, it was providing primary care, urgent care services, diagnostics, and community communities that did not have those. And so by improving access to care, we expanded our care offerings from what they had traditionally been and started investing in where people were.
So that built that sense that we were there for their community. They didn't, just didn't have to drive 30 minutes to come to. Or the hospital happened to be.
Judson: Yeah.
Rick: But that we were showing up where they lived. And once you're there embedded in a community, then you ask different questions. Is what can we do to create more value in this community?
How, if we roll out, community health workers with lived experience to help support vulnerable populations, how does that drive economic development in terms of giving people jobs in the healthcare industry that would never have been employed there before? Did you ever find
Judson: that this, alternative view of sustainability put you at odds with other financial leaders in the system that you worked for?
Rick: Yeah, so I think it comes back to metrics. What are we measuring? Back. In those days, 20 years ago or so, productivity was, signi was a significant way of measuring financial success. That's
Judson: labor efficiency and
Rick: that's looking at cost and labor efficiency and but if you're trying to grow revenue, ~~you know ~~what?
You have to create your capacity to grow revenue or you, so if you don't invest in making the hose bigger, you're never gonna get more water through the hose. And so if you keep focusing on how do you make it smaller, then you've restricted your potential for. What I'll call more transformative growth.
And so a lot of the investment that we did that drove double digit revenue growth almost year over year for multiple years, was always thinking about how do we build the bigger hose? Yeah. That meant, creating capacity before it existed, but once you create capacity, now your potential to drive revenue, and you do that by,
having relationship listening and understanding what the needs of communities are. Yeah. And I think having those discussions where they see you as part of them, because healthcare organizations, especially in rural America, are often the largest employer in the town. Yet oftentimes other than the services we provide, we show up in a very invisible kind of way.
But I think if we leaned into that and saw ourselves as community leaders around the wellbeing of the community and ways to enhance and support other businesses quality of life in that community, increasing employment, because with revenue go comes increasing employment, which improves economic vitality in many communities, which we're seeing that erode, then all of a sudden you've create you through leadership, have created an economic miracle that you now become a recipient of.
So back to the CFO. Position, it's about taking a longer view versus a shorter view. So one of the reasons we focus extensively on productivity is it's something we can measure every day.
Judson: Yeah.
Rick: Not because it's the most important thing to measure, but it's the thing we're good at measuring. It's the easiest to measure.
Yeah. We have built significant competencies and systems at looking at it, and so we tend to focus on that to the exclusion of what's necessary to grow. But I think strategic successes in our ability to grow and build deeper and more expansive relationships with our communities and with that is going to drive revenue be, because that tends to be more speculative.
Yeah. In terms of what we build for the future. So
Judson: we're creating feedback loops around things we can measure is maybe what I'm hearing. And sometimes those things that we're measuring may not necessarily be. The long arc things that, because they're more challenging to measure like community relevance perhaps.
And yet when we think about the story of healthcare in anywhere in the world, it's often framed in, a community sense. But today, it seems to be increasingly about the transactions. And I've sensed even about the investors, even in the nonprofits as well. Where do you see the greatest harm in this shift, assuming you agree with me in that shift, and how can we reconnect healthcare with the people who truly need it?
Rick: I think one of the things that's disaggregated the healthcare system from its communities is this wave of consolidation. So the consolidation in my view really began, to pick up a lot of steam in the early two thousands. And as we got into Obamacare, I think there was a lot of fear from the health insurers that, single payer alternatives and other things could, could basically imperil their business futures.
In 2008 we learned that there's such a thing as too big to fail. And we learned that through the financial crisis, and I think that lesson wasn't lost on the healthcare industry. And so you saw this massive wave of consolidation on the health insurance. When you look at it from the provider side, who has to negotiate contracts with health insurance companies, then fear started driving that.
So you had this wave of fear move through the system, and as health systems started seeing larger and larger, insurance companies and fewer of them, it became important for them to build scale. And so there was a lot of consolidation on the health system side. A lot of that was driven,
from that perspective, a lot was rationalized by the promise of lower cost. And I think there is a potential of lower cost. But I think what got missed was how we began to separate, from the communities we served. That didn't have to happen. If the intentionality had been to stay deeply rooted in communities, I believe that we could have seen more of this, of the, the cost benefit of consolidation, but with an accountability back to the communities and strategy built on real intelligence of what the communities were serving needed. What happened though is a lot of the decision making and strategy development moved away from, the local community without adequate feedback loops and listening.
And then begin to be formed in corporate offices. So they became system central strategies that may or may not. Constructively impact communities without the adequate iteration of the feedback loop. And I think that separation has broken down trust and is also, resulted in performance at the system levels that is disappointing and rarely meets the promise of when they announce their consolidations.
And I think when we think about the value we create, we become too separated from the communities we're serving. I think to turn that around, we need to really think about reinvesting not just money, but attention and relationship at the community level and, work to get them much more engaged with us around what it is we're trying to provide.
Judson: I'm processing what you said about too big to fail, because often I think about that in the banking and the financial sector. But you're saying that it probably pervaded across the American system, this mindset that if we are so essential, so big, the federal government will bail us out.
Have we seen that in healthcare
Rick: yet? I think, I don't think we've seen the be the benefit of that. I'm not sure we've quite hit the wall yet. I'm
Judson: not even sure I'm saying there is a benefit, but I think, and I don't know where I would've heard this, but I did go to a business school and we hear about this thing in capitalism called creative destruction.
Which is where capital is re-released to the economy through the failure of businesses being an essential part of the economic cycle. So I'm looking here for leverage points. I'm almost hearing you say that because we've pulled out creative destruction from large industries in the United States, we're probably not seeing the refreshing of.
Competitiveness even. And I'm honestly just going off the fly here, just thinking about this as we go, but I did hear it in my last system. The reason we were buying so many hospitals, even in 20 23, 20 22, when the for profits were exiting the market is because we needed to have scale.
And I've never thought about the fact that some of that is the two big to fail mentality coming outta 2008.
Rick: Yeah I think you see even large systems consolidating with each other for that reason on a national scale. Why, when you're already a strong regional player, why do you have to have national scale?
And what happened with those mergers is that as they merge into more. Remote system locations, they begin to separate more and more from those communities, even those that had a large regional scale to begin with. So the question is, where is the point of value? Is the point of value in the capital markets, is it in your ability to compete or maintain adequate managed care contracts?
Or is it in the value that you're actually creating in the communities you serve? And I think what's happened is we've turned inward and we look at what the value to the system is. So as we look at acquiring additional hospitals into systems, it's very interesting to hear the messages that are coming out of that.
And they're very much system oriented strategies and ideas, yet. How this makes a difference at the community level. How does this add value to people that live in those communities? Tends to be an afterthought or a PR tagline versus what's really driving the strategy. So the question is, where is the value come from?
Does it come from being big? Does it come from being part of the system? Does it come from your brand or does it come from the difference you're making in the lives of people that you serve?
Judson: Yeah. I'm hearing you say it should be in the community and the people you're serving, but then you also mentioned the capital markets and a couple other examples.
So is there a big incentive on the capital market side to be big?
Rick: Yeah I think there is, and I think, so I had worked in both for-profit and non-profit and, in my venture in the 1990s in for-profit, I saw the inability to invest in the long term. Quarterly profits were driving, decision making.
And it was just how do we get through the next quarter? And there was always this sense of immediacy and a lack of what I would call longer term thinking and strategy of how we do this. And because you're looking at the immediacy, you're looking very much at immediate impacts like cost and the things that we're good at measuring.
When I came back to the nonprofit side I actually believed that we could be equally as aggressive as for-profit providers, but we could be much more strategic. So we had a competitive advantage. The only probably advantage they had on us was the access to capital, being able to raise equity capital, versus debt capital.
But for the most part, for say the next 10 or 15 years, what I saw was our ability to make these investments in long term and really turn around struggling systems by, by doing that level of investing for that longer term. And I, and it worked. I think what I saw around 2010 was as these systems got bigger, bond rating agencies became much more influential, on the nonprofit sector.
And a lot of what I would say were decisions that were more. Immediate versus more strategic started being made with the. With the eye on what the next round of bond rating was going to be. And began to really feel the pressure and influence, the direction strategy of the organization. So what we had was a com was a competitive advantage, began to go away.
And then I think what the agencies look for is they look for consistency of what they're seeing across, across all of the systems. And so things that worked or things that didn't work that had not quite played out yet, there was an expectation that as systems came together, they would do similar type of things.
And so you basically had this, this sort of conformity of strategy and operations that took place in the health system without a lot of reflection as to is this creating strategic value for, for our communities and the customers and PA or patients that we serve. And so I think that disconnection, has had a significant impact of how systems are connected.
So the source of capital started drawing executive and strategic attention away from the source of value, which would be the people that we serve.
Judson: I'm also hearing you say. Nonprofits had a benefit from maybe a longer arc or a longer horizon than the quarterly. And you saw that truncate down to a quarterly cycle as
Rick: well.
Yeah. I see very little difference right now between nonprofit health systems and for-profit health systems. Wouldn't that be, and their
Judson: ability to think in the long term, won't that leave the for-profits more competitive then? Because of their access to capital markets is strategically, yeah.
Rick: Yeah. So that trend continues. If you collapse
Judson: your other differentiation, then you'll leave the for profits. That's right's. That advantages, right? Because
Rick: The strategic, the strategic advantage of the nonprofits is the ability one to do things that for-profits have a difficult time doing. And that is building relationships at the community level.
Embedding yourself with the communities you serve and making investments in partnership in the long term.
Judson: How would you go about reversing that trend? Let's say you're running a, take me in your mind to you, you're running a $10 billion health system somewhere in the United States. You're the president.
What are you gonna do differently to, to create a longer arc view of healthcare in your organization?
Rick: I think changing the idea of where values created. I think if systems get bigger, the idea is the value comes from the system. And this shows up both in leadership because of understanding the value employees and your teams bring to create the value of the system.
And also understanding what the value of the people who live in the communities, the people that you're actually serving. Part of that is due to the disaggregation in our system. ~~We. ~~We don't see the, I've had a lot of debates or, and participated in really ridiculous debates over the years on who the customer is.
Yeah. So when we do strategic planning, is a customer, the physician as a customer, the managed care company, as the customer, the government, ~~we~~ or as the customer, the patient, the fact that we're even having the debate is strange. What's the answer? I think the customer is the human being that we, are honored to be able to care for.
Judson: Is it the human being or, as someone once proposed to me. Is it the families around the individual and maybe the communities around those families?
Rick: They're all part of the human beings that we care for, right? Yeah. They're the humanity that we. As an industry, have an opportunity to live in partnership with and serve.
And so yes, it's the families, it's the patients, it's the people that aren't patients. When you start not thinking transactionally, now you're talking about how do we live in a relationship with these families? Yeah. How does our brand make a difference and create more value in their ability?
How is this community a better place to live because we are here. Those are in me Bigger strategic questions. Yeah. That, I think that reflection takes us to a different place of
Judson: value creation. So I hear you say hospitals can do more than just treat sickness on a transactional basis, and they can actually impact communities as a whole and they should.
What's an example you have seen of a hospital impacting those things that really matter, such as. Maybe the social issues, housing, education. Gimme an example of where you've seen that.
Rick: I think housing can be an issue. I think for communities that are facing significant issues around homelessness, many of those people end up in both our law enforcement system as well as our hospitals and dealt with in very inefficient ways.
We give them the best that our systems have to provide and oftentimes they continue to get. Be in worse condition. And so I think we have to think differently about how we live in relationship with those on the margins as well, and work in partnership with the broad community. Much of this is a very driven by whether we believe in scarcity and or abundance, in a community.
When you look at the resources that come into a community. And look at how much is spent on healthcare, how much is spent on education, how much is spent on food insecurity, how much is spent on public health, law enforcement? And if we redefine that all as healthcare, we would probably see five or six times what we think the healthcare spend in the community is in terms of resources coming into any given community.
So I think there's a significant opportunity to take a macro look at all of these things and recast some as healthcare. Now, when I say healthcare, I think it's much more than what we traditionally use around that term. But how do we make this a better place to live? And how do we reallocate all these resources in a way that makes the most difference to the people that live in this community?
And so I think hospitals that have invested in. And supported housing development, who supported economic development. Whether it's finding ways to build their own workforce from local communities. They can be engines of economic development in an organization which actually can raise the economic level and the wellbeing of people that live there.
So I think trying to think expansively beyond healthcare, just addressing illness and sickness and economic development, looking at more economic vitality, if we find ways to blur this and say, this is really all about the same thing, it's about the value we create as a collective community to the people who live here.
Then I think it challenges us to think about what services are going to be more effective and make more of a difference and be more relevant to the people that live in
Judson: any given community. Why isn't every healthcare executive talking the way you are?
Rick: Because I think. The pressure that, the pressures we feel and the, and and I think there is a lot of fear.
There's a lot of pressure to, get immediate, immediate results. And we go back to muscle memory. So we go back to how we were trained. And when I was trained as a CFO, you had financial problems. You figured out how many FTEs to cut. But I think where I got as a leader, if I believe that the people on my team are creating value, then as a leader, my accountability needs to be how do I increase, amount of value that's created outta my organization versus restricting or cutting back my potential to create value by having fewer people.
And so I think a lot of alignment around purpose, a lot of, alignment about how do I unleash the value? Innovation, the creativity and the fact that these people live in this community and care for their neighbors. That is really, in my view, the source of value in our workplace. And I think as leaders, we have to quit looking up and say, what does my boss want out of me?
The fact is my experiences when I did that, my bosses were happier because I was creating better results. So if I, they may not have always understood what we were, the strategies we were driving as much as we tried to explain them. But they do understand results. And I think when you begin to see that trust level go up, that revenue go up, productivity go up, innovation start to take place as people who know that community and find better ways to serve it.
I think that to me, yeah, is where that difference gets made. I'm
Judson: almost wondering, just reacting to that though if perhaps I'm looking, I'm thinking nationally, I'm thinking, industry-wide, that perhaps we're beyond performance matters anymore, where we might be in a post performance. Now it's purely pol politics and power.
And again, we're in a, we're sitting here in, what is this, almost April here, 2025. And. Many of us believe that national conversations and decisions are leading us towards adverse effects on our economies and the performance of America across the world and domestically. And I actually see that in my bias, in my opinion, almost in the healthcare industry as well, where maybe with this, too big to fail consult m and a, mergers and acquisition consolidation, we're actually seeing a shift from performance to power.
And I'm wondering maybe if you could react to that in the sense of, I have you seen times where people are actually performing at a higher level but are challenging the system and are a threat to the system? And perhaps that'll happen to you as well.
Rick: So I think you touch on the critical question, and that is where power sits. And I think what we see is when we see aggregation, it becomes more about power and the self-preservation of the institution than it is why power matters. One thing that made a big difference in me back in 2016, I read a book called Community by Peter Block, and he makes a statement in that book is that the only thing that will solve problems in community are the gifts of the people in the community themselves.
In many ways, our healthcare system is built on an extractive expert model. We provide the expertise and in that process, we move power away from the people that actually have the most impact on their own health and wellbeing. To the point that it, you begin to see an unraveling of accountability around that.
When the doctor says, I think you should drink less or smoke, quit smoking. That becomes. The power dynamic that the doctor's wanting from that person. And there's a resistance to that versus the patient feeling that, oh, I, this is my responsibility now. And so I think we look to others to solve our problem.
So we're frustrated with our healthcare system. Hopefully we can have health reform at the federal level or the state level will solve our problems for us, when in fact, if we really look at the health and wellbeing of any community, the gifts of the people in the community themselves are where the power structure needs to be to most effectively deal with that more.
Police and armored cars on the south side of Chicago are not gonna solve the violence issue on the south side of Chicago. It's the people that live there, but the more they rely and the more they give away power. The less effective are the interventions to address the issues. To me, this is about turning the power dynamic upside down and restoring power back to communities, to employees, to individuals, who really are the source of value and should be the source of power.
The aggregation of power is extractive in nature and it becomes self, self-fulfilling and continued need for ongoing extraction. But where I have seen community health make the biggest difference is when we turn it around and start moving that back. And getting people to start, accepting that and realizing that they have the agency to make the most difference in their communities.
I think that's how we begin to heal this country. And because healthcare exists in every community, we become potential agents of doing that. And, that I think is where real promise is and where real relationships and trusts can be built because neighbors tend to have more in common than our, the divisive nature of our national politics or even our state politics.
And so empowerment. I also s serve as a coach and one of the things in coaching is really helping people see the power that. Is in them all the time. And so I see this in a very similar way, is that the point of value are the people that are living in a community serving each other. And so how do we as organizations basically confer that back?
One way I did that, we were in the process of a capital campaign building a new hospital in Hanford, California. And I used to go to the community and I would say, we can't decide that. This isn't a great place to do business and pack up and move to Nevada because of the better business climate.
I said the fact is it doesn't matter who owns this hospital on paper. This hospital is your hospital. And as people that live here, you are more or less shareholders of this hospital. Our role is to be stewards of this. Health system here. And so if you take that role of servant leadership and stewardship, now all of a sudden you're moving accountability back to that.
You want people to have loyalty to your system. When it becomes their system that transforms that trust relationship and that sense of loyalty. What does that do from a business perspective? It drives market share. It drives, volume. It drives revenue. And it's not being manipulative. It's truly doing it because you believe that.
And I think, I think those that ignore that and feel that the power is somewhere else, keep reinforcing the structure that becomes extractive of communities.
Judson: What I'm hearing you say is there are external factors. Capital markets, investor mentalities that are maybe the too big to fail. 2008, introduction of that philosophy that are driving to these mass consolidations in a lot of different spaces.
We're here talking about healthcare, but you said insurance side. Here we're talking maybe a bit more on the provider side, hospital side and that consolidation is extractive pulling not just resources, but maybe agency. Yes, I'm using that term agency out of the local community and centralizing that in the form of power centrally.
And I'm also maybe just having an aha moment that also is, if we're going through what you're saying, which is that is reducing relevance and sustainability of that healthcare system in that community. So therefore, I'm thinking we're making that health system more fragile economically, operationally, long-term.
Kind of back to that mindset you had around the nonprofits had an advantage over the for-profits, which was the longer horizon. So now I'm hearing that we have some fragility in the healthcare system as a result of this. That doesn't make me optimistic, but I hear some optimism in you. What's driving that optimism for you?
Rick: I think the fact that the source of value and abundance lives within people. And the human spirit is, infinite in its potential of innovation and value creation. And I think if to the degree we can begin to unleash that, not just in our workforce or our teams, but how we unleash that in a community, that a community that can start caring for itself and caring for each other, drives, a sense of resilience and regeneration so that we begin to create more generative versus extractive business models.
And when you think about the economics of that, when you start getting those generative business models, there's value that you didn't even see or create there. And the state of California right now, the state has. Rolled out a program with me, Medi-Cal or California's Medicaid system around Cal aim, which is, investing about $4 billion in, things like enhanced care management and community supports to address the needs of vulnerable populations.
This has created a whole new business boom, and workforce development around community PE organizations, many of them community-based organizations that have been doing similar work for years, but making that part of the healthcare system. Why does that matter? It is because these are organizations that have lived in community and relationship for a long time.
They've just worked in silos and disconnected ways. But the idea is how do you really create a system of care around the person? And so the conventional wisdom was that Medicaid never pays enough. The more you do, the more you lose these kinds of ideas. What we're beginning to see is it becoming the source of transformation.
For health systems that are leaning into this because as we build our capacity to care for the people that are most vulnerable, in our communities, that capacity can be easily translatable to dealing with, vulnerable seniors, fragile seniors, as well as, healthier populations because now we are thinking much more expansively than just a transactional nature of the services that we've traditionally provided to ask bigger questions around what can we do to come in partnership with this community, to provide suites of services that we had never dreamed were possible that actually live with people every day, and so we become more relevant in their lives versus the small percentage of chance that they may need us due to a crisis or an illness.
Yeah.
Judson: You mentioned Cal Aim. Is it working?
Rick: So I think. I think that's an interesting question because when we talk about is it working, what are the metrics and measurements around that? I believe the state of California believes that by investing this kind of dollars, it's going to save significantly on downstream in their whole Person care model, that they piloted in a number of counties, which is.
Was somewhat similar. They saw some dramatic improvements in cost and wellbeing of their, of the Medi-Cal populations, especially those that were most, socially and clinically vulnerable. And as a result, they decided we, we can't wait. We need to push this out statewide. And went for their 1115 waiver from CMS to do that over the next five years.
So there's an valuation process that's taking place to measure the effectiveness, but I can tell you from my experience what I see. Our company right now, HC two strategies is working as a facilitator, with the Department of Healthcare Services to bring together collaboratives to work on developing this, what we call a connected community of care, or this new system.
Of care in 24 counties in California, I've seen transformation, in whole delivery systems. So I'll just use, use an example of two small rural counties in northern California, Calusa and Glen counties. That sit right on the Sacramento River.
Yeah.
Rick: They have very small hospitals, very limited healthcare.
But out of that. Has grown organizations that begin are serving this and have employed significant number of people to serve, people that are facing homelessness or vulnerability with the Medi-Cal population. And they've done it in partnership with their local hospital. And what we've seen out of that is business development.
We see, people that were living very much on the margins now in more in stable housing, but they're in a place where the value is caring for them. Not seeing them as the byproducts of the way things are, but really seeing each person as a person of value. Yeah. And now having resources and support structures to be able to come around and live in partnership with them.
And as I see these services starting to be provided, I see. People with lived experience, people who've been homeless. Now having jobs, I went to a a session with around justice involved populations in Santa Clara County, in California. What's the justice
Judson: involved?
Rick: People that are coming outta prison.
So when people come outta prison, oftentimes they end up homeless because it's hard for them to get jobs. It's hard for them to reenter. They've lived a very structured life and now they're just put out there to fend for themselves. These programs that help them transition back, are often, provided by.
Community health workers or care managers that used to be in prison themselves. Okay. And so not only does it give them a sense of purpose around how to, how they turn their own lives around and build a productive value, to back to society, but it gives others that pathway away from recidivism back into a constructive way to live in community.
Judson: So you said HC two, your firm is facilitating these conversations in multiple counties in California. Why is HC two doing it and not these hospitals that we've just been talking about that should be taking a central role in community healthcare?
Rick: So I think what's interesting is that what the state is trying to do is a very community based approach.
When, so I was CEO of a hospital up until 2021, and I saw this as a huge opportunity to build a coalition because what tends to be lacking at the community level is leadership. Both leadership and to some degree competence with more complex organizational structures. These are something that health systems have and have capability to do.
Oftentimes you have community based organizations, you have counties, you have managed care plans that have very little relationship and community. And this leadership gap is something that I think health systems. Can fill in a way, if they think outside of the traditional services they provided and say, what can we do to make this community a better place because we're here.
Up until the time I left that role, that was my strategic question, how is this community a better place because we're here And that began to drive our strategic relationships, community partnerships, and other things. Now, does that go back to our hose analogy,
Judson: like the, was the hose getting bigger through those conversations?
Rick: Yes, because what it turned out is that we had a significant issue with unhoused people in our community. There were ver, there were limited resources and we found that. There were things we could do in partnership with the Salvation Army, with the county behavioral health, with the police department and others that could come together and provide a system of care that could help, help mitigate the issues, that our community was facing.
And yeah, I think it, it created a significant opportunity because out of that came new business opportunities, to expand revenue. We're always frustrated 'cause we're not getting paid enough by Medi-Cal for the services we provide. But the fact is that's the
Judson: transactions.
Rick: Yeah, if you, so if you're looking at the transactions, but if you look at what is the value that of the revenue potential that's there available, if you provide the services that people need, then all of a sudden there's significant additional business opportunities.
So if you think it from a population health standpoint, what is the healthcare related spend on any individual that lives in the community, and now how do you structure your services in a way to address and meet those value opportunities? I think that's where a lot of business, development can come from that are not just rehashing the traditional things we've tried to do that have frankly hit a wall for reimbursement.
Judson: So I want to just pivot just slightly here. So we've talked about, incentive models. We've talked about communities. Again, you and I are sitting here on April one in a very unique political time in America's history. Yet on your website you talk about wellbeing and we're here talking about that here.
And some of us have been reading this book called The Donut Economy, and it has a tenant that there's a belief that the economic growth alone can't solve su societal problems. We interviewed someone a few weeks ago who believes that the government can't drive, can't alone drive meaningful change while others that we've talked to see the private sector's profit motive as an obstacle.
What's your take on balancing the government, the community, and the private sector's roles in creating wellbeing in our communities?
Rick: So all the all government has ever done to address healthcare is provide is one figure out how to move the money around. We were paying for healthcare in a very inefficient ways.
I think when we saw, under the Affordable Care Act, Medicaid expansion, we helped address issues around, the number of uninsured in our communities. I think in the state of California, we saw tremendous growth in Medi-Cal enrollment for people that previously had not been eligible. So I think there's things they can do around making, making service available.
But it's really about funding and incentives. When it, when we talk about system design, that really happens at the community level. The government can create incentives and then they hope that as a result of those incentives, people will do different things. So you see the a CO models that came out at work, an attempt at doing that the accountable care organizations to how do you coordinate care, and let's put some incentives or disincentives and maybe somebody will design something.
But there's no design that comes out of the federal government. CMMI, the Center for Medicare and Medicaid Innovation. They're there as a thought leader to try to provoke ways of, and ideas of doing things. We find others that platform what's working. But really the most meaningful system innovation has been developed at the community levels in ways that are very authentic to those communities themselves.
So I think where, federal policy comes up with, here's an incentive that needs to be translated and organized at the community level. And so system innovation is going to happen. Through leadership and perceived need at the community level, but it can only happen as we were speaking to earlier.
If the power and initiative is there to do that. And that's, I think, where leadership matters. If you look around the United States, in fact, what the Affordable Care Act tried to do was they just looked around what people were doing in different parts of the country that seemed to be working and then tried to incentivize that.
Those systems developed the way they were doing things. In ways that were very authentic to the communities that they served or the, or way their organizations were structured. But I think that innovation never stopped. What worked, in 1995 may need to be rethought and continued to be iterated in the year.
Yeah. 2020. I think
Judson: this is what concerns me has me up at night is as healthcare margins are shrinking, especially hospital margins and they've been negative in a lot of hospitals for many years, I sense that legacy leaders are reverting back to core product. You mentioned 1995, which is why my mind went there, which maybe someone listening.
The way I would define that, and I don't want to dive drive too much of this conversation. That's drive volume per surgeries, perioperative spaces, er volume, play the payer mix game. Be cute with services that are high Medicaid, and be liberal with services that are high Medicare or commercial.
Wow. And I'm seeing almost a trend of that across the country or some of the for-profits are moving out of hospital-based medicine altogether and moving into different spaces. And this leaves me a little bit concerned that I don't have the same optimism that you have, and yet I'm here looking for those leverage points or those places where I can spend my time influencing justice and wellbeing in healthcare.
And so give me one place that I should be focusing on for the next five years to continue to improve justice, wellbeing and community outcomes.
Rick: So I think. The space where that works is erasing the barriers we put in place between clinical care and social care. When you look at what the US spends on clinical care from A GDP standpoint, we are almost double, what any other nation on earth, provides. Yet when you look at the Perce perception from the Commonwealth Fund on satisfaction or quality, it's, yeah, we're a lot lower than what that price, would play out.
If you look at a, or at a country like France. They have very low, clinical per capita quality, or they have very low, cost of GDP for clinical care, but they have very high pGDP for social care. And so where we begin to raise those lines and see that the care of the individual, and the wellbeing of an individual is both a combination of clinical and social support.
How do we be more intentional about that? We have a lot of industrial complexes that have been designed around, around certain industries. And they all tend to be even a little extractive, even on the, social side. But how do we break that down and create a community centered model that sort of takes away these, these barriers and starts asking bigger questions Is like when we think of health and wellbeing of an individual, what do they need?
How do we use concepts of mass customization to give people what's. Most valuable to them, not what we have to offer. And, and trying to convince 'em that's what they need. And so I think as we do that we break the, break down the barriers that we've tried to work in and really, but at the center of that, again, as the people that are living in communities,
Judson: can that be profitable to make that shift that you're talking about.
And my mind keeps going back to the fact that these businesses feel too big to fail. How,
Rick: what is the, I'm just, I'm trying to connect those dots, Rick. So I think profitability comes from value. People will pay for what's valuable to them. And, I think how it gets structured becomes part of how do you innovate?
How would you tructure and define that model? How would you structure it? I think structuring, structuring a model that begins to combine, behavioral health, clinical care, both primary care, specialty care and what hospitals have traditionally done, and then expanding that out into, the social care systems.
I think the more we break down those barriers, the more we see, education, law enforcement as extensions of healthcare, then we start being able to creatively see how do we rethink about what a system of care looks like and how do we measure data across all of these Yeah. Disparate systems. Why is this so important to you?
It's important to me. 'cause I spent my whole life, working in an industry that, that has made money or not made money depending on what story we want to tell, but has, is probably broken down and has less trust in the communities we serve them. When I got into this 40 years ago, and that bothers me because at some point we become disconnected and I think what matters to me, why does it matter to me?
Because it, it matters to me that we make a difference and create a better community, a better country, caring for each other and seeing the value in that, that it's not just driven by the resources we can. Extract from the services we provide, but how we invest in and build value in our communities.
I think communities that trust each other, that trust the institutions that are there to serve for them, are communities that are good places to live. And it's where people that live there feel that they have a say, a voice, and are empowered to create the kind of world they wanna live in.
Judson: Has there ever been a moment in your career where you've been tempted to walk away?
Take me to that moment.
Rick: I think it's easy to be disappointed, but I guess at heart I'm a reformer and as long as I have a voice and agency to speak, I will keep looking for ways to reform it. I do that in many parts of my life and I think in my professional life, much of the reason, I left the health systems and we started our company is we saw this intersection between counties, public health plans and community-based organizations and the health systems that we'd worked in, as a gap in terms of how we improve the health and wellbeing of each community that we serve.
And so the reason we started that is, I worked at a of, a. An academic medical center with a great reputation, and it haunted me every day that we should be able to transform the entire region that we were working in. But for some reason, we just kept doing what we'd been doing and there was this huge amount of need and opportunity and I just couldn't look myself in the mirror anymore knowing and seeing that opportunity and knowing that we were making decisions to just keep the status quo going.
So for me, it was about how do we find and partner with change makers who really want to create a different kind of world. We're not here to define what that is because I think the definition of that depends on each community and it. Goes to listening. It starts with listening. It starts with deep listening.
And it's really about how do we become much more aware of these systems in which we're working? And then once we create this awareness, how do we become agents of change? And so finding ways to help, help organizations come together. Much of the work we do now in collaboration is the competitive model has run us into the wall.
But if we're talking about how we create more value in people and communities, how do we think about collaboration around that? Because collaboration is built on trust. Competition erodes trust. And then what is our accountability back to value? I think the fear of losing competition is that. There becomes more extraction and less value.
And so we looked at competitive markets as a way to try to make sure that the accountability back to the consumer or the communities is there. But I think this issue of trust is a much more important one, and with that comes public trust and I think you can address those issues through transparency and accountability back to communities.
I think the corporate models, were the competitive models often utilized as a safeguard. We're really about what can, how do, how do companies use markets to basically build their own value. But I think in a case where we're talking about the public interest, and if we're in a private system, how do we create a quasi-private public system that basically has ultimate accountability back to, and transparency back to communities.
I think the bigger we get and the move farther, we move away from communities, the less transparency there is.
Judson: Do you think this thing needs to break for us to get back to the community?
Rick: I think it's broken. I think it's already broken. I think we're seeing professionals throughout the industry that we're seeing it in. Physicians. I think this is where burnout comes from, is when people don't see a path forward and they realize, I went to school all these years for this is not the difference I wanna make.
This is not the impact I wanna make. I think we need to listen to them. I think we need to listen to people who become disappointed in the health system. We need to, it, it's difficult to navigate. It's not user friendly. When you go to get a service and someone looks at your card and say, oh, I'm sorry we don't take your insurance.
I'm a human being here. Who needs what? You have to provide me? And we've created all these barriers around that. How is that Okay?
Judson: Yeah.
Rick: And so I think we have to go back to say, how do we create a system that cares for everybody? And, yeah. I think there's a lot of difference we can make.
But does it have to break? No, I think it can be reformed where communities come together and say, we're gonna do something different here and start building principles. That's where I see innovation, taking place. And I think you'll see pockets of innovation connecting to other pockets of innovation that can become a movement.
But just like in social movement theory, when institutions become self-serving beyond the intent that they were established in the first place and lose trust, then movements emerge. And I think in healthcare we will see movements, but they're gonna be. Led for and driven by the community level. There will be systems that will be leading these you mean health systems to own hospitals?
Health? Yeah. Yeah. They will participate, but I think it's the degree at which they empower their own teams as well as the communities to become part of those solutions that are going to make the biggest difference.
Judson: So we're having this conversation in five years from now. How is our conversation gonna be different in five years?
Rick: I think this conversation's been going on for 40 years. I think we've struggled constantly with the promise of what US healthcare can be and the reality of what it is. I see risks growing and getting cha more challenged. I think health systems and hospitals are in a more distressed, place in any time during my lifetime in my career.
But I think there, I think what we will see is we will see models of innovation that will take place. And the challenge is going to be how do we tell those stories and begin to drive and start moving to scale a different kind of system. I don't really expect a lot from from federal policy.
I think there will be states that will drive innovation much like we're seeing in New York or California right now. And I think how those get measured in terms of the effectiveness. But this is, this is lean startup. This is innovation that's taking place. Are we going to judge at a failure?
If you judge innovation of failure because of your first prototype, you would not innovate anything. We can't judge at a failure. We have to keep iterating on what we are trying to do and keep improving it. Yeah. So when you ask Will, will Cal AIM and California work, or while other Inno innovative Medicaid waivers in other parts of the country work, I think we can't afford to sit back and judge was it a failure or a success?
I think what we all have to do is get the rapid learnings we can and continue to iterate a system that works more for all people and not just those with the power, but I think it has to do with, being able to let go of control and let go of power and be able to come as, come along as, as stewards of a system that matters to all Americans.
Judson: You provide some coaching, what are you saying to your approximately 40-year-old operations executives that are showing signs of burnout? What are you telling them to focus on?
Rick: So the future of corporate strategy and the future of personal strategy all starts with deeply embedding into purpose. Where we face burnout and where we face hitting walls is where we become disconnected.
We're replicating a system that was handed to us. We rationalize it. But I think when we dive deep into why we exist as organizations, when we take mission statements seriously, when we take our personal purpose seriously, the question is how do I show up then tomorrow to live that out in an authentic way?
I have not yet had a client who could not find a way. To do that. When they began to believe in the power that they always had within themselves and their agency in which to execute it, did they always stay with their current employer? No, but I think they came out of it with a much stronger sense of what they could do to live the life that they were feeling called to lead and to provide leadership in the world the way that they, that was more consistent with what they believed, was their purpose.
And so I think being able to do that, and I see this in the, in healthcare leadership, the goal that I had as a CEO was to figure out how do I align my. The purpose of my organization, a mission statement that should mean something. Not just rhetoric or words on a wall with the individual purpose that 2000 people bring with them every day.
That was my challenge of leadership because if I could connect that now, I had began to unleash the innovation, the perspective, the voice of a tremendous amount of energy innovation and people who could make that difference. Yeah.
Judson: We've talked about a bit about the consolidation, the motivations for these systems that the extraction of agency and maybe re financial and human resources from markets.
But my understanding of the way the nonprofits have become so big in healthcare is they came from, a, many of them came from a faith-based background and or other sort of humanitarian background. Is that in competition to what we're seeing today, that original mission, and I'm thinking governance here, Rick all of these nonprofits must have governing boards that are cons constituted differently.
What are you seeing in the governance space, in, in line with this conversation we've had today and in what role are they playing to help us improve where healthcare goes at the system level?
Rick: So governance is critical to creating sustained strategy over time. Otherwise it becomes a whim of whoever man is the management at the time, the CEO at the time.
And what happens, you'll see when one CEO changes and everything stops that was being worked on, or they shift direction. It basically, if you pull back and take a 40 year view of that, it just keeps spinning the organization versus a consistent direction. I think empowering strong governance to own the strategy of the organization and hold management accountable to execute it.
It's critical to the long-term nature of the, it's one of the key indicators of success for a successful organization. When I work with governing boards, we usually spend a lot of time on pur on collective purpose like we just talked about. Yeah. What is, why do we exist? What are we here to do?
And then how do we drive strategy consistent with that? I think we're where board struggle is when they become conditioned to the system in which they work and begin replicating that versus finding their blue ocean or there space in which can frankly be uncontested market space because there's things we do.
That are connected to mission, that are so authentic that they can't be replicated by others because it's deeply authentic to the organization that we represent. And I think when you have a governing body and executive team that are highly aligned around that, then the potential of what can be done differently wildly opens up.
And I think new business opportunities come out of that. There's a saying we've thrown around for years in healthcare, and it's usually apocryphally, assigned to some, a none at some Catholic organizations. And it's no margin, no mission. And most people have heard that. And, I find that really offensive.
Because usually what it is, it's a rationalization, and an abdication. So it's a rationalization why we can't live authentically into the mission that we proclaim, and that somehow there's a trade off between living our mission and creating a margin that creates sustainability. But it mostly, it's an abdication of our mission and purpose, and it's a way to rationalize why we have the hypocrisy of not living into what we say we believe, because we've gotta go do what everyone else is to get these margins.
My belief is when we lean deeply into mission, then the margin takes care of itself. The idea that living into mission is a trade off to financial success, I think is one of the biggest fallacies we face in the industry. I think it's quite the opposite. I think the more we lean into mission and purpose is where we find that uncontested market space, the idea of innovation that does things new, that basically changes the value proposition entirely.
And so we get a, it allows us to break out of the replication of what doesn't work in our industry and our systems, and allow us to live into a space where we can really create the new, so every time I hear that, I get really rankled because I just see this abdication of responsibility and. At most as leaders, we should be doubling down on our sense of responsibility and our accountability to why we exist as organizations and why we exist as human beings.
Judson: You answered my next question already, but I want more.
So we have, you believe that governing boards of these large health systems in the nonprofit spaces should have a conversation around purpose and mission, and yet over here we're seeing this trend towards investor mentality in the operating behavior of these large systems. You did answer my question a little bit and you said that they're getting more of a system mentality, inside their mindset, but if they're not thinking like nonprofits with longer arcs, should there be nonprofits in healthcare anymore?
Rick: So I think that's a conditional if, I don't think they have, I don't, I think that's a choice.
I think the nonprofit sector in healthcare is really important because ultimately it shows that the ownership of the institution. Lives in the community owns it, whether that's a larger federal a national community or a state community or a regional community or a, or an individual community.
The fact is there's community ownership and that profits get reinvested in that, and there should be accountability back to the community. I think in my view, the biggest problem with consolidation has been that separation and this loss of idea that we are really, these boards are really stewards of an asset from these communities.
Because if they understood that and were more serious about. What that means. There'd be much more intentional listening and understanding of how those services are showing up in communities and understanding the impact that they're having. I think that is easily changed for the better by a direction of a board that should, realize it's great to be a system.
We can build tremendous standardization and efficiencies, but ultimately we are accountable back to these communities we serve. And what does that accountability look like?
Judson: You say it's easy, but why isn't it happening?
Rick: I so it, I shouldn't say it's easy, it's simple. It takes courage to do that because it takes bucking where the status quo is going and where.
Where conventional wisdom is going. When you're at a system level that's serving 25 or 35 different communities, it's hard, it's complex to decide how you're going to adequately listen and understand the needs of each of the 35 communities you serve. Is it easy to listen if you choose to? Yes.
But is it complex? Yes. Do
Judson: they, do these boards have risk personally these board members?
Rick: Theoretically. But I've, I've rarely seen that in turn, and I think that's I think education around what your role and purpose is as board members is important for boards I sit on, and boards.
I've had the opportunity to chair, I've really tried to drive this sense of, responsibility and what that comes, education, board education around that. And then this ongoing question of what does, what is our purpose and how do we most authentically live into that? That should be kinda the guardrails for management to effectively execute strategy.
I think what I think the reality is of boards is there's a lot coming at them, a lot of information, the way it gets filtered, the way decisions get structured. And so sometimes there needs to be more frank conversations and sometimes necessary conflict.
Yeah.
Rick: In order to challenge the direction of the organization.
So where an organization feels pressure from moderating agencies or other things to take action that may not be, as. Strategically connected to the direction and purpose of the organization. I think that requires that courage. And I think boards can help, move that courage and at least create a significant debate around what's the right thing to do here.
And the more of those conversations that are happening, I think the healthier the governance of the organization is and the more dynamic and potential it has at addressing, a much more transformational way. Yeah. Of showing up.
Judson: I haven't followed it that closely, but we're sitting here in, in Boston, Massachusetts, and I think Massachusetts just had a big, not a nonprofit but a for-profit system, be held accountable or on investigations ongoing because of the way that the hos, the bankruptcy has played out.
What failed there in your limited understanding of that and how does that relate to our conversation? Yeah,
Rick: so I think the story of Steward Healthcare is a cautionary tale. And it's basically the looting of vulnerable communities in the state of Massachusetts and nationally because it happened in Louisiana and other states where Steward Healthcare had facilities.
But what happened in that situation is you had a system, which took private or turned for-profit, struggling non-profit systems, that were really deeply rooted in serving the purpose of their communities, but they serve poor communities. Were often margin, marginal, facilities and they aggregated these into a system and then, at the end of the day though, there was no, the accountability was to profit. So the idea of, let's see how much value we can pretend we have, let's sell that off. And then in the end, that system collapsed and a place close to where I live over in central Massachusetts, a hospital called Nashoba Valley, which was very necessary for significant, part of the population there basically collapsed.
Nobody bought it, nobody picked it up. And now people are having to go unreasonable distances to deliver babies and, get emergency care. It's taking emergency, vehicles out of the community as because of transport needs. So that collapse, I think, was a wake up call for the state of Massachusetts and a lot of reflection around how did we let this happen?
And so when it comes back to regulation, why do states regulate? Mergers. Often this becomes that cautionary tale because if anybody could roll time back into the early two thousands when this started, they probably wouldn't have allowed that in the first place. So what's to be learned about that?
The, that became a perfect example of how the relationship and accountability to the local community was severed in exchange for the accountability to, incur profits driven by the capital markets. So from a capital market standpoint, it was successful. They extracted tremendous amount of value from the state of Massachusetts and from the communities they served.
And a lot of people got insanely rich. But at the end of the day, who pays the price for that? It's the communities that are served. Yeah. And so I think that is a cautionary tale because all of what we've been talking about is how. As we become separated from the best interest of those we serve it, things like that become much more likely.
I've seen nonprofit systems that I've been part of divest, or closed down hospitals in certain communities, for operational reasons. But as I look back on it, it's usually a failure of imagination because many times people, choir and continue to operate those well, if it was possible to do that, why didn't we?
Because we couldn't figure out how to make it work, doing what we had always done. Because we weren't asking the right questions. What does this community need now that they may have not needed 20 years ago or 30 years ago? If we'd asked those questions, we could have moved to a transformative model that would've been much more relevant in serving what the current needs are in the community.
So I think where we get stuck in our business models and replicating our old business models, sets us up for those kinds of breakdowns.
Judson: Got it. We've covered a lot today. Governance, community driven healthcare, some leverage points. Just wanna do something fun here and in closing, you don't know who my next guest is.
Leave me a question for them and I will ask that on your behalf.
Rick: I.
I think the question, I would ask is how do we activate a network of innovators across this country, to begin system, to begin a process, a system transformation that can create a new system of care in our nation. But I think that idea of how we activate that, how we connect innovations that are happening together and give them space to experiment, to iterate, I'd be very interested in what that idea is.
Judson: Rick, thanks so much for your time today. I really appreciate it.