This week’s guest post comes from

The idea of implementing bundled payments can be intimidating for any hospital CFO. But, as a way of paying providers that combines all the services needed to treat a patient, bundled payments are an inevitable step for both payers and providers as the industry heads toward accountable care.

The challenges of implementing bundled payment models are more operational than conceptual – improving the flow of information between provider and payer, collecting and delivering the right information about services delivered to these patients across multiple care providers, and ensuring consistent reimbursement. It’s obvious how the task can seem overwhelming – as most providers are much more comfortable focusing on the appropriate care model for specific clinical conditions like diabetes or hip fractures – but here’s how every provider can prepare to make the shift:

• Get Organized – Providers need to determine how to assemble claims into bundles, how much a specific bundle actually costs, and which requirements for treating a patient have been met as part of that bundle. They need tools to notify payers that a patient is covered by a bundle and when the package of services begins and ends. Finally, they need to bundle data across multiple providers in a single claim for payers, and tools to properly distribute reimbursement funds.
• Divide and Conquer – Payers need to learn how to identify bundled claims within the stream of thousands coming in the door on a daily basis. To do this, they need tools to help understand which providers are involved with each bundle and enable communication with them. They also need a mechanism for identifying services with special exemptions and determine payment details (how much to pay for a bundle and to whom).
• Crunch the Numbers – Finally, to really change the way care is delivered, both parties need to track how the patient has been treated in different provider settings, and what appropriate care looks like. A database with the ability to query the shared data from both sides, close to real-time, will improve coordination and enable more effective patient management.

Providers need to think carefully about the costs associated with the care decisions they make to successfully implement bundle payment programs. By aligning the incentives between payers and providers to deliver high-quality care to patients, bundled payments are a necessary step to success in any accountable care model. Follow the steps above, and the transition should seem more manageable.

–Dean Farley, PhD

In this week’s guest post Dr. Miles Snowden, chief medical officer at OptumHealth, offers tips for stimulating patient accountability in the age of accountable care.

While payers and providers are usually in the spotlight when it comes to accountable care, the most successful models will be the ones that place a strong focus on patient accountability. More and more frequently patients are selecting doctors with the best outcomes, asking proactive questions, and taking an active role in their lifestyle and behaviors. Empowering patients with the support and tools to be responsible for and more involved in their own health is critical to improving outcomes and reducing costs as part of any accountable care environment.  In fact, Optum found that when given more information about a planned elective surgery, 1 of every 15 patients change course – either deferring, choosing a less intensive option, or changing facility or proceduralist.

Currently, patients navigate the medical system to achieve the best outcome in the shortest amount of time, but physicians are incentivized to provide more services. If the decision-making process of the physician and patient are not fully aligned, then it is not reasonable to deploy a strategy focused solely on stimulating greater accountability in the patient. An alignment of goals for the highest quality and most financially efficient care can help to ensure patients are never in a position to make a health decision against the advice of their physician. The burden of responsibility has to be directed equally at all stakeholders. Once alignment is established, strategies to stimulate greater patient accountability can be deployed.

Establishing a primary care relationship is key for patients because it provides them with the opportunity to view care more holistically, gain a better understanding of medical alternatives, and feel supported by an advocate for better personal health. Group visits can also encourage patient accountability by allowing patients to connect with others who have similar conditions, and providing physicians with an opportunity to educate and promote better overall patient health. In addition these strategies, tools to enable patient engagement are paramount. We’ve bucketed these accountability enablers into three categories:

• Demand Management: Stakeholders too often demand a greater intensity or frequency of service than necessary to achieve clinical success—experiencing more readmissions, ER visits, and MRI or CT scans than needed for example. It may sound simple, but asking discharged patients questions such as “Where will you go post discharge?”, “Are you certain any equipment or physical therapy has been arranged?” and “How can we reach you?” counters some of the system inefficiencies and better moderates unnecessary demand in the medical system. In fact, such efforts can cut in half the readmit rates.
• Population Management: According to a commercial insured 2010 population analysis, half of high cost claimants had minimal to no engagement with the delivery system in the prior year, indicating that providers need to better engage with individuals who are not active in the system, not just at the point of care. This is a significant challenge that can be overcome by partnering with organizations that specialize in identifying and engaging individuals who will become future sources of medical costs. It is particularly important for providers to reach out to individuals with a low intensity of need that don’t consider themselves patients and individuals with immobility or lack of access to care.
• Network Management: Oftentimes, individuals choose to access care at the wrong place. Transparency of information on physicians and specialists ensures that patients are receiving the best care at the lowest cost. By facilitating transparency providers can influence patients’ decisions, increase patient involvement and open the door for better communication across the care continuum.

All patients across the care continuum need to be participants in their own care, and providers should be implementing strategies to encourage this accountability both at the point of care and, more importantly, once the patient goes home. The focus should not be directly on changing a physician’s practice or reducing a hospital’s patient load, but instead on implementing an accountability model that aligns both physician and patient expectations to improve the health care system as a whole.

–Dr. Miles Snowden

Defensive medicine: I agree entirely that any discussion of the cost of medicine should pull in the defensive medicine costs. There are people much better qualified to do that than I am (Dr. Dan Sullivan MD, JD comes to mind), but I think that the cost of medical care driven by fear of litigation is consistently underestimated. I’m certain it has had an effect in my own practice. My last shift was Sunday, and I probably was overly cautious with a bronchiolitis child that might well have done well at home, and a mystery abdominal pain got a pretty aggressive (and negative) workup. How much defensive medicine effect was involved is impossible even for me to say, but like most of my colleagues I have been named once (and a jury found in my favor) and it is something I will work hard to keep from happening again.

Regarding any perceived criticisms of the ED/ED physicians: I love the emergency department and I always have. It is risky, unpredictable and difficult, and as I get older my feet hurt and my body complains after every shift (hats off to all of you who have done this a lot longer than I), but I still love giving critical care to someone who needs it. The cricothyrotomy on a young person this year who made it with his brain intact will keep me going for another few years, although I will retire happy if I never do another. I also understand that as good as the ER is at taking care of all comers (and yes EMTALA requires it), we are better at some things than others.  Regardless of our skills and commitment, our ability to take care of business the way we currently do will run into the simple fact that the cost of medicine to Medicare and Medicaid to the federal budget will not grow forever. We have been hearing the word “unsustainable” for years, and to those who think this is just one more episode of many, just call your billing company and see what your bad debt is on commercial insurance. As the cost continues to rise, more employers are passing a significant fraction of care on to the patients, who can ill afford it.  Deductibles of $2000.00 are now common, and I have seen them up to $10,000, which simply results in more medical bankruptcies and patient calls for system change.

Addressing the cost of care means becoming more efficient, and that means tackling where much of the waste is, in coordinating care for complex patients that are chronically ill. Medication reconciliation is step one there, and we need to get better at a wide range of similar activities because our patients are getting older and sicker. If that is not going to affect your practice, I am pleased for you, but it will be affecting mine. Personally, when I have 12 medications and 5 medical problem, I want all of my doctors on the same page about what the plan is for my care. Very personally, my father had a craniotomy and hematoma evacuation while taking Coumadin after being put on Levaquin. His INR was 11, and he did not sue his doctor because I get how hard it is, and my father likely didn’t connect his A-fib to his bronchitis and mention his medication history at all. Coordinated care there would have saved I don’t even know how many dollars over the years on just his case. As we see patients in the ED for the 5th, 6th, 7th time in a year, the opportunity is there for ED physicians to make a meaningful difference. To be clear, I am not suggesting that the ED physician needs to do the discharge planning and social work functions that could be so beneficial to these patients, but pointing out to your administration the need for care management, articulating the advantages of better social services support, and advocating for better outpatient support is a good way to start. Many physicians of all specialties are already doing so, and the ED has a significant place in this conversation.

Finally, an ACO is about incentives. Right now the best way for me to pay for my kids college is to make sure my ED is full of sick people. Financially, I would be better off spreading the flu around than washing my hands. Obviously, I would never let those mis-aligned incentives impact my behavior or patient care, and I do not know one ED physician anywhere that would allow any incentives to practice to a patient’s detriment (although I did know one that partially owned a motorcycle dealer!) That said, when the incentives are a problem, the uninitiated and uncertain can become concerned. For example, I would have issues buying a car from a mechanic (my father waived HIPAA on his neurosurgery, but he won’t let me tell the car story). I think the public has a reasonable concern where the incentives are misaligned. The great benefit of an ACO is that under a good clinical integration plan a good clinical decision becomes a good financial decision from all points of view. I remain concerned about how to navigate the conversation around bundled payments, but I do believe it can be worked out where clinicians are engaged and are making decisions centered on the patient’s best care. To be clear, fee for service has done well for me, but I understand why the public (employers, payers, and patients) would like to see incentives change to something that rewards health more than illness. I am going to work very hard to make sure that I am helping to enable the best possible outcome for physicians, patients, and health systems. The comments here indicate that other physicians are paying attention to this issue, and are with me on the need to navigate change with the patient’s best interest in mind.

P.S. To those taking issue with my writing style/grammar. I will attempt to improve on that one, but I majored in biology and went to medical school and spent a lot of time in the ED while my friends were learning how to write. An informal style is the result, and is unlikely to change much.  Sue me (see paragraph 2).

–Mark Crockett, MD

According to the American Medical Association and the Markle Foundation, four in five American consumers believe that using an online patient health record (PHR) would yield major benefits to them in managing their health care. In spite of this, the usage of PHRs has been very low to date, due in some part to patient concerns about privacy of their personal health information.

There are similar privacy concerns with an HIE. However, the HIE plays a critical role in the population of PHRs with clinical data from sources around the health care community. HIE stakeholders — such as hospitals, health plans, individual practice associations, etc. — should consider sponsoring or supplying a PHR to patients that is not only already pre-integrated to the HIE, but also empowers patients by allowing them access to the PHR on their own terms. By letting patients set the consent policies and access rules for their records on the HIE, the HIE potentially is helping to quell these patient concerns.

Effective patient education is key to increased patient involvement and empowerment, and this can be achieved by PHRs connected to the HIE. Doing so enables them to send and receive health care information to their own PHR and share it efficiently with the professionals providing care. But how do you promote this participation successfully?

• One way is to go directly to the patient. They need to be presented with the facts about HIEs when they are registering. Registration personnel should be well-trained to explain the exchange and its benefits in layman’s terms, and address any questions from patients.
• Beyond just the patient visit though, HIEs can implement broader, community-wide consumer education programs to help garner patient participation. These campaigns often include radio or TV commercials/appearances, direct mailings, billboards, presentations at local community meetings, and/or fact sheets, and can serve as resources for patients who have questions about an HIE or concerns about participating in one.
• Alternatively, making clinical staff aware of the exchange and explaining the benefits of their participation allows them to advocate for an HIE and encourage patient participation. Physician champions can lead to increased buy-in from patients, peers, and community leaders.

The best marketing program for each HIE will depend on its unique market, but at the heart of it all is the educated consumer. Informed consumers are engaged consumers, and engaged consumers are satisfied consumers. As the health care industry becomes more competitive and moves toward coordinated care and market-based economics, business models that place the consumer at the center of the health care universe will be in positions of strength.

–Glenn Keet

We’re excited to welcome Anand Shroff, vice president of product management at

It’s no secret that healthcare has historically been slow to adopt the latest and greatest in technology and even slower to embrace technological paradigm shifts, as evidenced by the continued presence of client-server computing in healthcare in the age of the Internet. While strides to catch up have been made in recent years – with shifts toward electronic health records (EHR), advanced health information exchange (HIE), and mobile computing devices – the world of business is changing rapidly, and the industry needs to do a better job of keeping pace.

Cloud computing is one such paradigm shift. Like other advances before it, cloud computing took root with consumers — think Apple’s iCloud and Google’s Gmail services — and has since triggered a shift in the way enterprises think about doing business. What began as a simple question of whether files could be stored in the cloud quickly shifted to a discussion of whether business processes could be hosted there as well, e.g. Salesforce.com. Now, entire business processes have been moved to the cloud and previously unthinkable workflows are achievable because of private (and public) cloud integrations made possible by secure cloud communications. Salesforce.com has built an entire ecosystem of extended business processes through its force.com platform, which relies on cloud-to-cloud integration.

Healthcare presents unique challenges to cloud infrastructures, operating under some of the most stringent data privacy and security regulations, but that doesn’t mean cloud is completely out of reach. As hospitals and health systems continue to adopt technologies to capture data and share it over an increasing number of miles, they’ll also need to think about how to store and access that data most efficiently, and cloud solutions could be the answer. Public cloud environments – where information is accessed entirely via the Internet and hosted outside the organization – may be too risky, but private cloud environments, which exist in healthcare today, can offer similar benefits and efficiencies with less risk. It’s also possible to take a hybrid approach, which is what I envision will work best in healthcare. For example, consumers could use their OpenID (public cloud technology) to authenticate with providers after passing additional levels of verification (private cloud offering).

Whether or not patients care about cloud, providers will have to care as their EHRs grow, but they aren’t the only constituencies that should pay attention. Vendors too will need to consider cloud infrastructures, privacy and security for its hospital customers. They’ll need to start with bolstering security, paying close attention to special certifications and solutions available to help instill confidence in cloud. Payers – given that they have such influence on the industry itself – are sure to capitalize on cloud computing as well.

Silicon Valley receives the attention it does for good reason. Whether it is business or consumer facing technology, human lives are transformed by the innovations made here. Healthcare can recognize the benefits of improved agility and efficiency by keeping closer tabs on how its technology industry counterparts are propelling the world forward.

–Anand Shroff

In today’s ED, patients may enter with a chronic condition that could be better managed by a primary care physician (PCP), but because ED physicians are incented to treat sick people in a fee-for-service model, they continue to take these patients on instead of referring them outside the ED walls. If instead both ED and primary care physicians operate as part of a team of care givers that are incented to ensure patients stay healthy and avoid hospital admissions and readmissions, they are headed in the same direction in terms of focusing on better patient outcomes vs. reimbursement dollars.

ED physicians used to be among the few physicians employed by the hospital, but that’s changing dramatically as IDNs snap up physician groups. The larger group working together will help make sure the ball isn’t dropped anywhere throughout the spectrum of care. If a patient with a laceration comes into the ED with diabetes, and that ED doc doesn’t think to check blood sugar – because that’s more of a PCP issue – that oversight will be visible in an ACO environment and the physician might be under the microscope in terms of the role played in ensuring quality outcomes.

Part of this movement requires implementing integrated technology solutions that provide greater visibility into the types of care needed in your community, allowing the health system to build care facilities that are catered to the population it serves, ultimately enabling the sustainable health community. But the real lynchpin for success is the collaboration between people, not just IT systems. This means choosing metrics to support each constituency that has a stake in the game – providers, payers, physicians and patients – so that they buy into the new strategy and are empowered to make changes that support lower costs, increased efficiencies and higher quality care. It takes strong leadership demanding teamwork across clinical, administrative and even third-party vendors, along with a shared passion for making sure patients are cared for in the best possible way to make this happen.

In my next post I’ll talk a little bit more about the kinds of metrics physicians will be measured against in this new environment and answer some questions from those who may be concerned about their new roles.

– Dr. Mark Crockett

Evaluating and managing population risk has traditionally been the payer’s role in the health care system. But as providers become increasingly accountable for populations, they will need to be equipped with many of the same competencies that payers have been relying on for years. This includes the right technology to capture both clinical and claims data, but also the ability to analyze and transform these data into actionable information that affords the delivery of high quality, efficient health care and ultimately real population health — that’s where actuarial services come in.

There’s a reason why actuaries are known for incessant number crunching, data collection and manipulation (along with the occasional pocket protector) — it’s a complicated field that first requires extensive training and then plenty of experience to practice effectively. Our team of over 175 actuaries, who are engaged on a daily basis to do this work, are hearing excitement, but also understandable caution from providers looking to assess and understand both the risk and the financial benefits of setting up any of a variety of accountable care models. Many providers — including some already approved for the more advanced CMS Pioneer ACO — just don’t know where to begin, so we’ve pulled together these tips for how to wear the “payer hat” when evaluating populations and assessing risk:

• Determine baseline utilization and expenditures: How well do you know your population? A clear understanding of what the patient population looks like from an exposure-based claims view — their demographics, morbidity, how and where they have been consuming medical resources and at what levels, etc. — is key. Without this, providers will be hard pressed to understand the gap between current performance and the appropriate number and type of services and level of care they should be delivering to a population in an accountable care model.
• Estimate the optimization of service utilization: Can I really improve — where and how? Providers need to dig deep into the data, analyzing it by type and place of service at a county (or even narrower geography) level to determine how their utilization of services compares to other regions, how physician performance varies in their own delivery system, and thus how to identify opportunities to improve by delivering a more optimal mix of health care. It should be expected that some services will be eliminated, some replaced and other added. These improvements can then translate into an opportunity through accountable care contracts.
• Identify tactics to achieve optimal utilization of healthcare: How can we make this opportunity “come to life” for providers? Identifying changes to make in the clinical setting to ensure the best possible patient care, appropriate utilization of services, and efficient clinical decisions is a first step. Then providers must execute on the fundamentals of care delivery, utilize actionable information at the point of care, put clinical programs in place, etc. to realize the full potential. Creating a definitive road map for their journey, placing needed tools in the provider’s hands, and wrapping them with the necessary clinical and operational infrastructure will be vital to both encouraging physician buy-in and facilitating their success. Payer partners can help with the latter. Providers must then execute on these opportunities without becoming overwhelmed with all the change — the reality is some physicians will need to alter very little in how they practice while others will have to make major changes to drive better system performance.
• Calculate the opportunity: How much upside is really available for the delivery system? This is where providers can decide how aggressive their transformation will be and over what time period. At this point they should also identify other levers to pull that will help them meet their goals — e.g. supportive technologies and/or engaging third-party vendors to facilitate the effort — and make sure that changes they make are sustainable. Providers not only have to think about improving the care they deliver but also about how to replace potential lost revenue (for example in the hospital as less-intense admits are avoided through better access to, and delivery of, ambulatory care). Quantifying the long-term opportunity for providers and understanding that achieving optimal performance will have to happen over time and will help them wrap their heads around the journey they will be taking.

In the age of accountable health care, providers need to act more like payers. In making this transformation, a tremendous amount of education and preparation is needed to enable providers to effectively assume more responsibility. While some providers can’t acquire enabling capabilities and services fast enough, others haven’t begun to see the need. The potential upside for providers can be enticing, but without embracing traditional actuarial consulting services and tools, providers may be at a loss — in more ways than one.

– Joel  C. Hoffman, ASA, MAAA, FCA

In my more than 20 years in health care, the Optum Institute is the most exciting organization I’ve been lucky enough to lead. As someone with a true passion for health care, I’m like a kid in a candy store. Our job is to be an authoritative source of information on trends in the marketplace – especially new collaborative care models – and a resource for folks who are working to make healthcare sustainable. We’ll do that by conducting research, monitoring trends, working with leading experts around the industry to keep a finger on the pulse of all things accountable care, evaluating what works and what doesn’t, and helping develop best practices to propel our industry forward in the development of Sustainable Health Communities.

To kick things off right, we went big, surveying 1,000 US-based physicians, 400 hospital executives, and 2,000 health care consumers to get a sense for how each group views this inevitable evolution of care, and to identify the most immediate opportunities for positive change. Some of the results surprised us and others were in line with our expectations, but here my favorite highlights:

• An Expected Payment Reform – Over the coming decade physicians and hospital executives alike expect payment reform that will require them to bear more risk. A third (35 percent) of doctors expect that between 10 percent and 25 percent of provider reimbursement will be tied to performance, and a further fifth (22 percent) of doctors think that the proportion at risk will be higher in excess of a quarter of reimbursement. At the same time the majority of physicians and hospital leaders said they were not ready today to take on greater risk – either for patient outcomes or costs. In follow on research, we’ll be focused on identifying challenges and opportunities, but also on who has been successful in the past, why, and how we translate that to other communities and providers.
• An Opportunity for Improving Transparency – Patient engagement is key to driving better health outcomes. But today, fewer than half (46 percent) of responding physicians’ EMR systems can provide patients with easy access to their medical records. And while nearly two-thirds of doctors (64 percent) report knowing that there is a significant variation in the quality of local patient care, under half (47 percent) of consumers are aware of that cost. Whether through the ability to access their medical records online or data about the quality and cost of care across multiple providers, making patients partners will be a critical element to sustainable success.
• A Shared Belief in the Ability to Cut Costs – This survey also showed that on average, consumers believed health care costs in their community could be cut by between a quarter and a third (29 percent) before having a negative impact on quality. And the average physician and hospital executive also felt there were significant cost savings (15-20%) to be gleaned from today’s delivery system. Looking to the future however, only a small portion of each stakeholder – 26 percent of physicians, 38 percent of consumers and 50 percent of hospitals – believed that, absent of new actions, their local health community is on track to becoming more sustainable. To me, this demonstrates that we share priorities and beliefs on what is possible, but we need new initiatives and tools to get there.

In terms of how this will all actually work, many tough questions remain – but everyone at The Optum Institute is looking forward to tackling them. Stay tuned in, and I promise to share my sugar high.

–Carol Simon, PhD

Donna Woelfel, Clinical Applications Manager at PeaceHealth in Bellingham, WA, discusses how she and her team tackled the communication and efficiency challenges of its health care system.

With the industry moving toward new models of collaborative care, one thing is clear: hospitals and health systems are under the microscope to improve efficiency, communication and quality across departments, facilities and regions. At PeaceHealth, implementing technology to improve patient throughput was one goal, but ultimately we aimed to move the needle on patient, family and employee satisfaction and quality of care across our facilities.

We are a diverse and dynamic organization – a healthcare system in the Pacific Northwest serving seven hospitals spread across five regions in Alaska, Washington and Oregon – and after five years of using a surgical patient tracking system in-house, we expanded and took the technology to the world-wide web, offering a portal where patient families could check in on their loved ones in surgery remotely by securely logging into an online portal. The results are astounding and we could not be more proud of the improvements we made for our patients and our physicians.

The Goals

• Improve communication among caregivers, patients and their families in each facility.
• Create a quieter and less chaotic work environment for staff with fewer phones ringing.
• Build cross-department and cross facility cohesiveness by improving visibility and collaboration between groups.

The Strategy

• Implemented a surgical patient tracking system displaying the progress of patients securely in surgery and ICU waiting areas, cafeterias, hallways and facility coffee shops to improve communication between caregivers, patients and their families.
• Launched a HIPAA-compliant family view online so that the status of more than 42,000 surgical cases across these facilities can be anonymously monitored anywhere in the world.

The Results

• Enhanced communication among caregivers, resulting in a reduction of 1,600 calls each day to the operating rooms across five of its facilities.
• Improved patient and family satisfaction by providing enhanced visibility of patient whereabouts and progress throughout their stay at each facility.
• Received Picis Customer Recognition Award in 2011 for improving patient, family and staff satisfaction.

–Donna Woelfel

Increased participation

• Reduced reporting requirements, condensed quality measures (65 to 33) and removal of mandatory up front approval from the Office of Inspector General;
• Removal of the EHR requirement, opening the door for organizations that have not yet invested in an EHR, but still manage patients through registries or other systems;
• Shared Savings Option 1 changed to create an option that does not mandate shared losses;
• Added advanced payment for rural health providers, allowing them to receive shared savings dollars up front to support infrastructure development;
• Inclusion of specialty physician attribution, creating a greater opportunity to designate specialists as primary caregivers as appropriate.

Better financial opportunity for providers

• Addition of first dollar shared savings after meeting corridor requirements, creating a greater financial opportunity for participants;
• Inclusion of Federally Qualified Beneficiaries and Critical Access members, creating a larger aligned population on which providers can receive shared savings.

More focus on population health management

• Creation of a new Primary Care Initiative, establishing another model of care transformation that can be tested;
• Addition of allowing of members prospectively, giving providers a greater opportunity to identify and manage patient populations.

At the same time, even with all of these updates, there were a few misses. The final regs will work well for most providers with obvious room for improvement, but didn’t address how to incent those who are already operating efficiently or already meeting these guidelines. And while the reaction to the final regs has been much more positive than the feedback on the draft, the initial investment required to enter into this model is still high – and there is still a question of whether these guidelines will generate enough shared savings to support the systems and process changes needed to meet these new metrics and truly move the industry to model of accountable care.

I’m cautiously optimistic that these regs will not only incent providers to test out CMS’ pay-for-performance training wheels, but also further push the private payer market to continue to team with providers to pilot new healthcare delivery models. Overall, I think there will be more take-up for CMS ACOs by providers than previously thought. The number of health systems preparing and enabling themselves to take on more risk while at the same striving to become a value-driven organization is already rapidly increasing. In the last six months alone the number of health systems actually buying tools and services to becoming clinically integrated and bear risk has skyrocketed. Healthcare reform aside, with all the pressures of entitlement reform, Medicaid solvency and impending Medicare cuts, we know that providers have a lot on their plate. They are going to need help taking on these new payer-oriented capabilities. So more late night reading to come… And now, I just need a bigger bookshelf…

–Todd Cozzens