Latest / CareTalk: Healthcare. Unfiltered. / Can Independent Physician Practices Survive?

Transcript

Can Independent Physician Practices Survive? · CareTalk: Healthcare. Unfiltered.

• 0:00
  David: 25 years ago when my wife gave birth to our first child, we had all sorts of choices for pediatricians, including solo practitioners, small groups, and larger practices.
• 0:09
  David: I also had plenty of choices for primary care for myself, but now pediatricians are struggling to make ends meet.
• 0:16
  David: My primary care physicians switch to a concierge model and nobody's happy.
• 0:21
  David: Well, what's going on?
• 0:22
  David: Who's to blame and what, if anything can be done?
• 0:33
  David: Welcome to CareTalk America's home for incisive debate about healthcare, business, and policy.
• 0:38
  David: I'm David Williams, president of Health Business Group.
• 0:42
  John: And I'm John Driscoll, the president of Walgreens Health.
• 0:44
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• 1:06
  John: So, David, what is this?
• 1:07
  John: You know, you, you're, you're running through doctors at an alarming pace, I think, of your family as being healthy.
• 1:13
  John: What's going on there?
• 1:16
  David: John.
• 1:16
  David: I mean, I think that there's, it's not me.
• 1:19
  David: That's what I'll say.
• 1:20
  David: It's not my family.
• 1:21
  David: I mean, some of my kids are a little difficult, but I don't think that's what it is.
• 1:24
  David: Overall, it's something that's happening more broadly.
• 1:25
  David: John, with independent physician practices, you know, first of all, an independent physician practice.
• 1:30
  David: What is that?
• 1:30
  David: It's a practice that's owned and controlled by the physicians that are running it rather than a health plan or some outside investor, although it could still be affiliated with the health system, and there's just fewer of those independent practices around now, John.
• 1:42
  David: Well, I think
• 1:43
  John: that what people ought to think about is over the last 30 years, hospitals have gotten bigger through acquisition, doctors' jobs have become difficult because of the administrative burden of running an independent practice.
• 1:59
  John: But many, many years ago when you were young, I mean a lot of years ago when you were young, the, the independent practice was sort of the, the, the ambition.
• 2:09
  John: Of the doctors, uh, to kind of control their own destiny and the identity of a doctor being an independent decision maker was matched with the ability to actually build, you know, a practice or a business individually.
• 2:22
  John: And as it, the administrative burden of running an office have gotten bigger, the percentage of time and dollars associated with running the practice has gotten bigger as opposed to practicing.
• 2:33
  John: A lot of doctors are moving to.
• 2:35
  John: More of an employed model, and obviously hospitals kind of ran the table to buy a bunch of doctors, uh, to employ them in order to control their, uh, their, their market share.
• 2:47
  John: Now, I think there's an, there's unfortunately, well, I guess the question for you is, do you think it's a good thing or a bad thing of the doctors or employers, employees as opposed to independent contractors?
• 3:01
  David: You know, I think about my own, uh, experience of getting a, a primary care doctor.
• 3:06
  David: You know, I, I was referred by somebody, actually, one of our former colleagues, uh, Jan Malick referred me to my doctor.
• 3:11
  David: A guy named Dr.
• 3:12
  David: Savitz just went down the street, went to see him, you know, it was, it was called Savitz and Wenger Associates or something like that.
• 3:18
  David: And then, uh, it, then it became known as, you know, Bi affiliates downtown or something.
• 3:24
  David: So it became kind of corporate and then he retired, and then you know, what's left is now concierge practice.
• 3:29
  David: So I like the idea of like going to a doctor, going to my doctor, not like a practice, not like a company or something like that.
• 3:36
  David: And I think from the patient's standpoint is generally a negative thing.
• 3:41
  David: Uh, not to have the doctor sort of in charge.
• 3:43
  David: Now, being an independent practice is only part of it.
• 3:46
  David: There's a lot of other forces that are going on out there.
• 3:48
  David: Right.
• 3:49
  David: A lot of it is due to having to compete with hospitals or to, you know, to deal with them in order to get the right, uh, insurance reimbursement rate.
• 3:57
  David: With the health plans, there's a lot of regulations and so on.
• 3:59
  David: So it's not just that the doctors can totally control this, but all else being equal.
• 4:03
  David: Yeah.
• 4:03
  David: I wanna go to an independent doctor.
• 4:05
  David: And,
• 4:06
  John: and, and remember David, there are sort of multiple buckets here.
• 4:09
  John: There's the, the old-fashioned practice of a couple of doctors owning their own practice together where the physicians own it and maybe those grow and maybe the employees of physicians or the employers of physicians are physicians.
• 4:22
  John: There are.
• 4:24
  John: Models where the new EM employees, uh, docs of a larger institution are run by private equity or individual business managers or in some places, hospitals.
• 4:35
  John: But there's just no question that, I mean, I think it's the, um, you know, the majority of doctors when we were growing up owned their own practices.
• 4:45
  John: You know, 60 to 70% of it.
• 4:47
  John: But I think since 2019, I think less than 50% of all doctors.
• 4:52
  John: Own their own practice.
• 4:54
  John: Again, that could be a mix of hospital and non-hospital purchasers, and more and more doctors are practicing in larger and larger practices.
• 5:04
  John: I, again, I don't know that that's a good thing or a bad thing, but certainly the, the, the small town feel and the connectedness that a smaller practice has with its community typically, uh, feels much more familiar.
• 5:19
  John: But I, I, I do think that, that because of just the industrial structure, Of healthcare is going to continue to get smaller and smaller.
• 5:29
  John: And the other interesting thing is that doctors under the age of 40 ha are much more likely to be happy to be employed.
• 5:36
  John: And those are over 40, are really, are really, are depressed by the prospect of, of, of, uh, of working in a large organization and having their independence kind of, uh, uh, clipped.
• 5:49
  John: Uh, but I, but I don't, I don't think there's much we can do about it.
• 5:52
  John: I think the, the question is what do you think the consequences are?
• 5:56
  John: Well,
• 5:56
  David: I know John, I don't wanna be accused here of waxing nostalgic, even though you, you know, always taken me back to the Eisenhower era or wherever you think what my childhood was.
• 6:04
  David: But let's actually distinguish a little bit between pediatrics and adults.
• 6:08
  David: There was a front page, uh, story, lead story in the Boston Globe, uh, this past weekend about pediatric practices not being, maybe not even being viable.
• 6:17
  David: And there's some reasons for that, and then it's a little different from the adult side.
• 6:20
  David: One issue has to do with just there's lower reimbursements for, uh, pediatrics in general, and pediatricians have always known, you know, they're gonna make about 25% less than, uh, than physicians overall.
• 6:31
  David: But another big factor is a lot of the patients now are Medicaid patients.
• 6:36
  David: So it's more than a third, like 36% of, uh, pediatric patients, close to
• 6:40
  John: 40, close to 40% of all chil.
• 6:43
  John: It means 50% of all births in America.
• 6:46
  John: Are two Medicaid moms.
• 6:48
  John: So it's, it, it's it, it will continue to kind of grow towards that 50% line.
• 6:52
  John: But I think, I think it's clo just under 50% right now of kids in pediatric practices are on Medicaid.
• 6:58
  John: So
• 6:58
  David: you've got Medicaid, which is lower reimbursements growing.
• 7:01
  David: You've got mental health challenges we've talked about with kids, adolescents.
• 7:05
  David: Um, that's, you know, the practices aren't always ready to handle that.
• 7:09
  David: They're starting to have more complex medical conditions, but they don't have the high price procedures to go along with it.
• 7:14
  David: And then the same issues as all sort of small companies hiring administrative costs, supplies it, cybersecurity, so they're just in a real tough spot.
• 7:23
  David: Now, some of that has to do with government policy, right?
• 7:25
  David: Because more.
• 7:27
  David: More patients are insured, so maybe they've got more people that do have insurance.
• 7:31
  David: But this, the issue of Medicaid is I think, a really big one.
• 7:34
  John: Uh, here Well, it's, it's a, it's, it's a, it's a multiple multifactorial, again, it's the structural economics.
• 7:41
  John: Uh, it's actually the, the pediatrician will make 30% less than an internal medicine doctor.
• 7:46
  John: That's true.
• 7:47
  John: But an internal medicine doctor will often make only 50 cents on the dollar of what a specialist would make.
• 7:53
  John: So if you look at where you're gonna go for residency, Um, which is kind of what doctors do after they get to medical school and you're looking at going into pediatrics.
• 8:03
  John: The great thing about pediatrics is most of your patients get well and that that's the, and, and, and you're very connected to the community and it's a beautiful time of life, and that's inspiring.
• 8:13
  John: Uh, but when you're sitting there with, you know, half a million dollars of debt, Because it's very expensive to get through college and medical school and you're looking at a specialty that'll pay three times as much.
• 8:25
  John: Uh, the other challenge is there aren't that many pediatric residencies to even compete for because they're low reimbursement and low yield.
• 8:33
  John: From a revenue perspective, hospitals tend not to create that many slots.
• 8:38
  John: So in addition to paying less, there's fewer places to get trained.
• 8:41
  John: And then when you add to the fact that just running an office billing a.
• 8:47
  John: Whether it's Medicaid, which is the state and federal program for the poor, or billing a health insurance company, if you imagine.
• 8:56
  John: All of the challenges each of us have, getting our bills understood and paid as a patient.
• 9:02
  John: Multiply that time to every bill that you send out.
• 9:05
  John: It pushes PD people into larger and larger pediatric practices or away from pediatrics because the yield isn't worth it.
• 9:13
  John: But at the same time, David, I think a lot of doctors would love to go into pediatrics.
• 9:17
  John: We've got a, a healthcare system in the US which is 70% specialists.
• 9:23
  John: And 30% in internal medicine and, you know, geriatricians and pediatrics.
• 9:30
  John: Whereas the rest of the world, it's the opposite.
• 9:32
  John: 70% of the care is provided by GPS and their, the salary differential is much closer between the specialists and the general practitioners.
• 9:42
  John: So I think the str we're, we're almost starving.
• 9:47
  John: The most, the, you know, one of the, one of the most vulnerable periods of life, pediatrics, to feed a specialist, you know, system.
• 9:56
  John: Uh, and, and then you add to that, the fact that you get all the, the, the, the graying of America.
• 10:01
  John: And the lack of the, the inability to expand the number of medical schools.
• 10:07
  John: I think we're talking immigration baby.
• 10:09
  John: We're gonna have to bring in a lot of new foreign docs.
• 10:13
  John: And if you look in those Medicaid neighborhoods, you see that a lot of, uh, most, the, the, the, the doctors who care for folks in the most vulnerable areas are often, uh, disproportionately immigrants because we are, we are kind of running out of doctors.
• 10:28
  David: Well, John, you make, uh, some good points, and again, I know you're gonna jump right on the immigration side.
• 10:32
  David: Let, let's talk about the adult primary care.
• 10:35
  David: It's not as bad as pediatrics.
• 10:36
  David: Now, in pediatrics, I think people realize they didn't go into it necessarily to make a lot of money.
• 10:40
  David: So there's, that's one thing.
• 10:41
  David: And some of them are reacting by actually cutting their own salaries even further.
• 10:45
  David: But on the.
• 10:46
  David: Adult care side, you've got a couple of re relief valves.
• 10:50
  David: One is that, uh, sometimes, uh, it's easier to be part of a hospital system there and, and get paid and subsidized for it even because you're getting the flow.
• 10:59
  David: They're giving the flow of, uh, patients into the hospital where they can make some money on them from the specialists and from the procedures.
• 11:05
  David: There's also, uh, adult.
• 11:08
  David: Physicians going into concierge medicine.
• 11:10
  David: So, you know, getting paid, not just the, what is that, what is is
• 11:13
  John: that call, what is that concierge
• 11:15
  David: stuff?
• 11:17
  David: It sounds vaguely French John, but, uh, the, the idea is you get extra service.
• 11:21
  David: So it's like you're going to the hotel and the concierge's just gonna help you.
• 11:24
  David: They're not just gonna, you know, put you in line with everybody else.
• 11:28
  David: Uh, but instead what happens is, You can easily get an appointment.
• 11:31
  David: The doctors have time to spend with you and you're paying extra for that service.
• 11:36
  David: Um, so it's time for the physician actually to, to listen a
• 11:39
  John: take call.
• 11:39
  John: Usually it's, it's, it's an, you know, an a elite, an upper middle class, a rich person's, uh, indulgence because you basically pay a subscription fee to the doctor to subsidize.
• 11:51
  John: Their practice or the end so they actually, it can spend more time with you.
• 11:54
  John: But that would suggest, given the fast growth of concierge medicine, David, that we're just not paying our docs enough.
• 12:00
  John: Why not?
• 12:01
  David: Well, well the thing is, John, the other problem with, the other issue I have with concierge medicine is that.
• 12:06
  David: One of the things that they say is, say, rather than having 2000 patients in their panel, they might have 250.
• 12:11
  David: Well, so that means that now another 1,750 patients that they tossed outta their prior practice has to go and see us, you know, the same number of, uh, of people.
• 12:20
  David: You know, one of the issues with primary care in general is that, and this actually goes to the American Medical Association, they set the.
• 12:27
  David: The value of specialty care, essentially higher, get paid more to do procedures or to be a specialist.
• 12:32
  David: And so that's actually part of the medical, uh, profession itself, um, tilting towards specialists.
• 12:39
  David: Now, there is a hint of some of the answer here, John, besides immigration, uh, which is actually happening, uh, which is value-based care.
• 12:46
  David: So at least for Medicare Advantage, Which is the managed care program for people of Medicare age.
• 12:53
  David: Uh, this is paid according to value and the primary care physician can, uh, get paid reasonably for taking care of the patient, uh, and helping them to, uh, reduce costs overall.
• 13:05
  David: So that helps the system and it helps the primary care physician.
• 13:08
  David: We a living, we don't really have that on the pediatric side.
• 13:13
  John: Well, why, why, why can't we, David?
• 13:15
  John: I mean, what's wrong with, I mean, value-based care, which is healthcare.
• 13:18
  John: In a budget where you're paid for performance or effectively managed care pays you the equivalent of a subscription fee.
• 13:24
  John: You know, you get paid a potentially a, a capitation or a fixed budget per, per member, per month.
• 13:29
  John: Like why can't, why wouldn't that work for pediatrics?
• 13:33
  David: Well, it could potentially work for pediatrics, but it hasn't been available.
• 13:36
  David: If you look at what Medicaid does, a lot of the shift of Medicaid has been to Medicaid.
• 13:41
  David: HMOs, um, which don't tend to, to do real value-based care.
• 13:46
  David: And what you've seen happen, uh, in Massachusetts, I know for example, uh, the state Medicaid called Mass Health is actually doing a program now where they will pay the physicians directly, uh, to manage the patients.
• 13:58
  David: And so this is, this is a new approach, uh, including with pediatrics.
• 14:02
  David: So that instead of, uh, giving them money to manage care, uh, organizations, Medicaid HMOs, which then just squeeze the.
• 14:10
  David: Uh, providers on a, on a fee for service basis, they are actually trying to do some of this.
• 14:14
  David: So I think it, it could possibly work.
• 14:16
  David: It, there's some reasons it doesn't work as well, just due to the health status of, uh, you know, of, of kids tends to be, they tend to be well in general, whereas you've got older people generally have chronic illnesses.
• 14:27
  John: So, ju so just so folks understand, you know, typical commercial rates, what a commercial payer would pay.
• 14:34
  John: Would be as much as 20 or 30% above what Medicare, the federal program for the elderly will pay a doctor for the same procedure.
• 14:41
  John: Um, if you get to Medicaid for the same kind of diagnosis codes, the same amount of time with the patient, it's 30% below that.
• 14:50
  John: So when you think about.
• 14:52
  John: Uh, pediatrics are relatively low paid profession, and then Medicaid being one of the majority payers, and your pay being 30% below something that's 20% below commercial, it's, it's a pretty tough run medic by Medicaid.
• 15:09
  John: What we're really saying is, uh, not fairly paid.
• 15:12
  John: Is what Medicaid is.
• 15:13
  John: Yeah, it's
• 15:14
  David: a nice rhyme, John.
• 15:15
  David: Um, but it's, I don't, if you refine it a little bit, if you wanted to roll off the tongue now, we tend not to be, I'm usually the negative guy.
• 15:22
  David: I can't remember if I'm supposed to be the negative guy or positive guy today, but one area that we're sometimes a little bit negative about, you just seem to be posing
• 15:28
  John: questions without really clear answers.
• 15:30
  John: I mean, this is a, we, we, we have a system, I think David.
• 15:34
  John: Which is changing permanently.
• 15:36
  John: Okay.
• 15:37
  John: So that I think is, is a thing.
• 15:39
  John: Now the question is how do we make that thing better given the structural economics, the undertow tour from individual practice to consolidation?
• 15:49
  John: How do we make that work for patients?
• 15:52
  David: Yeah.
• 15:52
  David: So, I do agree with you about immigration, and I do agree that value-based care are good to, to, uh, to try to in involve more of.
• 16:02
  David: And I also think that the specialists are overpaid relative to primary care.
• 16:07
  David: Uh, I think it's hard to get the profession to go and sort of shift the value away from, you know, procedures towards more cognitive, uh, care.
• 16:16
  David: That'll be difficult and maybe it can be achieved actually through value-based care.
• 16:19
  David: I do think that it's possible.
• 16:21
  David: The technology could make a difference here.
• 16:23
  David: And even though technology doesn't have a great track record in, in healthcare of improving physician practices, I think AI, in particularly generative AI, might actually be able to make a difference and possibly in a reasonably short timeframe.
• 16:36
  John: And what do you mean by generative ai?
• 16:39
  John: I mean all these big terms.
• 16:40
  John: Yeah.
• 16:41
  John: What, what G P t, David.
• 16:44
  John: Like what, what's the story there?
• 16:47
  David: Well, j John, the story here is I think you can actually, you're, you're stumbling.
• 16:51
  David: You're already, the answer is ambient listening, John, which means rather than having the physician banging away at the keyboard and filling in a bunch of things and, and dealing with pull downs during the appointment, you can actually have the AI listen in and generate notes automatically coming out of the visit.
• 17:11
  David: So they're listening in, they can provide everything, and then the.
• 17:14
  David: The physician can renew it.
• 17:15
  David: So that's Review it.
• 17:16
  David: That's a better.
• 17:18
  David: Experience for the patient cuz they can interact with the physician, the physician could even lay hands on them, et cetera.
• 17:23
  David: Um, and it's certainly better for the, uh, the physicians since they don't have to spend all their time there.
• 17:27
  John: So I think you could do a better job at rather than cutting hand hiding behind the the velvet.
• 17:33
  John: You know, uh, drapes of generative ai.
• 17:37
  John: Yeah, so what we're talking about here is large language models are basically scraping.
• 17:42
  John: They're vacuuming up all the information on the internet.
• 17:46
  John: Um, that's what sits behind these generative ai uh, uh, software programs.
• 17:52
  John: They vacuum up and they vacuum up.
• 17:54
  John: They vacuum up Google, Microsoft as much data as they possibly can.
• 17:59
  John: They look for patterns that they can then validate as being accurate, and they are particularly good at gen identifying those patterns where there is high confirmation based on the weight of the, of the, of the probability of the thing that you're asking for, being identified repeatedly and in similar form.
• 18:20
  John: On the internet, and it's, it's sort of a, a massive, uh, numbers, uh, uh, ma uh, computer CR math crunching exercise.
• 18:29
  John: Uh, but it's very prone to identify correctly things that are rules-based.
• 18:34
  John: And so one of the more exciting applications of generative ai.
• 18:38
  John: Is this, you know, penit so's Suki program, which we recently talked about, David, where he's built a piece of software that takes the, that just rather than there's, there's, there's a role called the medical Scribe.
• 18:52
  John: Um, well, let's back up a second.
• 18:55
  John: One of the challenges of a physician patient interaction today is actually having the patient look in your eyes.
• 19:01
  John: Not just your eyes, David, but anyone's to listen.
• 19:04
  John: And because they have to fill in a lot of information and they've constantly gotta document everything in their electronic health record in order to get paid.
• 19:12
  John: What Suki does is it listens or basically like, like a lot of software programs listens and then it can take.
• 19:19
  John: What the doctor's saying and what it's he's recommending verbally and turn it into a structured note so they don't have to be typing and looking away.
• 19:28
  John: And a lot since a lot of the critical information doctors get is actually in the conversation and that connection between the physician and the patient.
• 19:36
  John: I think that's a really interesting point, David, that generative AI may actually not just make the doctor's job easier, but make them more connected to patients.
• 19:45
  John: And to your point, most technologies just added costs to physician practices over time.
• 19:49
  John: It's unclear whether all this note-taking would've been just done better with paper.
• 19:54
  John: Uh, but the, the, the generative ai, and, and maybe we'll try to get pita on the show where it can take the information.
• 20:01
  John: The patient can be better connected to the doctor and it can feed that as a structured note into the ehr and maybe, maybe even, uh, improve the morale of the doctors while they're working in their, they're slowly, uh, consolidating individual practices.
• 20:16
  John: Yeah,
• 20:16
  David: John, so there's a few different.
• 20:18
  David: Pieces here and there, there's some nuances in it.
• 20:20
  David: So one is this ambient listening so that they can essentially do the notes from the, the encounter.
• 20:25
  David: Now, I think what you're, what does
• 20:26
  John: ambient listening mean, though?
• 20:27
  John: You keep using these big words.
• 20:29
  John: Yeah.
• 20:29
  John: Not
• 20:29
  David: everybody went to Harvard.
• 20:30
  David: It's in the background.
• 20:31
  David: Well, you did John twice.
• 20:32
  David: I only went once.
• 20:33
  David: But the, uh, the, it's listening in.
• 20:35
  David: It's hearing in the background, right.
• 20:36
  David: But so it's, since something's listening into the conversation now, having the computer in the middle where somebody's typing away actually kind of disrupts the conversation and makes it sort of too structured.
• 20:45
  David: And you don't get all of the, all of the different, uh, details and nuances that you might.
• 20:49
  David: So if you were freed from that and just having a conversation, the conversation might be better, and then the computer's gonna listen and you're gonna get a better result.
• 20:56
  David: So that's one element of it.
• 20:57
  David: That's good.
• 20:58
  David: Another piece is where the generative part of the ai that's more like chat g p t that you can think about is when the physician has to do some communication, let's say with the, with the patient back and forth, it can be teed up by the generative ai.
• 21:11
  David: For an email, for example.
• 21:13
  David: Then the other thing is sometimes you're trying to find a, you know, someone's on a diagnostic odyssey and you're trying to figure out like, what does this patient have, and it takes a long time before they ever get to it.
• 21:22
  David: The AI can actually be helpful in finding.
• 21:25
  David: Not just using the large language model, but can actually figure out like what resource should it go and find that has objective information that's way beyond what's in the doctor's head or in their, in their library to be able to help to get that diagnosis.
• 21:37
  David: And then the final thing is there's a lot of paperwork in the background that is just purely administrative and a lot of that can be, uh, automated.
• 21:45
  David: Potentially with ai.
• 21:46
  David: So I do see these as being real, uh, potential just on the AI side.
• 21:51
  David: Then there may be other things like, uh, wearable devices that are gonna be able to provide better data for when the patients, not just when they're in the office, but when they're out in their own.
• 21:59
  David: I thought you were a big
• 22:00
  John: skeptic of remote patient monitoring.
• 22:02
  John: Now you're turning into a buyer.
• 22:04
  John: Used to be anti-technology.
• 22:07
  David: Well, the technology's getting better, John, and I'm getting, uh, my, maybe my standards are going down.
• 22:11
  David: No, the technology's getting better mostly.
• 22:13
  David: And we have ways to process the data cuz it used to be someone would, you know, bring a bunch of data to their doctor, right?
• 22:19
  David: And they, the doctor wouldn't even want it cuz like, what am I gonna do with this?
• 22:21
  David: But now they have tools to be able to, uh, uh, to interpret it.
• 22:25
  David: And it's easier to, uh, get the data for people.
• 22:28
  David: Like, you know, people are wearing an Apple watch all the time, which used to be hard to get them to wear the, the wearable.
• 22:33
  David: Now they like it.
• 22:35
  David: Well,
• 22:35
  John: David, any, any final advice for the independent practice that wants to stay independent?
• 22:42
  David: Yeah, I'd say hang in there and, um, try some of these new technologies.
• 22:47
  David: I would say there's a, you know, this next six to 18 months is gonna be an interesting window when, um, practices have the opportunity to adopt some of these tools and should.
• 22:57
  David: And should definitely give it a try.
• 22:59
  David: That's my thought.
• 23:00
  David: John, what do you think?
• 23:02
  John: I, I think that independent practices need to move quickly into coalitions that can, that can accelerate the attempt to get into value-based care.
• 23:10
  John: I mean, value-based care, healthcare and a budget is gonna pay doctors to stay in business.
• 23:15
  John: I mean, they're coming out of a really hard period.
• 23:17
  John: Independent practices particularly suffered during covid because they were shut down, and I think that drove some of the consolidation.
• 23:23
  John: But patients generally, like doctors, Uh, practices that are run by doctors.
• 23:28
  John: And, uh, I think that, that if we can, if they can move faster away from fee for service, like those Medicaid examples that you pointed out in Massachusetts to where they're, they're paid a fair amount to to, to their jobs, I think they'll, uh, they, that, that and, and technology doctors are, are generally slow to innovate.
• 23:48
  John: These are two areas that are absolutely critical for independent practices, I think to, to align and survive within for the next generation.
• 23:54
  David: Well, that's it for yet another episode of CareTalk.
• 23:57
  David: We've been talking about independent physician practices, technology, value-based care, and so on.
• 24:02
  David: I'm David Williams, president of Health Business Group,
• 24:05
  John: and I'm John Driscoll, the president of Walgreens Health.
• 24:08
  John: If you like what you heard or you didn't, I'd love you to subscribe on your favorite service.