why don't you introduce yourself? Hey, Perry. Been here at VMware for about a month now. Joined to be a Tanzu value advisor, really help our customers embrace this concept of digital transformation. A lot of background of healthcare and related insurance. Also grew up around it. My mother ran hospitals. My father was a biomedical engineer. So my dinner table topics were usually just these amazing conversations of Medicare reimbursement rates and fun things like that growing up. A little bit of osmosis when I'm not playing geek here, I'm playing geek with robotics. So a member of the first Washington board, but a lot of robotics from elementary school all the way through high school. So when you were at dinner, did people ever use dinner for an analogy of healthcare reimbursement terms or bioengineering like this, this potato, imagine that's your, your liver. Medicare reimbursement. You could have one piece of broccoli. We negotiated with Blue Cross you could have three. That's right. It was always better than the out of network for sure. Like you mentioned, I thought it'd be fun. You've been around for about around here for about a month or so. And I thought it would be great to just get an idea of the healthcare industry and it more or less kind of US centric. I imagine some of the things apply to other geographies, but yeah, let's start with that. Is, do you think healthcare is like idiosyncratic to the country it happens in? Definitely the reimbursement and we could spend hours talking about the US and Medicare for all versus public options versus commercial insurance and all that kind of stuff. So that skews the US healthcare world quite a bit. I think there is a lot of consistency or synergy to use that word is on the care delivery side, right? How, especially post COVID, how that world has changed about how you see a doctor, what doctor you will see. But I'll also say you as an individual interacting with the healthcare system is one of the most personal things you can do. To be a little sarcastic for a minute, they literally get to see you naked. So there turns out to be a huge like cultural trust impact into
2:06that. And so that can have some real nuances country to country. I think in that area, when we were talking a little bit beforehand, I hadn't really thought about it, but you've laid out a pretty convincing case that there is a lot of whatever word you want to use disruption, a lot of stuff, but there's a lot of not only here's how we provide the service and the healthcare and here's how the interaction between the healthcare provider and the patient can change. But that also drags in hopefully for better, a lot of business changes as well. There's a lot of, let's call it just change. COVID was a real accelerant for the industry, a challenge for the industry, right? And obviously taking a moment to recognize everybody in the healthcare space that was on the proverbial front lines or still are, frankly, I guess we shouldn't call it over by any stretch of COVID in the treatment and all of those aspects. But there is a ton of disruption to use the buzzword that is starting to occur. And I would say we're still in the first half, much more than the second half. And how is this going to play out? It's exciting in that we're starting to see a lot of the assumptions challenged. And I think when I think about all the other disruption that's occurred, the Netflixes, Amazons, et cetera, et cetera, et cetera. From my perspective, one of the things they did is they went after those sacred cows, the things that will always be true. That's where they went to challenge. And I think of things like Zoom Plus Care up here in the Pacific Northwest. I'm based here in Seattle. That really challenged the assumption that you're going to want to see the same doctor all the time. I think about all the healthcare political fights in the U.S. and how much was I need to keep my doctor. And no doubt for a large part of the population, that's probably true. But younger generations, digital generations, gen, whatever letter we have to, ZZAA, whatever we're at, is that really true? The idea of Zoom Plus is that if I want a physical, I don't want to take off time from work or any of that kind of stuff. I also have no idea what four weeks from now looks. So why do I schedule that? Why can't I get up on Sunday morning and say, this is a good day for me and go
4:08and say, I want my physical and go get an appointment later that day and off you go. And it's really working that way. It's not urgent care. Use it as urgent care. I had the flu. I cut my leg. I did that kind of thing. But truly the whole general practice doctor going that way. That's just one example and one assumption. And how's it going to play out? I don't know. We'll see. Corbin Nielsen's running that. And I think the world of him. So I think he's a pretty smart individual, but we'll see if that bet plays. There's also, you've got things like Walmart who is talking about, or they publish plans to open three to 4,000 clinics in their stores from a healthcare perspective. That's actually really awesome. I will say, because Walmart is in a lot of rural areas and in rural areas, there isn't a lot of coverage. We call them care deserts. Actually, there just isn't a lot of that general practitioner. Am I getting my physical? Am I getting my vaccines? Am I getting all of that just normal stuff that's super critical to keep people healthy? The idea that Walmart would seed that is really good. And then, of course, you can see a business for Walmart out of that being really tremendously huge. They've got pharmacies. They've got all of that kind of thing. You can buy your chicken soup while you're there if you're not feeling well. CVS bought Aetna, the healthcare insurance company. CVS is also one of the largest pharmacy benefit managers. So these PBMs, which are these drugs, they're also the point of sale pharmacy. They're now also hiring nurse practitioners and things to have clinics within their pharmacies. They have all this retail space that they're frankly not using too much because their retail side is getting eaten by Kroger and Amazon and those kinds of things. So they're becoming this vertically integrated, just behemoth in the industry. Is that going to work? I don't know. But there's a lot of these things. And then you've got the whole digital side of the house too, that we all experienced during COVID. So that, yeah, that's all really fascinating. And it seems, so one, let's see, there's, I think, tell me if I've got these right and if there's more, there's three, as you call them
6:08assumptions, or we could also call them like constraints that previously existed. And that one assumption was maybe to expand it a little bit, that I as a patient always want to have a very personal ongoing hands-on, I guess sometimes literally, like relationship with my various care providers. And like you were saying, there's many times where that's good, especially for like ongoing knowledge of the patient, things like that. But then, yeah, oftentimes you're just like, you just, the stuff you do at a physical is pretty routine. And humans are more or less, this is the basis of medicine, right? They're very compatible with each other. There's a standard. And, but that assumption, it drives, it causes a problem with another thing that I notice a lot in, in healthcare, which is there's a supply problem, a supply, not a supply of patients, but a supply of doctors and nurses and everything. But it seems like if you have that more casual approach to things, you remove that assumption of, I can only see this one person that I'm bottlenecking on. Then you start addressing that supply thing. And then the second thing that you went over that was interesting is, I don't know, it's almost like moving from a very, what's the opposite of integrated, moving from a very like decentralized, to use the word again, supply chain, right? Like we got a hospital here, you got a pharmacy here, you got a pharmaceutical company over here. And then you have the whole like back office claim sort of stuff here and blah, blah, blah, to more of what if we collapse a lot of those into one entity? And then the third one is just technology. It's exciting horizon two and horizon three stuff. And two has been, you know, even accelerated the idea that in COVID, we didn't want any patients in the hospital, right? Boy, I hesitate to even call it a joke, right? Humor point is like the worst place to be when you're sick is a hospital. Because of all the other infections you get, you don't really get to rest because somebody is poking you every three hours, all of that kind of stuff. But especially with COVID, right? We didn't want COVID patients in the hospital because they might catch COVID. There's just so much of it and that kind of thing.
8:11So the idea of hospital at home and seeing all of that happen from a digital perspective, right? How do I track somebody with a heart condition from home or their diabetes from home, IOT, all of that kind of stuff. You got Best Buy Health leaning into all of that. So among several other players, it's a pretty exciting space there. So let's talk about the middle one, because I think the constraints and opportunities you have around business models drive most everything, which to put it a crass way, people need to be paid. So the way that money flows through the system determines a lot of what works out well. Was there regulation that caused non-integrated people and regulations were changed? Or what's causing the ability to have more integrated things nowadays? Some regulation. CBS and I remember when that was going through, there was a question of whether the US government would allow that from a monopoly kind of fair trade kind of perspective. And that seems to be okay. But they wouldn't let Anthem, which is the largest Blue Cross Blue Shield provider or payer and merge some years before they shut it down. So we're seeing a little bit of loosening from that perspective. But you're right. You've got all of these people making their bets, whether they're startups, whether they're existing players and what the healthcare system's going to be, how they get paid is potentially changing. Today you have the traditional, a lot of, most of the insurance is commercial employer-based, and we could have hours of podcasts of pros and cons around that system. But those are payers negotiating with providers being the doctors, labs, hospitals, right? The people you see and touch from a perspective thing. They negotiate rates one by one for you. Coté, I'm the insurance company, you're the provider. So we're going to talk about knee replacement. I'm going to say, I'm going to pay you $12,000. And you're going to say, no, I want $14,000. All of those negotiations happen. And then you've got the big elephant in the room, the US federal government, which, through the auspices of Medicare, tremendously influences how things are paid and what the regulators are. The direction Medicare
10:15goes also then directly impacts Medicaid. Even though Medicaid is a state-run thing, it's heavily influenced by federal. And so all of that works together. I think a perfect example I would have right now is pre-COVID, the idea of you seeing a doctor through Teladoc, right? Or any of these mobile apps or over the internet, instead of going and seeing them in person, they were paid at a much lower rate than if you went and saw somebody in person. A lot of historical reasons. Well, in COVID, one of the first the federal government did was waive that and say, we will reimburse you at a Medicare rate at the same rate, whether you're in the office or whether you're even over FaceTime. It didn't have to be through a heavily regulated thing. They actually waived a lot of HIPAA rules, but that's a whole rabbit hole. We won't go down that. But now post-COVID, right? So far, Medicare has said that exception is going to go away. That's a big deal. If you were one of the startups that said, I'm going to jump on this Teladoc space, frankly, I personally hope and whatever advocacy I can do to get that to be paid the same. When you start thinking about like Medicaid, which is out for those that are poor and all of that, those are the folks that can't pick off work, that can't go meet in person. Like we greatly can improve the outcomes of those that need it most by just saying, hey, we'll pay you the same whether you meet over the phone or in person. That kind of confirms some theories that I had that a lot of in this space and others, but a lot more in this space than some others, like retail and other things, like regulations drive a lot of what's possible. And I think obviously for all the bad reasons, it's not like great that there was a past year of pandemic stuff. Some of the few bright things are like, there are, as you were pointing out, many companies and situations where people just were forced to waive preconceived notions and rules about things. And even there's cases where it's not necessarily rules, but organizations who had to suddenly change the way they were doing their software, they just decided they could actually do it instead of they're like in year three of their digital transformation and it's meandering along and going nowhere. But then all of a sudden they're like, oh, we actually have
12:16to ship something. And then they do. So there's a lot of, there's a lot of those forcing functions. And it is, it would be interesting to kind of catalog, like, it seems like a lot of what we're talking about is there's convenience, right? For patients, but it's also, I don't know what the term of art is in healthcare, but it's like efficiency. Like us in the tech world, we would draw up a value stream map or a build pipeline. And we would find all the activities it took from me thinking I need to go to the doctor to what would be the end activity, probably putting a pill in my mouth and maybe even using my full prescription if I was prescribed something. And like, boy, I remember the quote I like to use that long ago, someone told me is they did a value stream map totally out of healthcare. And they had the, the executive, the stakeholder in there looked up on the whiteboard and the executive was like, wow, there's a whole lot of stupid up there. So it seems like a lot of what the potential is to find those inefficiencies and really figure out how to speed up those little chunks in the entire value stream. Yeah. So get out time, get out cost, but then also like, how do we increase outcomes? Type two diabetes, obviously incredibly growing community, a lot of diet based, a lot of exercise based, a lot of just depending on how you did in the genetic lottery, but compliance to that is a big deal. And if I could use your Apple watch, Fitbit, whatever insulin pumps, all of that kind of stuff and send you home and be able to track that you're following the plan instead of seeing you once every six months, I can't adjust your course once every six months. That's an interesting one to push on a little bit is when I was, I don't know a lot about healthcare as is evidence from my questions here. So I was doing a little bit of reading before we were talking and I was reminded that there's, you probably know much better than I do, but there's a few like whether they're health insurance or, or kind of healthcare related people who like use the Apple health kit thing that I think back when I was in Austin, the hospital thing I went to would put my records in there, which is, that's always fun to go look at your healthcare records and be like, that was a useless exercise for me. Just a whole bunch of stuff to quote a manager from a long time
14:16ago of mine. I've read that three times and I'm not even sure it's in English, but it does seem like that seems like an interesting thought exercise of how many like parts in that whole value chain of healthcare, how many of them are like integrated into something like healthcare? I think the community is growing, but what is happening again, Medicare being that incredible elephant in the room has mandated by January 1st, 23, that all providers be able to share with their customers. Members is the magic word. Who knows where that came from, but customers, their medical information, their records using a standard called fire integrated with your device so that you can take your iPhone. Apple was one of the big people that leaned into fire a few years ago to help bring it to life so that you can just get your medical records over your phone and then go see your other doctor and hand them their medical records and exchange information with insurance companies and all of that. You're going to start seeing a lot more of that integration today. Livongo was how do I provide services for diabetic patients? Again, focusing a lot on the type two, how are they doing of all of that? Teladoc bought them for a tremendous amount of money. I can't remember the exact dollar figure off the top of my head, but it was really big, especially for the healthcare space. The idea that I could merge this seeing a doctor over the phone and Livongo leveraged a lot of your device to help drive through a lot of those things and is now right through this investment from Teladoc spreading out into a bunch of other disease management as well. So from like a technologist point of view, right? Like digitizing all this stuff just seems like fantastic, right? Like it's fun. And it has the two criteria that you mentioned a little bit, but that's implicit in a lot of what you're talking about is that it's like anything. It just has different jargon for it is you want to be focused on patient outcomes, right? Them being healthy. It's right in the name there. And then also like part of that is efficiency and costs, right? Those are the two things everyone's focused on. And I would think that even the simple thing of healthcare record
16:19portability would peg out both of those. One, like I remember when I moved over to Amsterdam, I wanted to transfer my health records and there was obviously there was some HIPAA stuff or whatever, but then also like they would only fax it. And, and I don't think the doctors here even have facts. The idea that I could over here and a little bit back in the States nowadays, you can pay contactless with your phone and putting on my sci-fi technologist hat, right? Like it seems like I would go to the new doctor here and in the same way I can use NFT or whatever to pay a bill, I could just transfer my, my, my records there, which, which would be efficient and also give them better care. So that all sounds cool. Now, like what, but what are the problems that come up, right? With digitizing stuff? Cause it seems like we've had a long time to digitize things and like, we're still on the cusp of it. Health records are, I would say most of the way there. Now. Yes. Look, I was, we're at the CIO had a Primer in 2020 at the beginning of COVID. And like, we celebrated upgrading our fax system. You think about Epic, you think about sooner, you think about these electronic health record companies, or I'm sorry, electronic medical record. I think EMR is the better term these days. We're there. Purchase of nuance today is really about how to, or a big part of it is how to help doctors fill out those EMRs. So we're relatively digitized. Now what we aren't is API driven, right? So I have all of this information within Epic and I could go from Epic to Epic really well. I can go from Epic to probably a healthcare system pretty well, but even that's a lot of EDI flat file things these days. But how do we drive to the, the kind of API driven economy that the, you know, many other, if not, it seems every other industry when you're in healthcare, that we're the only one, I'm sure there's others, but I think that's what potentially the, this interoperability standard for January, 23 potentially could help drive and really open up. What, what kind of new experience can you have? What third party is going to start up and drop a $5 app at the app store. That's going to help you. You just said, I'm not even sure that's English. How can they help translate that for you? And what's that new experience?
18:20Closed systems. It's harder for innovation, right? Like you were just saying, like within each system, each, whatever a system may be a computational system in a hospital or a clinic or even a hospital system, like things work. Okay. But then once you go outside of those systems, we know this from all other walks of life. If you don't have like data interchange compatibility to use a really strange phrase, it's impossible to do any type of innovation, right? Paying with your phone works well because there's standards and there's, you can cross lines and you don't notice any of this stuff, stuff working. So maybe that's another like aspect that is opening up a lot of opportunities is that if we actually make things compatible, it means that we invite more and more people in to compete innovation and try out new things and try new ideas out. Absolutely. And then you've got the harder problems to solve, which are the people problems. I think about when we were Primera and the idea that we could establish real-time claims APIs and that while you're in the doctor, they're filling out in whatever the EMR system is, what they did with you today, that could automatically go to the payer insurance. So the idea that by the time you got to your car, you could look at your phone and see what you owe and pay for it. And that's a really amazing concept until you stop to think that the doctor's office isn't staffed for you to have a billing question there at that moment. You've got the one person and look, this is stereotyping and generalizing, which is really dangerous. We've got that one person there that checks you in, has you fill out your form if you're a new patient or whatever that kind of thing is, get your insurance card, all that stuff. That same person's probably rescheduling you on the way out the door and answering the phone to stop and have a billing conversation creates a staffing problem. Yeah. You need some tele-billing. There's a lot of interesting side effects downstream of that, but absolutely, there's no reason technologically why that world and in that world will come, absolutely will come as we come through this. But look, parts of the industry are still fighting this. Price transparency is a regulation that went into effect January 1st. I'm sure there's lots of waivers because the healthcare industry was a little busy over the last few months. But the idea that they have to publish in machine-readable
20:23format, their costs for all these things, and how they negotiated with the insurance companies for each of those costs and all of that, from my perspective, that could be a real huge opportunity. In general, the health systems have run away from it. And so they've put them in these systems that sometimes you have to log into, which kind of goes against transparency, but also like they've hidden them from all the Google crawlers and all of that kind of stuff. So you can't do that. So now you have this whole industry of startup of people who manually go through all these because that's how they can call it. But whatever, my point there, the industry is, is evolving and slowly. And like every disruption, you've got those that are fighting it both just outward, but just even accidentally, they don't mean to fight it, but that's new. I don't like that. I'm not going to do that. Versus the others that are just completely on the other end of the bleeding edge. I think we got a good part one down here, which is beyond fax machines. Like what's the era after fax machines? And that's like a snarky way to put it, but I don't know. It is genuine. And I think, I think the point that like I'm thinking of after this little conversation is that again, there are new, there's always new ways computers can help and make things better, but there's actually like industry and regulatory and even like customer as in patient and probably on the other side as well, just what would you call it? Sentiment and desire changes. So there's a lot of, there's a lot of room for doing things differently. And I think for part two, we should talk about like which people in this big system first, who are the people who think about the following? Like, all right, so what should I be doing differently? Like, how should I be, am I that little startup that's going to use all this free information to do something new and different? Or what do I do if I'm, if I am one of those like epic companies out there, like the big existing companies, like how are they adapting and doing new things as well? So in the meantime, would you point people towards anything? You got a Twitter account? That's a circle JTP is probably the, the place to go back to keep track of most of this stuff. LinkedIn as well, JT Perry, but most of it will be on Twitter. Yeah. All right. Good. This was exciting. We've known each other online for a long time. I don't even remember. I don't even remember when, but I've, I've known your, the circle JT name for a long time.
22:26And yeah, so that's good stuff. All right. As always, this has been an episode of Tanzu Talk. If you want to get the archives for this videos and podcast, you can go to tanzutalk.com and find everything there. And hopefully it won't be too long, maybe a few more episodes and we'll have a part two here. We'll dive into the, the exciting technology beyond fax machines. We'll see everyone next time. Bye-bye. you