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why don't you introduce yourself? Hey, Perry. Been here at VMware for about a month now.

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Joined to be a Tanzu value advisor, really help our customers embrace this concept of

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digital transformation. A lot of background of healthcare and related insurance. Also grew up

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around it. My mother ran hospitals. My father was a biomedical engineer. So my dinner table topics

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were usually just these amazing conversations of Medicare reimbursement rates and fun things like

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that growing up. A little bit of osmosis when I'm not playing geek here, I'm playing geek with

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robotics. So a member of the first Washington board, but a lot of robotics from elementary school all

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the way through high school. So when you were at dinner, did people ever use dinner for an analogy

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of healthcare reimbursement terms or bioengineering like this, this potato, imagine that's your,

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your liver. Medicare reimbursement. You could have one piece of broccoli. We negotiated with Blue Cross

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you could have three. That's right. It was always better than the out of network for sure.

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Like you mentioned, I thought it'd be fun. You've been around for about around here for about a month

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or so. And I thought it would be great to just get an idea of the healthcare industry and it more or less

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kind of US centric. I imagine some of the things apply to other geographies, but yeah, let's start

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with that. Is, do you think healthcare is like idiosyncratic to the country it happens in?

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Definitely the reimbursement and we could spend hours talking about the US and Medicare for all

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versus public options versus commercial insurance and all that kind of stuff. So that skews the US

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healthcare world quite a bit. I think there is a lot of consistency or synergy to use that word

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is on the care delivery side, right? How, especially post COVID, how that world has changed about how you

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see a doctor, what doctor you will see. But I'll also say you as an individual interacting with the

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healthcare system is one of the most personal things you can do. To be a little sarcastic for a minute,

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they literally get to see you naked. So there turns out to be a huge like cultural trust impact into

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that. And so that can have some real nuances country to country.

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I think in that area, when we were talking a little bit beforehand, I hadn't really thought

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about it, but you've laid out a pretty convincing case that there is a lot of whatever word you want

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to use disruption, a lot of stuff, but there's a lot of not only here's how we provide the service

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and the healthcare and here's how the interaction between the healthcare provider and the patient can

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change. But that also drags in hopefully for better, a lot of business changes as well.

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There's a lot of, let's call it just change.

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COVID was a real accelerant for the industry, a challenge for the industry, right? And obviously

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taking a moment to recognize everybody in the healthcare space that was on the proverbial front

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lines or still are, frankly, I guess we shouldn't call it over by any stretch of COVID in the treatment

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and all of those aspects. But there is a ton of disruption to use the buzzword that is starting

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to occur. And I would say we're still in the first half, much more than the second half.

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And how is this going to play out? It's exciting in that we're starting to see a lot of the assumptions

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challenged. And I think when I think about all the other disruption that's occurred, the Netflixes,

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Amazons, et cetera, et cetera, et cetera. From my perspective, one of the things they did is they went

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after those sacred cows, the things that will always be true. That's where they went to challenge.

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And I think of things like Zoom Plus Care up here in the Pacific Northwest. I'm based here in Seattle.

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That really challenged the assumption that you're going to want to see the same doctor all the time.

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I think about all the healthcare political fights in the U.S. and how much was I need to keep my

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doctor. And no doubt for a large part of the population, that's probably true. But younger

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generations, digital generations, gen, whatever letter we have to, ZZAA, whatever we're at,

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is that really true? The idea of Zoom Plus is that if I want a physical, I don't want to take off time

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from work or any of that kind of stuff. I also have no idea what four weeks from now looks. So why

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do I schedule that? Why can't I get up on Sunday morning and say, this is a good day for me and go

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and say, I want my physical and go get an appointment later that day and off you go. And it's really

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working that way. It's not urgent care. Use it as urgent care. I had the flu. I cut my leg. I did

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that kind of thing. But truly the whole general practice doctor going that way. That's just one

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example and one assumption. And how's it going to play out? I don't know. We'll see. Corbin Nielsen's

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running that. And I think the world of him. So I think he's a pretty smart individual, but we'll see

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if that bet plays. There's also, you've got things like Walmart who is talking about, or they publish

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plans to open three to 4,000 clinics in their stores from a healthcare perspective. That's actually

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really awesome. I will say, because Walmart is in a lot of rural areas and in rural areas, there isn't

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a lot of coverage. We call them care deserts. Actually, there just isn't a lot of that general

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practitioner. Am I getting my physical? Am I getting my vaccines? Am I getting all of that just normal

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stuff that's super critical to keep people healthy? The idea that Walmart would seed that is really

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good. And then, of course, you can see a business for Walmart out of that being really tremendously

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huge. They've got pharmacies. They've got all of that kind of thing. You can buy your chicken

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soup while you're there if you're not feeling well. CVS bought Aetna, the healthcare insurance

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company. CVS is also one of the largest pharmacy benefit managers. So these PBMs, which are these

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drugs, they're also the point of sale pharmacy. They're now also hiring nurse practitioners and

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things to have clinics within their pharmacies. They have all this retail space that they're

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frankly not using too much because their retail side is getting eaten by Kroger and Amazon and

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those kinds of things. So they're becoming this vertically integrated, just behemoth in the

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industry. Is that going to work? I don't know. But there's a lot of these things. And then

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you've got the whole digital side of the house too, that we all experienced during COVID.

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So that, yeah, that's all really fascinating. And it seems, so one, let's see, there's, I

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think, tell me if I've got these right and if there's more, there's three, as you call them

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assumptions, or we could also call them like constraints that previously existed. And that

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one assumption was maybe to expand it a little bit, that I as a patient always want to have

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a very personal ongoing hands-on, I guess sometimes literally, like relationship with my various

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care providers. And like you were saying, there's many times where that's good, especially for like

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ongoing knowledge of the patient, things like that. But then, yeah, oftentimes you're just like,

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you just, the stuff you do at a physical is pretty routine. And humans are more or less,

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this is the basis of medicine, right? They're very compatible with each other. There's a standard.

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And, but that assumption, it drives, it causes a problem with another thing that I notice a lot in,

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in healthcare, which is there's a supply problem, a supply, not a supply of patients, but a supply of

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doctors and nurses and everything. But it seems like if you have that more casual approach to things,

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you remove that assumption of, I can only see this one person that I'm bottlenecking on. Then

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you start addressing that supply thing. And then the second thing that you went over that was

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interesting is, I don't know, it's almost like moving from a very, what's the opposite of integrated,

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moving from a very like decentralized, to use the word again, supply chain, right? Like we got a

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hospital here, you got a pharmacy here, you got a pharmaceutical company over here. And then you

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have the whole like back office claim sort of stuff here and blah, blah, blah, to more of what if we

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collapse a lot of those into one entity? And then the third one is just technology. It's exciting

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horizon two and horizon three stuff. And two has been, you know, even accelerated the idea that in

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COVID, we didn't want any patients in the hospital, right? Boy, I hesitate to even call it a joke,

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right? Humor point is like the worst place to be when you're sick is a hospital. Because of all the

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other infections you get, you don't really get to rest because somebody is poking you every three

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hours, all of that kind of stuff. But especially with COVID, right? We didn't want COVID patients in

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the hospital because they might catch COVID. There's just so much of it and that kind of thing.

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So the idea of hospital at home and seeing all of that happen from a digital perspective,

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right? How do I track somebody with a heart condition from home or their diabetes from home,

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IOT, all of that kind of stuff. You got Best Buy Health leaning into all of that. So among several

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other players, it's a pretty exciting space there. So let's talk about the middle one, because I think

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the constraints and opportunities you have around business models drive most everything,

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which to put it a crass way, people need to be paid. So the way that money flows through the system

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determines a lot of what works out well. Was there regulation that caused non-integrated people

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and regulations were changed? Or what's causing the ability to have more integrated things nowadays?

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Some regulation. CBS and I remember when that was going through, there was a question of whether

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the US government would allow that from a monopoly kind of fair trade kind of perspective. And

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that seems to be okay. But they wouldn't let Anthem, which is the largest Blue Cross Blue Shield

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provider or payer and merge some years before they shut it down. So we're seeing a little bit of

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loosening from that perspective. But you're right. You've got all of these people making their bets,

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whether they're startups, whether they're existing players and what the healthcare system's going to be,

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how they get paid is potentially changing. Today you have the traditional, a lot of,

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most of the insurance is commercial employer-based, and we could have hours of podcasts of pros and

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cons around that system. But those are payers negotiating with providers being the doctors,

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labs, hospitals, right? The people you see and touch from a perspective thing.

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They negotiate rates one by one for you. Coté, I'm the insurance company, you're the provider.

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So we're going to talk about knee replacement. I'm going to say, I'm going to pay you $12,000.

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And you're going to say, no, I want $14,000. All of those negotiations happen. And then you've got

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the big elephant in the room, the US federal government, which, through the auspices of Medicare,

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tremendously influences how things are paid and what the regulators are. The direction Medicare

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goes also then directly impacts Medicaid. Even though Medicaid is a state-run thing,

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it's heavily influenced by federal. And so all of that works together. I think a perfect example I

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would have right now is pre-COVID, the idea of you seeing a doctor through Teladoc, right? Or any of

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these mobile apps or over the internet, instead of going and seeing them in person, they were paid at a

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much lower rate than if you went and saw somebody in person. A lot of historical reasons. Well, in COVID,

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one of the first the federal government did was waive that and say, we will reimburse you at a Medicare rate

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at the same rate, whether you're in the office or whether you're even over FaceTime. It didn't have to be

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through a heavily regulated thing. They actually waived a lot of HIPAA rules, but that's a whole rabbit hole.

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We won't go down that. But now post-COVID, right? So far, Medicare has said that exception is going to go

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away. That's a big deal. If you were one of the startups that said, I'm going to jump on this Teladoc space,

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frankly, I personally hope and whatever advocacy I can do to get that to be paid the same. When you

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start thinking about like Medicaid, which is out for those that are poor and all of that, those are the

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folks that can't pick off work, that can't go meet in person. Like we greatly can improve the outcomes

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of those that need it most by just saying, hey, we'll pay you the same whether you meet over the phone or

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in person. That kind of confirms some theories that I had that a lot of in this space and others, but

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a lot more in this space than some others, like retail and other things, like regulations drive

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a lot of what's possible. And I think obviously for all the bad reasons, it's not like great that there

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was a past year of pandemic stuff. Some of the few bright things are like, there are, as you were

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pointing out, many companies and situations where people just were forced to waive preconceived

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notions and rules about things. And even there's cases where it's not necessarily rules, but

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organizations who had to suddenly change the way they were doing their software, they just decided

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they could actually do it instead of they're like in year three of their digital transformation and

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it's meandering along and going nowhere. But then all of a sudden they're like, oh, we actually have

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to ship something. And then they do. So there's a lot of, there's a lot of those forcing functions.

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And it is, it would be interesting to kind of catalog, like, it seems like a lot of what we're

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talking about is there's convenience, right? For patients, but it's also, I don't know what the term

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of art is in healthcare, but it's like efficiency. Like us in the tech world, we would draw up a value

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stream map or a build pipeline. And we would find all the activities it took from me thinking I need

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to go to the doctor to what would be the end activity, probably putting a pill in my mouth and

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maybe even using my full prescription if I was prescribed something. And like, boy, I remember

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the quote I like to use that long ago, someone told me is they did a value stream map totally out of

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healthcare. And they had the, the executive, the stakeholder in there looked up on the whiteboard

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and the executive was like, wow, there's a whole lot of stupid up there. So it seems like a lot of

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what the potential is to find those inefficiencies and really figure out how to speed up those little

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chunks in the entire value stream.

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Yeah. So get out time, get out cost, but then also like, how do we increase outcomes?

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Type two diabetes, obviously incredibly growing community, a lot of diet based, a lot of exercise

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based, a lot of just depending on how you did in the genetic lottery, but compliance to that is a

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big deal. And if I could use your Apple watch, Fitbit, whatever insulin pumps, all of that kind of

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stuff and send you home and be able to track that you're following the plan instead of seeing you

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once every six months, I can't adjust your course once every six months.

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That's an interesting one to push on a little bit is when I was, I don't know a lot about healthcare

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as is evidence from my questions here. So I was doing a little bit of reading before we were talking

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and I was reminded that there's, you probably know much better than I do, but there's a few

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like whether they're health insurance or, or kind of healthcare related people who like use the Apple

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health kit thing that I think back when I was in Austin, the hospital thing I went to would put my

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records in there, which is, that's always fun to go look at your healthcare records and be like,

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that was a useless exercise for me. Just a whole bunch of stuff to quote a manager from a long time

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ago of mine. I've read that three times and I'm not even sure it's in English, but it does seem like

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that seems like an interesting thought exercise of how many like parts in that whole value chain of

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healthcare, how many of them are like integrated into something like healthcare?

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I think the community is growing, but what is happening again, Medicare being that incredible

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elephant in the room has mandated by January 1st, 23, that all providers be able to share with their

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customers. Members is the magic word. Who knows where that came from, but customers, their medical

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information, their records using a standard called fire integrated with your device so that you can take

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your iPhone. Apple was one of the big people that leaned into fire a few years ago to help bring it

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to life so that you can just get your medical records over your phone and then go see your other doctor

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and hand them their medical records and exchange information with insurance companies and all of

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that. You're going to start seeing a lot more of that integration today. Livongo was how do I provide

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services for diabetic patients? Again, focusing a lot on the type two, how are they doing of all of that?

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Teladoc bought them for a tremendous amount of money. I can't remember the exact dollar figure off

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the top of my head, but it was really big, especially for the healthcare space. The idea that I could

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merge this seeing a doctor over the phone and Livongo leveraged a lot of your device to help drive

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through a lot of those things and is now right through this investment from Teladoc spreading out

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into a bunch of other disease management as well.

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So from like a technologist point of view, right? Like digitizing all this stuff just seems like

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fantastic, right? Like it's fun. And it has the two criteria that you mentioned a little bit,

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but that's implicit in a lot of what you're talking about is that it's like anything. It just has

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different jargon for it is you want to be focused on patient outcomes, right? Them being healthy. It's

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right in the name there. And then also like part of that is efficiency and costs, right? Those are the two

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things everyone's focused on. And I would think that even the simple thing of healthcare record

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portability would peg out both of those. One, like I remember when I moved over to Amsterdam,

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I wanted to transfer my health records and there was obviously there was some HIPAA stuff or whatever,

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but then also like they would only fax it. And, and I don't think the doctors here even have facts.

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The idea that I could over here and a little bit back in the States nowadays, you can pay contactless

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with your phone and putting on my sci-fi technologist hat, right? Like it seems like

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I would go to the new doctor here and in the same way I can use NFT or whatever to pay a bill,

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I could just transfer my, my, my records there, which, which would be efficient and also give them

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better care. So that all sounds cool. Now, like what, but what are the problems that come up,

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right? With digitizing stuff? Cause it seems like we've had a long time to digitize things

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and like, we're still on the cusp of it. Health records are, I would say most of the way there.

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Now. Yes. Look, I was, we're at the CIO had a Primer in 2020 at the beginning of COVID. And like,

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we celebrated upgrading our fax system. You think about Epic, you think about sooner, you think about

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these electronic health record companies, or I'm sorry, electronic medical record. I think EMR is the

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better term these days. We're there. Purchase of nuance today is really about how to,

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or a big part of it is how to help doctors fill out those EMRs. So we're relatively digitized.

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Now what we aren't is API driven, right? So I have all of this information within Epic and I could go

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from Epic to Epic really well. I can go from Epic to probably a healthcare system pretty well, but even

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that's a lot of EDI flat file things these days. But how do we drive to the, the kind of API driven

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economy that the, you know, many other, if not, it seems every other industry when you're in healthcare,

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that we're the only one, I'm sure there's others, but I think that's what potentially the,

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this interoperability standard for January, 23 potentially could help drive and really open up.

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What, what kind of new experience can you have? What third party is going to start up and drop a

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$5 app at the app store. That's going to help you. You just said, I'm not even sure that's English.

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How can they help translate that for you? And what's that new experience?

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Closed systems. It's harder for innovation, right? Like you were just saying, like within each system,

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each, whatever a system may be a computational system in a hospital or a clinic or even a hospital

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system, like things work. Okay. But then once you go outside of those systems, we know this from

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all other walks of life. If you don't have like data interchange compatibility to use a really strange

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phrase, it's impossible to do any type of innovation, right? Paying with your phone works well because

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there's standards and there's, you can cross lines and you don't notice any of this stuff,

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stuff working. So maybe that's another like aspect that is opening up a lot of opportunities is that

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if we actually make things compatible, it means that we invite more and more people in to compete

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innovation and try out new things and try new ideas out.

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Absolutely. And then you've got the harder problems to solve, which are the people problems. I think

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about when we were Primera and the idea that we could establish real-time claims APIs and that while

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you're in the doctor, they're filling out in whatever the EMR system is, what they did with you today,

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that could automatically go to the payer insurance. So the idea that by the time you got to your car,

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you could look at your phone and see what you owe and pay for it. And that's a really amazing concept

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until you stop to think that the doctor's office isn't staffed for you to have a billing question

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there at that moment. You've got the one person and look, this is stereotyping and generalizing,

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which is really dangerous. We've got that one person there that checks you in, has you fill out

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your form if you're a new patient or whatever that kind of thing is, get your insurance card,

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all that stuff. That same person's probably rescheduling you on the way out the door and answering

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the phone to stop and have a billing conversation creates a staffing problem.

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Yeah. You need some tele-billing.

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There's a lot of interesting side effects downstream of that, but absolutely, there's no reason

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technologically why that world and in that world will come, absolutely will come as we come through

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this. But look, parts of the industry are still fighting this. Price transparency is a regulation

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that went into effect January 1st. I'm sure there's lots of waivers because the healthcare industry

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was a little busy over the last few months. But the idea that they have to publish in machine-readable

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format, their costs for all these things, and how they negotiated with the insurance companies for

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each of those costs and all of that, from my perspective, that could be a real huge opportunity.

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In general, the health systems have run away from it. And so they've put them in these systems that

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sometimes you have to log into, which kind of goes against transparency, but also like they've hidden

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them from all the Google crawlers and all of that kind of stuff. So you can't do that. So now you

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have this whole industry of startup of people who manually go through all these because that's how

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they can call it. But whatever, my point there, the industry is, is evolving and slowly. And like

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every disruption, you've got those that are fighting it both just outward, but just even accidentally,

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they don't mean to fight it, but that's new. I don't like that. I'm not going to do that. Versus

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the others that are just completely on the other end of the bleeding edge.

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I think we got a good part one down here, which is beyond fax machines. Like what's the era after

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fax machines? And that's like a snarky way to put it, but I don't know. It is genuine. And I think,

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I think the point that like I'm thinking of after this little conversation is that again, there are

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new, there's always new ways computers can help and make things better, but there's actually like

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industry and regulatory and even like customer as in patient and probably on the other side as well,

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just what would you call it? Sentiment and desire changes. So there's a lot of, there's a lot of room

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for doing things differently. And I think for part two, we should talk about like which people in this

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big system first, who are the people who think about the following? Like, all right, so what should I be

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doing differently? Like, how should I be, am I that little startup that's going to use all this free

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information to do something new and different? Or what do I do if I'm, if I am one of those like

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epic companies out there, like the big existing companies, like how are they adapting and doing

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new things as well? So in the meantime, would you point people towards anything? You got a

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Twitter account?

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That's a circle JTP is probably the, the place to go back to keep track of most of this stuff.

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LinkedIn as well, JT Perry, but most of it will be on Twitter.

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Yeah. All right. Good. This was exciting. We've known each other online for a long time. I don't

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even remember. I don't even remember when, but I've, I've known your, the circle JT name for a long time.

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And yeah, so that's good stuff. All right. As always, this has been an episode of Tanzu Talk.

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If you want to get the archives for this videos and podcast, you can go to tanzutalk.com and find

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everything there. And hopefully it won't be too long, maybe a few more episodes and we'll have a

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part two here. We'll dive into the, the exciting technology beyond fax machines. We'll see everyone next time. Bye-bye.

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you