Tuning Healthcare, Episode 1: Who Will Win in Healthcare?

Ryan Panchadsaram, Advisor at Kleiner Perkins and Co-Founder & Coach, Measure What Matters

Few individuals know more about the intersection of health care and technology in government than Ryan Panchadsaram, the former U.S. Deputy Chief Technology Officer. Ryan, who served in the Obama administration, now works as an advisor at the renowned venture capital firm Kleiner Perkins, where he helps the firm invest in disruptive companies that solve big problems and transform industries.

“[Regarding] this shift to value-based care: the exciting part is that the system wins if it’s done well. … Anyone who’s putting the patient first with the efficiency mindset of getting them to be the healthiest they can and not pointing them to excess waste, those are the winners.”
– Ryan Panchadsaram

In this episode, Ryan talks to Lumeris Senior Vice President Nigel Ohrenstein and shares:

• What he learned from the technology debacle that followed the government’s $40 billion investment in Healthcare.gov
• Why data transparency is the key to achieving value-based health care outcomes
• How public-private partnerships can drive digital innovation and transform health care
• What the health care industry can learn from the Ubers and Airbnbs of the world, as well as the two things today’s most successful health care companies have in common
• His four key pieces of advice for budding entrepreneurs trying to disrupt their industries
• Who will win and lose in the new healthcare system

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• Read Transcript

  Nigel Ohrenstein: Welcome to Tuning Healthcare by Lumeris. My name is Nigel Ohrenstein, one of the co-founders of Lumeris, the market leader in value-based care. In these podcasts, we will talk to leaders from across the healthcare spectrum and learn how they are tackling real issues in healthcare today. Join me as we chat to different pioneers and discover their journey, what motivates them and how they are solving some of the most pressing topics facing the US healthcare system.

  Nigel Ohrenstein: I’m joined today by Ryan Panchadsaram, a highly accomplished executive. Ryan is currently a partner at Kleiner Perkins and the former Deputy Chief Technology Officer of the United States. In this episode of Tuning Healthcare, we discuss data transparency, how healthcare services will evolve and Ryan’s advice for budding entrepreneurs. Join Ryan and me in Kleiner Perkins’ San Francisco office for this episode of Tuning Healthcare.

  Nigel Ohrenstein: I’m joined today by Ryan Panchadsaram in the Kleiner offices in San Francisco. It’s a sunny day here and beautiful to be here. Ryan, thanks for joining me.

  Ryan P.: Always. Thank you, Nigel.

  Nigel Ohrenstein: So, I must admit that I thought I was quite accomplished until I read your bio. Any one of those things you’ve achieved would be impressive in and of itself. But looking back, which experience gives you the best feeling? What do you feel like, “Wow, I really did something amazing here?”

  Ryan P.: That’s a hard question. Each of those experiences on their own was so meaningful. I think that’s the beautiful part about working in government is that you’re working on really important problems that matter. And if you can make a difference to them, it feels really good. But if I had to pick one, it would likely be the HealthCare.gov rescue. I think as a technologist in government working on a problem like that, which meant every bug you fixed meant someone got healthcare. I’d never been so close to where tech was fixing the problem. So this really: You could see the number of people getting enrolled. You could see the number of people signing up for plans, and it meant a lot. And being able to be a part of that and to support the implementation of the Affordable Care Act afterwards, it felt great. It really did.

  Nigel Ohrenstein: It’s truly amazing. How does that team come about? There were seven or eight of you that were core right there on the picture of Time of people who fixed HealthCare.gov. Take us through what was happening.

  Ryan P.: Of course.

  Nigel Ohrenstein: The sky was falling.

  Ryan P.: The sky was falling. You’ve got to remember October 1st, 2013 is when the site launched. That was set into motion just three years earlier in March 2010. The Affordable Care Act gets signed. It says in it, “As part of this, there’s going to be a website that helps enroll people into  quality health plans.” And when it went live, it was this massive waterfall style project that asked for everything to appear on that day. And not just that, no one had ever used the site publicly before that day. You had 20 plus contractor organizations all trying to integrate the weeks before that day. And so October 1st ended up not being a great day. If you go back even through my Twitter feed, I think I congratulated the team on that day for the launch. Because from our perspective, it was going to be a great day.

  Ryan P.: What ended up happening is millions of people, of course, visited this site, hundreds of thousands of folks tried to apply. And I think only six people were actually able to get through on that first day. It just was a testament of how bad and broken it was, but we weren’t asked to help for a good 17 days. You have this site on the news 24/7, not working. And I was working at The White House at the time for Todd Park, and so a lot of us were trying to find ways to help, but because of the government shutdown we couldn’t. And so it took a little while to get the wheels moving.

  Ryan P.: But we ended up at the scene at the middle to end of October, first, as an assessment team for The White House to find out if we could fix it. And then after we spent a really exhausting weekend trying to see how we could, we realized there could be a path to doing it. And it took a lot of teamwork. It took a lot of aligning the thousands of people that are already working on it towards fixing the problem. And we could spend a whole hour together talking about it. But the best thing about that story is what happened actually afterwards.

  Ryan P.: Post the crisis, post fixing HealthCare.gov, you had a government that was very aware of the role of technology to future policy. Anything that we wanted to accomplish in government, no matter how big or small, tech was going to play a small part. And so because of that, we started the United States Digital Service to recruit amazing technologies, to work in government, to partner with their colleagues that were great policymakers, to ensure these projects and policies were successful.

  Ryan P.: I think in healthcare we have that similar analogy. The best healthcare companies are ones that have great clinical teams paired up with great technologists, paired up with great policymakers, and I think those are the companies that ended up being successful in the healthcare space.

  Nigel Ohrenstein: If we look back at that time in healthcare and the government, obviously made enormous strides to helping to push healthcare along, right?

  Ryan P.: Mm-hmm (affirmative).

  Nigel Ohrenstein: Healthcare is in so many ways a backward industry compared to all the other great investments that you’re working with here at Kleiner. And as we also know in healthcare, the government leads and the commercial industry follows. But meaningful use, right?

  Ryan P.: Yeah.

  Nigel Ohrenstein: Tens of billions spent on meaningful use. Good use of money? Would you do it differently if you went again?

  Ryan P.: Was it a good use of money? I would say yes…but no. Yes, we needed to digitize. I don’t think there would’ve been any other way to convince the hundreds of thousands of doctors across the country to make that shift. A lot of them were running really great practices, but the benefits of digitization and why that $40 billion went behind it was really stuck in this Rand report that said, “If you were able to digitize, we as a healthcare system would achieve all these great efficiencies. We’d have great measures at the national level, but at the individual level, we’d be able to take care of you better.” So on that front, yes, it was well spent to get the digitalization to happen.

  Ryan P.: But I think, the execution part is where it could have absolutely been better. I think that meaningful use was never strict enough, and I always get ragged for that because it’s like if you think about what meaningful use asks for, the bar is low in what it needs if you want to create a great electronic health record. And so I always felt meaningful use should have asked more. For $40 billion, it should have asked for more.

  Nigel Ohrenstein: Maybe interoperability?

  Ryan P.: Especially on interoperability. And I think there were ways to approach interoperability from a practical point of view, maybe more of an academic point of view. And I think we forget that for interoperability to be done well, it does take some central coordination. And so part of me feels that that’s the role of government. And so I think that we needed ONC to be able to do more, but in many ways they were handcuffed. Industry would push back on them, folks in government would push back on them. I just wish ONC was able to do what it could on the more coordinating side, because then I think we would actually have gotten even more value out of this system.

  Nigel Ohrenstein: I couldn’t agree more. The digitalization, obviously, necessary but for $40 billion, a little bit of interoperability would have been nice.

  Ryan P.: Absolutely.

  Nigel Ohrenstein: And we as well as other companies spend a fortune of time and effort in integrating different data sources, making EMRs talk to each other. It’s incredibly frustrating, right?

  Ryan P.: Yeah.

  Nigel Ohrenstein: As you well know, one version of Epic doesn’t talk to another version of Epic, and it’s an enormous amount of time, money and dollars spent doing that.

  Ryan P.: Absolutely. The thing that I’m so inspired by is actually the energy from industry in trying to fix this. If there was some energy to maybe slow it down back when MU2 was coming together, MU3 and the other regs post were really about saying, “Hey, let industry figure this out.” Efforts like Project Argonaut to strengthen FHIR and to get the EHRs to come to the table. And to look at that group that was part of Argonaut, it was all the big players, and so seeing that was really powerful. The other effect was seeing other companies like an Apple come into the picture and say, “Hey, this FHIR thing is cool.” If we’re going to create a health app on our phone that’s super private, we need to make these APIs work.

  Ryan P.: And so I think in some ways, Argonaut got everyone to talk in a similar language, but Apple helped say, “Well, this is the quality bar.” We’re not going to integrate in our prestigious app on a phone if you don’t meet a certain bar. And I thought that was really powerful because guess what every hospital CEO has in their pocket? Likely an iPhone. And so they can physically take this thing out and say, “Why does my EHR not work with this?” And that driving factor, even more powerful than anything I think a government could …

  Nigel Ohrenstein: Undoubtedly. And that talks a little bit to the private sector-public sector partnership. But then you bring a unique perspective here. You’ve worked for many years in public service and now, obviously, at Kleiner on the private side. What’s the optimal way that the public and private sector come together to help transform healthcare quicker? Because from my perspective, this is so critical for our children and our grandchildren, right?

  Ryan P.: Absolutely.

  Nigel Ohrenstein: It’s not just about healthcare. America becomes uncompetitive in the world if our healthcare costs continue to rise at the rate it does. We have to fix it. I’d love your perspective on how does public and private do it? And maybe as part of that, what do you see as the Amazon, Berkshire? What do you see? What role do you see them playing in this transformation?

  Ryan P.: Two very, very different questions, but two very big ones. I would say role of public and private, they both have to … The public sector and private sector need to both do the hard thing. The hard thing for, I think, the public sector is how do you create an equitable healthcare system? How do you ensure there are no bad actors that are in it, whether you are a tech provider or pharmaceutical company? How do you even the playing field? There’s a lot about equity and access that I think government really needs to be the torchbearer on, because that’s the hard problem that they can solve.

  Ryan P.: They can also be the central coordinator for things that need to be coordinated. And it’s equally important for the private sector to do the hard thing. That starts with how do you build and invent the next new drug, the next new therapy, the next new device, the next new way to take care of large populations? How do you deliver care better? That, the private sector is phenomenally good at because there’s competition, there’s a market that really celebrates that. I think there might be this trend and thought that, “Well, doesn’t the private sector make everything really expensive?” And I think, no, it’s not always true.

  Ryan P.: I think there’s only two places where trickle-down theory works. And to me it’s in healthcare and technology. In both industries you come up with the next best thing. It starts off expensive because you pour a lot of effort into it, and as time goes on, it becomes cheaper, and it then reaches the masses. And so if the public sector can keep things equitable in that level playing field and be that coordinator while the private sector is about delivery today and delivery tomorrow in the best way possible, I think, you’ve got the best balance.

  Nigel Ohrenstein: We’re sitting in San Francisco, the innovation capital of the world. It’s unreal what’s come out of a relatively small area that has transformed almost every part of how we live our life. But a lot of what Silicon Valley has in San Francisco and the tech industry have done immensely well is go straight to the consumer. Cut out in the middle man, and activate the consumer. Uber is a short stone’s throw from here. They figured out how to go directly from myself when I get off a plane to get the car I need as opposed to ringing some third-party car service and et cetera, et cetera. How do you do that in health care? Can you do it in health care?

  Ryan P.: Great question. How and then can you? And the flip, I think, is can you do it in healthcare? For most of it, I think, the answer is no. But for parts that you can, the parts you can’t do it for is when you have no choice. When you go to that emergency room, when you have that moment where you are in a healthcare emergency, you don’t have choice in that situation. And even if it’s an elective procedure or maybe you can shop around a little bit in some degree, it’s really hard there because you only have access to the things around you. You can’t order a knee surgery online and have it get delivered to you. And so I think if you don’t have the choice, then no. In those places there is no market and we have to be really thoughtful about that.

  Ryan P.: But there are a lot of places where you do have a choice. And I think that’s where you are seeing more consumer-oriented models popping up and having patients and consumers picking. I think you’re seeing this trend in clinics happen where you have a choice, One Medical that is offering things around convenience and access because as a patient you want that, and so you sign up and you pay for that kind of membership. You have groups like Forward or Tia, which are pushing that even farther forward on this more holistic sense. Tia for women’s health care.

  Ryan P.: And in those cases you have choice up front because it isn’t urgent. And so I think there is a market and a consumer nest to those parts of the equation. And I think that’s where you can learn from the Uber’s and Airbnb’s of the world. It’s a lot harder on the other side when you have to go for these issues … If you get diagnosed with cancer, you don’t have the same choice.

  Nigel Ohrenstein: In expanding on that a little bit, we roll the clock back. I lose track of time, but let’s say, we roll the clock like 20 years. It’s almost inconceivable that you would’ve gone anywhere other than the mall to buy sneakers, right?

  Ryan P.: Mm-hmm (affirmative).

  Nigel Ohrenstein: Or shoes, right? And now today you just have five pairs sent to you and you send four back, and you do that from your home at midnight. And IKEA, another great model, right?

  Ryan P.: Mm-hmm (affirmative).

  Nigel Ohrenstein: Took over things that were historically the domain of the supplier to deliver it to your front door, to put it together. It was unheard of that you would have said, “Hey, I’m going to push those jobs onto the consumer.” What jobs can we push to the consumer? And in particular, as you think about, I know it’s a buzz word, but think about the advancement of artificial intelligence. What jobs do you think we can push to the consumer that can be the things that can occur outside of the hospital, sitting outside of the doctor setting, in the home with support of AI, or even maybe the advancements of robotics? As you say, they’re expensive now, but chances are they’re going to become cheaper. What things do you think will potentially happen outside of the expensive medical center? Do you think of IKEA or the mall changing over time?

  Ryan P.: Maintenance and triage. Without a doubt, those have to happen more and more in the home with the person, with the individual. When I say maintenance, I mean it’s all the things that if I had to go in for this visit, could I be doing them at home instead? If I am supposed to take care of myself better to prevent some escalation from happening, are there inputs because of new sensors or new tests that I can take? That’s on the maintenance side.

  Ryan P.: On the triage side, that, I think, is where there is a lot of getting that over utilization of healthcare in the physical presence of a provider to being pushed to the home, where you can get diagnostic tests done at the home, you can get triages done via text message or a video call. I think if there are ways to do things at the home, the successful ones are more asynchronous than synchronous. Like telemedicine at home, maybe not as efficient because it’s still taxed as a doctor’s time in the same way. But text message threads, taking diagnostics on your own, things collecting on sensors are all asynchronous, and so that’s where I see a lot of the magic happening.

  Nigel Ohrenstein: Right. That makes a lot of sense. As you think about where Lumeris plays, Lumeris plays in the evolution of, particularly, health systems to value-based care, and we’re incredibly excited by where the market is now. We’ve spent a lot of time waiting for the market and the market’s really arrived and that’s truly exciting. I think not only for Lumeris, but, obviously, for health care and particularly for patients. But in this transformation to value-based care, there inevitably have to be some winners and some losers, right?

  Ryan P.: Mm-hmm (affirmative).

  Nigel Ohrenstein: We’ve made a bet on health systems, which some people think is a bit odd because they’re under pressure. My personal perspective is the payers are going to be losers unless they change rapidly. They never miss an opportunity to miss an opportunity. But how do you see it from your vantage point? Obviously, you’ve… again, what I love about the perspective you bring Ryan, as you have the government perspective, but now you are in the heart of perhaps the best investment firm in the world.

  Ryan P.: This shift to value-based care, the exciting part is that the system wins if it’s done well. And when I say the system: I think patients win first. I think providers win because they’re using their time in very meaningful ways. And the core payer wins:  the actual person that’s spending the dollar. When you talk about the losers in this system, it is the folks that you could consider to be the inefficiencies, and it happens everywhere. And so the hope and desire is that by shifting and pushing these kinds of models, all of the efficiencies come to play as well as all the improvements.

  Ryan P.: And so to your point of the Lumeris approach, that goes closer to hospital systems, to me that makes a lot of sense because it’s where the care is happening. If you look at the most successful companies that are being founded now in healthcare and even outside, it’s the ones that are taking on more risk. Risk in every sense, not just risk in the healthcare sense. And so it’s owning more of the problem, being more aware of everything that’s happening, and in a healthcare system that really rests on the shoulders of these provider systems. And so giving them more tools, giving them more incentives, giving them everything they need to take care of that person in the moment is a powerful approach.

  Ryan P.: And so anyone who’s putting that patient first with that efficiency mindset of getting them to be the healthiest they can and not pointing them to excess waste, those are the winners. And I think the losers in this system, when they lose, we’re not going to miss them because they’re not the ones making the system better. And so it’ll be very, very fascinating to see, and I think these changes are going to happen quickly.

  Nigel Ohrenstein: “Quickly”:  what does that mean in healthcare? Healthcare breaks your heart, quite literally and figuratively. It seems to take forever for healthcare to change. There are entrenched forces that almost try and prevent change. What is “Quickly”, what do you think? What does that look like?

  Ryan P.: It’s a great question. Quickly, looks like the bad actors changing. And the bad actors changing first, I think, for them, the ones that realize and wake up that the old model is not working and they have to be the first to change, those ones are going to be the winners because they’ll understand how their space is supposed to look and change and then absorb and get that market share.

  Ryan P.: I think the ones that end up losing quote unquote in this, if you want to call it a game, are the ones that don’t adapt too quickly. The ones that think that their fiefdoms will be that way, the ones that don’t understand that all the lines are blurring now. The lines between a provider to a payer, to what a patient is supposed to do is all changing. Each of them are taking on more of the problem, and so if you don’t actively do that now, you will be left behind because you’ll only be targeting a small little point solution when this shift of value is requiring each of us to do more; payer, provider and patient.

  Nigel Ohrenstein: [So as the] Deputy Chief Technology Officer of the United States, which is a pretty cool title, and I think any title over the United States is a pretty cool title. And then you chose to come to Kleiner. I imagine you could have gone anywhere almost in the world after that. Why here? What excites you about what you’re doing here? Why here as opposed to anywhere else?

  Ryan P.: The work at The White House was inspiring and motivating on two fronts. One, it was not only helping government to be more effective, but our office was also responsible for lifting up entrepreneurs all across the country, celebrating their successes, celebrating their industries, waving the flag that this is where innovation happens. In thinking about what I wanted to do next, you can celebrate these industries or you can help roll up your sleeves and put the capital behind them. And so at a place like Kleiner Perkins where we invest in disruptive technologies that are changing industries or even creating new industries, there was no better fit for what I wanted to do next.

  Ryan P.: I think the beauty of this space and the ability to work with the chairman here, John Doerr, the purview of what we want to change is bigger than just the consumer and enterprise market. It’s also what’s happening in healthcare, what’s happening to our education system, what’s happening to our climate. And I think as engineers we are so motivated to find ways to solve these problems and a for-profit model is one of them. But as John and I also believe, you have these nonprofit lovers and advocacy lovers as well too. And if we can harness all of those to make good in the world, then I think we are making the best of our time here.

  Nigel Ohrenstein: I have not met anybody who thinks bigger than John.

  Ryan P.: So true.

  Nigel Ohrenstein: When I first had the privilege of meeting him when I came to this company, the scale of which he thinks, the vision is unparalleled. But what advice do you give to entrepreneurs? You have these entrepreneurs, they’re trying to change the world. We’re faced with operational challenges, we’re faced with some of the entrenched forces that we already spoke about in healthcare and, obviously, in other industries as well. We’re faced with building sales at the same time. The list of things that potentially sinks an entrepreneur along. What advice do you give to entrepreneurs? And what advice would you give as you think about and interact with all these entrepreneurs on a daily basis?

  Ryan P.: This advice that I give applies both to entrepreneurs in the for-profit and nonprofit space. Social entrepreneurs too. I think, both groups of people are trying to change the world with the new organization that they’re starting. Of course, the first charge is to be ambitious and audacious. The next organization you build just can’t be 10% better. It has to be 10 times better. And only when it’s 10 times better are you going to get people to switch and use you and adopt you and come to you and work for you, and all of those kinds of things.

  Ryan P.: I think the second piece of advice also is to fix a problem you know well, and I think that’s really important. We like to sometimes solve problems that we see from afar, but if we don’t know it well then how are you going to solve it? And so if you don’t know it well, how do you build a team around you that are subject matter experts of that particular problem?

  Ryan P.: The third one really is a reminder that John always says is to be thoughtful about your finances and your financing. The business model you have is super important, and so being thoughtful of that upfront for both the for-profit and nonprofit. But also what do you need to do with respect to your next raise? You have this desire to grow your organization. So how much capital do you need? Be thoughtful about that.

  Ryan P.: And then the last bit, which is a true Johnism, which is ideas are easy [but] execution is everything. I think the piece there is about setting goals and achieving them. As entrepreneurs, we’re building things out of nothing…yet…so we see the world in this beautiful way, but you can preach what the world should look like. But the best entrepreneurs don’t just preach, they actually do and practice and create.

  Nigel Ohrenstein: That last one resonates well in particular for me. I remember when we closed our very first Lumeris deal and I got an email from John that said, “Congratulations. Now, let’s go execute,” which talked to that. Let’s come back to data transparency.

  Ryan P.: Yes, my favorite subject.

  Nigel Ohrenstein: Right?

  Ryan P.: It really is. It really is.

  Nigel Ohrenstein: Where do we go from here? It still pretty much exists today that when I go to a doctor, I still don’t really know how much it’s going to cost if I’m going to have a procedure that involves a physician and an anesthesiologist, et cetera, et cetera. I really don’t have visibility to cost. I don’t have visibility really to quality. Still it remains very much word of mouth. I ring a doctor, does the doctor truly know how well another doctor does? Or is it just a friendship that they went to medical school together and so they know the people they know? And so they refer to the people they know? Where do we go from here with data transparency?

  Ryan P.: This quest of data transparency… what is it for? If we want this true value-based healthcare system, we won’t be able to achieve it without data transparency. I think value-based care at the highest spiritual level is getting more ownership of the outcome from the people that take care of us. There’s that bit there, but then there are all the tactics behind it. And a big part is, well, what are the analytics around what’s being paid? Who’s doing what? How do you build the tools that actually drive more engagement? How do you improve the EHRs? How do you get better drug pricing? How do you get all this content …? All of these things require data to feed and fuel them, and so meaningful use started the train. And I should always say, people have done incredible work to get us where we are, and there’s all these outside forces that are stopping some of these changes from happening.

  Ryan P.: And so what’s next to keep this data transparency thing rolling? I’m one of the big advocates that we need some unique ID for all of our healthcare data. And there are ways to do it where I can choose when to use my unique ID and when I can choose not to be part of this system. But I think it’s super important for all of my stuff to tie together. Because if it’s not, how does my care team know exactly what’s happened to me if they can’t pull that data back?

  Ryan P.: I think for more data transparency, we need more structured data and more sources of data as well too. EHRs are the operating system. That’s what my doc sees when they see me. And so how do I make sure that there is more structure in that? But also that they can see more data maybe from my Apple watch or my blood pressure cuff or any other sensor I have on the outside. How does it go to them? And so with this unique ID they have access to all my information, and then with more structure they can start to do more with that information. And then now when that’s going, let me pump more information to you so you as a clinician can do more, but you as a technologist and entrepreneur can do some really neat things with it as well too.

  Nigel Ohrenstein: So do you see a world, hopefully in the not too distant future, where maybe the analogy is a brokerage account? I might have a portal and I pull in all my different sources, so I have one view of my financial situation. I bring in my 401(k), I bring in … And I have that view, and I could give access to a spouse, I could give access to a caregiver, a kid. Is that the vision, [where we in] the end we own our healthcare data, which obviously HIPAA gave us the right to own our healthcare data. Whether we’ve delivered on HIPAA’s intent is another question. It’s really still housed in the provider setting in each different provider setting. But is that a vision? Is that what you mean by having a unique identifier so I can put in all my healthcare data into one portal and then I can choose to give Doctor X access or not, as you said, if you choose not to for whatever reason?

  Ryan P.: Something very much like that. I think if you want to pull it into that brokerage you can. But the idea is that if I end up in an emergency room and they see me and they know my unique ID, they can pull my records from wherever they are across the country and get that on my behalf so they can take care of me in the best way possible. Today, it’s this amalgamation of send out 18 things about Ryan to find these matches. Weirdly, the reason why we don’t have a unique ID today is because of privacy reasons. We say that we want this… It’s about privacy, yet today, to do patient matching, we share so much, so much data to get these matches to actually happen.

  Ryan P.: HIPAA originally had the request and asked for a unique ID and it got blocked for privacy reasons and things like that that were thrown. But I think we are to a point where you talk to the folks from Estonia who have a unique ID and they say by having unique ID, that’s the only thing that’s being pushed around. And so they actually feel like it’s more private and they actually know when people access their records, so they have more visibility. Today, you and I and all of our records, they’re flying.

  Nigel Ohrenstein: Almost like I can put an alert on my credit card.

  Ryan P.: Yes.

  Nigel Ohrenstein: That any one of my family that spends more than $10 or something, I get an alert. And so anytime where we get hundreds of emails alerts from our financial institutions, but we don’t get any.

  Ryan P.: For ourselves. It’s a brilliant idea. It’s for myself, but for your loved one. As a new parent, it’s like, wouldn’t it be great if I got a flag for things like that? Or when you’re taking care of your parents, this whole dealt like … We could do so much. Data transparency combined with entrepreneurs, combined with more flexible payment models to incentivize all these things wanting to happen, I think, are the ingredients. These are the ingredients Todd Park preaches, these are the ingredients that John Doerr preaches. And it’s like you can see how those ingredients create this future that we want, which is a better healthcare system.

  Nigel Ohrenstein: Great. From a healthcare perspective, as you look at the Democrat field, any candidates get you excited or too early to tell?

  Ryan P.: For me, I think, it’s too early to tell, but the beautiful part is healthcare is being talked about by all of them. Healthcare I think will be an issue on the stage for both all the Democratic candidates as well as the Republican as well too, and that’s really special. And so the question that I’m asking myself is, “Whoever gets elected, will they do something meaningful to healthcare within those first hundred days?” President Obama did it in his first term. Can we do something with healthcare in the first hundred days? And which candidate is going to be willing to do that? Because I think from the Affordable Care Act, we saw this shift of all this good happening where people aren’t losing healthcare because of preexisting conditions and so forth and all these good changes happened, but it’s still not done yet.

  Ryan P.: There are a lot of things that can be improved with the ACA, and so someone’s got to be elected and do it. Whether you’re a Republican or Democrat, I think it’s important for that to happen, and I think it could happen within the first hundred days. I think we’re, as a country, so much more aware of how government plays in our healthcare than I think we were 10 years ago.

  Nigel Ohrenstein: Undoubtedly. Medicare for All?

  Ryan P.: I’m a big fan of Medicare for All. With that said, I also believe that you have to figure out how that works with private options as well too. And so can you have Medicare for All as an option? The public option was missing as part of the Affordable Care Act piece. I think competition on how we provide care is going to be so important and I think the government deserves to compete as well too because they can even do it so much better than everybody else or show that this is a really hard problem in being a player in this.

  Nigel Ohrenstein: Right. The exciting thing from my perspective is that not only are both parties talking about healthcare, but to my mind the value-based care train has left the station, and no one’s really talking about turning it back. And so that’s pretty exciting. So we like to end with a little quick fire round of questions. Best piece of business advice you were ever given?

  Ryan P.: Ooh. We talked about ideas that are easy and execution is everything. I’d say the other Johnism that I love is you make plans and then you make those plans.

  Nigel Ohrenstein: Favorite thing to do when you’re not at work?

  Ryan P.: Right now it’s playing with my eight month old. He’s the smiliest, biggest bundle of joy that my wife and I have right now. And so it’s just so much fun to see him every day.

  Nigel Ohrenstein: That’s great. Will a major payer or health system go the way of Kodak or Blackberry in the next 10 years where we look back and say, “Hey, remember that payer or remember that health system?”

  Ryan P.: Absolutely. Who? I’m not sure yet, but without a doubt.

  Nigel Ohrenstein: Favorite business book?

  Ryan P.: I have to make a plug for Measure What Matters. Helping John put that together was so much fun to see the stories from different kinds of businesses and Lumeris is in there as well too. And if I had to pick a book outside of Measure What Matters, for business, I think Andy Grove in his book called High Output Management is so practical and so wonderful. And when I say business, I mean any type of organization, whether you’re a for-profit or nonprofit. Measure What Matters, and Andy Grove’s High Output Management are fantastic books.

  Nigel Ohrenstein: And I love the way you’ve tied together the for-profit side and the not for profit side, and how they actually have to work together. I’ve actually given Measure What Matters to a number of people in the nonprofit side and said, “This applies equally to what you do as well as it does to the for-profit business side.”

  Ryan P.: Setting audacious goals and describing how you’re going to achieve them is something that applies to everybody, and even governments too. And so if I had a dream, it’s when we set the next regs for Meaningful Use. Whatever it ends up looking like, what if a set of OKRs could be applied to them, or any of these policies that we put out? We have this grand objective, but what are the key results that show that that was successful? And so I think it could be a powerful, powerful lens for policymaking.

  Nigel Ohrenstein: Great. Ryan, thank you for joining me today. I think we could probably chat for hours on these topics, but I really appreciate you taking the time out of your day to chat to me about it.

  Ryan P.: Always. Thanks for coming to San Francisco.

  Nigel Ohrenstein: Thank you.