https://www.linkedin.com/in/barbouche

This interview with Michael Barbouche takes us deep into the rapidly changing world of health care. Health care is moving away from deeply embedded, outdated reimbursement structures to new approaches based on successful outcomes – a strategy known as value-based care. Michael is the Founder and CEO of Forward Health Group, which is a value-based population health management company based in Madison, WI. Michael, a mathematician married to a physician, has a long history in and around health care. In the interview we talk about how health care providers must use data in order to successfully transition to value-based care, and improve patient outcomes.

If you want to understand where health care is and where it’s going, I think you’ll learn a lot from Michael.

Here are some other questions Michael answers:

-Why did you start Forward Health Group?
-Can you walk us through how you start working with a new client? What questions do you ask?
-How have advisors helped you?
-Where do you see healthcare analytics going over the next few years?
-What’s your favorite restaurant in Madison?

Transcript

Dave Kruse: Hey everyone, welcome to another episode of Flyover Labs from Madison, Wisconsin. Today, we are lucky enough to have Michael Barbouche with us. Michael is the Founder and CEO of Forward Health group, which is a population health analytics company based in Madison. So, I am actually in Michael’s office today, which is great to be interviewing in person. Michael has a deep background in healthcare data analytics and he’s in the middle of using data to make better informed health decisions. So, I am pretty pumped to learn more of exactly what they’re doing. So Michael thanks for coming on the show.

Michael Barbouche: Hey man, thanks for coming by.

Dave Kruse: So did I slaughter your last name?

Michael Barbouche: It’s all good, Barbouche, you got that right, yeah.

Dave Kruse: Alright so let’s get right into and it would be really interesting to hear about your background, and kind of what led you to starting Forward Health Group.

Michael Barbouche: You know, in brief, I went, very proud badger alumni. I went to UW and I was pretty confused but probably an okay smart kid. I studied maths and I studied history in the divergent past, so I don’t get a lot of use day to day from the 19th century French history, but I do lean on it on pretty regular occasions, so outside of Stendhal and Baudelaire I was just looking at algebra as my path forward and then I had an old professor, 89 years old at the time that took me under his wing and said I’m going to put you to work and I ended up getting involved in several activities on campus related to UW Hospital and it’s privatization and I got the healthcare bug and I ended up…

Dave Kruse: What was the most ……….

Michael Barbouche: I remember sitting at the hospital in the 8th floor conference room and questioning this document I was looking at, I’m like, I know business but there are so many zeros here, this possibly can’t be a balance sheet. There isn’t that much money in healthcare. This income statement, I’m reading it wrong clearly, so it was just fascinating and I was the only student really in the mix, so this was a long time ago, 27 years ago, I don’t know, I just got the healthcare bug and I then went on to grad school immediately and feel that I didn’t understand then and I still don’t think I understand it today, which they call health services research. I was basically trained a health economist, but really just from a data background using my math. I set out a bit prematurely from grad school with no real work experience and I had a very Forrest Gump-like complex journey. I am married to a general internal medicine doctor and at the time we were engaged to be married, she was in medical school in the great state of Oklahoma, so I started my career there and I worked on the payer side, the provide side, the research side, the government side and everywhere I went the data just stunk, it was really crappy and it was quite poor and so I bumbled around, I made some mistakes, I made a lot of mistakes.

Dave Kruse: Do you remember any of those mistakes?

Michael Barbouche: Oh gosh, the state of Oklahoma produced, you know, in printers speak, a four-color glossy fifty page brochure comparing the states indemnity plan, like the state’s owned insurance plan versus these nascent HMO’s and I thought the methodology was flawed, so I made them shred them all, 94,000 copies shredded the whole thing, 3 palettes just, you know, a couple of hundred grand in printing costs, I’m like we are not going to introduce bias to the market so, oh and I made a lot of dumb mistakes, you know, I was working with a legislature there and we were passing a lot of laws and bills, but I didn’t understand the protocol and I didn’t understand the rules, I spoke out of turn, I interrupted legislatures when they were in session and a bunch of other stuff. When you don’t have a rule book and nobody tells you what the rules are, that’s what you end up doing so…

Dave Kruse: I like it, alright…

Michael Barbouche : It was a great way to learn. So, my wife and I moved to Madison in 1996 and we’ve been here ever since and really for me how all of Forward Health came about, I had a lot of work in and around different health care settings as I mentioned, early 2000 we were starting our family and I think I had delusions of entrepreneurism that I wasn’t kind quite going to be able to meet and quite have the right idea, but in 2004 I was asked to participate in a project something that was a very important contribution by our State called the Wisconsin Collaborative for Health Care Quality, wchq.org, a wonderful website, really the country’s first ever public reporting website and I was very fortunate to be part of that and upset a lot of people there too along the way, but in the name of progress and getting us to an end goal, so we kind of built this website, we built this measurement approach and we gathered a lot of data about outcomes and that really helped put a lens on, a baseline if you would on how as a state we were doing in areas like diabetes, hypertension, colonoscopy screening and the like.

Dave Kruse: So what would be an example like around diabetes or another area that the website showed?

Michael Barbouche: So, like blood sugar control, blood pressure control, cholesterol and the like, the important components of management of diabetes, but in 2004 that was really an era that kind of preceded in large part the advent to electronic records, most of the systems hadn’t gone down that path. The employer community and the payer community, those who buy healthcare were like, we want to get to outcomes, you know, we don’t want to look at just kind of superficial process measures, we want to understand how patients are doing and that challenge in that charge was very important and I took it to heart and I said well you know there is also the challenge of you know for my wife who is a practising primary care doctor, you would probably just say to her, well you’re somewhere in the range of 42 to 68 and you’re in the middle tier or you know you’re 48.7, and she was going to say 48.7 what? and be quite unhappy if you couldn’t give the full list of all of her patients to her so being a math guy, I was like well I don’t think that I am ever getting consensus on what the numerator would be, what standard 140, 130, 120 for the blood pressure, I’m not a clinician and it was not going to be my role to resolve that, but nobody ever talked about the denominator and I said well let me work on that, I am an algebra guy and so we build a denominator.

Dave Kruse: What do you mean by that?

Michael Barbouche: Who are the patient’s that have diabetes and not what standard diabetes should be measured it to, but who had diabetes, who was in the pod and by getting that figured out we were able to kind of look and if you would , kind of apples to apples at least say we got 6200 over here in this system, 4400 in this system, and 9000 in this other system, 400 over there and it allowed us to work on one of the more substantive data challenges that were really important for the project to succeed, so we got the website up, it was a great success, spent a lot of time trying to educate across the state and I was just struck, I mean we had kind of solved this great riddle. We had built out a way to look at measurement and at least set a baseline and then come back a year later and see whether that moved the needle, but I would meet with my wife and her friends and others at dinner and what have you and say hey! what are you doing with your list of those diabetes patients and she would say I don’t have a list, what are you talking about? and there were many of the people that now help us run Forward Health Group that were part of those conversations including a friend of mine, John Studebaker who is a physician and had been in medical school with my wife long ago and I was like, John what are we missing here? What are we doing wrong? He’s like, I don’t know, I mean one would think this data would be available, but it simply wasn’t.

Dave Kruse: Were they supposed to get sent that data for their patients or how were they supposed to ……….

Michael Barbouche: That was the mystery question.

Dave Kruse: Okay, what were they going to do with it, yeah gotcha.

Michael Barbouche: I mean, I was like, we got to the end game, here you are and you need to make it better and I was like, so what are you doing to make it better?

Dave Kruse: And they weren’t doing anything.

Michael Barbouche: Well, it was this block of the data flow and the data migration and other things and again people were starting to get quite busy with the idea of installing an electronic record which is very important and needed to be done, but I kept saying, well shouldn’t we have the list of patients, you know, got gaps in here kind of bubbling up to the surface and that was just a very difficult challenge at that time. So we started Forward Health Group in 2009 to really address that kind of measurement gap, that kind of aha, you know, we need to figure out which patients aren’t doing very well and figure out a plan to do something about and we should probably have a new service or a new solution or a new program or new intervention and then we should measure whether or not we did that well and so that’s the kind of model in which we started, we said gosh, you know, we are here in Madison, the best electronic record company in all the land Epic is based here, so we need to compliment the work that they are doing, that work in and of itself will be quite busy and keep people quite full, but they are still going to have to figure out, like so what are we doing with our HIV patients, what are we going to do with, you know, the behavioural health population? There is a bunch of questions and now as we look, you know, forward in 2016 and beyond, the way we pay for healthcare is not going to change, we aren’t going to pay differently, we are not going to pay just based on the number of units of service that get done, and so all the more that understanding gaps and lapses and opportunities for improvement become an important part of the work that needs to get done.

Dave Kruse: Back in 2009 how did you get started and who is your first client and what did you do for them and did you raise any money or just kind of bootstrap it initially? 5 questions but…

Michael Barbouche: We were actually kind of getting phone calls before that from venture capitalists and others saying “hey! You guys figured out the riddle about how to get that data. Why don’t you start a company and sell that data to Pharma.” I’m like no. Would you give a copy to my wife though and then we could figure out how to sell it.” No, we don’t think that is important, we don’t think you should do that. I think it is really important, and so there wasn’t, you know, a lot of alignment there. We are actually, you know, not the best business people. To be sure, you don’t necessarily start a company in June of 2009.

Dave Kruse: Perfect timing..

Michael Barbouche: In the economic cycle. I can’t put into words the support and the sacrifice that the team that is still with us made. We bootstrapped for the first 5 years of this company and nobody was raising their hand saying I got to get paid. I am the one that needs to be paid a lot. We had a commitment and a dedication that I can’t put into words and I can never repay. We had our first client which was a public hospital within a couple of months and that was focused on some pretty at risk HIV patients and from there we just began to move upstream, but we wanted to start with challenging groups like HIV and other areas that were maybe, lets say, not the mainstream, because in part if we could get the work and get the data done for a group like that then it would probably make sense that we could do orthopedics or cardiology, kind of more of the mainstream group, so part of it was also to kind of test our mettle and test our approach so and what we did, I mean, in part, you know, how in 2009 it was like, well gosh, these tools you built us at Forward Health are really cool, I have never seen that before.

Dave Kruse: What kind of tools?

Michael Barbouche: We built some data visualization, we built some otherwise kind of canvas through the data, but when we would meet with prospects, they were like “wow, that’s cool” but they weren’t buying anything. There was no question about buying it. There was no budget. There was no CFO showing up at the meeting asking hard questions, you know, we were ahead of the market. I would certainly say that was the case through 2012, 2013, and 2014.

Dave Kruse: Well, that’s good and bad. It is hard but…..

Michael Barbouche: I think we knew and what it allowed us to do was instead just focus on our craft.

Dave Kruse: Yeah.

Michael Barbouche: So, we knew how to get the data, we knew how to get it cleaned up, and what would you do with it? So, we built tools and we built solutions that we knew would be compelling and knew would be intuitive. And, you know, we had a lot of time to really focus and do right by our clients because we weren’t under a time pressure, there wasn’t a big chunk of revenue to go out and be made, and so we were, you know, in a very fortunate place to get very good at our craft.

Dave Kruse: And with the HIV project or a different one early on, did you go in there saying “hey, let’s just look at the data and we probably can find something or did you have like, very early on in the engagement, did you have like to find outcomes, like this is what we’re looking for.

Michael Barbouche: It’s a great question. I mean, here we are today in 2016 and we literally last night at a dinner with my team we were talking about this very phenomenon which is even today the practices don’t know what they should measure and there is this whole mountain of quality performance measures to get published hourly it seems, but none of them really seem to work, they are all about trying to hold people to task, but in my language, you know, those are a bunch of numerators people are throwing out, nobody is really focused on the denominator and so we say “okay, well there is a thousand new numerator standards, but how is the population doing? how is the denominator doing? and let’s track and trend over time a bunch of these and see how they are doing and let’s understand which one is working, which ones don’t, and then from there see where the practice might go, so you know, I would characterize what we do today and where we sit is really a company that is there to help stakeholders, be it the health system, the physician group, the hospital, the health plan, the researcher, the government or others engage with and understand how improvement occurs and how difficult that is in the healthcare space.

Dave Kruse: When you go on a project or engagement are you serving one of those parties or you are usually dealing for a number of stakeholders?

Michael Barbouche: I think invariably more and more it’s a plurality of stakeholders.

Dave Kruse: That’s a tough process, so you have big meetings sometimes.

Michael Barbouche: Yes, big meetings, you know, it is really about these, you know, tectonic plates coming together right. The health plans and the health systems kind of have to figure out how to work together. It is going to be a very new world order together. Most challenging and sometimes fun for me being married to a physician, I have to say to my wife and her clinical friends, you know, we might enter an era where the health plans are the good guys, I mean almost unheard of, you know, can’t even imagine it, but a lot of this is about healthcare trying to figure out how to correct itself and improve things and there is plenty of research and plenty of articles that have been in the newspapers that reflect that, you know, we spend a lot of money, we don’t get a lot of good care for that, it’s time to try to bring some of those things into balance.

Dave Kruse: So, from a macro view, do you have a vision for where healthcare should go?

Michael Barbouche: I’m pretty, you know, I was trained by some very esteemed economists and you know, they trained me very, very well, that the only model for the country to go forward was an individual mandate, otherwise what we would call the Affordable Care Act or Obamacare. The idea of being insured and mandating insurance as an independent task or an independent responsibility was the most conservative tenant of healthcare I had ever known. The fact that people think it’s the opposite of that is interesting. I believe we spend too much on healthcare. I believe as an economy, we should spend less. Those are pretty harsh sentences for me to make, but that’s what our philosophy is, that’s what my belief is. I would love to see us spend less on healthcare and spend more on schools and roads and all those other things that have had to be cut because of that.

Dave Kruse: That makes sense. I mean, we have all seen the stats of how much more we spend per person versus other maybe arguably healthier nations, which makes sense, I mean that is a valid goal and vision and it is good that you are helping move that forward at Forward Health Group, so what type of organizations do you work with now, is it mainly hospitals, do you work with health insurers?

Michael Barbouche: Yes and yes, and others as well.

Dave Kruse: Others, who else?

Michael Barbouche: I think, you know, we fit into a space where stakeholders because of the amount of money and the amount of effort and the amount of energy that goes into healthcare are needing and wanting to understand how to look at outcomes, how to look at trajectories of patients, how to look at did this work, does not work, does this thing work, does it not work and the like, and so much money gets spent on things with potential and promise, but we don’t often know if they work. So, our clients include directly hospitals and health systems big and small, esteemed research groups like the American Heart Association and others. We work with health plans. We work with really a broad spectrum of stakeholders that fit into the healthcare arena, all of whom in some form or another need to get in on this flow of clinical data, but not necessarily to know the names of the patient and need to call them, but to understand, you know, from a tracking and trending perspective, you know, where are things going, does this work, does it not work and the like.

Dave Kruse: And your platform is called Population Manager?

Michael Barbouche: You bet.

Dave Kruse: Okay.

Michael Barbouche: Pretty simple name. That was a very easy URL to get a long time ago. We were just trying to literally say what would it be? What would we do? Wouldn’t you manage a population, you know, URL speak back in the day that was pretty intuitive and remains as such today. I mean, you know, what we are talking about is going from paying for healthcare one patient at a time, one service at a time, to one population at a time, so it was a pretty simple step for us, although there wasn’t again a market for this to say “aren’t we really going to be in the population management business, so therefore shouldn’t our URL be Population Manager” and of course, you know, we went out and it was fully available, nobody was guarding.

Dave Kruse: That’s amazing. Now it would not be available.

Michael Barbouche: Nobody was worried about those titles back then, so again we were a little bit early, so we thought, okay, the right way to talk about this is to say it is simply about managing a bulk of patients, a group of patients, not one patient in a day.

Dave Kruse: And what’s the platform entail? You earlier mentioned visualization tools, does it like adaptors that bring in data from databases or what is …

Michael Barbouche: That’s a great question. So, it is purely just a visualization layer and it is one that we have entirely built by hand. We are big believers in the power of data visualization, but all the cool fun stuff that is out there, we don’t do any of that. We build some really basic, really simple stuff because that is what our users have told us they need. And I think when you look at our tools and you begin to use them, particularly if you understand clinical care, it makes sense, although we have training and manuals and videos, none of our users gravitate to them. They are often running because they already know what to do. It is presenting information in a way that they could rapidly consume it. To the data, it is really just the visualization layer is just simply reflecting, you know, kind of curated and derived metadata that we have cleaned up and presented back. We don’t build any interfaces. We don’t build any APIs. We don’t do any live connections to bring the data in. We can do that, but we don’t require that. In order to kind of get that realtime flow of data, you need to think about spending real time dollars on IT resources and the like. Again, you know, to our approach, we can point to a group of patients and reveal a whole mountain of gaps that doesn’t, you know, require any interface.

Dave Kruse: What do you mean by a whole mountain of gaps?

Michael Barbouche: You know, when we turn on and we show how many patients need a colonoscopy or how many patients have poor blood pressure management or how many people that should be on a drug that aren’t, you know, it can be in the thousands of patients. These are big, big operational challenges.

Dave Kruse: Wow.

Michael Barbouche: They are big gaps to fill and you know, you are not going to really need to update in realtime a bunch of information about a patient’s, you know, body mass index, BMI. I mean, if you have a whole slew of patients who are quite obese that doesn’t change tomorrow. If you update that BMI every 5 minutes, it’s not going to change the fact that you have got to put them on a life-correction course to bring that down or to bring the blood pressure down, to bring the blood sugar under control and the like and so it is about understanding what are our goals at a population level and what are the data inputs we need to see how we are doing and again, for us, we are meant to be a rich complement, a balance to what you are already doing and should be doing realtime in your electronic record. We are not here in any manner to compete with electronic record. We are here to support that and really help refine the use of that.

Dave Kruse: Yeah, yeah…

Michael Barbouche: We are not here to compete with that in any way.

Dave Kruse: I am curious, can you walk us through kind of a typical, well no project is typical, but walk us through a project like with the health insurer or hospital or whoever and like how you started and like, you know, if you can keep this anonymous, what questions would you ask and then how would you figure out what to tackle? Do they usually come to you with questions or do you start asking them questions and then….

Michael Barbouche: You know, 3 quick responses. The first is as we see how we pay for healthcare, reimbursement shift. There is more and more awareness on the hospitals, the physician groups, and the health system side that they best be doing something. There is a whole new mountain of demands being put out on those groups to send in data, to send in summaries, to give us results. That burden is scary to a lot of the groups and it is hard for them. So, a lot of them are calling simply to get help and to get started there.

Dave Kruse: So they are report analysts?

Michael Barbouche: Yeah, but I mean they don’t know what to ask for when somebody has already asked them.

Dave Kruse: Okay, right.

Michael Barbouche: That’s number one. Number two is really more around, “wow, you know, we have got this wonderful electronic record but we are not sure what we are supposed to be doing.” You know, for us then, it is really around helping them realize and maximize that investment. We want them, you know, as a system and even as the leadership group that wrote the check to say “this thing is paying us dividends now.”

Dave Kruse: So, how would you know even where to start, I think there might be a, that’s a big…

Michael Barbouche: So, there are so many places to start…

Dave Kruse: Yeah, yeah.

Michael Barbouche: But a lot of what makes sense today is to focus on areas again that are going to be tethered to that reimbursement shift, so there are some simple things like “okay, how are we doing at the management of chronic care and chronic disease.” Right, we have a product that just gets you started right on that, boom, product care, this is your bread and butter hypertension, diabetes, and the like. The things that would correlate with just about every incentive program that anybody could create.

Dave Kruse: And that just brings up like the people who are most vulnerable? Do you have a list of chronic patients?

Michael Barbouche: We have libraries of all the measures under the sun you could create and we actually encourage the practices to build their own, but you know, what we are trying to help them do is get beyond the kind of initial kind of canvas of the clinical side to go a couple of steps deeper into so what’s driving this, you know, what are the challenges? We have a remarkable group that we work with in Milwaukee at the AIDS Research Center, Wisconsin. They have blown past the clinical side and management of HIV and now they are looking and challenging the heck out of us and themselves looking at dental as an area for infection.

Dave Kruse: Really?

Michael Barbouche: Transportation and depression. These are remarkable things. They do not really have anything to do with electronic record. I mean, they are outside of the 4 walls of electronic record, but they are saying “look, these are the dimensions that also correlate with the challenges our patients face” so we have to do that.

Dave Kruse: Interesting.

Michael Barbouche: The third part to your question from long ago, so it really comes down to and it is a minority today, but those who want to take control, those who want to own their destiny, this to us I think is the most important, which you know, we are in this really important time for healthcare, one that we have never been in before where those who get their data together can kind of set their course and set their path. That may be for another 2 or 3 or 4 years tops, but those who can get their data together and say “here’s how we define quality, here’s how we define progress, here’s what our priorities are” and are willing to share their data and put their data out there have a real chance to get ahead and those are the groups that we most want to support.

Dave Kruse: And would they share their data internally or it is externally?

Michael Barbouche: I think it is both. I mean, internally they need to learn how to share at full depth and the right people at the right time. Externally, they might only share at an aggregate view like kind of overall and maybe only on a quarterly basis, let’s say, but the idea is to bring in as many stakeholders as possible and say “help us, give us the right incentives, give us the right support across the community so we can move the needle all the way out there.”

Dave Kruse: So, if a healthcare organization came to you and said “hey, we have all this data, we want to be the leaders,” you would essentially start kind of with that chronic care and then….

Michael Barbouche: We might.

Dave Kruse: Try to figure out kind of the low hanging fruit and what’s going to have the most value.

Michael Barbouche: We are really focused as a company on seeing if we can drive physician engagement. We think that is very important and the reason is maybe because I have married one, but we think that getting the docs to trust the data is an important initial hurdle. We have got to get over that hurdle. We don’t think that docs are going to be the ones to do the work, but if they think the data is bunk, if they think the data is just a wreck we are not going to get very far and so a big part of our work is essentially getting that initial confidence and trust from the physicians and then moving out the data at scale to schedulers and to nurses and medical assistants and clinic managers and others and say go do something, go get it done.

Dave Kruse: Interesting, that makes sense, I never thought about that. Yeah, have you seen where that makes a difference?

Michael Barbouche: Absolutely. I mean part of the challenge though is that you kind of turn on this data, you reveal these gaps and lot of them kind of go “whoa, now what.” I mean, there are so many things to work on, and these are big systems and they make a lot of money and they are very powerful and turning those ships is not easy and changing that culture is really not easy and so, you know, we look at our work as kind of necessary but never sufficient, it is just about getting them started and giving them that opportunity to improve.

Dave Kruse: And how do you get by and with some of these organizations is it kind of the ____29:43____ or is it the physicians or is it just everyone?

Michael Barbouche: You know, it varies by market. It is a great question. I think we are always going to try to make sure we bring the docs along, but more and more now today, to really be candid to your question, I think we are looking at the CFO needing to start to have conversations with the operations leadership and the clinical leadership to say “guys, what can we pull off here? What should we go for?” That’s very new. In the past, it used to be just volume based and metric driven and how much throughput could we get. Now it is much more about what could be performed.

Dave Kruse: It makes sense. Well, especially with, yeah, health care is being paid for differently, so yeah, it’s a great time. We kind of talked about it some, but where do you want to take Forward over the next 5 years? Do you want to add to the platform? What do you want to add? I mean, you mentioned that you are really interested in working with parties who want to kind of leaders in data, but…

Michael Barbouche: You know, we built the company really to make a contribution in trying to help fix healthcare. We don’t pass judgment. We are pretty open to working with any party, but we are not trying to scavenge the old world. We are trying to be part of where the new world is going. So, you know, I think in the area of product and product development, there is nothing more important for us to be working on. We need to continue to help our clients get ahead and stay ahead. You know, I am very proud of the work that we are doing in areas right now that are still very new, behavioral health, and we just did some work in opioid addiction. We have a great tool. To begin to understand just how and why opioid RXs proliferate and not passing judgment and not passing blame, but just understanding, you know, at a very simple level, how does this happen? Where does it happen? What are the sources of that proliferation? You know, we are looking at this and saying when we meet with our practices, primary care, specialty care, and you sit down and say “hey, tell us what your priorities are, talk to us, fill us in.” They’ll talk about product care. They’ll talk about, you know, management of new reimbursement models like bundles ___32:00___, but opioids are kicking our butt. You know that’s sobering, like we continue to listen to the market and to our clients to understand where our product needs to support them.

Dave Kruse: Interesting and if you could say what type of inputs go into that model to identify the issues?

Michael Barbouche: You know, I think what we are trying to figure out is, you know, for a long, long while I used to walk around, wave my hands in the air and say there are 2 buckets of data. There is administrative data which was ubiquitous and everybody played with and there was this new fountain called clinical data and that was really the data that was unlocked and unleashed in the Wisconsin Collaborative and in big foundation of our work with our clients for Population Manager, but you know, it occurred to us years ago that we weren’t really tapping into the great potential claims data which come from the health plans. We weren’t at all tapping into the richness of data that patients were capturing. So now that is ubiquitous. That is part of our world. That has to be part of our strategy and our thinking for every client is that what are all of the data sources available and how are we maximizing those and we are not maximizing claims data for example. In the old way, I used to do in the 90s we are taking it in a very different manner today which is to say “how do we leverage claims to be a rich complement to the information we are already able to get from the electronic record, what does the claims reveal that the electronic record does not fully, and how do we dovetail those 2 together to see a more complete picture.”

Dave Kruse: Do you see the payers and providers sharing a lot of information, more than they used to?

Michael Barbouche: I think they need each other really badly.

Dave Kruse: Yeah, yeah.

Michael Barbouche: They don’t trust each other, but the payers need the data from the providers, the providers need the data from the payers, so these guys are going to have to learn how to do that. A lot of that will come through on a trust, I think a lot of where Forward Health Group will go over the coming years as kind of being that neutral arbiter between the plans and the providers so that the data can be swapped and shared. There will be winners, there will be losers, and ours isn’t to pass judgment and ours isn’t to pick sides. We do think that data can reveal that and it should and a lot of it will be then that, you know, those who take the initiative do the much harder work of trying to drive the improvement. Those who get ahead can really have a chance to not only stay ahead but chart their own course. I think a lot of others are going to be very powerfully moved around, jerked around, and it is going to be hard. We are going to go through a lot of difficult transitions, but I would make this open declaration to your podcast audience here. I mean, look in your wallet at the card that is your health insurance. All of us pay higher co-pays and co-insurance and deductibles and the like now. You know, this is just a transition of where the expense for healthcare goes and obviously it is going to come on the heads of individual patients. Again, to our overall belief, we need to make healthcare more affordable not just for the health insurance companies, but also for the patients and cost of care cannot be a barrier to receiving care so, you know, we want to try to bring that down and that means sadly some people who make a lot of money today probably would not be able to still make that amount of money practicing in the way they did. They are going to have to practice in a new manner and provide care in the language of our times that aligns to value based constructs.

Dave Kruse: What is an example of somebody going to change how they practice?

Michael Barbouche: So, there are rich examples at play right now where the Medicare program has essentially said to the orthopedics community “you need to make some very new good friends, the skilled nursing facilities, the home health providers, the rehab folks, the PTs and others, when you do an elective hip replacement or an elective knee replacement the collective group of you is going to be paid on 1 check, so you guys all better learn how to work together and communicate together and transition altogether, and if there is a hiccup, you guys are going to have to figure out amongst yourselves.”

Dave Kruse: Wow! I did not know that was coming, is it already here?

Michael Barbouche: Oh, it is here.

Dave Kruse: It’s happening.

Michael Barbouche: It is here and it is actually mandated.

Dave Kruse: It is mandated.

Michael Barbouche: So, it is no longer voluntary.

Dave Kruse: Alright. Wow! That’s interesting, yeah. I can see where a lot of organizations are going to need you guys. Alright, so, we are nearing the end here, but I have 3, kind of more personal, not that personal, but before we finish, and one is, you know, do you have in generally from starting Forward Health and even before that any lessons learned for the audience like things that you would do differently. You can pass too…

Michael Barbouche: Oh, gosh, how many years do you have? You have so many lessons learned. You know, the thing I say to young entrepreneurs and I just met with a group of great young guys this morning over coffee, you know, build yourself a board, a board of directors. The folks that were on my board early on really gave us this opportunity. They gave me support. They gave me guidance. They gave me direction. They scolded me at times. They disciplined me and they really gave me the ability for us to be here today and so getting that guidance is critical, and having people that can, you know, look you square in the face without fear of your friendship or your past history together and say “that’s just the dumbest thing you have ever said, I can’t believe you said that.” That is so important to have that. You know, I think lessons learned as the company grows, roles change, responsibilities change. I don’t think anybody ever tells you ever that being a CEO is really a lonely job. It costs you dearly. It costs you friendships, it costs you collaborations, it costs you many things, it is very hard but in the same breath the support that I receive from the team, from some of my early friends and family who helped write a check to help us, you know, buy our computers and buy our insurance for, not the individuals, but for the office and our liability, you know, I can never repay that, and so, you know, now in, you know, real kind of looking back in the rearview mirror, we would not be here if it weren’t for just this amazing amount of support and I am grateful, very grateful.

Dave Kruse: Those are some good lessons. Thank you. Well, you kind of already answered one, but my next one is did you would have any mentors and who they were and it sounds like the board really…

Michael Barbouche: Well, I started the board and more importantly the advice was, have the board be not somebody that came to your wedding, you don’t go bowling with them, you know, you don’t have pizza with them or the like. You know, new fresh faces that can gel too, but I had many other mentors. I mean, I have a photo up here of my old French History professor who was the very first person to show confidence and he has since passed away, but Edward Gargan grabbed this shaggy haired kid who was afraid to write, believe it or not, and pulled him out of the shadows and said write me an essay right now and, you know, that type of stuff was very helpful. There were others along the way that, you know, taught me about business in this journey and the like that, you know, which was very helpful. I think I never fancied myself to be some CEO type, but the support, the mentoring, the training I received along the way in my jobs very much helped me get there. You know, I hope that for our employees most of all, they feel that this is a safe environment, they feel that it is an open environment and it is one where they feel free to innovate because I think innovation particularly for healthcare right now is the most important thing.

Dave Kruse: Yeah, you have a great office. It is definitely a cool office when I walked in here. I like it.

Michael Barbouche: Yeah, cool, we love it too, yeah.

Dave Kruse: And, one last question, this is mainly for the Madison folks, what is one of your favorite restaurants that you like around here.

Michael Barbouche: Well, goodness.

Dave Kruse: You could name 2 or more.

Michael Barbouche: Well, my kids will be quite unhappy based on how I answer this question because there is a real dispute, so you know, lets break it down into structures.

Dave Kruse: Yeah, lets analyze this.

Michael Barbouche: Lets get down on the leads. I think if it’s just my lovely bride and me heading out for dinner we are probably hit one of the places in and around the square, you know, Nostrano or Forequarter something like that.

Dave Kruse: Nice.

Michael Barbouche: We don’t get out as much for dinner as we need to. If the kids are with us though, which is more often the case, it is a big dispute, and we are open. We will travel to Isthmus, but it will be something between Tex Tubb’s or Vintage or if my daughter has her way, we will be at Sushi Muramoto.

Dave Kruse: Oh yeah.

Michael Barbouche: So, there’s a balance and like, I’m overjoyed, I mean, when we have friends come in, you know, we are often at Sujeo. My wife’s a little unhappy how often I get to go to Sujeo and she doesn’t, so if I had to pick one I would probably throw summer Sujeo outdoor grill as the best.

Dave Kruse: Yeah, that’s a great one.

Michael Barbouche: And I got one thing for you, I’ll throw you out at Belize.

Dave Kruse: Okay, I like it.

Michael Barbouche: There’s an important new initiative underway. This is really work that some of my colleagues and peers in the health tech community have been pushing. The idea of really looking at Madison and saying it is a leadership hub for health IT and healthcare innovation and a lot of that support and the wind at our backs obviously comes from Epic, but there are many other companies that have pioneered their way through, so in April of 2016 here there will be a launch of really a new brand, a new identity for all of the companies, Forward Health, Moxie, Redox, Epic, all of them looking our area under the brand name of Health Tech Capital.

Dave Kruse: Oh.

Michael Barbouche: And I just want to put in a plug that what we are building in Madison is very significant and it’s very important and I think it can not only be a great economic engine for our community, for the area, but I think more than that it can really represent real kind of advance in helping to fix healthcare, so I’m proud to be a part of it. I think it’s a great initiative and would love to see more and more energy and support and interest flowing to Madison to project out to fix this.

Dave Kruse: Yeah. I’m really glad you brought it up. We didn’t even talk about the health tech is Madison and how the burgeoning community in, is that the HealthX, kind of helped with that group…

Michael Barbouche: Yeah, there’s Mark Bakken, formerly of Nordic, now with HealthX, he’s in the mix, UW-Health’s in the mix. All sorts of stakeholders are in the mix and the idea is to say, listen we’ve got something here that’s important and we need to project it out.

Dave Kruse: Interesting. Well, that’s a great way to end on a high note from how awesome Madison is and yeah, thanks Michael for coming on the show. It was a great interview.

Michael Barbouche: Great to meet you man, thanks.

Dave Kruse: Thanks everyone for listening to another episode of Flyover Labs and we will see you next time. Thanks.