Episode 39

Innovation from the Public to Private Sector

with Brad Smith

August 9, 2022

Brad Smith
Founder and CEO, Russell Street Ventures; CEO, Main Street Health

Brad Smith is the Founder and CEO of Russell Street Ventures. He was also the Co-Founder and CEO of Aspire Health. He served as Chief Operating Officer of Anthem’s Diversified Business Group. In government, Brad served as Deputy Director of the White House Domestic Policy Council, Senior Advisor to the Secretary of the U.S. Department of Health and Human Services (HHS), Deputy Administrator at the Centers for Medicare and Medicaid Services (CMS), and Director of the Center for Medicare and Medicaid Innovation (CMMI). Brad received an undergraduate degree from Harvard University and a Master of Philosophy from Oxford University.

It's way easier to build an innovative solution in a space where you're the first or second person than when you're the fifth person.



[00:00:28] Laura Veroneau: Hi everyone. Laura Veroneau Managing Partner with Optum Ventures here and thrilled to invite you into another session here with my friend here, the one and only Brad Smith.

[00:00:40] Brad Smith: Thanks so much for having me, Laura.

[00:00:42] Laura Veroneau: Of course. And thank you for taking the time. At Optum Ventures, we are very privileged to have worked with Brad for the last few years, first with a company called CareBridge, who has had a lot of success at this point in the LTSS space, and more recently with a company called Main Street, focus on serving rural populations. If you can’t tell by my excitement of having Brad with me today, I will just say more clearly. It has been an absolute honor working with Brad Smith, and we feel very lucky to be partnered with you in multiple different ways, Brad. So to get into it, why start with Brad for the first interview that I’ve done here as an Advisory Council Member? And the short answer is, Brad, I have never quite met anybody like you, and I’ll speak to the audience a bit here to explain what I mean by that. Brad is visionary and execution oriented. He is very logical and directional, and always a problem solver in partnership minded person, you have success across any sort of measure across multiple spheres, yet probably one of the most humble people I’ve ever met. And I think most importantly, you genuinely care about the impact of what you’re doing. At OV, we like to say a “Brad Smith Company” or a “Brad Smith like Founder” is a category in itself. What I want to do today is spend most of the time, most of the 30 minutes here, unpacking you, Brad, and your journey as a leader, because I think there’s just so much to be learned from you and I, myself, am excited to hear your answers to a lot of these different questions here. So I’ve heard you say before that the last place you expected to be was in front of entrepreneurs and probably investors talking about a company that you founded, at this point companies, but here we are, again, so where I’d like to start is just asking you to please tell us a bit about your journey and how you got here today.

[00:02:39] Brad Smith: Yeah well, it’s been a really windy and fun road. When I got out of college, my first job was literally being a driver for someone who was running for the U.S. Senate. So I drove 140,000 miles in a year or two. And after that, I ended up being literally like an executive assistant to somebody for year. And then eventually ended up starting an education- nonprofit and then going to work for the Governor in Tennessee doing Economic Development, so really a lot of things outside of healthcare. And, what got me interested in healthcare was my brother, he was trained to become a palliative Care Physician. He had taken a year off from school to work with Atul Gawande on book called Being Mortal. He was one of the Research Assistance on it. And he started talking to me about palliative care. And I’d always been interested in healthcare and education policy in those areas but never really thought about the business of healthcare.

And as he started talking to me about palliative care, it became clear that maybe there was a need there. And then what happened? Probably three months later is my grandma got really sick, and I live in Nashville. She was in Knoxville. And I was driving over three and a half hours to see her. And long story short, she ended up going into the hospital a few times and ended up passing away without ever going to hospice. And it made me really interested in my brother’s idea, even more. And I actually went back to Bill Frist, who I’d met through this education-nonprofit. I had Ron, he chaired the board and pitched him on the idea of starting Aspire. And I would just say the whole path has never been one that I’ve expected, whether it was going to DC or whether it was starting the company, it’s just at different moments, different doors have open. And like the only logical thing has been to do is to walk through it. And so we’ll see how it plays out, but it’s definitely been a, been an interesting path.

[00:04:23] Laura Veroneau: Yeah, definitely. So maybe to pick up on some of those threads and focus on maybe you a bit first and then getting into the different steps here and some questions on the different paths and stages along the way. I think you talked through some of the different roles, the public sector, the private sector, the Economic and Community Development Office, Aspire, obviously a role at CMMI and to now Russell Street, I think all of those areas on the surface may be very different and different in terms of where they’re focused in the spaces that they’re in. But seemingly from an outside perspective have a common thread in sort of service of others, and often it seems like a very big focus on toughest problems, maybe most complex areas, when we think about what you’ve been going after in a lot of these different pieces. I think for me, from an observational perspective, something unique about you is that you don’t seem to be driven or focused on just finding the largest opportunity area and running after that in a given moment in time; you do really seem to be focused on finding the most challenging areas that you are probably uniquely positioned to solve and solving those problems. And the care seems to be very focused first on above everything else solving the actual problem that you identify. So, sort of what throughout all of those different paths, what makes you tick? What inspires you and gets you excited to go after all of these different, challenging areas, toughest problems in healthcare now? And what about the path and the different roles and things like that have contributed to that?

[00:05:57] Brad Smith: I think the biggest driver honestly, is probably my faith, probably more than anything else. And it just makes me think that really the purpose is to be here and try to make the biggest difference you can whatever way that looks. My wife and I are very different. She’s very good at impacting one person at a time in her life, which I’m not particularly good at actually, but I like building things. And for me, that’s been the journey, looking for opportunities where you can really use your skills to make a difference. Some of those early doors that opened were in politics and things like that, like the way I got the driver job, which was a great job, it was for a guy running for the U.S. Senate. I got to spend just tons of time listening to him and learning. It was really from somebody I knew from my hometown, whose brother happened to be this guy’s roommate in college, it’s just one of those things you could never imagine. As I got farther along, like my brother being interested in palliative care, my grandma getting sick, the fact that I knew Bill Frist, again, those are just like a set of circumstances that almost like all those things had to be true to create that opportunity. And so I think my real way I’ve thought about it has just been seeing what door opens up. And as those doors open, trying to run through them and run through them well. And I think tackling the hardest problem is fun. It’s challenging, but it also honestly creates a lot of opportunity. And I think you’re able to draw a lot of people into those endeavors to run after them. And so while in some ways it’s hard, I think– this is actually an analogy that Bob Corker, who is my first boss, used– he said, you know, if you go to a football game and you just run it up the middle every time nobody wants to come to the game. But if you’re trying to throw a Hail Mary every time, everybody wants to come watch. And I think just like the more aggressive you are and like the bigger things you go for, the more likely it is that people want to be a part of that. And so it’s actually worked out okay.

[00:07:39] Laura Veroneau: I relate to that as a former three-point shooter, much more fun to watch in my opinion than some of the more, let’s say, forward-led basketball approaches, so I like that one. And I think it’s helpful as we think about, I assume a lot of people in the audience are, entrepreneurs or even people earlier in their career, and I think that orientation around seeing the opportunities for what they are in the moment and knowing that later they might make much more sense in terms of the pieces and the string of pearls that you’ve put together over the career makes much more sense looking backwards sometimes than in the moment to running out the different opportunities. So that’s great. Okay. So moving from here now, I want to go a little bit through the career and the different steps and how you approach different things at different points in time. So let’s go back to the early days of the career, as you just mentioned, first time, probably on the public side broadly speaking and moving to the private sector. Starting as a driver, as you mentioned for Bob Corker and then ultimately working in the state’s Economic Community Development Office before starting Aspire, I think many of those early jobs, there might not be a traditional path for an entrepreneur, but many people would probably look at these roles as nontraditional for a healthcare entrepreneur. If you rewind, how did you come to the decision? You mentioned some of the pieces that led you towards the thesis of Aspire but how did you come to the decision to actually jump from where you were and start Aspire and make that leap? Anything about those sort of non-traditional settings that led you to feel confident in making that leap?

[00:09:13] Brad Smith: Yeah, I’d say maybe like a couple of things. Part of it was I’ve always been a little not wanting to go down the path everybody else is going down. So I’d done a summer at McKinsey. I had an offer to go back to McKinsey. I deferred it like literally three years in a row. And then they were like, you can’t defer anymore. So part of it, that was as I was doing all the government stuff and part of it was, I just had this decision point of do I want to go down this traditional safe path, or do I want to do something a little bit different? And I think two things drove the desire to do something different. One was, I really did have a lot of great mentors. Bill Frist was one of them. There’s other guy, Bill Hagger, who’s now actually in the U.S. Senate who’s been my boss doing the Economic Development. And they all really encouraged me to take a bigger risk. And I’m not sure without that encouragement that I would’ve ever made that leap necessarily. And I would say the other thing that they both said to me and turned out to be true is that, there’s a lot of things that are different about running a company than being in government or nonprofits, but there’s also some important things that are similar. And I would say, one of the most similar things in government and nonprofits and campaigns, it’s all about building a group of people and rallying them around some calls. And at a campaign it’s obviously around ideological causes and getting people to vote for you. In a nonprofit, we started a nonprofit around education, so you’re building a board; you’re raising money; you’re recruiting a team. And in a very similar way, starting a, company’s almost the same thing, right? You got to go out and find customers; you got to recruit the team; you have to find investors. So I would say that idea of bringing people together and rallying them around something was similar across those. Obviously in some ways I think the business bottom line is a little bit more straightforward than some of the nonprofit, political bottom lines of what you’re aiming for. But I think that I idea of bringing people together ended up being really helpful and the things I’d seen people do in campaigns and in nonprofits and in government was a leverageable skill set, probably more so than I honestly anticipated going into it.

[00:11:03] Laura Veroneau: Yeah. Makes a lot of sense when you explain it that way, and maybe as you think about leadership in that context, you just described the expertise and building of skills around rallying people around a cause when you thought about stepping into that sort of from the outside again, arguably first, clear, big leadership role in running Aspire. How did you in that moment think about your own leadership style and what you wanted to be as a leader and maybe more broadly, how would you describe your leadership style today, and how it maybe looked at that time period, and how you thought about even getting started and rallying that team around you as the CEO in that first step with Aspire?

[00:11:43] Brad Smith: I think it’s honestly changed and evolved a lot. When I was doing Aspire, my first goal honestly was not to fail. And everything that we did, I ran super, super hard at. And I think if you talk to the folks from Aspire, they would hopefully appreciate how hard we ran at everything, but it was also like a tireless pace. Because I couldn’t tell the difference between what was like the most important and what was kind of important. So I just ran hard at everything, literally,

[00:12:10] Laura Veroneau: I relate to that.

[00:12:11] Brad Smith: And. Yeah, exactly. And things would happen like the org we had wouldn’t work cause we’d be getting bigger, and I would think it was like this crisis moment when it turns out like that’s what always happens, but you just don’t know any of those things. And so I think, Aspire, I like describe it as we got through with a lack of sleep and grittiness basically. We just powered our way through it. And I think as we’re doing these new companies we still have a lot of those elements, but we have a little bit more insight around, what are the things that there are in these startups, like certain things have to be perfect, like certain things do have to be A+ and knowing what those things are and focusing on them, but doesn’t mean every single thing has to be A+ at least right at the start. And I think figuring out how to prioritize it and keep the team focus has been like a big, a big evolution. And I also think honestly figuring how to delegate was like a big challenge for me. The story I’ve told a couple of times is there was this week at Aspire, where we had the big RFP deal. And so literally me and this guy, my chief of staff, we stayed up till 3:00 AM one night and literally almost the entire night the second night to write this like a hundred page RFP. And after that, the next day I had a call with a National Health Plan to pitch them. And I was just exhausted. And it was this moment where I realized, wow, I’m working as hard as one can possibly work, and if I don’t change what I’m doing, I’m going to run this thing into the ground. And it was almost like you had to hit that barrier to realize, okay, there has to be a different way to organize things. And I definitely don’t think we’re perfect, and we’re still learning a lot as we’re doing the second and third companies now. But it’s definitely evolved a lot, as you live through those things and realize, wow, there’s different ways to do this that might be a little bit, I don’t want to say any of it’s easy, but at least a little bit more reasonable, maybe.

[00:13:50] Laura Veroneau: Definitely. And I guess as a lot of founders or a lot of folks looking at the early stage companies, in my seat are obviously often focused on the team and the team building and the importance on that side. What is your philosophy on, if you are running a company, how you think about building a team around yourself that compliments you and can achieve the type of success that you’ve achieved.

[00:14:11] Brad Smith: I’d say a couple of things we’ve learned. Number one, the thing that we always sign people up for is we really want people who want to be successful and want to win. And our plan is to build really great things, and people have to be willing to have the drive and make some of the sacrifices that it takes to be able to do that. And I think that’s always the first thing we screen for. And there’s a lot of people who for really good reasons that’s not what they want to do. And that’s completely fine. And there’s lots of great places for them to go. It just happens, like one of our companies that’s growing real fast, it’s not the right fit. And so, I think that’s always the first screen. I think the second screen, which was not a screen to Aspire, but we’ve been able to do with the new companies is, we are screening really hard for cultural fit. And we’re now at a place where recruiting’s gone pretty well. And so I think we’re able to say, hey, not only are these people that we know if there’s a hill like we’re all going to take it together and everybody’s going to work really hard to do that, but that we like working with cause we do work hard. And I think that’s been, another screen. And then I think the last thing you said about how people compliment each other, we’ve got several people that have been in several of our companies together, and none of us are perfect, we all have good and bads, but we’ve learned how to work together and how to compliment each other. And I think as we’re bringing lots of new people onto that is the same thing. You can expect people to be perfect. Some people will be more diverse in what they can do well than others. But lots of people have strengths and also weaknesses and figuring out how to put people in the right roles where they can be successful and shine, I think, it is a part. And when I think about building an executive team, of course you’re going to have a CFO and a COO and these other roles, but it’s really about what are they actually really good at, and how do you put people in the right lane where they can be successful. Cause I’ve learned it’s much harder to make somebody good at something that they’re not naturally good at than just letting them focus on the thing they’re already good at, and then figuring out how to have another person hedge them on the thing they’re not as good at.

[00:15:57] Laura Veroneau: The fun part for me here, Brad, is that I’m very excited for your answers to all of these questions. So I’m hopeful everybody else’s as well, but it’s fun to hear how you think about these things in depth. Okay. So a lot on the startup space here, a lot on your time at Aspire and how you thought about sort of leadership building and making the jump originally and building the team. Where I want to go next is the next part of the career. Thinking about the relationship that you’ve had over time with the incumbents in the space on the healthcare side, obviously with Aspire, you had a phenomenal experience of selling your company to Anthem, one of the largest institutions in the space or incumbents in the space, and got to see that through that lens. You’ve partnered over time, both in previous life and with your current companies, with a lot of folks across the entire landscape in a really differentiated way, that I think is hard for many folks to understand how to do that, and how to think about that, and how to think about the role of innovation on the incumbent side of the landscape as well. As someone who sold to an incumbent partners with a lot of incumbents and held a role inside of one before moving on from there, how do you think about the role of incumbents and innovation and what is your approach to thinking about that part of the ecosystem, given how healthcare works overall?

[00:17:14] Brad Smith: Yeah. I think when you look at the healthcare space, whether it’s on the payer side or on the provider side the reality of the system we’re in is you just have some really big players on both of those sides. And the payers tend to have national footprints, a lot of the providers tend to have more local but very dense footprints. And I think if you’re going to innovate in this space, you have to accept how the landscape looks today. It doesn’t mean you can’t try to disrupt them massively, but that’s very hard. What I’ve found, and this probably more on the payer side but probably turn on the providers side too, is that people understand the healthcare world is evolving a lot and is changing a lot. And whether that’s Amazon buying One Medical and saying there’s new entrance coming in, whether that’s the payers moving into service businesses, what CVS is doing on retail, like everybody understands the world is moving, and they’re trying to find their place in that world. What I’ve also seen being inside of some of these places is the places where large organizations can really add value are combining things together, leveraging their scale, but starting something from scratch and really innovating from that very early phase, it’s not to say it’s impossible, but it’s not very easy. And it’s antithetical, honestly, to some of the structures they put in place to make other kinds of decisions that are really important for them. And I think, all of the incumbents, or at least a lot of them, have recognized this at different levels. And so have teams of different levels of maturity, starting to try to think about how do we find partners or how do we invest in things, or how do we create that outside pipeline. And I think, we found a lot of success in partnering with those folks and honestly, I think what you guys have figured out, both at UHC, at Optum and at Optum Ventures is like the best in class version of that where, one, unlike the plan and services side, separate from OV, you guys have figured out how your health plans and your services units integrate probably more closely. Lots of other people, Anthem, CVS, others are trying to solve for that. But I think you guys are farther along in that maturity cycle. And I think you guys are also farther along in thinking about how your venture groups worked. And how do you integrate the investments that you’re seeing and the needs you’re seeing in your business with investments in early stage companies, and then being able to sell them into as customers into the plans or the Optum side. And I think you guys are really sophisticated at that. And what we’ve seen is that if we can take these big, but very discrete problems where there’s not really a solution today and build a solution, whether it’s around rural healthcare, around HCBS, these are things that in general, the plans know are important, but they’re not going to be on their top three or five lists. And both cases, you need something pretty early stage, cause nobody’s built out the solution. And I think it just makes these really rich partnerships where, for us, we’re getting access to being able to scale and access to capital and access to partnerships in a way that allow us to grow the businesses faster than we otherwise could have. And hopefully for those folks, they’re getting a way to solve some problems that, maybe eventually they will insource somehow or build out a solution, but they’re seeing what’s happening and what’s working, and they’re able to test things out or at least watch things being test out in the way that’d be very hard for them to do from an innovation perspective. And so I think it’s ended up being these really symbiotic relationships. It doesn’t mean that some of these startups, can’t go against the incumbent in a more direct way, and maybe some of them will have success, but I think at least the path we’ve picked and the path I encourage folks to think about is like this partnership path, cause I think it really is a “one plus one makes three” kind of thing.

[00:20:31] Laura Veroneau: Yeah, I think we could spend probably two hours talking about your approach and your success on the sort of incumbent institutional partnership side, but it has been unbelievable to watch how you go about that. And honestly requires a deep, deep understanding of the complexity of the system today and why it is there to even, frankly, identify the opportunities like the things you’re going after. I don’t think anybody else knows enough about LTSS or HCBS to even know that there’s an opportunity there, nevermind to even think about how to begin solving that problem. Yeah. What you have done is a model in itself in terms of that large scale innovation. So an interesting area to hear you talk about. From here, you obviously jumped back into the government. We’re moving into the lovely time period of 2020. So you take a jump into the public sector again; you’ve just started as the new director of CMMI, 10th year of CMMI, if I have my facts, correct. And you probably had all kinds of ideas on continuing progress of past folks like Adam and Patrick and others. And then the pandemic hits. Can you talk us through what those first six months in Washington were like for you?

[00:21:41] Brad Smith: Yeah the first two and the last four were very different. You know, I went up in January of 2020, and the first thing Alex and Seema who was running HHS, and Seema was running CMS, asked me to work on was, as you mentioned, CMMI was 10 years in; it’s spent about depending how you count it, $10 to 15 billion on all these pilots across the country. And they kept saying, hey, we get all these like one off reports about how they’re going, and they don’t look that good, but we don’t really know how to add them all up, and can you organize it basically. So we went back through, literally in the first two months I was there, went through these 54 models, all the reports to see how had things gone over the last decade, and we can get into it more. But the short answer was it hadn’t gone that well. And started to build a plan with Seema and Alex for what we might do about that. And in the middle, I was realizing all my colleagues were getting distracted by this COVID thing. And I was literally one of the few people in January and February at HHS who was not working on COVID. And what happened is there was this day in early March, you know, people don’t remember this, but we’re like the stock market came down like 10 points literally in one day, the President gave a big speech, lots of questions about what was the strategy and at that point, Jared Kushner, who was over in the White House, ended up getting more involved in the COVID Response. And when that happened, he knew Adam, he called Adam, Adam called me anyway, long story short, early March, I ended up going over to the white house the day they call me. And I called my wife on the way and said, I’m not really sure what’s happening, but I’m either going to be here for a few hours and I’ll be home for dinner, or like I’m going to be here for a really long time. And I’m not really sure which one it is. And anyway, it was really early in the crisis. I ended up getting pulled into this team that was working out of the West Wing, and really the way that they used me was really for setting up solutions for things that the government hadn’t done before. And then as those things got set up, I would hand them over to people in the government and move on to the next thing. In those very early days, I don’t know if you remember this, but there was this lack of testing everywhere. And nobody was, we didn’t know if it was spreading, cause we’d had many tests. And literally the first three days I worked on COVID, which sounds like not that long but it felt like forever, was figuring out how to set up these testing sites. And so we ended up looking at South Korea was running testing sites. And so we were literally like reading newspaper articles. Then we found people to call over there and just understand how were they running them. And then we built this model for how you could run a drive through testing site, which was something the federal government had never done honestly. We went out to this parking lot in like Arlington and like model to that and all that stuff. And then we launched a bunch of them literally within three or four days. And as we did that, I turned it over to this division within HHS that ran that. But like in the middle of that what we realized is you needed swabs to do the test and everything. And there was this Strategic National Stockpile, which, we just assumed, I think had lots of supplies in it. And, day two or three, I finally got the list of what was in it. And then you realize, wow, there’s a million swabs for the whole country in this thing. And so we immediately realized that there were a lot of supply issues. And as soon as we started calling around, we realized that everybody was calling around and that there was not enough supply in the country. And through that, we came up with this idea because a lot of things were getting shipped over on boats and it takes 30 days to come over on a boat. We came with this idea to fly a bunch of stuff over on airplanes, basically. And so we got all the approvals for that. And then we got some of the DOD guys to execute against that. And so anyway, the long story short. It was this moving between different fires, for lack of a better word, and getting a new thing that the government hadn’t done set up, and then figuring out how to hand it over to the part of the government that could really do it on a recurring basis, cause the government, especially the military folks, after you have a clear plan, they are extraordinarily good at executing it. And so it ended up being this like nice symbiosis really, between entrepreneurs willing to cope up with new things and push the boundaries a little bit, and then, really good executors who could then take an idea and just go stamp it out over and do it at scale.

[00:25:36] Laura Veroneau: Yeah. A super interesting time to be in a government seat and seeing the sort of partnership and innovation that happened between both sides. So maybe with that lens and with that seat how do you broadly think about that government led innovation and how that ties into the private sector? What did that role evolve? Obviously you had the public sector role before, but did that evolve anything in terms of how you thought about the government’s role in a lot of this broad innovation?

[00:26:02] Brad Smith: I would say the way I think about what we learned in the COVID response about that and what we learned in the CMMI work are slightly different. So I think in terms of a pandemic or crisis response, I think, for outlier events like that, that definitely happen but happen infrequently, right, the government has a really important role to play in planning for those and helping on executing the response. What’s unique about America, there’s lots of other countries like this too, but one of the things that’s unique about America is our private sector is really strong. And when you get into how do you develop a vaccine, or how do you distribute test, or these things, the answer is, you have to use the private sector. There’s like literally no other answer you could pick. There’s not a government agency that really can build or develop vaccines or that can– the military has some trucks to do distribution– but we use mostly FedEx and UPS. I think you just realize that there’s, there has to be a crisis, this in the U.S., the symbiotic response between the private sector and the government, cause neither of them can do it by themselves, and they have to work together, I would say. What’s a little bit different about the CMMI work is that was really where the government was trying to step in and drive innovation and change by changing how things got paid. And I think the learnings there were really interesting. I think the government has an important role to play. But if you look at what the effect has been so far of the CMMI work, I think it indicates where the government can be effective and not. So when we went back and looked at these 54 models, what we saw is that five of them had saved and most of them hadn’t. And so you’d say, okay, by whatever standards we had for CMMI, it was probably to do three things: I think probably, change how people got paid, improve quality, and reduce cost. It definitely changed how people got paid right. In every single model we were change. So it was very successful on that front. The quality findings were mixed, I would say. And the cost findings were probably if you’d net it all out, negative, it probably lost several billion dollars, if not 10 billion dollars or more potentially, depending on how you calculate it. And I think you say why did that happen? And I think what happened is because the government has to respond to all the stakeholders, they decided probably appropriately to make the models voluntary. And, although there’s a lot of ways it looked, the way they basically got people to participate in voluntary models was by paying them more than they would otherwise get. And there were a lot of ways that got described: it was a cure coordination payment; it was setting like a favorable benchmark; it was doing all these things, but the effect of it was we were basically paying people more. And what all the analysis showed is that while there would be some gross savings, like utilization would come down a little bit, when you weigh in what we were paying people, the net, it was almost always negative net savings. And when I took that approach or finding, to Alex and SEMA, and said, hey, here’s what it looks like, I believe that CMMI can save money over time, but it’s very hard because they have to make difficult decisions. They have to make models mandatory, or they have to set harder benchmarks to make it harder for people to make money on the programs. And I said it’s pretty straightforward how you do that. The political will to do that is very hard. And so I think it’s, based on that theory, hard for the government to innovate in a meaningful way around these things, and I think where the government can be much more effective, it is in one of two strategies, either one, looking at innovations that are happening in the private sector, let them get proven out there. And then the government really be the person who’s responsible for scaling them up. And so look, if all the MA plans or the private plans are doing certain things and they’re saving money, then maybe the government should look at that for traditional Medicare. But I don’t know that the government needs to be the first one testing out new things for lots of reasons. I’d say the second thing that I think works the best is when the government lays out the goals of what needs to be accomplished and then allows the private sector to build solutions to address those goals. And I think this is what happening in Medicare Advantage. This is what happens in Manage Medicaid. And I think that’s a much better role for the government to play than really trying to pick winners and directly seed innovation. Cause I think this story at CMMI is that, in my opinion, that really hasn’t been successful when we’ve tried to do it, even with like really smart, good people, leading it in a lot of political will to try to make it happen.

[00:30:11] Laura Veroneau: I think we’re almost at time here. So to wrap, we’ve covered your path in many different ways; we’ve covered the startup landscape; we’ve covered the incumbent landscape and some perspectives there; and then obviously just going through more of the government side of the equation, but now we find you obviously transitioning back to Nashville with your beautiful family. And at this point, focused on Russell Street and a lot of very hard problems and a lot of intentional focus around solving those problems with a little bit of a different angle. So, we’d love to wrap with maybe a two part question. I’ll hit you with the first part. First, just tell us about this next chapter and how you landed on exactly what you’re going to do. And some of the problems that you’re going to solve.

[00:30:57] Brad Smith: Yeah, for sure. Yeah. So moved back to Nashville after the government, and really wanted to start three or four, might be more like two or three, companies that could run after really hard problems. And we looked, especially in the Medicaid and Medicare, we also looked in commercial space a little bit, and we kind of said, hey, where are the big thorny problems that seem complicated that not a lot of people are running after, that we can, build a business model around. And so far we’ve found two of those, we got a third one that we’re baking on, but the first one was this company called CureBridge. It is, we’ve referenced a couple times, takes full risk on patients receiving home and community based services. This is a part of the Medicaid program. It’s about 2% of the Medicaid patients across the country, but it’s about 20% of the Medicaid spend across the country. And continuing to grow. And there, we’ve really built out this innovative solution that leverages the fact that the program pays for this, typically non-clinical caregiver to be in the home. And so we both work to make sure that caregiver and the other supports in the home are the right levels of support to keep that member as independent as possible in the home. And then we deploy tablets to the home to be able to leverage that caregiver as the frontline of an interdisciplinary clinical team. So it’s cheaper than, for example, our Aspire model, but then able to bring a lot of those same resources to bear through that caregiver and through the family members that are in the home. A second company we built is called Main Street, which is a rural primary care company. We’re going out to like little towns. This is from driving the 140,000 miles, where my family is from. But going out to part of with these little doctor practices of one doc or two NPs things, and then helping them move into value based care, starting with Medicare Advantage, but we’re just launching in traditional Medicare, we plan to go into commercial, Medicaid over time, and then just finding a huge need in that space. We started last year in nine counties in West Tennessee. We’re going like 11 states this year. And it’s been amazing the take up we’ve seen from doctors there. Our goal was to have about 42,000 MA patients. And, we’re definitely going to be north of a hundred, and maybe like 125, or even 150, depending how some things land. And so it just speaks to the need that there was, and the desire there was for this solution. And then we got one more idea we’re working on, but I think that the common theme to them all was like running after expensive, unique, complicated underserved populations. And one of the other best pieces of advice I got was from Annie Lamont, which was, it’s way easier to build an innovative solution in a space where you’re the first or second person than when you’re the fifth person. In every space we’ve gone into, we’ve tried to be first or second. That just creates a little bit more room to run and figure things out along the way.

[00:33:30] Laura Veroneau: And it truly does feel like your team is uniquely positioned to solve every problem that you go after, which is probably a decent part of the success that you’ve had so far. To wrap, recognizing we still have a long way to go towards the real sort of better healthcare system we all envision in the future, where would you like to see us, collectively, in five to 10 years? And where do you see yourself in five to 10 years?

[00:33:54] Brad Smith: I have no idea where I see myself. But I when I think about like the system that we want to work towards, I think about three things. One, there’s been fantastic medical innovation in the country that extended life expectancies and helped a lot of people live healthier and better lives. And so I think number one, you want to keep the United States at the forefront of that innovation and driving those true therapeutic and other kinds of innovations. Two, it is a lot of the chronic conditions in the country and the general health of the population is burdensome both on individuals but also on the system. It is very hard to move those things, but that’s got to be, at the national level, something we’re at least thinking about. And then I think the third part is, the cost is really high. And I think so far we have not shown that we really have any great ideas for how to lower that cost in a meaningful way. And I think that there’s got to be a lot of work on that in a way that doesn’t sacrifice the first two things I mentioned. And that’s where I’d love to spend more of my time, whether it’s doing it with some of these smaller, specific populations like we’re doing in the business context or, you know, in a government nonprofit context, but I think this cost question is still out there. And I don’t think that a value to value based care as it stands today is going to solve that. I don’t think that’s going to be the solution. So the question is how do you get there? And I do think there are things around competition and the private sector and all these things that do create an alternative path forward that maybe has a higher chance of success. But hopefully get a chance to help run some of that down in the future in some way.

[00:35:23] Laura Veroneau: Okay. That wraps it. So I think, I want to say thank you, Brad. I think in other areas, other arenas, let’s say sports or something like that, we’ve used that a few times, it’s much easier, in my opinion, to get insight into leadership and different people’s paths and how they approach problems and have achieved success over time. I think that’s actually incredibly hard to get at scale in the business world, and so, incredibly grateful for you sharing your insights and what has been so far already an unbelievable journey for your career, and letting all of us learn from that, and for taking some time with us, because we know you have a lot going on. So thank you, Brad. And we’ll wrap there.

[00:36:02] Brad Smith: Yeah, thanks so much for having me.

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