Accountable Care, ACO

On Lessons NOT Learned from Managed Healthcare v1.0 and Beyond

by Gregg A. Masters, MPH

First in a series of lessons NOT learned tweets to be enhanced and re-posted to @ACOwatch.

In the 80s Sanford C. Bernstein analyst Kenneth Abramowitz predicted for-profit hospital systems would dominate the market by 2000. One of the strategy ‘diversification arrows‘ in the quiver of hospital system executives was to enter the insurance market via managed care strategies of various strains. During this consideration phase, my then employer American Medical International (AMI) elected (against my counsel) to build its own insurance company dubbed ‘AMICARE’ vs. creatively ‘parter’ with the insurance sector. /1

Editors Note: See: ‘SuperMeds Hoping to Reshape System‘ by colleague Michael Millenson.

/2 Context: Abramowitz predicted the relative competitive under-performance of 501c3 hospitals & thus their parents. Too clunky and with the wrong governance structure they’d be swarmed by their more nimble for profit operators with easier access to the capital markets required to support a full range of acute care services.

/3 Hospital Corporation of America (HCA) (follow @HCAhealthcare), National Medical Enterprises (NME)  & AMI (merged into @tenethealth) dominated the emerging for-profit sector. Humana was actively repositioning itself from a hospital owner/operator into a health insurance company with a robust portfolio of managed care products.

From major academic medical centers (see: ‘Corporate Takeover of Teaching Hospitals‘) to regional non-profits, c-suite strategists were aggressively courting their engagement given bond debt service coverage requirement concerns amidst an uncertain future.

/4 While all major systems where looking into ‘integration model 1.0’ (recently and cleverly rebranded as ‘pay-vidor’) the mission critical decision in board rooms was: ‘do we make, buy or lease’ the infrastructure? Some sensibly chose the ‘payor neutral’ route, while others built brands.

/5 As then ‘director health system development’ @ AMI California, and previously serving as founding member of Preferred Health Network (PHN) now portfolio company @UnitedHealthGrp post Pacificare acquisition, I counseled AMI to NOT build AMICARE, but partner with the ecosystem as a payor neutral aligned, managed delivery system.

/6 The theory was don’t compete with insurance companies but learn to partner and co-brand local market products from PPO to HMO to POS and ‘OWAs’ (other weird arrangements). Furthermore hospital operations & insurance company cultures were ‘oil and water’ and would not mix. More later (think pre @texashealth formation where Presbyterian Healthcare and Harris Methodist Health Services merged and the health plan leadership where shown the door while DFW market dominant Harris Methodist Health plan was shopped to Pacificare).

/7 Rather than ‘risk’ the payor neutral, lack of vertical integration control (the lessons forged at PHN) and what I advocated at AMI, most majors’ (including 501c3s) with some local market (operations & branding) variations chose to ‘build’ vs. partner. #wrong #move 

/8 I digress. On the branding thing (another wrongly reasoned corporate brand extension decision), what’s wrong with the pictures above? At AMI I advocated that the product/service is the local market asset (a co-branded insurance product) and NOT an extension of corporate nameplate!

/9 I reasoned hospitals serve as ‘hubs’ of community trust (not too mention economic engines and potential integrators of the then dominant independent practice of medicine) & thus the assets to brand & market locally. A sensibly if not delicately calibrated blending of corporate vs. local market identity is more likely to create the goodwill & trust to build upon. Again I was over-ruled by corporate marketing gurus shopping a corporate branded nameplate. For example, all AMI hospital names were preceded by AMI, e.g., AMI Tarzana Regional Medical Center, AMI Irvine Medical Center, etc. 

/10 There’s much more to the story here. This is just an install in the hospital/insurance dance we’ve witnessed in the 80s-00’s playing out today and in some respects completely oblivious to painful lessons of the past (think NorthWell Health’s strategic entry and rapid exit from provider sponsored health plan ownership due to massive losses).There’s a similar story on hospital/health system side (both branding and strategy), to be elaborated in a separate post. 

/11 Concluding thread as follows. So what happened to those systems who elected the ‘build’ option? Massive losses & write-downs were reported with d/c operations posted to the balance sheets of public companies’. The gamble of assuming ‘insurance risk‘ was repelled as if the plague. Health plan or health insurance division employees were looked upon with suspicion. Welcome to FFS maximization era which reigned supreme until the recent round of re-engagement with managing the burden of the total costs of care (think triple aim) envisioned by various risk transfer provisions in the Affordable Care Act (ACA), where Accountable Care Organizations (ACOs) serve as the principal – but not exclusive – workhorse.

Comments:

Hey @VinceKuraitis, please checkout thread 1 – 11 below. Would love your thoughts and commentary. c #ACOchat #phychat #hcldr #JPM19 @jpenso1 @DonCrane @Farzad_MD @bobkocher @DrShlain @sgschade @davidmuntz @RejuvalifeBH @NACOMSO @NicoleBradberry @drnic1

Gregg Masters MPH @2healthguru

Replying to @2healthguru @jpenso1 and 10 others 

Vince Kuraitis @VinceKuraitis

Nice thread. On point.

IMO the jury is back — high probability of failure/$$ loss. (Most) hospitals do not have expertise, culture, patience, scale to become successful health plans.

Newer model of hospital/health plan JV MUCH more promising, e.g., Aetna + Inova.

John Moore @john_chilmark

Replying to @VinceKuraitis @2healthguru and 11 others

It may be promising Vince but we’ve been studying this for several years and still dumbfounded by the shear amount of distrust between provider and payer.

Requires a degree of transparency that few are willing to abide

 

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Accountable Care

In Pursuit of the Triple Aim: Can Population Health Management Lead the Way?

By Fred Goldstein, MS and Gregg Masters, MPH

Every sector in health care is under pressure to articulate and implement a viable population health initiative that delivers on the triple aim of better health, better quality at a better cost.

Despite a significant investment of resources, we have only achieved ‘mixed results’ to date, and so the industry remains in a continuous learning mode. Although we’ve taken away some insights, we still have a long way to go.

Recently on Pophealth Week, we chatted with the ‘Dean’ of Population Health who spearheaded and continues to steward the nation’s first freestanding College of Population Health at Jefferson University in Philadelphia. David Nash, MD, MBA weighed in on the industry’s evolution — including best practices to emulate —and what near term challenges we are likely to face.

To listen to Dr. Nash’s take, click here, and for additional context checkout The Road From Volume-To-Value: The Pivotal Role of Population Health.

If you’ve worked in this space – at the strategy or operational level — you know that it can be truly daunting to implement a population health program. This can lead some organizations to shy away from attempting meaningful programs, perhaps even into a copycat ‘me too’ effort. Given the inevitable drive to value-based care, it is a strategic imperative to understand how to build and implement population health initiatives that work.

In its simplest framework, one can think of a population health program in terms of the following components as articulated by the Population Health Alliance Outcomes Guidelines Report Volume 6,  2015.

The steps of the Population Health Framework as shown in the image above include:

  • Identify the population
  • Assess the person for risk(s)
  • Stratify the person into risk levels to target for various interventions
  • Engage the person in a program
  • Intervene with specific services and resources and
  • Measure the process and outcome results

These results are then fed back into the system and the process continued all seeking to improve the overall health of the population.

In Search of Answers

One forum many look to for best practices and key insights is the Population Health Colloquium, now in its 18th year with the Jefferson College of Population Health as academic partner. Scanning this year’s Agenda, one can find presentations in each of the elements above.

Data and Analytics are the essential ingredients of any population health program with intent to identify individuals, assess them for various risks or conditions, stratify them to ensure appropriate levels of intervention and measure a program’s success.

Within the area of assessment, we are moving to an ‘N of 1’ approach given the advances in precision medicine and genomics. This exciting area will be covered at the conference in the mini summit entitled Personalized Medicine, Machine Learning and Genomics: a Clinical Approach to Employer Population Health and Wellbeing.

Payment models and the move to value-based care are among the key levers. Although there have been more than a few stops and starts along the way with the change in administration at the federal level, employers are rapidly embracing these approaches.  There are a number of presentations on this topic, including Journey to Value-Based Care — Experience and Expectations, Accountable Care Atlas: Mapping a Path to Value-Based Care and a Mini Summit ACOs at an Inflection Point: Where the Movement is Headed and Why Some Succeed While Others Don’t.

In the Intervention area, there are presentations covering ‘On the Ground: Population Health initiatives’… and we can’t forget about the patients — they, too, have a strong role to play in these efforts. The Mini Summit, Improving Patient Care and Provider Experience through Population Health Management, is timely and informative.

Community-based programs have become all the rage as we better understand the impact on your health based on where and how you live.  A breakout track entitled Population Health in the Community includes discussions on life expectancy gaps in Chicago; Rural and Urban Issues; and primary care and behavioral health that will address some of the approaches.

The program will feature a session on designing and implementing population health, and of course there will be some incredible keynotes and small panel discussions. The program includes a discussion with two former HHS Secretaries, Tommy Thompson and Michael Leavitt, and baseball great Darryl Strawberry will discuss addiction, a critical issue we are now facing with the opioid crisis.

If you are committed to learning more about Population Health, this meeting is a must. It’s an event where you can learn from experts covering the full breadth of population health services and have an opportunity to network. Whether you choose to travel to Philadelphia or attend via live webinar, please plan to join us and stop by to say hello. We’d love to hear all about what you’re doing in this exciting space.

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This post is sponsored by the Jefferson College of Population Health

Accountable Care, population health, Triple Aim

Blab the Blockchain: Healthcare Implications?

by Gregg A. Masters, MPH

blockchain blab screen grab

Yesterday, April 27th 2016 I joined twitter colleagues and principal co-moderators and my ‘go-to Blab experts James Legan, MD (@jimmie_vanagon) and Charles “Chuck” Webster, MD (@wareflo) for a ‘Blab‘ on ‘blockchain implications in the heathcare space (both delivery and finance).

Our featured expert du jour Jeff Brandt was a no-show, so we winged it with an excellent overview and introduction by Chuck. We’re all learning in this space but one of the potential applications of the emerging technology might be in the granular if not seamless adjudication of complex bundled payments.

During the session many excellent references were included in the chat box. Several resources were mentioned including Smart Contracts, the Consensus 2016 conference, Youbase, and the article posted by Dan Munro on Health Standards, titled ‘Digital health lessons from BART‘.

I have a feeling there will be major application in the healthcare financing and delivery space as we progress into scaled assumption of risk under a value based healthcare incentive structure. Watch and see if you agree with some of the points made in the discussion!

 

Accountable Care, Affordable Care Act, health insurance reform

CMS Quality Measure Development Plan: A DRAFT

by Gregg A. Masters, MPH

An inspirational leader and ‘disruptive‘ politician taken down well ahead of his time once opined:

“Ask not what your country can do for you, ask what you can do for your country…” John Fitzgerald Kennedy

Fast forward some 55+ years and season such an invitation with the relentless drone of 24/7/365 faux patriotism, hate mongering, intolerance, and emotive ‘hell no‘ sound-bytes proferred by those who self righteously claim title to the ‘take back our country’ narrative and you may ask yourself how did we get from there (the Peace Corps) to here (carpet bomb em)?

Yet, in our unique strain of American democracy even through studies empirically demonstrate a consistent disconnect between what Americans want and what their representatives codify via policy with a capital ‘P’, the bottom line is look in the mirror ‘we are the government’.

CMS_quality_development_planWhether it’s the creation and passage of what merged into the ‘Affordable Care Act‘ (ACA) or how the ‘public’ participates in both the legislative process and its implementation via the rule making process initiated aka the ‘notice of proposed rule making’ (NPRM), we are presented with both the opportunity and as it turns out obligation to engage in and thus granularly shape (via a dialectical bottoms up vs. top down exchange) the ground rules which in turn govern our economy and the conduct of its constituent industry stakeholders.

In the quest to advance the efficacy of quality initiatives (garbage in garbage out) one recent effort is the DRAFT release of the ‘CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models‘.  

As an industry we are process oriented sometimes to a fault. Moreover the ‘check the box’ or drop down nature of many of these measures lends itself to the argument that the state of the industry to actually measure, document and report healthcare quality is at best a crude representation of what is actually going on. Clearly there is more work to be done if this industry is to matter.

To help readers of this blog, the introduction of the executive summary is pasted below:

I. Executive Summary

Background

A transformation of the U.S. healthcare delivery system gained momentum in 2010 with the passage of the Patient Protection and Affordable Care Act (Affordable Care Act).1

The law established the Health Insurance Marketplace to extend consumer access to affordable care through private payers and provided strong incentives in publicly financed healthcare programs to connect provider payment to quality of care and efficiency. 

Building on the principles and foundation of the Affordable Care Act, the Administration announced a clear timeline for targeting 30 percent of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50 percent by the end of 2018.
These are measurable goals to move the Medicare program and our healthcare system at large toward paying providers based on quality, rather than quantity, of care.2

The passage of the Medicare Access and Children’s Health Insurance Program (CHIP)
Reauthorization Act of 2015 (MACRA)3 supports the ongoing transformation of healthcare delivery by furthering the development of new Medicare payment and delivery models for physicians and other clinicians. Section 102 of MACRA4,i requires that the Secretary of Health and Human Services develop and post on the CMS.gov website “a draft plan for the development of quality measures” by January 1, 2016, for application under certain applicable provisions related to the new Medicare Merit-based Incentive Payment System (MIPS) and to certain Medicare alternative payment models (APMs).

The law provides both a mandate and an opportunity for the Centers for Medicare & Medicaid Services (CMS) to leverage quality measure development as a key driver to further the aims of the CMS Quality Strategy:

• Better Care,
• Smarter Spending, and
• Healthier People. 5

Measure Development Plan Purpose
The purpose of the CMS Quality Measure Development Plan (MDP) is to meet the requirements of the statute and serve as a strategic framework for the future of clinician quality measure development to support MIPS and APMs. CMS welcomes comments on this draft plan from the public, including healthcare providers, payers, consumers, and other stakeholders, through March 1, 2016.ii The final MDP, taking into account public comments on this draft plan, will be posted on the CMS.gov website by May 1, 2016, followed by updates annually or as otherwise appropriate.i

So here it is… have at it. Perhaps your input will in fact shape the substance and steward the glide-path of how the transformation from volume to value can be realized. Certainly it’s worth your consideration. Afterall, another attributed Kennedy quote with biblical DNA may apply here:

“We are not here to curse the darkness, but to light a candle that can guide us through the darkness to a safe and sure future. For the world is changing. The old era is ending. The old ways will not do.

The problems are not all solved and the battles are not all won and we stand today on the edge of a New Frontier – a frontier of unknown opportunities and perils, a frontier of unfulfilled hopes and threats.

It has been a long road to this crowded convention city. Now begins another long journey, taking me into your cities and towns and homes all over America.

Give me your help. Give me your hand, your voice and your vote.”

John Fitzgerald Kennedy

Accountable Care, ACO, Affordable Care Act

Courtesy of our friends at AJMC: ‘5 Things to Know About Accountable Care Organizations’

by Laura Joszt

This week, The American Journal of Managed Care was in Palm Harbor, Florida, hosting the fall live meeting of its ACO and Emerging Healthcare Delivery Coalition, where stakeholders from across the healthcare industry discussed best practices. As the country moves from volume to value, accountable care organizations (ACOs) can play a key role during the transition from fee-for-service. However, ACOs not only remain largely a mystery to the average consumer, but also to providers who may be part of an organization participating in an ACO. Here’s what you need to know about ACOs:

1. ACOs are older than the Affordable Care Act. At least, the theory of ACOs is older. While the inclusion of ACOs in the health reform law has accelerated adoption of the delivery model, the term “accountable care organization” was first coined in 2006 by Elliott Fisher, MD, director of the Dartmouth Institute for Health Policy and Clinical Practice.

2. There are multiple models established by CMS. There are a number of different ACO models being offered by CMS. The most common model is the Medicare Shared Savings Program (MSSP), which has 404 ACOs and is accepting more. The Pioneer ACO Model is for healthcare organizations and providers already experienced in coordinating care, and while it started with 32 ACOs, just 19 remain today. The Advance Payment ACO Model is designed for physician-based and rural providers. And the newest model is the Next Generation ACO, which takes on greater performance risk with potentially greater rewards. The Next Generation ACO model is….

Complete article by Laura Joszt posted here.

Accountable Care, Affordable Care Act, health innovation challenges, public health

‘Non-Profit IDNs’: Where’s Da Beef?

By Gregg A. Masters, MPH

I have followed this narrative for quite some time albeit inside the industry contained debate of whether so-called ‘non-profit’ [501(c)3] hospitals or their parent systems (really more aptly characterized as “tax exempt”) actually earn this financial advantage via material ‘returns’ to the communities they serve.

NASI_Goldsmith studyAs can be expected you have the party line of the American Hospital Association (AHA) a trade group of predominantly non-profit members vs. that of it’s for-profit brethren The Federation of American Hospitals (FAH). You can guess which side of the argument each of them favor.

Now thanks to a recently published landmark study ‘Integrated Delivery Networks: In Search of Benefits and Market Effects’ by Healthcare Futurist Jeff Goldsmith, PhD et al, of the 501(c)3 cast of characters in the related but more often than not distinctly different ‘IDN culture’ we extend that line of inquiry into what has been a somewhat conversational ‘safe harbor of sorts’ – not any longer?

The Executive Summary notes both the rationale and basis to study the market ‘incident to’ a more focused pricing (via asset concentrations) power line of inquiry:

In January 2014, the National Academy of Social Insurance commissioned a study of the performance of Integrated Delivery Networks (IDNs), incident to its Study Panel on Pricing Power in Health Care Markets. The premise of this analysis was that any examination of the role that hospitals play in health care cost growth is complicated by the fact that in most large markets, the significant hospitals are part of larger, multi-divisional health enterprises. In these markets, hospitals may be part of horizontally integrated hospital systems operating multiple hospitals; vertically integrated health services networks that include physicians, post-acute services and/or health plans; or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums) like Kaiser Permanente. The latter two models are collectively labeled IDNs.

IDNs have very different stated purposes than mere collections of hospitals: to coordinate care across the continuum of health services and to manage population health. IDN advocates claim that these complex enterprises yield both societal benefits and performance advantages over less integrated competitors. The purpose of this analysis is to evaluate the evidence to support these claims.

And now for the less than surprising but wholly unacceptable answer albeit modestly caveatted by the limits of publically available information:

Despite more than 30 years of public policy advocacy on behalf of IDN formation, there is scant evidence in the literature either of measurable societal benefits from IDNs or of any comparative advantage accruing to providers themselves from forming IDNs. We have similarly found no such evidence in our analysis of 15 IDNs. Serious data limitations hamper anyone attempting to evaluate IDN performance based on publicly disclosed information. IDN financial disclosures obscure the operating performance of their hospitals and physician groups.

There does not appear to be a relationship between hospital market concentration and IDN operating profit [emphasis mine]. However, if the performance of the IDN’s flagship hospital is any indicator of overall systemic efficiency, the IDNs’ flagship hospital services appear to be more expensive, both on a cost-per-case and on a total-cost-of-care basis, than the services of its most significant in-market competitor.

This runs counter to the theoretical claim of IDN operating efficiency. Further, the flagship facilities of IDNs operating health plans or having significant capitated revenues are more expensive per case (Medicare case-mix adjusted) than their in-market competitors.

The authors would have greater confidence in these findings if they covered not only multiple years of information but also multiple institutions in the IDN portfolio (e.g. its suburban or rural hospitals, etc.). Further, the central question of whether IDNs have abused their market power in metropolitan markets can only be answered by examining actual service-specific payments to their hospitals by local health plans and by determining the profits generated by their hospital portfolio.

NASI_Goldsmith study_cohortI am struck by the reaction or better yet absence of a reaction in public discourse let alone in health wonk or big data evangelists circles particularly at time when there’s been so much mis-direction and battle fatigue surrounding the endless debate/efforts at repeal of the Affordable Care Act.

Such a profound observation and ‘counter intuitive’ result (i.e., ‘hey, there may not be a there, there insight’) based on frequent accolades and ‘innovation’ recognition extended to such trophy name plates as Kaiser Permanente, Geisinger Health, InterMountain Health and so little public debate (see complete list) causes me to question whether we’re paying attention to what matters?

How can we intelligently debate, discern and buildout the qualities and characteristics of financing and delivery system platform efficacy and business model innovation that delivers on the triple aim and lays a solid foundation for a sustainable healthcare economy if we do not understand their root DNA and the results (“community benefit”) they ostensibly generate?

Anyone?

Accountable Care, ACO, Affordable Care Act, digital health

Mark (I’m Not a Doctor but So What) Cuban’s Bold Vision or Big Ego?

By Gregg A. Masters, MPH

Mark Cuban CigarLast week witnessed a rather spirited discussion stimulated by a series of tweets from Billionaire owner of the Dallas Mavericks (and anointed judge of entrepreneurial insight on CNBC’s ‘Shark Tank‘) Mark Cuban.

What’s perhaps most poignant in this energetic public exchange is it comes at a time when ‘health’, ‘healthcare’ [and the emerging promise of ‘precision medicine’] including it’s increasing share of GDP (albeit at a decelerating rate of increase) are top of mind for many.

Considering the long, labored and ‘the jury is still out’ nature of whether the Affordable Care Act is necessary and sufficient to cure the ills of volume incentivized but silo-ed U.S. healthcare Mark Cuban aka @mcuban tweeted:

‘If you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health’ 

Followed by:

‘create your own personal health profile and history. It will help you and create a base of knowledge for your children,their children, etc.’

‘A big failing of medicine = we wait till we are sick to have our blood tested and compare the results to “comparable demographics”..’

To wit the veteran and respected investigative healthcare journalist and @ProPubica reporter Charles Ornstein aka @charlesornstein replied:

Please don’t listen to @mcuban for medical advice. Paging all doctors. https://t.co/gxV1UMMxUU

If you’re tempted to listen to @mcuban, read/listen to this: Is Preventive Medicine Actually Overtreatment? http://t.co/6H0HSFh5dr

Then many health-wonks, clinicians, patient advocates and those aligned with responsible healthcare social media stewardship chimed in with their ‘take’ on this exchange including yours truly:

Gregg Masters @2healthguru Timely and good read! via @ddiamond @mcuban Doesn’t Understand Health Care’ onforb.es/1yGBrY3 c @charlesornstein http://t.co/cIjQ1DqCKe

Dr. Florence Comite @ComiteMD @mcuban Comparing results to so-called normal range is not ideal. Preferable to use own data. @JCVenter @2healthguru #PrecisionMedicine

Ryan Lucas @dz45tr I’d just assumed he had invested in @theranos. lol. @2healthguru @ddiamond @mcuban @charlesornstein

Michael Tomasson @MTomasson @fqure @2healthguru @mcuban @ethanjweiss @johnpharmd My take: https://michaeltomasson.wordpress.com/2015/04/02/mark-cuban-understands-the-future-of-health-care/

Gary Wolf @agaricus @2healthguru @lsmarr @mcuban @charlesornstein Don’t think of these tests as entries in a lookup table, but as a basis for learning.

Perhaps the tweet that best framed and unfortunately may prevail in the ‘take-away’ narrative associated with Mark Cuban’s foray into health, healthcare and unwittingly so health-economics was posted by patient advocate and e-health expert Sherry Reynolds aka @cascadia:

Disconnect in medical testing thread @charlesornstein + et al are giving facts @mcuban is building a brand – guess who will win?

While I completely disagree with Mark Cuban and attribute his presumptive perhaps ‘intuitive ‘insights’ to the privileged perch he occupies (I doubt he concerns himself with the cost, systemic impact or health consequences of his recommendations, let alone co-payments, deductibles or co-insurance of his health plan), his argument may align with the broader movement into ‘digital health’ and patient empowerment as most recently expressed by Eric Topol, MD‘s new book ‘The Patient Will See You Now’ which aligns with the likely future of medicine or ‘Medicine 2.0’ – if you will. In this vision clinical medicine is ‘informed by’ genomics and manifests the promise of ‘precision medicine’ to better understand and thus target the fundamental mechanisms of underlying disease pathology and thus prevention.

My net take away from this exchange is reflected below:

Gregg Masters @2healthguru Well if nothing else @mcuban has sure stimulated debate on the value prop of ‘medicine 2.0’. This one via @RogueRad http://bit.ly/1GafTL8

Meanwhile at The Healthcare Blog Radiologist Saurabh Jha MD further opines in ‘Radiologists vs. Mark Cuban on Don’t Ask / Don’t Tell’ an itemized series of responses to additional queries posed by Mark Cuban.

So back to the ‘bold vision’ or BIG ego’ question: some of this ‘brashness’ may be attributed to what I’ll call the ‘Dallas Effect’ where everything is BIG especially mega-churches, football stadiums, ‘non-profit hospital systems’ and heck even the egos’ of their principal cheerleaders?

Only time will tell who’s on the right side of this narrative. Meanwhile, Mark thank you for your willingness to engage in an important conversation via this democratized medium known as twitter!