Across the three days of THMA’s 2025 Spring CSO Forum, top strategy leaders from 15 leading health systems shared practical knowledge and debated how to respond to issues facing their organizations. Here are three insights from the forum.
Highlight #1: The CSO’s role as their organization’s truthteller
Cleveland Clinic’s CSO Jim Cotelingam led a presentation on the changing role of the CSO within health systems and across different industries. Cotelingam discussed the multitude of roles CEOs are expected to play in their organization: jack-of-all-trades, internal influencer, medium-term planner, multitasker, and trusted advisor, among others. Here are some key themes that attendees discussed:
Objectivity: Several participants agreed that CSOs need to be an “alternate source of reality” capable of breaking up groupthink in the C-suite.
One strategy leader for a leading academic system discussed his role as a “contrarian” willing to point out where clinical efforts are falling short despite the system’s top reputation.
Other attendees discussed the importance of strong internal data analysis capabilities to help guide operational leaders’ decision-making. To cultivate these skills, strategy teams need access to the right data and tools, internal competence with data interpretation, and the right mindset to translate data-driven insight into strategic decision making.
Small teams: One participant argued that the strategy team’s small size and budget (relative to other divisions within the organization) makes them a more objective leader because they’re less concerned with preserving the status quo.
On the other hand, smaller team sizes can make it harder to justify salaries and senior job titles reserved for managers that oversee larger teams of direct reports. One CSO lamented that “all of the rockstars on my team took a pay cut to join.”
Other attendees discussed working out exceptions with their HR departments or CEOs so that internal titles match the level of responsibility assigned to strategy teams.
Time management: A common lament is that playing the role of a multitasking “Swiss army knife” divides attention, leaving them with inadequate time for the kind of longer-term strategic thinking that they see as their core responsibility.
Attendees discussed ways to “make time” for this kind of planning. A CSO for a health system in the Midwest discussed his habit of taking a three-hour walk with his CEO every Sunday to discuss big picture issues.
CSOs also discussed how new generative AI tools could act as a force multiplier for strategy teams. After a short demo of ChatGPT, one participant argued that AI tools are capable of “the level of work you’d get from someone one year out of grad school”—possibly helpful for routine work, but not at a level where it will be replacing junior analysts altogether.
So What?
CSOs were struck by how different their roles can be in terms of team structure and core responsibilities. Despite this, attendees were able to find common ground when discussing how they drive value, especially with their role as a “truthteller.” By focusing on their shared challenges—internal relationships, recruitment, time constraints—attendees exchanged practical advice that felt applicable despite differences in their roles and organizations.
Highlight #2: Learning how to say ‘no’
Indiana University Health CSO Nicole Paulk led a session on strategic tradeoffs, using her system’s decision to sell its health plan to Anthem as an example. The system invested in its own health plan to drive population health capabilities, gain intelligence into the payer side of the business, and hedge against potential shifts in the market. While owning a plan accomplished many of these goals, system leaders had to reevaluate their initial assumptions about the market’s appetite for value-based care.
Attendees used the example as a jumping off point to discuss the importance of saying “no” in decision-making. A major theme was the importance of capital constraints: while a health system strategist might have ten or more worthwhile initiatives to invest in, they might only have enough capital for one or two of those ideas. Several CSOs described their internal process for competitively pitting these ideas against each other to decide which projects merited spending scarce resources. There was broad agreement that it’s harder to stop doing something than it is to start.
“Who wants to be the Chief Divestiture Officer? The grim reaper.” – CSO for a health system in the Northeast
CSOs also discussed the state of value-based and managed care more broadly. While there were a few success stories, most participants discussed a desire to slow walk VBC efforts or pivot away from them, given the financial challenges involved and a lack of interest from some payers.
So What?
Without internal discipline, health systems risk overextending their resources and losing focus on their core mission. By learning how to say “no,” strategy leaders can keep their organization tethered to reality and focus investment in areas where health systems will get the “biggest bang for their buck.” This is especially important as health systems face new cost pressures and policy risks that threaten to undo much of the financial progress they’ve made since the COVID pandemic.
Highlight #3: Differing perspectives on combined ED/urgent cares
During a session moderated by The Health Management Academy’s VP of Industry Insights Robin Brand, CSOs discussed asset-lite approaches to growth strategy that minimize the risks of financial exposure, debating the relative merits of hybrid/digitally enabled care, JVs and partnerships as an alternative to M&A, and facility expansion with combined ED/urgent care locations.
ED/urgent care combos sparked some of the most interesting conversation. Several of the systems represented in the room had already piloted or established their own combination facilities, but results were mixed. Several CSOs said they loved the model and had already implemented it with success, with backing from both payers and local regulators. However, another CSO for a major system in the Northeast said they faced hurdles with state CON laws and said that payers were unenthusiastic because of the vast gulf between ED and urgent care rates.
Several participants discussed partnerships with Intuitive Health—a major operator of these hybrid facilities—with divided opinions.
Some attendees described largely positive experiences with Intuitive.
A CSO said that Intuitive was mostly interested in locating facilities in areas with a high commercial payer mix, rather than the underserved areas where they wanted to build out more ED capacity.
Another CSO mentioned that their ED docs were uncomfortable at first with the combo model due to quality and reimbursement concerns, but they were eventually won over after taking tours of the new facility.
One strategy leader relayed an experience from a colleague who ran their own freestanding EDs in competition with Intuitive. Overall, they felt that their own in-house effort outperformed Intuitive’s competing facility.
“If you can’t manage a freestanding ED correctly, partner with someone. Otherwise, do it yourself.” – CSO for a health system in the Northeast
So What?
In a period of relative economic uncertainty, health systems are looking to grow while limiting their financial risk. With these considerations in mind, many systems are leaning more heavily on partnerships and JVs rather than their own in-house efforts.
The discussion around Intuitive Health highlights both the promise and perils of such partnerships: while some systems are highly satisfied with the arrangement and appreciate the ability to jumpstart growth by leaning on an experienced partner, others were disappointed with the execution and felt like they could do better on their own. Ultimately, each system needs to evaluate partnerships based on their needs, an honest assessment of their core competencies, and their willingness to invest resources.