The Voice of Healthcare - Episode 7
Co-hosts: Dr. Matt Cybulsky (Principal, Ionia) and Bradley Metrock (CEO, Score Publishing)
Guest: Dr. Jim Rickards, Senior Medical Director for Population Health & Delivery System Collaboration at Moda Health.
Duration: 33 minutes, 44 seconds
Google Play Music
YouTube (+ closed captioning)
Bradley Metrock: [00:00:13] Hi, and welcome back to the Voice of Healthcare for November 2017. Episode 7. My name is Bradley Metrock. I'm CEO of a company called Score Publishing based here in Nashville, Tennessee. My co-host on The Voice of Healthcare is Dr. Matt Cybulsky. Matt, say hello.
Matt Cybulsky: [00:00:33] Hey everybody. Glad to be back, Bradley.
Bradley Metrock: [00:00:36] Matt, it's great to be back with you. It's always a pleasure. We've got a great, very interesting guest today, Dr. Jim Rickards. Jim, say hello.
Dr. Jim Rickards: [00:00:47] Hi. Thanks for having me. It's great to be here.
Bradley Metrock: [00:00:49] Yeah, thank you for joining us. It's very interesting stuff you're doing and work you're doing. But I want to lead with a plug for your book which I really, really like. It's called Our Health Plan: Community Governed Healthcare That Works. It's on Amazon. It was released just a few months ago. We're going to include a link in the show notes to the book, as well as on VoiceFirst FM, so people can check that out. Jim, let's just start off. Tell us a little bit about the book.
Dr. Jim Rickards: [00:01:19] Yes. I'm a radiologist by training, meaning I'm a physician who interprets medical imaging studies. About six to seven years in my career, I was becoming frustrated because I was getting to know my patients too well, and I think you might be taken aback at first and go, "Wait a minute. You're a doctor. Aren't you supposed to know your patients well?" And I'd say, "Well yeah, if you're a family practice doctor, maybe a pediatrician, then you should know everything there is to know about your patients." But as a radiologist, the way I practice medicine is with high cost imaging exams, and I actually expose people to radiation that can increase risk of cancer down the line. So I was frustrated because I lived in this small community in Oregon. And we had a number of so-called "frequent flyers" and that's somewhat of a pejorative term we use in the medical industry. But these were folks that would come in every week with big complaints in the emergency department, and we'd do the full work-up, and oftentimes that resulted in a CT scan or some other high cost imaging study.
Dr. Jim Rickards: And what I realized is that even though I was doing everything correctly, interpreting the imaging exams, and my colleagues in the emergency department were doing everything right on their end, so much of our health is not determined by the medical care we received. Only about 10 percent of our health is determined by medical care. The majority is determined by other things like our behaviors, our socioeconomic status, our access to transportation. These are all areas that I didn't have any influence or ability to impact. And so if I really wanted to improve the health of individuals or the health of the population of my community, I needed to find a way to get out there and help impact those other determinants of health. And the traditional medical model is not set up to allow us to do that. Well, in the state of Oregon, we were changing that about five years ago, developing community governed health care plans called CCOs, or coordinated care organizations for the Medicaid population. I helped start one of these organizations.
Dr. Jim Rickards: [00:03:10] And basically, what these organizations do is they combine payment for not just medical care, but also behavioral health care, dental care, and other services, like non-emergency medical transportation, under one roof, under one umbrella, under one organization with a defined budget set of metrics that they have to meet. So I helped start one of these organizations, and basically the book is the story of how I helped create this organization and really the power of the organization, and its ability to help control costs but also improve access and increase quality of care for the Medicaid population. But these are things that could also be translated to commercial population Medicare as well.
Bradley Metrock: [00:03:48] Beautiful. Beautiful.
Matt Cybulsky: [00:03:49] Yeah, that's excellent.
Bradley Metrock: [00:03:49] So we're going to include a link to the book on Amazon, as I mentioned, in the show notes, as well as in the description information on VoiceFirst.FM for the show. And talking about coordinated care models and how you're working to influence behavior and things of that nature, you're broadening the scope of a traditional health care effort. There's a whole lot of intersection with that, in my mind, with voice technology. When I say voice technology, of course I'm referring to some of the mainstream technologies like Amazon's Alexa, Google Home, Apple Siri, those voice assistants that are being created by the big players, but also the countless efforts of many smaller companies. I was on vacation last week, and I was trying out this personal trainer that's AI-based called Vi from this company that will be at The Alexa Conference next month. Shameless plug, by the way, The Alexa conference is coming up next month in Chattanooga. AlexaConference.com. But the equipment like that to other voice technology that's maybe B2B or hospital-to-hospital or health organization-to-health organization. And my question for you is, just in general, do you share the optimism that that I have and many others have, Dr. Cybulsky has, on what voice technology and voice-first technology can bring to health care? Or are you a little bit more skeptical?
Dr. Jim Rickards: [00:05:23] Well, I think in general, I'd say I'm very optimistic that technology in general can help advance healthcare, improve quality, decrease cost. With the coordinated care model that I was involved in, the governance structure that was was crucial to advancing healthcare improvement at the local level, because our governance structure allowed for not just physicians and hospitals and the traditional medical side of the healthcare house to be involved in developing the vision, but also folks from the public health department, from the behavioral health sector, from dental care organizations. And so we're able to bring all these different sectors of health care together to help them develop a vision and a set of priorities for how we want to improve health at the local level. But I think a lot of our efforts really did look to technology to help us advance healthcare.
Dr. Jim Rickards: [00:06:21] One of the things that we did for instance, or one of the challenges we identified was the fact that for our 25,000 members, we did not have a local dermatologist. Our members had to drive over an hour, maybe an hour and half sometimes to see a dermatologist for specialty skin care. So we identified this, and what we did was we leveraged technology. I've been practicing teleradiology my whole career. Basically that means that I pull up a picture, the picture happens to be a C.T. scan or an X-ray, and I apply my knowledge and skill as a physician to interpret that image and turn it into words in the form of a radiology report. Well, the practice of dermatology, diagnosing and treating skin conditions is very similar. Most of the time, dermatologists can just look at a skin condition and they know what it is. They don't need to do a physical exam. They need minimal in terms of the clinical history. So what we did was we identified dermatology access to the problem.
Dr. Jim Rickards: We saw that teledermatology was a growing field, so we went out and contracted with the national tele dermatology provider named Dermeo. We placed them in our network, and then we purchased iPads, and put those into 15 of our primary care clinics. So now if a Medicaid member went to a primary care clinic, instead of having to travel that hour and a half to see the dermatologist, the primary care clinic could simply pick up the iPad, log into the Dermeo secure website, take a picture, send it off to the teledermatologist, and within 24 hours, a diagnosis and treatment plan will be sent back. We opened up some so-called "Q codes" to allow for the primary care providers to build a little bit of work they were doing on their end to help facilitate the console and then also negotiated a reduced rate for the dermatologist services less than what we'd pay if they were receiving the patients in a brick and mortar setting. So the point there is that we were able to come together as a community, use our governance structure to identify a problem, identify a solution, and implement it. Unless the CCO was there, we would never have had this teledermatology solution in the Yamhill County where we started the CCO. And so I think that community governed health care could look to other technology solutions, such as the voice when you're speaking to help solve some other issues around access.
Matt Cybulsky: [00:08:30] Excellent. The other question that I think comes to mind for me when you look at these CCOs is another topic that I believe is really near and dear to you, especially regarding some of your work described in your book. But when we have high levels of folks that are receiving Medicaid, and are chronic-condition patients, technology like voice languages hypothetically are a very useful tool to keep them connected, engaged, and offer them access they couldn't normally get. With that work with the CCO and Medicaid patients, there are also some thoughts about challenges regarding sophistication of the patient as well as compliance, like understanding how to take care of various parts of their illnesses without that one-on-one human emotional interaction. What thoughts come to mind that were successful in that CCO with Medicaid patients that you think might translate well with someone who's at the home, utilizing a tool with voice language and AI, for example?
Dr. Jim Rickards: [00:09:34] You know, early on in the CCO, one area of opportunity we identified to improve upon was the level of patient activation that our members have. Patient activation is this notion that individuals have the knowledge, skill, and ability to manage their own health care issues. Those could be acute issues, or they could be chronic issues. And it turns out you can actually objectively score someone's level of patient activation. It's the so-called PAM score, Patient Activation Measure. Out here in Oregon, a researcher at Oregon Health Sciences University, Judith Hibbard, has done a lot of work around this. And essentially what's come out of the work is a simple one through four scoring system for the patient activation levels.
Dr. Jim Rickards: So basically, if you're a four, you're highly activated, you know you have a disease, you know how to manage it, you probably know more about it and how to better manage it then your provider. But if you're a one on the score, then you might not know you have a disease. You might not know, for instance, you have diabetes, and then you certainly don't know how to test your blood glucose level, you don't know the most effective medications, you don't know about exercise and diet. And so in the CCO, we saw that there was this kind of spectrum of sophistication among our members when it came to managing their own conditions, a spectrum of activation. And the research has shown that the higher level of activation you have, the better health outcomes you have, and the lower cost you incur. So as a community governed health care plan, it was really our goal to try to get all of our members as highly activated as possible.
Dr. Jim Rickards: So we purchased a screening tool through a company out here in Portland, and we embedded the screening tool and a team of community health workers that we employed. And when these community health workers would engage a member for a variety of reasons, maybe it was because they had a chronic health condition, or maybe they had a large number of visits to the emergency department. They would conduct one of these PAM assessments, or Patient Activation Measurement assessments, grade them, or score them on that 1 to 4 scale. And then they were able to use a set of coaching tools to help improve their level of activation, to basically train them to become more activated. And when I think about voice technology, I think that our solution was to use the community health workers to perform the assessment and do the coaching. I think that is probably an opportunity for voice technology, like you're describing, to do that work, or even supplement what those community health workers are, to help educate members to encourage them, to coach them, and to activate them so that they can have better health. So I think that might be an opportunity for voice technology.
Matt Cybulsky: [00:12:18] Yeah, that's one of the first things that comes to mind when I hear you mention this PAM score, about being 1 to 4, is shifting those lower activation patients to a little bit more active folks. Now some of the work that we've been putting together at IONIA involve using behavioral influence and persuasion to move patients through a scale similarly to that, that gets them engaged. Some of that even includes comparing them and connecting them into other patients with a similar disease. But when you look at the technologies like this, and you look at a CCO model that you're proposing, does cutting the costs end up being something that takes away from quality of care? And does technology like voice language tend to make up for that loss of of quality if there really is any?
Dr. Jim Rickards: [00:13:10] So to back up a little bit, one of the main reasons why we developed this coordinated care model and these CCOs here in Oregon was because our Medicaid budget, which is unsustainable, about six years ago we had a 1.9 billion with a B, budget shortfall in our Medicaid budget. And typically, when states go to try to fix shortfalls like this, they employ a combination of three strategies in the Medicaid space. One, they'll decrease provider reimbursement. Well, that doesn't usually work in the long run, because that just decreases access to care, and people whine about getting the preventative services they need, or if they have chronic conditions, those are unmanaged, and when they do come to care, it's more expensive. The second strategy is to decrease the number of individuals eligible for Medicaid benefits. Well, that wasn't going to work in Oregon, because we were actually going to be an expansion state. And we were going to go from 600,000 Medicaid lives to over a million.
Dr. Jim Rickards: And then the third and final strategy that is typically employed is to decrease the number types of benefits and services are covered. So certain surgeries might not be paid for anymore, or certain diagnostic tests. Well, we were already pretty limited in what we covered here in Oregon, and to shorten our list of covered services anymore wasn't going to be reasonable and might actually wind up harming more people than it was helping. And we probably weren't going to get approval to shorten that list of services from the federal government. So our decision was to create this fourth path of creating these coordinated care models, these community governed health care plans, these CCOs, where we combined all the payments for health care services under one roof and had them be a community government. When the CCOs came together, when they went out and started contracting with providers, they didn't try to employ any of those three traditional strategies to save costs. They were of the mindset that they wanted to improve care, and that improvement in care would then result in cost savings, and then those cost savings could be put back into the system to support transformational programs to support better quality care.
Dr. Jim Rickards: And so what I'm getting to is, one of the big thrusts of the CCO model is to encourage all of our primary care clinics to become recognized medical homes or certified patient center primary care home. These are basically primary care clinics on steroids. So we now have in our state more than 90 percent of all of our Medicaid members enrolled in a recognized medical home. We've done some research and seen that individuals enrolled in a recognized medical home, under our Oregon certification process called the PCPCH, or Patient-Centered Primary Care Home program, that they incur a 13 to 1 ROI, meaning for every dollar spent on primary care in one of our recognized medical homes, there's 13 dollars in savings elsewhere in the system. So savings from decreased hospitalizations, decreased surgeries, decreased radiology, utilization etc. And so really, our focus for cost savings has been to really improve the quality of care not to decrease the reimbursement rate. And so to your question around voice technology, I think the question is how can voice technology be incorporated into either self-management by members, or facilitating provider members, or patient communications resulting in cost savings and how big health care systems or CCO type models pay for and support the use that voice care technology has been shown to improve quality which then results in decreased costs.
Matt Cybulsky: [00:16:41] Right. That's a good point. I think that something else comes to mind as far as being able to understand these breakthroughs in primary care which would be....what are some of the breakthroughs that you get with a little bit more of a local government coordinated care plan for Medicaid patients? Are there some are there some notable breakthroughs that you thought to yourself, "Now we're cooking with gas here. We've made some real changes to how these people are engaging with their own care or how we're engaging with them."
Dr. Jim Rickards: [00:17:14] Yes. And I think that one of the big breakthroughs is, if you look at communities there is a lot of health care going on. But it's not all medical and this gets to my point earlier, that only 10 percent of our health is impacted by the medical care received the rest of it is you know our social circumstances, what public health does. And our big breakthrough was figuring out how we connect the medical community, or the primary care community even, with other resources in the community in a meaningful way. And I'll give you an example of one where we did that.
Dr. Jim Rickards: We had a local fire department that had some paramedics and ambulances that had some extra bandwidth and also had a bit of a gap in their in their budget. So they were able to do more work and they were looking for an additional revenue source. Well, when we looked at where our costs were and where our utilization was with the Medicaid population, a lot of it was around....our Medicaid members didn't have access to transportation. They would call 911. They would go to the emergency department for pretty routine things that they could have seen a primary care provider for. So we had these paramedics. We had these ambulances which were going out regularly. Medicaid members were utilizing the emergency departments. And instead of having this reactive care model where the paramedics would just go out when they got an 911 call, what we did then was to create instead a proactive model of so-called para-medicine program. What we did was we paid the paramedics to go out to members' homes who had a certain number of emergency department visits. We set the threshold at six visits per year. So if you had six or more emergency department visits per year, we would send out the paramedics in a non-emergent fashion to meet with you in your home to do things like a safety check, to make sure you're living in a safe, stable, secure environment, that your environment's not contributing to your emergency department use, to do medication reconciliation, to look around your house to find all those scattered pill bottles from the multiple emergency department visits, or multiple hospitalizations that have never been organized and help you put those in one place, and figure out when you need to take those, to do things like lab draws.
Dr. Jim Rickards: So maybe you have a chronic condition. You need your hemoglobin A1c checked to manage your diabetes long term. So they will go out and do that. So we now have this para-medicine program where we proactively go out, work where they're high utilizers, and those paramedics have then become a bridge or a conduit between the member and the primary care clinic, because oftentimes, the primary care clinics are not set up to go to people's homes, but if they need help with the medication reconciliation, if they need help with a health risk assessment, they could leverage those paramedics to go out there in the community, who already has the relationship with these high utilizers to do that work. So your question was about a breakthrough, I think it was that type of breakthrough. How do we connect these different resources in the community? They're delivering health care. They're not all medical. But how do we combine them, and pay for them, and then capitalize on what they have to offer, and then generate better health outcomes, and that's what we do with that para-medicine program.
Bradley Metrock: [00:20:32] There's a number of companies that are looking at the health care space and this intersection with voice technology and voice-first computing. Approaching it from the standpoint of improving mental health, as opposed to physical health, so many people just don't have someone that they can have a conversation with, much less anything else down the line. So they they get hurt and no one knows and they decide....they get discouraged and don't want to take their medicine. There's no one there to encourage them. There's a lot of thought right now that these voice assistants can help alleviate this problem to some degree. My question for you is in the coordinated care model that you have gotten some experience with....there's no doubt that had a positive impact on the mental health of so many of these folks. Share with me what you saw with that and just the importance of that.
Dr. Jim Rickards: [00:21:35] A big focus of the CCO is not just to coordinate the management of financial risk or the budget associated with paying for medical, behavioral, and dental care services. So to manage that and pay for it and aggregate it, but also to make sure that not just the payment is integrated and managed, but the delivery is actually integrated and managed. So at the CCO level, when it comes to so-called physical behavioral help integration, one of the first things that we did along with another number of other issues was to actually physically integrate behavioral health services with physical or medical health services in the primary care setting. So basically what that means is the CCO used some of its revenue to actually support the hiring of behaviorists, so these are Sign-D Level or doctor-level psychologists. We would pay for their hiring and placement within primary care clinics. And so the behaviors thing could work side by side in a single location with the primary care docs. So if somebody did come in with a behavioral health issue and the primary care doc wasn't comfortable managing or didn't have the experience managing.
Dr. Jim Rickards: Or maybe the primary care provider identified a behavioral health issue. There was a behaviorist there in the clinic and a so-called warm handoff could be made or during that same physical health visit, the behaviorist was available, then they could see that member and deliver some behavioral health services and the value of that then is that all the information around this patient's health is at one place. It's all occurring in one physical location. But then, more importantly, when the EMR is used for documenting what they have, it's all in the single EMR. And so some examples of how this plays out is, say someone comes in for a cough. Because the CCOs are focused on this behavioral health physical integration, one of the metrics that this tracks is the performance of a so-called "esper" exam which is a screening and brief intervention and referral for treatment. It's essentially a drug and alcohol screening questionnaire.
Dr. Jim Rickards: So someone came in for a cough, or if you came in for any medical issue you were also asked to complete this esper exam and assess your risk for substance abuse. If you screen positive, because you were in a clinic while you were there to see a medical doctor, and because there is a behavioral health provider there, after you were done seeing the medical doctor, the physician, they could have you immediately see the behavioral health provider to do a further assessment to evaluate your risk for substance abuse. And then they could start to build a relationship with you. And they were better equipped to help you connect with community resources or even provide you with ongoing counseling. Then the physician is equipped for seeing you for the cough. So because the physical health and behavioral health care was integrated at the clinic level, those types of handoffs could occur and better care what happened as a result.
Matt Cybulsky: [00:24:52] Yeah. So as a psychologist I totally agree that connecting those two services is paramount to having a successful healthy community. We talk a lot in the United States about mental health parity. But to your point earlier, where 10 percent of your health care is the clinical work and the medicines that you take and the examinations that are made. Largely, emotional health and mental wellbeing is ongoing, and having a psychologist on hand to work with the patient and the provider and a warm hand-off, as you described it, is excellent insight on y'all's part, so hats off to you for that. Your model, in the context of the opioid epidemic, for example, might be really useful for others to hear about how you might handle addiction, how you might handle patients that are either at risk for an opiate addiction or who are actively fighting one. Was there any work done during this development and then maybe afterwards that you could share with our audience and with us about how you might have handled addictions, specifically opiate addiction, with this particular model. I'm working with a few health systems that are struggling with this, but I'm really curious to know what your hands-on experience have been with this epidemic and maybe any breakthroughs or any insights that you've had with this model that might be useful for others to hear.
Dr. Jim Rickards: [00:26:13] Yeah, thanks. We did quite a bit of work around opioids and the opiod epidemic at both the local CCO level, and now we're doing more at the state level. So when I first started with the CCO, we really wanted to work with our provider community, to have them give us some insight into what they thought some of the problems were regarding delivering access to effective health care, and then what the bigger health issues were. And so one thing that our local providers, local physicians, and other providers wanted us to do was to look at the medications that were being prescribed to Medicaid members. And the idea initially was that perhaps there wasn't as much generic drug utilization as there could be.
Dr. Jim Rickards: So we worked with our third party administrator. We pulled all this data on medication, prescribing amounts and costs, etc. And I remember before actually reviewing the report, I was thinking that I was going to see this report and I was going to see a lot of medications prescribed for depression, for diabetes, for high blood pressure, for COPD. Some of the more chronic conditions that are oftentimes associated with the Medicaid population. And I was thinking out that's what the report would show, and then I was thinking that I would you know see a lot of opportunities where we could use more generic drugs for treating depression or high blood pressure, etc. Well, to my total surprise, when this report came back, it turns out that our top 10 prescription drugs by number of prescriptions written and also volume dispensed, were all opioids. And I was just blown away. The reality was that we had a lot of chronic pain.
Matt Cybulsky: [00:27:54] That's really unbelievable. That's unbelievable. Gosh.
Dr. Jim Rickards: [00:27:57] And so we were really taken aback. And this was something that we shared back with the provider community, and it turns out the problem with medications isn't that there's not enough generics being written. The problem is too many opioids are being prescribed and it seems like that's maybe the only thing being prescribed. And so we need to do something about this, because it's a particular problem for the Medicaid population.
Matt Cybulsky: [00:28:18] Yeah, we had an interesting conversation at Ariadne Labs last week, which is Atul Gawande's lab in Boston and Cambridge, and there was an epidemiologist at a presentation on the opioid epidemic. He basically stood up and said that this isn't a problem in West Europe. This isn't a problem in Japan. It's a problem in the United States. He pressed the physician making the presentation and said, "Listen, it sounds like the medical community of the United States or the Pope was just here." Now if you were giving that presentation, how would you respond to him?
Dr. Jim Rickards: [00:28:53] Well I would say that oftentimes physicians aren't left with a lot of options to help treat people, and they're not given the team based support they need, and the data they need to help effectively manage individuals or populations, and that's what we saw in Yamhill County. So really, the reason why our top 10 medications are opioids is because quite frankly, there weren't other options available to treat chronic pain for the Medicaid members. Physical therapy, occupational therapy, chiropractic therapy, acupuncture, cognitive behavioral therapy, nutrition, these were not covered services that were available to the Medicaid population when we had such high prescribing rates of opioids, so in light of that, what else is a primary care doctor going to do when someone comes back continually with chronic low back pain. And they don't have options for treatment available to them other than opioids. So I think that the benefit structure in large part was creating this issue with the providers. They just weren't left with any other tools. That's since changed.
Dr. Jim Rickards: Now all those other services I just described are available to treat these chronic back pains. But with that, so what we also did in the CCO that I helped with was we gave the providers another tool to help manage their members. We created what was called a persistent pain program. So because we identified this community wide program, we started this ten week program that Medicaid members with chronic pain, and whether or not they're using opioids or not, could be referred to. And the program really had three components. One was an educational component where we educated individuals about what chronic pain was, what can trigger it, and how they could self-manage it. Two, it had a behavioral health component, where some counseling was provided to individuals, to help them understand you know the personal level, what might be causing their pain, does it perhaps not have a physical etiology, is it maybe a result of PTSD or depression? And three, there was a movement component to the program, where individuals were taught Tai Chi and yoga and other methodologies to help self-manage their pain. So we were able to develop this this program, this tool for providers to refer members to that had persistent pain. So instead of reaching for the prescription pad, the providers can reach for a referral sheet and send them the persistent pain program.
Dr. Jim Rickards: But then with that, we also were able to provide the physicians and clinics with data. We were able to show them, "OK. Here's your list of members who are on opioids, and here are the doses." And then we also develop a set of community prescribing guidelines with an upper level threshold of what is the appropriate maximum amount of opioids that should be prescribed to individuals. So there's this concept of MEDs, or morphine equivalent doses, where you can essentially look at any type of opioid, and set it to a standardized threshold, and convert the MED to that standard number. And we set an MED level of 120 initially. It's since come down. We were able to share with providers data showing, "Okay. Here are your Meprozine opioids. Here's who's above 120 MED." And then we also developed a group to help assist members, develop taper plans, and identify other resources in the community that the members could be referred to to help manage their chronic pain. So basically you know we created a number of tools other than just opioids that were there to help providers and help individuals manage their chronic pain. And I think without that, we're not going to make a lot of headway with the opioid epidemic, but we're seeing these types of tools be developed across the nation and society.
Matt Cybulsky: [00:32:40] I totally agree with you that it's going to take some introspection and some synthesis of multiple modalities to really heal us from this epidemic, and I'm glad to hear that you've made some progress there.
Bradley Metrock: [00:32:52] The book is called Our Health Plan: Community Governed Healthcare That Works. There will be a link in the show notes as well as on the web. Jim, thank you very very much for your time today. Dr. Cybulsky, thank you for your time as well.
Matt Cybulsky: [00:33:05] It's great to be here. And Jim, it was fantastic conversing with you. Thanks for your really comprehensive answers.
Dr. Jim Rickards: [00:33:10] Yeah. Great speaking with you. Thanks.
Bradley Metrock: [00:33:12] For the Voice of Healthcare. Thank you for listening. And until next time.