Medical Management

I'm your general contractor and host Mike Krupa. I lead our analytics here at Connorand Gallagher.last episode we started interviewing subcontractors specifically on thepharmacy benefit side along with me today isis Deval president of all International MedicalI'm excited for today's webinar becausewe're gonna we're gonna show you that the Right medical management partneris a key structural componentof a remodeled Health Plan.you know a lot of times when you're remodeling it'sgonna it'sWhat happens down the line is about how you set itup in the first place and and by gettingthe right Care at the right time and right place and Healthcare.You can really avoid a lot of problems.Down the road as well. Just one quickhousekeeping item. If you do have any questions,please ask them throughout the meeting eitherin the chat box and the question box. I'll I'll bemonitoring that.I might have done some questions, but this is your webinarwant to make sure you get the most out of.So, please feel free to ask those questions.Before we dig into medical management justa reminder on whyyou might have attended the webinar today, and I'm goingto do a quick refresh of remodel health.You know, you might be an HR or CFO or a CEObut chances are you know right now you're startingto look at at your health plan and it might looklike the one on on the left and that was that wasmy bathroom a couple years ago. Things were fallingapart had a lot of leaks going on in thatshower you see there.um and not a lot of functional space for me ormy wife and as I started taking thingsapart, I I started to understand howhow to make it better and how I wanted to makeit better andthat picture on the right isis the final product and you know,we we both love it and and that's that's kind of the point.You know, you're you're Health Plan can can looklike that too at the end of the day after after youremodeled this and I think right nowthat's that's really important becauseyou can you can use your health plan as aas a tool, you know, we're in a market right now where it's it'stough to find talent to attract talent toretain it.And a lot of talks about a recession rightaround the corner and a health plan can really be agood tool to start to.Get in front of that.and a couple of things I you know want to continue tostress throughout this series isLook first you can you hear me talk about education? Yougot to understand why the things aren't working theway that you want in your health plan.The solutions will start to make sense when you startto understand why and second youcould do a lot of remodeling on your health.but at the end of the day youGotta love it. There's going to be bumps inthe road, but you got to level your health.plan lastlyYou don't have to do it all at once.By the end of the series some of you may want togo all in some of you may want to do one room at atime. Some of you may just defer altogether and wait,but regardless of how fast you go.My Hope Is that the seriesgives you the confidence that you can do itJust a quick reminder on on how this works remodelhealth.First Step you got you got to get control your healthplan and that starts with a funding mechanism and selffunding you got to be self-funded to do this.That's when you can get the second partof control, which is starting to control the different.Partners that are in the healthplan and how do we align those partners ofappropriately?Key rule, there is make surethat the partners that you align with have your best interestsin mind and your employees and patients rightbest interests in mind.In third is you know, we talked about everybody's gotta lovethis your your members have to love it too. So yougotta figure out a way to reward them for fordoing the right things.You do that you're well on your way for success.But none of this comes without education.Education is a key component of this webinar. It's a key componentas we start to roll out remodeled.You got to buy in across the board HR and thec-suite need to need to be talking together. Yougot to understand why thisThis is this is necessary and all Buy intogether. And then you know change management starts tokick in you got to get employees to buy into thistype of change. It will make it more successful downthe road and that canhappen in various different ways and at theend of the day if you do these things.It is this is what you can expect. I'mnot going to promise this. There's not going to be bumps in the roadthere. There will be bumps in the road as you go through this, but atthe end of the day, you're gonna have happier employees, you'regonna lower their costs. Hopefully get them betterquality of care. You're going to see lower costs inthe long run andBut ultimately againWe want you to have the confidence that that youfeel like you're on the right path, and that'swhat this process can bring you.We're gonna dig into medical management. I'm excitedabout the guests. We have today debits.It's a it's a pleasure having you heretoday. You know, we're all II got some questions for you, but I youknow as as we're interviewing subcontractors, oneof the things I I think it is important is isto understand the motivation of Industry leaders likeyourself, it helps explain some ofthe dysfunction and Healthcare. I love to startoff with just you know, brief introduction. We don't have tospend a ton of time here, but just you know, what? Why did whydid you get into this? And what drives youYeah, absolutely. So I was one of those peoplewho was born to be in medicine. I wasI like to say I was born to be a nurse is the only thing I everwanted to be and you can certainly read the entire longsorted story. It's out therebeen interviewed a couple of times specifically about thewhy or you can just buy me a bottle of wineat the next industry event. Now bore you with my longstory of why but I have one of thoseEpiphany moments when a manager saidto me, do you know how much money thisHospital would have lost had we transferred that patient andshe was referring to a patient that weshould never have accepted and admitted toour facility and that patient ultimatelydied.And that was the point where Iwas like best is not why I became anurse. This is all about money.Healthcare is a business. It's not really Healthcareand I became very disenfranchisedand went intoa pretty deep depression as a result of that experience and fortunatelymy husband kind of brought meback to my senses and forced me to apply for some jobs thatI could get as a nurse away from the bedside and that'show I'm wound up and managed care. I thoughtgoing into those that Managed Carewas evil. It was all their fall they were the ones whowere refusing to pay reasonable amounts of money for care, butI had to have a job. We were two income householdwith small child. So so Iyou know, it was willing to do a brief stent Onthe Dark Side came to find out that that'snot really an accurate picture. Um,and was fortunate enough.Up with other nurses who were practicing a patientadvocacy model.My background after nursing is in business. SoI have my MBA and with aminor in math and statistics the beautiful thingthat I realized and what has kept mein healthcare on the Managed CareCare Management, or as I call it Medical CareManagement or medical utilization managementside is really the fact thatyou save a ton of money inthe US Health Care system.by taking the best possible care ofpatientsAnd so it's this beautiful dichotomy that youdon't usually find when you're purchasing other things, right? Ifyou're buying bathroom faucets, you thinkhey the more money I spend the better the faucet. IfI really want the creme de La Creme. I'mgonna have to spend, you know, three four hundred seven hundred bucks,right if I get the $70 one at Menards,the quality is not going to be so great. The exactopposite is true and Healthcare in America and that'shard to get people to wrap their head around but ifyou get the right patient into the rightcare meaning the best care for them evidence-based medicineand you get them to the right place withthe right providers meaning the doctors who graduatedwith an A+ not the doctors who graduated with a DminusThe right price in a fee for service systembecomes the natural consequence. Soif we could all just refocus our effortson getting individual people thosepeople who are sick of those employees andtheir dependents that are using the employersponsored health plan if we can take really reallyreally good care of them.They will be cheaper by natural happenstance.That was you know, I'm a numbers guy. I started offmy career as an actuary. That was probablythe most surprising thing to me.It took me a while to get my armsaround with the fact that quality and costwere were inversely related, but it didit started to make.More sense when you start to see some ofthese look for lack of a better term these perverse incentivesthat are baked in.baked in hereso it it's just you know, it's it's totallyit totally interesting and then you know,I think the other part was what I didn't realize isYou know, somebody goes in they get a knee surgery. Theyhave a complication. Maybe they have to go getsomething redone.They have to pay for that again. The employer is paying forthat. The patient is paying for that again. It's just it's likethat would not work in any other industry. I don'tget it. I don't understand it. But there's there's waysaround that andand I love it.So, okay. Let's let'sThey're right. There is where you can be wrong andstill get paid meteorology and Medicine.I didn't I didn't think of the other industry. But yeah, you got thatone right there.Well, I want to talk about a little bitof the state of the US Healthcare System. You know,when I I think about remodeling a homeor even just like a specific room. There's there'sthings you don't want to touch there's thingsthat are not negotiable. I think like structural issues,right, butLet's think about the US Healthcare. You know your opinion hereis is there anything anything that's workinganything? That should just we should just leave it alone.UmYes, but those things are pretty fewand far between so direct PrimaryCare Done Right is a great thingin the US Healthcare System. Unfortunately, they'renot a ton of people who are doing it, right.But when you have a good direct primary care physicianworking Hands-On with patients, itmakes a huge difference in both quality of life. Ithink we will eventually have enoughcase studies of good direct Primary Care toprove actuarily that it's that itis making a significant impact. I've seencase studies. We just haven't gotten to enough volumeyet and enough longitude forthose to be statistically valid, but my guttells me that that's a goodthing to do. Even if all it does is break even the Improvementand quality of care is phenomenal.Um, other than that, it's prettychallenging. I mean most of the bedside practitionersthe Physicians the nurses the respiratorytherapists the pts the X-ray techs.I mean they're all doingEverything that they can possibly do given theconstraints and the volume and and what they'reup against I don't think that most ofthe challenges lie there. Although I would liketo see for example, the AMA Embrace evidence-basedmedicine and clinical care Pathways. They've beenpretty resistant to that. I'd liketo see medical schools make some changes and howthey train Physicians and to incorporatemore and space clinical criteria intothat butYou know, let's face it everything else in theUS Healthcare System is pretty doggone brokenmoney motivates and healthsystems are businesses and healthcareadministration is a business.I'd like to see a lotof that go away the fact that 74% ofdoctors in the United States are now owned by hospitals andHealth Systems. They are not independent their employees.I mean, we finally got rid ofpharmacist gag orders, right? When are wegoing to get rid of physician gag orders? Because when you're an employeeof a hospital or health system andyou know that the Independent Imaging Center acrossthe street costs one tenth ofwhat the hospitals Imaging Center cost.And you have a gag order that says no no, you have tosend all referrals back to the Mothership.That's that's a major problem and understand whydoctors do it, right? They got to see onepatient every six minutes to make ends meet their own practice. Theydid not go to medical school to get a businessdegree. They don't want to be business people. They don't wantto be leading office staff and managing thatwhole process and they come out $250,000 indebt.Right. So I mean if we want to start for giving student loans, howabout we start doing some sortof a program in the United States where if somebody gets ascore on the MCAT of X orabove?They can go to school for free to become aphysician.Right that would make medical schools open up and acceptmore students. We have a major shortage of Physicians andnurses in the United States.That would solve a lot of problems. So I mean, it's justthere's so many things broken inthe system that no oneperson. No one entity is going to be able to solveit. But an individual patientarmed with the right information the rightresources the right support the right guidance canget through the system and have a really goodclinical outcome. That doesn't cost theman arm and a legyeah, and I the underlying tone ofwhat I'm hearing from you is is incentivesright? Like you start to change the incentivestructure across the book like isn't thattrue that everybody human behavior? Right? It's alldriven by incentives whether we like it or not. It's it'swhat's guiding our decisions every daylike that. That's what's wrong with health care. We canchange some of those things that you're talking about today. I'm I'm withyou that that's where that's where I start tosee a difference coming in and that's what I startedto realize when when I started to get educated, youknow through this journey. I'm on is that when youfollow the incentive structure? Okay, Iget why this is happening the waythat it is.So so let's take them, youknow.You walk into a fixer-upper, right? We buy afixer upper.You're gonna gut the whole thing. Everything's got to go Plumbing Electroelectrical you're moving some walls.So we talked about that incentive structure.Glad to hear you talk about direct primary care. That'swe're going to talk about that again as well.Like if you're if you're tackling this from from the groundup, you gotta you got a blank slate. Youknow, what's what's on what time your list other thanyou know direct Primary Care.I would say resources, right soyou've got to give the individual person whois sick and using the healthcare system andusing the benefit resources. You got to givethem support. You've got to give them guidance. It's gotto be objective. One ofthe biggest challenges with Health Care is thatit is such an emotional issue.Right. So how many here are terrified ofthe prospect of hearing the word cancer?Everybody right? And so what is the numberone most price gouge medical treatment inthe United States?Cancer treatment right they buy a chemotherapydrug. They mark it up 2,000 percent. They sendthe bill into the insurance company. I'm sorry,but there is no PPO discount on the planet thatis going to get that cost down to afair and reasonable amount 60% off a 2000%markup is not doing anybody any favors andit happens because of theemotion that's involved in that diagnosis.And so unless you havean objective.Unbiased unemotioned personwho can come alongside thepatient and I love technology. Don'tget me wrong. I get it you could geton an app and see how much is this going to cost in someinstances? You can even now begin to see physician andfacility quality scores that are objective on an appBut most of your claims are being driven by people overthe age of 40 who are not real inclined to turn toan app 20 years from now, you better have an app because you know,the folks that are going to be falling apart then that's theirpreferred motor communication, but it's still ahuman business right Health Care is still a humanevent. So you have to have somebody tocome alongside that patient who isnot emotionally invested who's notfinancially motivated or rewarded right?It's one of the reasons. I have a real problemwith medical management firms that take a percentof savings. Are you guiding that patient to that particular surgeonand that particular Ambulatory Surgery Centerbecause it's cheaper or because it's better.Right because you can have a great direct contract with a real dogof a provider.That's not where I want to send in patients to so.Making sure that all those motives and incentives arealigned and our focused onwhat's in the patient's best interest because if youtake good care of the patient, the plans bestinterest automatically are taking care of it's likeRichard Branson says if you want to take careof your customers take care of your employees because they will take careof your customers, right? Same thing in healthcare. Ifyou want to have a good Healthcare experiencefor your employees got togive them the resources and the support to do that. Andwhen they have a good Healthcare experience, then your costwill automatically come down.Soone of the most interesting things to me as I talked todifferent employers and you know, even throughthe education process have talked to you know members, rightand because hey look the employer themself. They're they'rea member they're utilized their patients are utilizing thehealthcare system. And you said the word emotion, right?itit the Fear Factor it just itplays into this.so much, you know you a lotof times you hear about people picking in the doctor becauseyou know, their friend's mother's brother had a reallya really good experience, you know youYou and your team at aim have have different toolsto help people pick rightthe right the right Partners, butyou know, we're not we're not telling people that thisis what you have to do. Right? So youget this emotional response in the background. Like how doyou functionally and how does youryour team functionally?Get people to try to change their behavior get overthat emotion. Like what's the skin in the game for them?I will tell you there's a couple different ways todo that the way that I train my new nursesis actually based onsome of this Sam sha guidelines formental health addiction.Right, so we talk about ifthis person we're an alcoholic and we're making bad choices.You could point out all ofthe logical things.That they need to do to have better outcomesand have a better life. But until they'rewilling to accept the help. You can't reallyforce it on them. Now. I dohave some plans that are moving to strict playor pay right? So ifyou don't follow the nurses advice it's not coveredby your plan.Those are not really prevalent andthey're usually reserved for companies that are on thebrink of bankruptcy who are going to say listen. We'reonly going to pay for this and ifyou want to color outside of the lines you do it onyour own dime.Most plans are doing an incentive. Somaybe a group's been on a high deductiblehealth plan. We used to think that thosewere the answer right until we realized wait aminute. We're trying to make consumers out of people who don'thave a consumer reports of healthcare to rely on that's kindof the role that my nurses see us fillingwhen we're interacting with patient. We're theconsumer reports a healthcare here are you know,five top notch, you know, Whirlpool GE LG.Do you want to get into the youknow, no name brand Etc. Same kindof thing from Healthcare is just putting outthere the objective quality data and havinga conversation with the patient understanding thattheir emotional but us not gettingemotionally invested in that right? I getpaid a flat peem whether they do what we say orwe don't it makes no difference to me. They're notmy employee. It's not my money. No.Not my sibling my parents. I'm just hereto give them the information resources tools support themthrough that and it's amazing thetimes that people are highly emotional whenwe're having that conversation and thenwhen they've had time to kind of sit down and think about itand review the data, they're much lessemotional or they make the better decision in the end. Butultimately healthcare's personal,right? What's right for me may not be right for you and viceversa. We have all kinds of social determinants ofHealth. We have cultural and religious considerations, right?Please don't tell the Seventh Day Adventist thatthey need to stem cell transplant.That would be just horribly disrespectful, right sohaving that kind of Rapport andrelationship and human interaction and dialogue andjust saying here's the information.The plan and it's structure can incentivize them.So if you're on a high deductible Health Plan mightconsider putting them into a system whereif they call the nurse and they follow the nurses guidanceand advice and recommendations their copay intheir deductible or waived.We've had groups that have been doing that six seven eight years. Alot of those groups are now zero premium zerocopay zero deductible. Sothey're doing free health care for all oftheir employees don't have any that are doing dependents andfamilies for free yet. They all have a little bit ofPremium attached to dependents and families, but evendependence and families in those plants if theycall the nurse first and follow the nurses guidance, no copay,no deductible. So the only thing that you're payingfor your family is your premiumNow there's a challenge there, you know,you talked about those bumps in the road. They haveto call right? They have to engage with the nurse. Theyhave to follow the nurses recommendation and advice ifthey don't or they don't like the advicethen it's subject to their deductible and their co-pay justlike their health insurance has always worked but at leastwe've given them the information they still have free will to makethat decision. Right but we'reincentivizing them financially togo to the highest quality providers toget the best care humanly possible. Andso that works very very well. Whenyou look at the validation Institute study ofour Pei performance on our book of business. You canhave a standard PPO planthat's only costing youabout four thousand dollars per employee per year inclaims.That's pretty amazing given that the national average issomewhere between 13 and 18,000 depending on whichsource you look at. Right? So but it'sdisruptive. The patient has toengage they have to be involved. They haveto accept the responsibility for theirdecision and that's not always popular andit's not always convenient right? Ican't tell you the number of times. We have a patientthat I personally spoke to yesterday. She hasbeen given 19 different OBGYNrecommendations byus all of them with a97 out of 100 or higher quality score.And she is upset because the doctorwho is across the street from her office is notone of the recommended Physicians it isso convenient to go to him. His qualityscore is 17 out of a hundredshe wants to go to him for free andwe said you can go to him subject toyour co-paying deductible because his wallet qualityscore is 17 out of 100. If you'rewilling to go to the doctor who is literallyat the end of the block instead ofacross the street.It will be free and she is throwing a hissyfit because the one she wants isn't freeand she doesn't care what the qualityscores are. She's not willing to look at that objectively. Soyou will have some of that.Yeah, you know in our in our firstepisode when we we got intoyou know, how we got here.We talked about the PPO Network.This this concept that youknow, it's called preferred right preferred provider organization.I always tell everybody like how preferred would you feel if95 out of every hundred were were in your peergroup? I don't I don't think thatpreferred but it is like totally perpetuated this problemthatpeople just they I think as Americanswe don't like to be told what to do people want to go wherever they wantto go do whatever they want to do in this PPO has really perpetuatedthis problem because literally everybody isis in the network in these big fourmajor carriers and you have this unlimitedChoice which feels like a great thing, but it's it'snot when you couple it withYou know, I don't have the tools as a consumer totry to make the the right decisions. It'sjust this this quandary, butyou know, that's what we're trying to educate and and break the moldup. But yeah at the end of the day, you know employers that arethat are on the phone here, you gottaShe got to understand is people.people are gonna be told some some different things now, but thisisit's it's in their best interest, but it doesn'tmean that it's not going to be painless as weas we go through this process, soYou know interesting perspective think ofit this way.We've all been there. We're in the grocery store andwe're Wheeling down the ice cream aisle andcoming toward us are the parents with the toddler in the cart. Right andthe toddlers screaming. I want ice cream. Iwant ice cream. I want ice cream. They're really twokinds of parents and in that scenario.The ones who lean over and whisper in the ear of thetoddler. I love you too much to give you the ice cream. If nothad dinner. I don't want you to grow up to be an obesediabetic. No ice cream. If you're gonna throw atemper tantrum, that's fine. I can live througha temper tantrum. I don't care how much noise you makeI love you too much to let you make that bad decision.Or the other kind of parent who opens upthe ice cream cabinet gets out. The popsicle hands itto the kid and says, please sit down and be quiet. You're embarrassingme.Which kind of parent as an employer do youwant to be when it comes to the life anddeath of your employees? Because whenyou really start to examine this and I will tell you since Isaid life and death if you've not seen life and deathdecisions in the c-suite, you need to get a copy ofit because people don't realize 30% ofHealth Care is fraud waste and abuse.It's unnecessary. It's inappropriate. It does harmright I talk in here about a CTscan and everybody has that personin their Circle. They're convinced their fifthgraders gonna go to the NBA right and whenlittle Johnny or little little Jill twist her ankleon the basketball court, they want two things the localpro sports teams position in a CTscan, right? That's what their mind goes to wellthe local pro team sports physician isnot the best doctor, right? He dealswith adults not with kids who have growth PL.All kinds of other issues. So that's a bad choiceand oh, by the way that CT scancontains the same amount of radiation as hundredsof plain film x-rays, youknow, there's a reason we wear a LED vest coverup the important parts when we're in the X-ray room, right? Sobut does anybody tellthe parent that there was actually a surveydone around CTC that's where they went to doctors andthey said how often you order aCT and do you explain to the patient the risk associatedwith theAnd the doctor said 20% of the time.They went to the production.Who had been ordered those CT scans and said did yourdoctor explain any of the risk associated withCT scans? Do you know how many said? Yes.two percentSo the doctors think they're explaining the risk 20%of the time which is abysmal right should bea hundred percent of the time but the patients thinkthey got that the risk information onlytwo person at the time.But that's what everybody goes into enough. And if you don't give thema resource to go, whoa time howLet's think let's take a breath. Let's back off ofthe emotion for just a minute.And let's talk about the facts and the risk andif you want to do that, you can certainly do that.rightBut especially going into this recession ontop of the great resignation.I think the only employers thatare going to be able to recruit and retain good employeesare the ones that offer spectacular benefits.Can you afford to offer spectacular benefitsthrough the existing carrier system?You're probably barely affording itright now.So if you don't do something to improve the benefitsand lower the cost.And you know, it's going to be disruptive. Ithas to be right if you're gonna switchfrom Yellow Taxi to Uber there's disruption.You're going to offer free healthcare. There'sa price.The member has to be engaged. They have to maybe travela little bit further. There may be convenience challenges.But if you truly love them and want what's best forthem, they'll send them to the A+ physiciannot the D minus physician.alright, so are you seeing employers thathaveyou know figured this out that that are doing allof these different components andI'm sure theyrun into bumps in the road is wellis does it change over time as as people aspeople get more used to it asas members are going through this experience. Butyou know for the employers on the phone is there hope outthere that at the end of the day, you know, you get to a place whereyou feel like you're offering a great benefit.Yeah, their employers all over the country. I'mhundreds just in my book of business hundredsthat are taking other approaches and using a differentmedical management vendor, but yes, absolutely. Itis doable and has been for quite awhile. You know, everything is on a bell curve,right? We're definitely on the uptick ofthe bell curve the early adopters that have been doing this five sixseven eight years. They're all inthey would never fathom doing Healthcareany differently than what they're doing. Itell groups. Listen if there isnot a line out the door of HR the first threemonths that you're doing this there's a problem you're notactually doing it because it is so differentthat everybody's gonna have questions. Who arethese people? What do these quality score means? Why doI have to make a phone call? Why did they tell my doctor thatI had to call in and they wouldn't give my doctor the authorization.No, I mean there's a whole, you knowanLength list of questions that people are goingto be asking those first few months by aboutmonth six. The noise issettled down. Everybody's adjusted. They're all going to Top Notchpractice practitioners.And that's when you really start to see.Oh my God, people are healthier when you'rehealthier faster. Yeah file for your claimsis a natural consequence. They're more productive. They're morepresent. I mean, it's a world ofdifference, right? You start a good vicious circle.But there is disruption in that beginning point ofsaying no. No, we love you toomuch to let you get mediocre or bador injurious Healthcare.So yeah, maybe maybe a good place toStart thinking about from an employer's perspective to them.You know, you mentioned some.Some per employee for your costs.I I would agree with the national averages, you know,I I've seenSome of my worst performing clients that havedone nothing I've seen in this high as$20,000 per employee per year.Probably more so average inbetween that 12 and 15,000 range.What what's the low end in high?End of what you see on your your best performing clients andyour worst performing clients?So it depends depends on how quickly somebodywants to make a difference. So when I'm talking witha new client, I kind of ask them for key questions.Watch your Pei now.What do you want it to be how quickly do youneed to get there? How much noise are you willingto endure in the process? And then I always askthe c-suite leadership.When it's you or your family member, areyou going to embrace this or areyou going to want to be treated differently than what your employeesare being treated. So when your wife's OBGYNis not a top notchdoctor.And she throws a fit because his qualityscores too low so she can't gethis care for free.Are you going to be like well, honey? We can changeyour OBGYN or we can pay your deductible. Areyou going to be like, I'm the owner of the company. Iwant this doctor paid at a hundred percent because if you don'tsee the value in it for you and your family,then you should not do it for your employees. Ifyou're only doing this to cut coststhen nobody wants to work with you.I'm just gonna be blunt about it. Right because ifit's if it's not something that you believewholeheartedly is better for you andyour own family.Your employees are going to see that they're gonna feel that they're gonna pick upon it. And this is no longer a reward. It's nowa penalty they're forced to do this to controlcosts so that you can make more money. Several of our colleagues in the industry ask thec-suite when they embark onthese kinds of plans to make a commitment of whatthey're going to do with the money that they save andhow they're going to return that backto the workforce. So we have boughtnew fire trucks. We have equipped policedepartments with all new vests. We have gotten the maintenance Bay of auto dealerships to have HVAC in them. Right no more sweating in the summer and freezing winter. I mean, we've had employers that take their entire company and their spouses to Vail for a long weekend company Retreat just to get everybody away and de-stressed and relaxed and team build. We've built walking paths around campuses. We have groups that cover massage and water aerobics. Tell me any health plan on the planet that covers water aerobics for their members, right? What's important to you and your organization, what do your employees want that you can't afford to give them? If I take your spend from $13,000 to let's let's say you don't you're not ready to go all in let's say take it down to 6,000. Right? So I'm just say do what Seven Grandpepy. Are you willing to put 3500 of that into something that's going to benefit your employees make that commitment going in because what will happen is there are all these pesky federal laws around self funding. If you just let the money roll over year over year over year eventually you're gonna get to the position that you can't contribute anymore. You've got the maximum claim Reserve in your erisa trust fund. And so you have to either start spending it out or you have to stop contributing. You don't want to stop contributing because they're major tax advantages to contribute you want to spend it out. So start covering massage and acupuncture and you know, all those things that are going to get your people healthier faster that are going to be good benefits. I love that right you gotta you gotta love your health plan at the end of the day and that may Mean that you're making the health plan better through incentives. It may mean that you're taking some of the savings and putting into something else. That's away you can make employees and employers love their health plan is to give back in other way with that savings. You know, we're we're getting close here on time. And as I as I talk about Who's gonna be here next? You know, we we did get a question early on I want to I want to address it now because it's probably a good time todo it you and then we'll open it up for for questions, you know, you mentioned direct primary care and there are ones that are doing it the right way and some that are not doing it the right way. What what do you think makes a good? Direct primary care practice. That's our next episode that we're going to talk about. But what do you think makes a good practice? Well, number one, I would say the guess that you're having is probably one of the top if not the top DPC in the country. So good selection on the guests there good just like you started the conversations with me kind of examining. What are your motives?You need to look at the dpc's motives because I've seen dpcs who've gone into DBC because they have rightfully been kicked out by the insurance carrier now. I don't know how bad you have to be for an insurance carrier to say we're kicking you out of our PPO Network. I'm thinking it's pretty bad. Right so examine their motives as well. The other thing I will tell you is that it's really difficult because a lot of dpcs want to be the end all be all everything to their patient and I understand the motivation in doing that. But if they don't have the right tools and resources that they're disposal they're going to make some really serious mistakes. So when I talk to a new DPC that a groups using one of the questions that I ask them is, okay, I'd like the list of each of the specialist that you refer to your neurologist. Geologist pulmonologist gastroenterologist orthopedist, you know, give me the give me the list. I know you have your favorites, who are they and I go through that list and I look at the objective quality scores of those Specialists and I would say most of the time I've never had any doctor any DPC doctor give me their list and it be100% everybody on there is top quality. Typically somewhere between 30 and70 percent of the Specialists that they picked as their favorites have really low quality scores. Like I'm talking less than 70 out of a hundred right 70is a sea grade. I want my patients going people that are in the 90s the higher in the 90sthe better but I'm definitely don't want them going lower than the 90s right, but we get lower than 70 and I'm talking like no no no no, no. They don't really have the tools and resources that they're disposal. They're they're deciding who they're going to refer to based on other things right based on patient feedback Yelp Angie's List Google reviews kind of stuff. That's not cool. I also would caution you to examine what their dual ownership are. So we had a deep he was telling everybody go to this particular Imaging Center and we looked at the Imaging Center good quality Independent Imaging Center not owned by a hospital or health system. But when the claims came through we're like it's not that much cheaper than going to the hospital because usually Independent Imaging is about 25% of the cost of a hospital. Imaging right? I mean, it's drastically cheaper. And so we call the Imaging Center and start to examine their charge master and their response was yeah, but it's cheaper than going to the hospital. But it's not on par with other Independent Imaging and so we start you know, I'm getting frustrated trying to work with the billing manager and the office manager. So I start to look at who's the ownership and guess who I find in the ownership the DPC DotYeah, little self. No why? That's why aligning aligning with the right Partners is is key and understanding every single way people are paid really starts to drive drive that home. Well, yeah question I would tell you is ask them when a patient needs a procedure or service that is not included in their subscription fee. What do you do? How do you do it? Because if they're not sending those off to a firm like ours where that members being guided to highest quality lowest cost care. If they're you know doing it willy nilly or with their own devices. That to me is a major in.