April 16, 2021: The patient experience changed dramatically during COVID. Workflows had to adjust and change as part of that. We asked Kevin Manemann, Chief Executive Southern California at Providence, what expectations do patients now have? What are the most impactful steps you can take to meet those expectations? What home care technologies are emerging as critical? Can we sustain telehealth? Has the covered lives business grown for Providence? What does a CIN look like in Southern California? What are the technologies, the communication platforms and the data that you need to bring together? How do you move seamlessly from multiple EMR platforms to just one? What is the complexity of delivering on bundled payments and what are some of the strategies to approach that? Plus learn more about Providence St. Joseph Health’s “Own It” program and how it has impacted the organization.
A Discussion with Kevin Manemann from Providence on Tech in Healthcare
Episode 391: Transcript – April 16, 2021
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[00:00:00] Bill Russell: [00:00:00] Thanks for joining us on This Week in Health IT influence. My name is Bill Russell, former healthcare CIO for 16 hospital system and creator of This Week in Health IT, a channel dedicated to keeping health IT staff current and engaged.
[00:00:17] You’re in for a real treat today. Kevin Manemann joins us. He’s the Chief Executive for the Southern California markets for Providence. And actually he’s not even in that role yet. He is starting that role in March. His current role is the EVP Chief Cxecutive [00:00:30] for the physician enterprises for all the Providence markets.
[00:00:33] And I’m excited to share this conversation because when I became a CIO, Kevin was an executive at the organization I was at and he helped me to really learn the business of healthcare. Kevin has extensive knowledge. He’s a technologist at heart. And I’m really looking forward to sharing this conversation with you.
[00:00:49]Special thanks to our influence show sponsors Sirius Healthcare and Health Lyrics for choosing to invest in our mission to develop the next generation of health IT leaders. If you want to be a part of our mission, you can become a [00:01:00] show sponsor as well. The first step is to send an email to [email protected]
[00:01:05] Just a quick note, before we get to our show, we launched a new podcast Today in Health IT. We look at one story every weekday morning and we break it down from a health IT perspective. You can subscribe wherever you listen to podcasts. Apple, Google, Spotify, Stitcher, Overcast. You name it, we’re out there. You can also go to todayinhealthit.com. And now onto today’s show.
[00:01:28] Today we are joined [00:01:30] by Kevin Manemann, Chief Executive of Southern California for Providence. Good morning, Kevin. Welcome to the show.
[00:01:36]Kevin Manemann: [00:01:36] Good morning Bill. Good to see you.
[00:01:38] Bill Russell: [00:01:38] You know Kevin I’m looking forward to this conversation and I do have to give you some kudos. When I became CIO at St. Joe’s we worked together and I knew I knew so little about healthcare. It’s almost scary how little I knew. And you were fantastic. You came alongside of me. You explained how healthcare worked as [00:02:00] much as you possibly could.
[00:02:00] I remember my favorite story is, I don’t know if you remember this but I asked you how to physicians get paid. And I thought, you know, this is a what, a five minute conversation. And you said, all right, set some time for Friday afternoon. And we sat down and two hours later you had filled the whiteboard with the different mechanisms and ways that physicians get paid.
[00:02:21] And I’m not even sure we finished that conversation in those two hours. It was, it was, it was kind of fun.
[00:02:26] Kevin Manemann: [00:02:26] Yeah. It’s a complicated business from that standpoint. Isn’t it? Yeah.
[00:02:30]Bill Russell: [00:02:30] [00:02:30] Yeah. It was just, it was kind of fun. So to get us started, tell us a little bit about, about your role at Providence and what kind of work that you’re overseeing right now.
[00:02:40] Kevin Manemann: [00:02:40] Yeah. So I’ve been with Providence for about 17 years and I’ve worked in a couple of different roles. Recently. I’ve worked with all the medical groups across the system. We have about 10,000 providers in our organized medical groups. And so I spent several years. Working in Washington you know, Alaska California [00:03:00] Texas, et cetera, but well more recently I’m going to be running the Southern California market which is really all the hospitals, medical groups ambulatory footprint that we have in the LA and orange County markets and really trying to bring all those pieces together and really make a big difference in the way that we serve our communities and really change the way that we’re delivering healthcare.
[00:03:23] I’m pretty, pretty excited about it.
[00:03:25] Bill Russell: [00:03:25] So you, so you’ve moved into a new role now. Yeah.
[00:03:28] Kevin Manemann: [00:03:28] Yeah. So [00:03:30] the new role officially starts March 1st, but like, you know, whenever you get transferred into another role it starts immediately, even though it’s going to be starting in March. Right, right.
[00:03:40] Bill Russell: [00:03:40] So you know, over physician practices, that’s you know, that’s one of the areas that was impacted pretty dramatically early on in the in the pandemic.
[00:03:50] Give us a little window into the work you guys were doing in say the spring of 2020 to as this was ramping up and elective surgeries were coming down. What kind [00:04:00] of things were you guys doing in the physician practice side?
[00:04:03] Kevin Manemann: [00:04:03] Yeah. I mean, I like a lot of other organizations, we were trying to pivot pretty quickly and figure out how to continue to serve our patients.
[00:04:10] And we, you know, I’m sure you’ve talked about this on the show, but we, you know, overnight really within like a two week period, we had 8,000 providers set up on telehealth and seeing patients you know, through telehealth, through Zoom and connected into our Epic platform. And then of course the, the hard work [00:04:30] was just logistically trying to figure out how to get the right PPE available.
[00:04:34] We were putting, we were standing up tents and flu clinics and trying to direct patients into those specifically that had illness like symptoms. It was just a big logistics sort of nightmare for the first several months. Once we got the PPE components figured out. And we were able to get the right structures in place for our clinics and kind of direct patients to the right place in the [00:05:00] tele-health components.
[00:05:01] Then it was really about how do we safely get people back into surgeries and, you know, back into procedures that needed to be performed and not delay care as much as we could. So that was the
[00:05:13]Bill Russell: [00:05:13] Yeah. You, you just put a whole bunch of 80 hour work weeks into a, into a couple sentences, which is pretty amazing.
[00:05:21] The, the when you, when you talk about telehealth you know, I mean, a couple of things sort of come to mind. Did you end up with [00:05:30] different solutions based on market or different approaches based on market or was it you know, you just rolled one thing out system wide?
[00:05:36] Kevin Manemann: [00:05:36] Yeah we actually ended up rolling one thing out system wide.
[00:05:39] So we ended up really rolling out Zoom. Now what we did do is there were a couple of different solutions that we use to complete the kind of check-in process and filling out the forms and all that kind of stuff. We used a couple of different solutions for that which the consumers or the patients were pretty excited about because they could schedule their stuff.
[00:05:58] They could fill out all their [00:06:00] paperwork. We had all that stuff that could be done you know, prior to the visit which obviously is going to carry over into, you know, people coming back into the office and all that, that is w we were able to quickly set up Is going to sustain itself and people will be able to fill out you remember the no clipboard strategy we had for years.
[00:06:21] I mean, the clipboards are officially, probably gone now. And people stop holding onto to that, which has been great. That’s been the greatest thing about this whole [00:06:30] pandemic, because there’s just been a significant breakthrough in how care can be delivered and the explosion of. Of telehealth and video visits are accepted and people are pretty comfortable with it.
[00:06:41] Bill Russell: [00:06:41] Yeah. The no clipboard program goes back to what, like 20 … 2012 2013.
[00:06:48] Kevin Manemann: [00:06:48] Oh my god. Probably further back. Right. I mean, it was just, I feel like we take a run at this, like every five years. We’re like, can we get rid of these clipboards? Why are we filling out a form? I mean, you’re a patient you’re sitting there going, okay, how many times do I have to give [00:07:00] you my social security number?
[00:07:01] I filled out the paperwork like 500 times now. And so we just need to be done with that. I mean, it’s just sort of a ridiculous process that we’ve put people through. And it just really makes our industry ancient. So that’s been a little bit of a blessing from this pandemic, cause it’s just forced that like there’s just, there was just no more fighting it’s just over.
[00:07:21] Bill Russell: [00:07:21] Yeah, no, that’s fantastic. You know, back when we worked together, I remember in the Southern California market we had a fair number of covered lives through a partnership, [00:07:30] I think with Blue Shield at the time. And, and I, I just finished going through the JP Morgan conference. We, I listened through the the nonprofit track.
[00:07:40] And number of covered lives. The amount of covered lives was one of those things that mitigated the financial impact and really gave those systems a leg up in terms of how they were able to go back into the market and do things for the community. Has that business [00:08:00] grown for Providence?
[00:08:03] Kevin Manemann: [00:08:03] Yes. So we it’s a little bit, so it’s a tale of two stories, I guess, in a way we have about 500,000 covered lives in Southern California, between LA and orange County. And there’s a whole mix of how those are put together on a capitation basis. But it certainly saved us significantly in 2020 from the standpoint of.
[00:08:27] You know, we did really financially really well, even though we [00:08:30] were still able to reach out to those patients and provide you know, services. The amount of volume that we had coming through was obviously slowed down a little bit. And so that helped us financially. Now, what will be interesting as we get into the first quarter of this year I think it’s going to be the opposite. I think we’re going to have. You know, a fair number of high claims, just because the number of commercial patients and Medicare patients in Southern California you know, are, are struggling. You know, our numbers are pretty high right now in this market.
[00:08:59] So I think it’s [00:09:00] going to be a flip side of it, but what it, what it has done is. Because we have a portfolio that’s pretty balanced from a contract standpoint, we can sort of handle these ebbs and flows. And, you know, if the risk business sorted helped us be successful in 2020, and then in 2021, we have enough fee for service business.
[00:09:19] That’ll help offset some of the performance on the risk business. That might be down a little bit.
[00:09:25] Bill Russell: [00:09:25] Yeah, this, these are the conversations I miss having with you. You were, you used to sit and sit [00:09:30] in my office and explain these things. And it was, it was like I got a master’s degree in just really understanding how that the business healthcare ran.
[00:09:39] But let’s talk about this a little bit, just a little bit further, which is are there special tools from a technology standpoint or skills from a staff standpoint that you need to run that that managed, managed lives business.
[00:09:55] Kevin Manemann: [00:09:55] Yeah, without a doubt. I mean, so it’s really all about, well there’s a couple of things that come in.
[00:10:00] [00:10:00] Let’s just break down a few. A big part of it is really understanding and risk stratifying your population. So that’s a big thing. So data’s king. When you come into doing any sort of premium business premium pay business or capitation, or value-based care, whatever you want to call it. And the more that you understand your high-risk patients, and you can really wrap your arms around them quickly through different programs, if it’s high risk clinics, nurse navigation programs you know, really engaging pharmacists [00:10:30] in helping people manage their medications.
[00:10:33] I mean, the list goes on, but the data really drives the ability for you to wrap your arms. Usually about five to 10% of your population is where. You know, 80% of your spend comes from. So if you can get your arms around that population and sort of, you know, help keep them from going to the ed, embracing more you know hospital at home programs or just [00:11:00] giving them places to go where they don’t have to go to the emergency room.
[00:11:03] You know, if they’re having something that’s going on with them is a big thing of how you can get in front of it. So data’s really, really crucial from that standpoint. And then the second thing I would say is, you know, utilization is super important when you’re looking at being in that type of business and what you want is you want things that need to happen and you want the care to be appropriate.
[00:11:30] [00:11:29] And this is the sort of the, I don’t know, it’s, it’s what a lot of healthcare systems need to figure out how to thread the needle here, where you have providers that are really providing the right care at the right place. And it has to be appropriate care. So you’re not overdoing testing or overdoing certain procedures, which, which we know from national numbers that about 20 to 30% of care that is provided is unnecessary.
[00:11:58] And so that’s the space, I [00:12:00] think, where you gotta use a lot of data to get your providers together, looking at their data. And starting to have conversations with one another and that’s been a big part of what we’ve done over the last probably seven or eight years.
[00:12:10] Bill Russell: [00:12:10] Kevin, I don’t know if people know this, but early on in your career, you were an IT guy, right?
[00:12:15] So you worked a little bit for All scripts. And so you have a, you have a technology background.
[00:12:20] Kevin Manemann: [00:12:20] Yes, sir. Spent a lot of time working with different groups across the country and wrote code. Actually know how to write SQL code, which nobody really knows, but I guess [00:12:30] they do know.
[00:12:31] Bill Russell: [00:12:31] No they still use SQL code for sure. And I’m sure I’m sure that BJ Moore’s going to be calling you up after he listens to this, asking you to help write some code. But I did want to go back and you know, cause when we first met you, you were really setting up the technology framework for the clinically integrated network in Southern California.
[00:12:52] And you know, let’s talk about some of that because I think the idiosyncrasies of California [00:13:00] make this especially difficult. But let’s start with this. What does a CIN look like in Southern California?
[00:13:09] Kevin Manemann: [00:13:09] Yeah. So a clinically integrated network or a structure that allows you to bring independent physicians and medical groups together to really contract on the managed care side or on the fee for service platform where you can, you know, take on some value based care contracts on the fee [00:13:30] for service framework is really with what we’re looking to do with the CIN. So the goal is to drive costs down, improve quality and really get to better health outcomes with the population you’re serving. And yeah it allows us to kind of bring all the pieces together, but not force a, you know, a specific model, like an employment model.
[00:13:50] Bill Russell: [00:13:50] Yeah. But in that case, you’re talking about a lot of disparate systems, a lot of different data elements, communication platforms, portals, and that kind of stuff. [00:14:00] So let’s just go, let’s start by going back in time.
[00:14:03] Right. So back back in the day, when you were really setting that stuff up what were the technologies, the communication platforms and the data that you had to bring together?
[00:14:14] Kevin Manemann: [00:14:14] Yeah, so probably the hardest thing is really, there’s so many different EMR’s that we’re out in the community. So all the physicians when you know the high-tech act was passed, there was a, there was just an explosion of EMR implementation.
[00:14:29] But many [00:14:30] independent physicians implemented, you know, whatever they chose to. So within Southern California, we probably had, you know, I’m probably not exaggerating. We probably had like six or 700 different EMR that were. in our communities
[00:14:43] Bill Russell: [00:14:43] And people might think you’re exaggerating but I remember getting the spreadsheet and it was practice fusion this version, and even Allscripts this version, this version, this version Metatech, Epic. It was, it was all over the board. It was [00:15:00] amazing how many EMRs there were.
[00:15:02] Kevin Manemann: [00:15:02] Yeah. Yeah. There’s so many, so many different. And to your point, it could be e-clinical works or it could be. You know practice fusion, but it’s what version it was. And then, you know, it’s so complicated it even more. And so we had to put in a health information exchange to really connect all of those systems together and drive it into a, a platform or a portal that we then hooked into our [00:15:30] main EMR, which for us was all scripts and Meditech.
[00:15:33] And then we’ll be moving to Epic. We’re kind of having that button available, where you could aggregate all that data together. And if you’re on a patient record, you can flip into that HIE and see more go onto to no view of what’s going on with that patient. And that was a very complicated thing to build, and it took us years to get that built up.
[00:15:53] And now we have a situation where we have, you know, thousands of physicians that have their data connected together [00:16:00] on that health information exchange. And we connect it into. You know, our main EMR is, as I said, and it it’s helped. It’s really helped us to begin to do real work that we need to do.
[00:16:10] So the first thing is getting the data connected, but the real work is really closing the gaps in care and identifying when patients are overdue for screenings or we need to do different quality programs. We’re able to do it even though people have different EMR is because we have it all in that HIE.
[00:16:28] So now it’s kind of building on top of that [00:16:30] is really been our focus the last couple of years.
[00:16:32] Bill Russell: [00:16:32] Yeah. So it’s experience it’s quality. It’s interesting. Cause when you talk about that, the simple thing like scheduling is, I say simple thing and you have to cringe when you, when you hear that. But I remember trying to, just to plow through that, cause on a portal that you’d come in and you put a portal and then you’d say, okay, we can do scheduling and you’d be like, [00:17:00] yeah, but we have to, we have to across a clinically integrated network, multiple EMR that’s that’s a, that’s a complex task.
[00:17:09] So how, was part of that technology and automation and part of that really some things, some people driven processes on the backend to make it a better experience for the user.
[00:17:23] Kevin Manemann: [00:17:23] Yeah. So ultimately you can kind of go through down two paths. If you wrote the API wrote into the [00:17:30] APIs, you could schedule into that particular provider’s EMR which is more complex and a little bit more expensive, but doable. And the other flow that you can put in places, there would be like an email that would go to that physician staff that said there was an appointment requested during this time. And then they would slide that in to their appointment scheduling system, or they would call the patient and coordinate a time.
[00:17:52] So it could be one of those two workflows. Ideally it would be more of a just, you know, write it into that particular software. [00:18:00] I think. No CMS does anything. They need to continue to push on the interoperability standards and really prevent EMR companies from charging so much to build integration in between them because it’s, it really does prevent better quality care and really driving the costs down.
[00:18:18] When you’re delivering care in a community, we just shouldn’t have to pay, you know, an enormous amount of money and it shouldn’t be this complex, that connect systems. So I just think that’s an area that. We’re really [00:18:30] need more more standards around and, and people you know, the EMR companies probably shouldn’t be able to charge as much.
[00:18:38] I know Simman SIEM has been looking at that.
[00:18:41] Bill Russell: [00:18:41] Well, you know, one of the things way back when you and I sitting across the table, it’s not that there wasn’t an abundance of tools to bring all this effort there. We had, we already had too many tools within our system, right. So we had Explorers. We had, we had just a ton of them. And [00:19:00] for us, it was sort of sitting back and going, all right, gosh, we’re doing this on the, on this side and this over here and this over here, we have an enterprise data warehouse, a bunch of data repositories, but you really have to sit back and think through what are we trying to drive?
[00:19:16] What are we trying to accomplish? And one of the things that, I mean, you guys really educated me on was this whole aspect of of interacting with the interacting with the patients, [00:19:30] those alerts that you were talking about, getting them in for their appointments, getting them in for their follow-ups and how challenging that was.
[00:19:37] But again the number of tools that were doing that back then, it felt like every time the doorbell rang, somebody was selling a different, different tool. I mean, how, how did, how did you go about, did you build it? Did you buy it or was it stringing different things together?
[00:19:53] Kevin Manemann: [00:19:53] Yeah, it was really stringing different things together.
[00:19:55] We, I mean, to your point, we had a lot of software. The challenge with the [00:20:00] CIN is getting that last mile connection in. So we have a lot of stuff on the health system side that we can lean on. We just needed to get all of those disparate systems connected in, I think what we’re finding today, and this shouldn’t surprise anybody, but where are we get the biggest uptake is we’re able to send text messages to these patients that say you’re overdue for a microphone, overdue for your immunizations. And they’re able to click right on their phone, on that link and take them to a scheduling platform. And we get a lot of [00:20:30] people that, you know, follow through on that.
[00:20:32] It’s very different than sending an email saying you need to get an appointment. People tend to follow up pretty quickly when you, when you send a text. So we’re seeing that technology work pretty well. And that can sit on top of. Your data warehouse or, you know, whatever your main system is. And if you have independent physicians, you still can include them in there.
[00:20:51] It’ll just send you know, the text message will go to the patient. The patient will click on the link. And like I said, on the back end, it’ll just send an [00:21:00] email to the staff but it still allows you to create a much, an experience that seemed seamless regardless if you’re with an independent physician or with a medical group physician. So we’re finding that to work pretty well.
[00:21:11] Bill Russell: [00:21:11] So, you know, one of the things about a clinically integrated network is the reports that go to the physician so that they can see how they’re doing and how effective they are. Is that coming out of the same system or is that a different system as well?
[00:21:25] Kevin Manemann: [00:21:25] Yeah it’s a combination of coming out of the HIE and then there’s [00:21:30] two systems that sit on top of it.
[00:21:31] Our main system is going to be Epic. So a lot of that exists in their healthy planet. But we have other solutions that we allow our independent physicians to connect and do to get their quality data reporting. And we push it to them through through a platform that we use that that kind of manages all of our quality data.
[00:21:53] Bill Russell: [00:21:53] Yeah. You know, and one of the things I remember, this was always a significant challenge was [00:22:00] to create the experience that it was every time you were going to a hospital, it was a Providence St. Joe’s hospital but then they were going to these again, these clinics and these various physicians. Will will this move to Epic? Will have you made a lot of progress and really making it feel like a seamless system, like every doctor you go to you’re in the same system and your data’s moving with you. Your experience is similar [00:22:30] across the entire network?
[00:22:32] Kevin Manemann: [00:22:32] You know, for the, for the physicians that have committed to connect to the HIE and we are able to we’re able to do some of the scheduling things that we’ve talked about.
[00:22:42] It does feel more seamless to the patient there but for the providers that haven’t connected into that HIE it probably still feels fragmented for them to be honest. I mean, there’s more work to do there. We are offering like most of the country, you know, we’re offering community connect to the independent physician.
[00:22:58] So those that are interested in [00:23:00] that we’ll sign up for that. I mean, I think ultimately over time, it’s going to turn into a situation where if you’re not connected to us from a technology standpoint it’s going to be harder to participate in these, in these new contracts that really ex have experienced expectations that have, you know, quality expectations that have total cost of care improvement expectations.
[00:23:24] If you’re not connected in to our systems, then we’re just not going to be able to allow you to participate in it because there’s just [00:23:30] too much room for error.
[00:23:32] Bill Russell: [00:23:32] Well, people are probably going to cringe at this but you know, back in the day it was I mean, we talked about hundreds of EMRs, but our inpatient and outpatient were different EMRs as well.
[00:23:44] You’re, you’re moving to Epic. It’ll be the same inpatient outpatient as we discussed. So will that change things and then you’ll have community connect? Well that chang things significantly from what I remember, five years ago.
[00:23:59] Kevin Manemann: [00:23:59] It’ll help [00:24:00] everybody that’s in the organized models. So if you’re in the medical group or obviously if you spend, you know, if you’re a hospital based physician and you spend all day in the hospital, that information will be much more real time and seamless.
[00:24:11] If you’re an independent physician and you have in your own system we’re still gonna have to lean on that HIE to be the way that we connect stuff in. So that will not go away unless you come up on community connect and then it will be part of the, it will be part of the Epic world then.
[00:24:27] Bill Russell: [00:24:27] Now you’ve thrown out HIE. Is this [00:24:30] a private HIE or is this a community HIE?
[00:24:33] Kevin Manemann: [00:24:33] It’s a private HIV. We do connect into public ones. S, but yeah, we have the same HIE that that when you were here that we had, yeah.
[00:24:45] Bill Russell: [00:24:45] Yeah, no, I, so there was the Southern California. Rio. And I forget the name of it now, but and that was, that was available. But the interesting thing to me is that one of the largest players in Southern California didn’t [00:25:00] participate. I’m not going to say which ones, but I think it’s pretty obvious if they know who the players are. And so that always limited the value of that, of that HIE. It’ll be interesting to see what happens with 21st century cures and, you know, the movement to you know, more open systems.
[00:25:18]Are you guys focused on 21st century cures? You think there’s some, some you know, what, what value do you think it’s going to create for your patients and providers?
[00:25:28] Kevin Manemann: [00:25:28] Yeah, I think it’s got a lot of potential. I mean, [00:25:30] if it’s as seamless as it’s as it’s proposed to be.
[00:25:34] I think we can, we can really simplify these different technology solutions being able to connect. So I’m hopeful that it will make it a lot easier because it’ll make the strategies that you’re trying to do in your markets a lot it’ll be more effective to get them off the ground. We are limited in a lot of our business strategies based upon.
[00:25:57] The text technology solutions being able to deliver. [00:26:00] And it’s less on the technology solution itself. As much as it’s on, we have so many different versions of the technology with all these different independent physicians that we can’t really put a good coordinated solution.
[00:26:10] Bill Russell: [00:26:10] Yeah. You were you, you were a technologist at heart when when we were working together and I remember you, the hospital at home and the care at home, you were constantly pushing the envelope on those things.
[00:26:24] I think you brought Livango in when Livango was like, I don’t know, a couple of months [00:26:30] old as a, as a, as a company
[00:26:32] Kevin Manemann: [00:26:32] Yeah. We just knew that if we could monitor the diabetic patients and when they had areas where they started to get concerned, if we could intervene in that moment, you know, more times than not, you could like figure out what to do without having them come into the emergency room. So it was just you know brilliant. I mean, Glen’s, Glen’s great. And it’s been a good partnership.
[00:26:55] Bill Russell: [00:26:55] Yeah. I mean, are there other tools that you’re looking at to sort of get in front or or [00:27:00] or to precipitate some, some home-based monitoring of your high-risk populations?
[00:27:06] Kevin Manemann: [00:27:06] Yeah, we look at a lot of tools, so we were invested in Omada. So we use that platform as well to do monitoring for and then, you know, we’re looking at all sorts of different tools that, and partnerships, we have a partnership right now that we’ve. Put together with a Duro. One of my partners in crime Mike Waters has put that together, but you know, that’s something employers [00:27:30] use it’s a lot like kind of like Virgin, but it has like Virgin health where you remember that, where we would track steps and all that kind of stuff.
[00:27:37] But this is more around helping people with their diabetes or their hypertension kind of know their numbers, paying attention to it. And if something happens, we’re able to intervene and reach out and find out what’s going on before it progresses too far.
[00:27:50]Bill Russell: [00:27:50] The last project that you and I actually worked on together we were mapping out the patient experience across the the orthopedic journey.
[00:27:58] And [00:28:00] let’s talk about experience. That’s obviously a huge topic. A lot of the CEOs at the JPM conference we’re talking about the, I mean, obviously they were talking about COVID and their response, but they were still talking about the patient experience and how dramatically it’s changed and how the workflows had to change and adjust as a part of that.
[00:28:20] Are you seeing that the expectations of the patients are changing in your markets?
[00:28:25] Kevin Manemann: [00:28:25] Yeah, I am. And I think it’s a good thing. I mean, I think we’re finally [00:28:30] getting to a point where we will meet people where they want to be met. So if somebody’s like, Hey, I just want to do a video visit as a consult and you really don’t need to do a physical exam.
[00:28:42] We’re able to provide that. If, you know, we talked earlier about not having to fill out all this paperwork and go to the office 30 minutes early and wait for your appointment. Like, like that stuff is, is starting to, you know, be in the past. And I think that’s such a great thing for the, for the consumers now, what I, what I, [00:29:00] what I don’t want to see happen is.
[00:29:02] There’s so many sort of convenient care options that people lose sight of the value of having a primary care physician, because somebody that can really help you manage everything that you have going on, especially as you get older, I heard a really great statistics the other day that. When it comes to spend for individuals your healthcare spend, there’s sort of this hockey stick effect when you hit 44, like it just sort of goes along like this, and then you hit 44 and it does that until [00:29:30] you get to 65.
[00:29:31] So it’s really appreciating that we have to have these convenient care options and you need to be able to quickly be seen for just, you know, basic acute stuff. But the importance of having that relationship with a primary care physician helps. You manage how that person will help you really manage everything you have going on, both from a physical and a psychosocial standpoint. And we shouldn’t lose sight of how important that is.
[00:29:55]Bill Russell: [00:29:55] I’ve always expected the providers to get into the insurance space, to get [00:30:00] into the payer space, to get in it, get more managed lives because it would appear to me that it just gives us such a, it’s such a better incentive to. It’s a be a part of people’s lives all along the way to to, you know, to have those tools and to have those those relationships all along the way to, to help them.
[00:30:22] I mean, cause, you know, at a certain point, if you know that hockey stick exists and you know that, you know, Bill is going to put on [00:30:30] you know, 10 pounds during COVID you know, there’s, there’s things you can do to sort of circumvent that when you’re talking about one person. That’s one thing, but when you’re talking about a population of you know, whatever orange County is 3 million or LA County, which is even more than that you’re, you’re talking about a significant impact to the total cost of care and the overall you know, quality of life of the people that you’re serving I would think.
[00:30:55] Kevin Manemann: [00:30:55] Yeah, it really does. And the great thing about having those types of payment models, I mean, we [00:31:00] spent that time in your office and I was mapping through like, you know, some people get paid on RBU’s, which is you have to be seen, you have to be in front of the physician. And these other models where we started walking through, this is how we can get a per member per month.
[00:31:13] It breaks open all these technology solutions. I mean, the providers are no longer trying to force people to come in because they’re incentivized differently. You know, and we’re paying them differently and they’re like, Hey. You know, I mean, I have providers that are like, you know, as long as it’s secure, you know, [00:31:30] they’ll allow you know, patients to text them a question and be like, okay, you know, either let’s do a video visit or, you know, maybe you need to become in to be seen but just the ability to have that connection point in with your provider and be able to kinda know what you need to do is something that has been missing in health care for a long time. And I think this is significant breakthrough that we’re moving towards and capitation or prepayment stuff allows that. And that’s just one example. I [00:32:00] mean, you could, you could really cover dozens of examples of where technology plays a significant role and providers embracing it.
[00:32:08] And the community embracing it is, is you know, all the, all the incentives are aligned. Finally.
[00:32:15] Bill Russell: [00:32:15] Yeah. So we have a new administration and I’m not, I’m not going to ask you to comment on the administration. So don’t worry. I’m not going to take you there, but what I’m going to, I am going to take you is I think we’re going to go back to, because you know, that this president is, [00:32:30] was under the Obama administration a lot of the 21st century cures, a bunch of that stuff was passed during the Obama administration. And they had bundled payments during the, the the administration and that it was making a lot of progress. Not so much under the last administration, but I think we’ll see those things come back.
[00:32:48] What’s the complexity of delivering on bundled payments and you know, what, what are some of the strategies to approach that?
[00:32:58] Kevin Manemann: [00:32:58] Well, I mean, it’s really bringing the [00:33:00] continuum of care together. When you do something like bundles. I mean, you got to have your primary care physicians along with your surgeons, along with your, you know, home well you know, skilled nursing facilities, your hospitals, I mean, everybody’s got to kind of get around the table and you figure out what parts you can do more efficiently and start to pull. Those pieces out. So for example, a lot of times you’ll get like a, like a knee replacement. You’ll be in the hospital for so many days or go to a skilled nursing facility for, [00:33:30] you know, a bunch of days.
[00:33:32] And we’re able to insert rehab more quickly get people more active and maybe not have as many skilled nursing facility days. And it allows the bundle to financially make sense. So it’s stuff like that I think works pretty effectively. Plus you can do a lot of the followup visits without having to be an in-person.
[00:33:53] So a lot of those things start to the incentives get aligned there and you’re still following up with the patient, but it could be like [00:34:00] over a video like we’re doing here. And it just makes it a lot easier for the patient. Then I have to figure out how to get a ride and park and you know don’t go into the office.
[00:34:09] Bill Russell: [00:34:09] I appreciate you approaching that from the patient perspective and whatnot but as the CIO, I remember the complexity of that was we we’ve, we’ve gotta be able to share information across that entire continuum. We’ve gotta be able to attract costs across that entire continuum. We’ve gotta be able to manage the quality.
[00:34:25] I mean, that was one of the challenges managing the quality of those skilled [00:34:30] nursing facilities and. And rehab facilities and not all of those were owned by the provider. And that’s you know, that in and of itself is the sharing mechanism getting better across that entire continuum?
[00:34:50] Kevin Manemann: [00:34:50] In some ways it’s getting better. So, I mean, health information exchanges help with having data available. I mean, in my [00:35:00] opinion, the administration that we have now really needs to put a pressure on EMR vendors to open up. I mean, just the, the cost to build a connection into every everybody’s system is astronomical and sort of ridiculous.
[00:35:15] I mean, it just shouldn’t be like $10,000 for me to connect into a two doctor practice that has a different EMR. So I feel like there needs to be you know, more regulation maybe, or just the [00:35:30] demand that, you know, you can’t charge those kinds of prices. You have to provide a certain amount that’s standard.
[00:35:36] I think that would be, make it a lot easier, but I mean, of course, you know, we have made progress. It’s just not, I mean, to your point, I mean, you have skilled nursing facilities or you have acute rehab, or you have some of these players that are part of the overall continuum of care and. You just can’t get everybody’s data connected in. So there’s, there’s big gaps that can occur.
[00:35:58] Bill Russell: [00:35:58] Yeah. And I’ve tried to [00:36:00] explain, cause I’ll talk about, on the show, I’ll talk about the need to connect in all these physicians for the integrated delivery, the clinically integrated network and people will just look at me like, I don’t understand what you’re talking about.
[00:36:14] I’m like, well, you have to understand California and how it’s set up. I mean, we had to connect into a lot of independent practices and and different medical groups across GE. And that was just orange County back then, you know LA as LA as well. I mean, that’s, [00:36:30] that’s a lot of connections and you’re not kidding. I mean, it was like, $5,000 coming back to this 10,000 to connect to this. And I remember those bills coming in and just look at it going. This makes no sense to me.
[00:36:41] Kevin Manemann: [00:36:41] No, it doesn’t. And then of course the consumer and the patients, I mean, most people don’t even understand that that’s all the craziness that’s going on on the back end and they just don’t understand why your primary care sent you to an orthopedic physician.
[00:36:55] And then the orthopedic physician. We’ll come back to your primary care doctor and there’s no [00:37:00] communication there, you know, there’s that just doesn’t make sense to, to consumers. Now, obviously, if you’re in the same medical group, it’s not an issue, but if you’re connecting across, you know, markets that have physicians that are in organized groups and then physicians that are independent, that the communication and the, the, the care plans and stuff like that need to be shared pretty seamlessly. If you’re going to effectively bring the total cost of care down.
[00:37:27] Bill Russell: [00:37:27] So I, I want to go back to telehealth real quick. So [00:37:30] you just like most health systems probably saw significant gains are in numbers. I’m not even sure. Gains is the right terminology to use a significant use in tele-health. During the you know, March, April, may timeframe we saw some of that come back. Do you have a goal of growing telehealth or is it more appropriately using telehealth across the across the markets that you serve?
[00:37:58] Kevin Manemann: [00:37:58] Yeah. You know, there’s [00:38:00] multiple strategies, so I can break down a few. I think for the most part we’re running about 20 to 30% of our visits are still video visits.
[00:38:09] Of course it varies by specialty, but when you look across our whole footprint, that’s about what we’re averaging. I think as long as reimbursement parody sticks, which obviously varies by state, the feds have been pretty supportive of keeping that in place. I think the video visit percentages will stay in that 30% range.
[00:38:30] [00:38:30] You have multiple strategies that that we’re carrying forward. You know, some are lifestyle strategy. So you have certain providers that are like, Hey, you know what? I will see patients two days a week, do all video visits. I can be home with my kids. And then I’ll be in the office two days a week. And what that allows us to do is introduce more physicians into the same footprint physically.
[00:38:54] You know, and so if I had 10 physicians in an office, I can now have 15 physicians because you’ll have any given [00:39:00] day where five of them will be working from home and, and being able to do video visits. So there’s those strategies that we’re undertaking. I think other strategies are really providing a more significant care for rural communities or, you know, when you start to get into that out of the specific urban you know, space. And if you think about, you know, the market that, that we worked in together, you have orange County, but then you have Riverside and San Bernardino County where a lot of people would drive to orange County for their care. And now we can provide that. So the [00:39:30] medical groups and the organized medicine components are, the walls are coming down and it’s no longer a requirement to have a bricks and mortar to do that.
[00:39:38] So you have some of those strategies that are beginning to take off. And I think you know, if you have a reputation to have great outcomes and provide quality care. You’re going to see your business grow because of the capability to do a lot of the visits without having to be face-to-face. And of course, people are more than happy to do like two or three visits, and then if they need to come in for [00:40:00] a physical exam and go through, you know, the parts that you have to do in person, people are very willing to do that.
[00:40:07] Bill Russell: [00:40:07] You’ve always been a proponent of the physician experience as well. I know as a CIO used to push me pretty hard on the clinician experience how, you know, how is the clinician experience at this point? And we still struggling with it, not just with regard to technology. Cause I know, you know, the EHR has [00:40:30] some challenges and those kinds of things.
[00:40:32] But, but just overall, I mean COVID and just the stress of it and whatnot. How are clinicians doing through this through this pandemic?
[00:40:44] Kevin Manemann: [00:40:44] Yeah. I mean, it’s, it’s one of our biggest concerns, right. Because right now there’s so much. Focus on taking care of the community. We really worry about people not taking care of themselves.
[00:40:57] I mean, as you probably remember, we had a [00:41:00] program that we did a cultural kind of immersion that we did called own it, and it was really about bringing people into why they came into medicine and really breaking open the. Compassion and empathy about what we do and making sure that we take care of one another, which is, you know, carries forward and how we take care of patients.
[00:41:20] We’re going to have to reinvigorate that. And you know, we spent quite a bit of time. You probably remember the sacred encounters is a phrase that we use a lot. And as [00:41:30] this immersion program really helped people crack that open and know what it meant. And it was really the opportunity to connect and communicate with each other and really bring those, those moments where.
[00:41:41] You know that you’re making a difference in somebody’s life. And right now physicians are so and nurses too. I mean, they’re just so on the ground, dealing with everything that’s coming at them when we get to like April and may and the dust begins to settle a little bit more. We’re going to have to take a serious time out and say, okay, now it’s time to take care of [00:42:00] you.
[00:42:00] And we’re putting plans together on how we’re going to do that. And giving people space, making sure people are able to take time off and. You know, just give them an opportunity to reconnect with one another in a different way. So we have some, we have some pretty big plans to help ease people through that.
[00:42:16] Bill Russell: [00:42:16] Yeah. That’s one of the things I, I still remember the first day I was a contractor sitting there at St. Joe’s and I was presenting to the executive team and it, and they stopped [00:42:30] me couple of minutes in and said, let us tell you about our organization. They sort of laid it out. And I remember sitting there saying, I want to work for this organization because they communicate and a you know, a depth of caring for the community that, yeah you know, they’re, they’re smart people and they run a business well, but it is a ministry and they talked in ministry terms. They talked about caring for the individuals. Not only the people in the community, but the people within the four walls of the health system. And [00:43:00] and that, that really really spoke to me.
[00:43:03]Can you expound a little bit on the Own It program and you can talk a little bit about, about that.
[00:43:09] Kevin Manemann: [00:43:09] Yes. Sure. So we, let me talk about the roots of it. So the, the, the reality is at the time, and this was probably 2012, we had. You know, let’s just use orange County. We had five different medical groups that had come from different walks of life.
[00:43:28] So some came, we [00:43:30] organically grew from the beginning. Others were acquired through different business deals that we did. So we had all these docs that were in these different groups and had these different cultures. And they had different language and they have different belief systems, et cetera. So the owner program was intended to reconnect people into why they came into healthcare, but it was also an opportunity for us to have a common language.
[00:43:52] And so we had communication standards, we built a service cycle that everybody connected to. [00:44:00] So we own how we meet and greet. Patients, we own how we show up patients respect. We own how we you know, transfer for people’s care. I mean, there was this whole service component that came with it. And it is the way it launched is it’s a four hour program.
[00:44:17] You do a tables of like, You know, five people at a table, you might have 10 tables and there’s facilitators that lead it. And then at your table, there’s a facilitator helping you through all the [00:44:30] different material. And it’s we do quite a bit of videos, but then we do a lot of table discussions and. As an example of when we were talking about sacred encounters, the table facilitator would, would explain what their sacred encounter was and sort of open the space up for other people to share once that they have, and it created this vulnerable moment where these providers who are like, you know, Superman and superwoman, you know gave them the opportunity to like really open up and it [00:45:00] created this connection into why they want to be at Providence or St Joe’s and, and the difference that they’re making. And then on top of that, we, you know, we’ve talked about compassion and how compassion spreads. It was pretty interesting. We had a number of providers that, you know, you’d look at their patient experience score.
[00:45:20] This is a little bit of an anecdotal story, but I think it it’ll resonate with the audience. We have providers that would. Would have these unbelievable reputations of great outcomes, [00:45:30] but their patient experience scores would be low and they couldn’t figure it out. Cause they’re like, I’m, I just feel like I’m really great with my patients.
[00:45:37] And the answer was they argued with their patients, but guess who they weren’t great with their staff. They come walking out of the room and they’d yell at their nurse, or they get mad that some lab order wasn’t there and they start hollering. So of course what happens when the nurse walks, walks back into the room?
[00:45:51] You know, they just got torn up one side and down the other. So they’re not being very nice to the patient at that point. And we started to get providers to understand how you treat one [00:46:00] another carries on about how you take care of your patients. And so that, that was a big eye opener for a lot of providers.
[00:46:06] And we just saw a big culture shift then and our patient experience scores, our caregiver engagement scores, our provider engagement scores in orange County are in the top. Core tile and decile as far as provider experience or provider engagement rather than the top decile in the country.
[00:46:23] And it’s not all related to own it, it’s, you know, there’s so many pieces you have to do to get there. It’s a combination of that. And then we have [00:46:30] really good governance where physicians feel like they’re partners and they’re at the table. I think those two things made a big difference for us to get people super engaged.
[00:46:39] And I agree with you. It’s a wonderful place to work. It’s so grounded in. taking care of everybody in the community. You know, we’re not an organization that only focuses on certain parts of the population. You know, we serve everybody and and it’s, it’s pretty rewarding.
[00:46:54] Bill Russell: [00:46:54] No and Kevin, I’d be remiss if I didn’t ask this question because there’s an awful lot of technology, people that are listening to this [00:47:00] going how did this guy go from working for All Scripts writing code to being an executive over a significant portion of a you know, the Southern California. It’s the Southern California markets. Predominantly, I mean, you’re, you’re over a fair number of of amount of that business from a business leadership standpoint. I mean, what, what do you attribute that, that movement does that technology background help or [00:47:30] did it enable you, or did you really focus in on no, I have to know and understand the business and that’s what propelled you forward.
[00:47:37] Kevin Manemann: [00:47:37] Well, I mean, to be honest with you, I think a lot of it came from trying to implement technology platforms. I mean, I spent time implementing EMR. That’s pretty obvious based upon what we’ve discussed, but I also implemented master patient index and tried to put together solutions that allowed systems to keep you in context.
[00:47:55] So that patient context, switching type stuff, but see counseling. [00:48:00] And what I recognized when I was doing that work is. The operations has to be behind what you’re doing. And so I started to get more involved in the operations put a lot of work into, into leadership and then really started learning a lot more of the business side, the, you know, the financial contracting side and how we could drive costs down.
[00:48:20] And technology was a big enabler. And so it was being able to drive change. And so I just started getting into roles where I could influence change more. And. [00:48:30] I just kept evolving from there. I, I didn’t really plan to be in this kind of role. It just somewhat came to me and as you know, working at St Joe’s and Providence, you know, sometimes things are calling and, and that’s really how I feel about the work that I do.
[00:48:47] It’s a calling, it’s a vocation. I have the opportunity to lead the largest health system in Southern California. And much of it is going to be around driving towards value based care. And a lot of it is around. [00:49:00] You know, using servant leadership as a way to get everybody to lean in. If you’re independent physician, if you’re part of the medical group, if you’re running a hospital.
[00:49:09] So yeah, it’s the technology background does help though, because I know how to put the pieces together. And I am not in the abstract as much as other leaders because I’ve been there. Like I know how the pieces can fit together and how you can accomplish a different patient experience or a different, a [00:49:30] different flow. You can have your operations be more efficient, you know, that, that type of stuff. I have a pretty good handle on,
[00:49:36] Bill Russell: [00:49:36] Yeah and I think that’s the you know, that’s the, the thing about your progress. I, you, you really understand the technology at a deep level but I think it was, it was sitting down with you and others and just No, and I, Oh my gosh. I can’t remember his name. The gentlemen who was before [00:50:00] you at CR. CR. CR Yeah. I mean, CR was like a machine. I mean, he just understood the business and I think you worked very closely with them and just understood the business, the contracts, the you know, how to to set these things up effectively and how to negotiate with the payers and those kinds of things.
[00:50:21] And all that was just a part of the natural progression.
[00:50:26] Kevin Manemann: [00:50:26] Yeah. I mean, you know, CR and I, we joke about this now, but when I wanted to [00:50:30] set up the clinically integrated network, he asked me why I was wasting my time. And I’m like, no, no, no. We can get fee for service contracts into this CIN, as long as people are committed to quality and patient experience, and he’s like those independent physicians, they’ll never agree to do that, but if you really want to do it, knock yourself out.
[00:50:48] And so we put it together and now we have 200,000 lives in that CIN that are on fee for service contracts. So
[00:50:54] Bill Russell: [00:50:54] I can’t, I can hear him say that too. Do you want to do it? Go ahead and have fun. So that had, [00:51:00] that had to be, I mean, I guess that, that was a, a sort of a support of saying, yeah, go ahead and do it, but I mean, you had to go out and have those initial conversations.
[00:51:10] So, I mean, was it, were they receptive at first or did you have to keep tweaking the model before people signed on.
[00:51:17] Kevin Manemann: [00:51:17] Yeah. I mean, ultimately we had the right independent physician leaders that, that understood the vision of putting stuff into a structure that allowed them to do better financially, because we would have different [00:51:30] bonus pools that we can tap into based upon how we perform.
[00:51:33] And as you know, we have had enough independent physicians that really understood that it would help them grow their practice and it would help them build some financial stability. And from there we implemented, you know, solutions that allowed us to understand utilization. If you remember that roadmap platform, which is now owned by Cotiviti.
[00:51:52] But, you know, we did a lot with that and really started educating providers on what they were doing and how they were practicing and [00:52:00] what created more expense versus other ways that they could do it, that would get the same outcomes, but it would be less expensive. Way to do it. And that generated a lot of fuel to continue to build onto this CIN.
[00:52:12] And as people saw contracts come in and they were getting pretty good rates because we were driving total cost of care down. So we were able to afford to bring pretty competitive rates into that. People really got excited about it, and we’ve just been able to grow it. You know, we put Oscar in there, we put a bunch of our ACO work has been put [00:52:30] into that.
[00:52:30] We have unlimited doc scheme, which is an insurance license in California, but. It’s just allowed for a lot of growth outside of your normal payer provider relationship direct to employers, we’re able to put an employer contracts directly into that CIN and, and actually do quite a bit on the Medicaid front.
[00:52:49] We were able to do some managed Medicaid on there, which is, you know, part of the community we’re going to serve. Forever. I mean, that’s just who we are. We’re going to serve the whole community and, and being able to have the [00:53:00] technology and the CIN to better manage that Medicaid book of business is pretty important to them.
[00:53:05] Bill Russell: [00:53:05] Did these strategies translate to taxes and then other markets the Providence was in or were there tweaks that you had to make?
[00:53:15] Kevin Manemann: [00:53:15] You know it’s done well in Oregon. They have a health plan there and then they have, you know, a group and a independent physician practice. So they’ve been able to kind of do something similar.
[00:53:25] There are, we’re starting to see it really take off then. And Texas, [00:53:30] as they take a look at comparing Medicare fee for service to Medicare advantage, you know just for everybody out there, when you can take a Medicare advantage. Agreement. And you can earn more than a hundred percent of Medicare on the facility side on a yield basis, meaning that you get a per member per month on the facility side.
[00:53:50] And then you can, you can earn 120% of Medicare on that by managing it effectively, it’s a lot more enjoyable than getting a hundred percent of Medicare and trying to cut your costs to get [00:54:00] down to. You know, serving that a lot of people try to break, even on Medicare. That’s been a goal for a lot of health systems and my perspective on it is move as much as you can to Medicare advantage and let’s manage it well.
[00:54:10] And then we don’t have to worry about cutting expenses as aggressively. So that kind of stuff is starting to translate more into, you know, places like Texas and Alaska, even.
[00:54:20] Bill Russell: [00:54:20] You know, just, just out of curiosity. So we just covered a fair amount on the clinically integrated network with I jokingly call this the [00:54:30] education of Bill Russell, and you’ve been a big part of the education of Bill Russell.
[00:54:34] So I, I just, I asked this question sort of jokingly, but seriously. I mean, is there anything else we should talk about that I haven’t asked you?
[00:54:46] Kevin Manemann: [00:54:46] Oh you know, I think the technology components that help you drive a better business strategy is a whole topic that we should spend more time on.
[00:54:59] I [00:55:00] mean, you know, when I look at what our opportunities are, I’m always looking on the revenue side and technology really helps you enhance revenue. Some of us HCC coding, some of it is just understanding where you’re down, coding. You know, some of it is doing restratification and predictive modeling.
[00:55:16] If you’re running a risk business, what’s your high-risk population, getting your arms around that and really managing them well. So you’re not having a lot of spend understanding how the technology enables the, the business strategies I think is [00:55:30] where we need to continue to go. So we’re investing in the right technologies and we’re enabling the right experiences that ultimately get us to, you know, higher.
[00:55:40] Well, let me say it this way. We are looking to get more healthy people in our community, so better health outcomes and drive that quality at a lower cost and technology is just it’s the center of it. It’s it’s what allows you to do it.
[00:55:57] Bill Russell: [00:55:57] Yeah, absolutely. Well Kevin, [00:56:00] thanks. Thanks again for your time. Thanks again for for educating Bill Russell. Always appreciated.
[00:56:05] Kevin Manemann: [00:56:05] Hey next time we’ll do it on the golf course.
[00:56:07] Bill Russell: [00:56:07] Sounds like a plan. What a great discussion. If you know someone that might benefit from our channel, from these kinds of discussions, please forward them a note, perhaps your team, your staff. I know if I were a CIO today, I would have every one of my team members listening to this show. It’s conference level value every week. They can subscribe on our website thisweekhealth.com or they can go wherever you listen to [00:56:30] podcasts, Apple, Google, overcast, which is what I use, spotify, Stitcher. You name it. We’re out there. They can find us. Go ahead. Subscribe today. Send a note to someone and have them subscribe as well. We want to thank our channel sponsors who are investing in our mission to develop the next generation of health IT leaders. Those are VMware Hill-Rom, StarBridge Advisers, Aruba and McAfee. Thanks for listening. That’s all for now.