Introduction: Burning Questions for Plan Sponsors
[00:00:00] Stacey Richter: Episode 484. "What Are the 3 Most Burning Questions That Plan Sponsors Have Right Now?"
Guest Introduction: Dave Chase From Health Rosetta
[00:00:08] Stacey Richter: Today I speak with Dave Chase.
[00:00:27] Stacey Richter: Today I am speaking with Dave Chase from Health Rosetta, and I'm asking Dave Chase three inferno level burning questions. Questions that across the country, many self-insured employers are trying to find the answers to.
To listen to this episode or read the show notes with the mentioned links, visit the Episode Page.
Understanding the Role of Brokers and EBCs
[00:00:41] Stacey Richter: Now an important underlying point that comes across loud and clear, but remains unsaid actually in the conversation that follows is this:
There are amazing brokers and EBCs and benefits advisors or TPAs, third party administrators, who put their clients first and have the receipts, ie, they have data and they're willing to share it to prove this.
And then there are those with the exact same titles, often enough, who are very much the opposite of this. But super charming, I'm sure. I mean, it'd be a stretch to assume that the same roles don't apply to brokers or EBCs that apply for titles like hospital administrators where there's great ones and really not great ones, but everybody often gets lumped into the same category or even the term hospitals.
Each of these terms is a broad stroke and contains multitudes. And do listen to the bonus clip from two weeks ago with Jonathan Baran for just more on this point. We dig into it for like 10 minutes or something. I also talk about this same concept in an upcoming episode with Dr. Mick Connors.
So keep that underlying and unsaid theme in mind because a lot of these questions do boil down to how do you figure out who's on the up and up and who's not.
And if you need an example of the latter category, listen to the show with Ann Lewandowski about the whistleblower lawsuit or the show with AJ Loiacono about the myriad of brokers taking $7 or $14 per script written payable by the PBM and not reported on, as far as I know. This is very much still going on today, by the way, despite the CAA and the 5500 forms.
Burning Question 1: Ensuring Your Benefits Advisor Protects Your Interests
[00:02:53] Stacey Richter: Alright, so first burning question. Question 1: After seeing J&J, Johnson & Johnson and Wells Fargo sued for fiduciary breaches, what specific questions do I need to ask my benefits advisor to prove that my benefits advisor actually protects my interests?
Okay, paraphrased this question is employers trying to figure out what they can ask or how they can figure out if their benefits advisor or broker or employee benefit consultant is really as trustworthy as they'd like you to believe they are.
There's been a whole bunch of shows that circle up on this. The thing is though, the stakes are very, very high right now, so yeah, I can see why this is turning into a burning question for anyone worried they might get sued personally, unless they can figure out how to vet for real in writing who their broker, EBC, or advisor serves actually, at the end of the day.
Question 2 that I ask Dave Chase, and I'm not giving you the answers to these questions. You gotta listen to the show.
Burning Question 2: Avoiding Personal Liability With TPA Contracts
[00:03:48] Stacey Richter: But here's the second question I ask, how do I avoid personal liability when my TPA, third party administrator contract has hidden conflicts that could trigger an ERISA lawsuit?
Kind of a continuation of Question 1, but yeah, you can tell that self-insured employer teams are really digging in here and many, many are very aware of, first of all, the extent and depth of middle people doing things like, again, allegedly taking $20 million of employer clients money and funding their executive bonus pool.
So yeah, definitely this is another doozy of a burning question. Also on these same topics, listen to the show with Justin Leader and also the one with Cynthia Fisher about spread pricing.
Burning Question 3: Identifying Overcharges in Pharmacy Costs
[00:04:31] Stacey Richter: Question 3 that I ask Dave Chase. My pharmacy costs keep climbing despite PBM Pharmacy Benefit Manager guarantees.
How do I tell if I am being systematically overcharged? Well, if your consultants are taking your rebates to fund their executive bonus pools, as I just mentioned, there's a whole show about with Ann Lewandowski or if they're taking $7 a script for every script that gets written for your members, which, yeah, that's afoot, and I've seen the contracts and the cease and desist currently flying around our industry about that one.
Or read that Osceola County lawsuit against their longtime brokers. All these links are in the show notes.
Bottom line and end of this intro, informed employer teams are for sure wondering these questions. But even more than just wondering what these questions signify to me, kind of at the macro level, they're realizing the danger of kind of sitting on that knowledge or just assuming that because everybody else is doing whatever, it's somehow safe.
Though status quo is getting kind of more and more dicey every single day.
Conclusion: Open Source Resources and Final Thoughts
[00:05:34] Stacey Richter: As some additional foreshadowing, this show finishes up with Dave Chase talking about the open source resources that are available so that you too can create a high performance health plan where members get higher quality healthcare and as Dave Chase says, the cost savings for free.
There are links in the show notes to many things that you can get from Health Rosetta and their sister company, Nautilus. Again, all the stuff is for free. Go to nautilushealth.org. That's their main website.
Dave Chase's Background and Health Rosetta's Mission
[00:06:02] Stacey Richter: Dave Chase who has been on this podcast I think this his third time, although it has been a while. Dave Chase is co-founder and CEO of Health Rosetta.
My name is Stacey Richter. This podcast is sponsored by Aventria Health Group.
Dave Chase, welcome back to Relentless Health Value.
[00:06:17] Dave Chase: Super happy to be back. Thanks Stacey.
In-Depth Discussion: High Performance Health Plans
[00:06:19] Stacey Richter: All right, so, I asked Dave, Dave Chase here, to answer the top three most burning questions that employers nationwide are asking. I said to Dave, not just lightly smoking questions. I mean, we're talking infernos here. You ready, Dave?
[00:06:35] Dave Chase: I'm ready.
[00:06:35] Stacey Richter: All right. After seeing J&J, and Wells Fargo and others sued for fiduciary breaches, what specific questions prove my benefits advisor, my employee benefit consultant, EBC, my broker is actually protecting my interests.
[00:06:55] Dave Chase: Yeah, I mean, this is one of the things we open sourced is a RFP, but I like to sum it up as you know, there's canaries in the coal mine of trust. Number 1, is their comprehensive compensation disclosure without any excuses. Like as soon as you start hearing excuses, Oh, we can't measure this. We can't measure that. Big red flag.
Number 2, comprehensive on how they support data and reporting. That's the most predictive thing. Access to data of a high performance health plan, and do they actually do that?
Do they have experience with the high performance health plan components that you have a lot of episodes on, which we know about, whether it's Centers of Excellence or advanced primary care and so on.
And then also, a pretty good question is what percentage of their business, their book of business is with an independent plan administrator? If it's zero or very low, that tells you a lot.
So there's a bunch of things that are underneath that, but I think those are really good places to start.
[00:07:57] Stacey Richter: The first thing that you said was no excuses.
And Andreas Mang from Blackstone was on the pod. He basically said the same thing, like if you're dealing with someone and every single time you ask for something, they're like, well, we can't do that because dot, dot, dot, right, like that is an immediate red flag.
Someone said the other day, and I love this so much, you can't make a good deal with a bad partner. And if someone or that Maya Angelou quote, you know, "When someone tells you who they are, listen".
And sometimes these people are lovely. Sometimes these people have been, it could not even be them. It could be the company that they work for. But at the end of the day I think what you're saying is if any of these three things or four things that you just mentioned are present, there is adequate insight that the company or the person is not working in your best interest, which puts you at legal risk, which is scary, right.
Claire Brockbank also was talking about this. She said if someone, every time you say something, they mention the D word, disruption, you know, it's kind of like, oh no disruption, which is a great way to get people to not do something.
So you said no excuses you said you gotta have thorough data and reporting because that's transparency. If someone just gives you discounts, they won't tell you the net. Just all of that stuff is problematic and maybe indicative of some underlying goings on which again, maybe not in you or your company's best interest.
Experience with high performance that's something that also has come up a number of times on the podcast. There could be people with the best of intentions, they just don't have the experience.
And then the last thing that you said, what percentage, this is really interesting, what percentage of their business is with an independent plan administrator? That's kind of a two-prong one. If I was just gonna recap one of them is the experience. It feeds into the experience, but the other bit of it is there are so many TPAs and ASOs that are conflicted. Listen to the show with Justin Leader. Listen to the show with Elizabeth Mitchell. Like, just listen to a lot of them. And, yeah, you'll get the drift real, real fast.
So the answer to after seeing J&J and Wells Fargo sued for fiduciary breaches, what we just went through are the four or five specific questions that, you know, if a benefit advisor answers them flat out, here you go, I think you can be pretty reasonably sure that there aren't underlying structural conflicts.
[00:10:19] Dave Chase: Absolutely. And you know, I just trusted my consultant is definitely not a legal defense and people were seeing that pretty rapidly. And, and two of the items you mentioned are legal requirements under the CAA in terms of the complete disclosure of direct and indirect compensation and the prohibition on gag clauses.
You know, which translate, it means you have the duty to get access to your claims data. And so those are really black and white. And people are finding out the hard way that just saying, I trusted my consultant isn't gonna cut it.
[00:10:55] Stacey Richter: Yeah. What’d Edwards Deming say, "In God we trust all else bring data". Alright, let's move on to the second burning question.
How do I avoid personal liability when my TPA contract, third party administrator contract has hidden conflicts that could trigger an ERISA lawsuit?
[00:11:16] Dave Chase: Boy, there again, there are so many good practices and probably the thing that I would say you gotta start out with is this kind of data hostage situation. You know, you can't audit what you can't access.
And going back to that previous discussion around access to claims data, that's prohibited. And so you're in massive exposure and you see some of the recent lawsuits such as the Tiara Yachts versus the Blue Cross Blue Shield of Michigan. Where they're just making in network, you know, so-called Blue Card claims outta network so that they can jack up the price so they can so-called save you money.
And they get gazillion dollars on these so-called savings. And that's a type of thing that if you don't have access to your your data, you're not gonna be able to see. And when you do, it's there in black and white.
And there's just all kinds of examples there that we've, you hear a lot about spread pricing in the pharmacy side of things, but there's absolutely spread pricing on the medical claims side. I think that was something that Justin Leader talked about. So you just really have to make sure that you have access to the data.
And there's all kinds of hidden fees of various forms that we know that when an employer goes from fully insured to self-funded, the carrier loses maybe 90% of their profit opportunity. Well, they've been exceptionally effective at clawing all that back, so you're functionally fully insured when you're doing just everything that the carrier wants with their boilerplate agreements, and that's really not being self-funded and taking control in the way that your fiduciary duty requires.
[00:13:10] Stacey Richter: So again, the question was how do I avoid personal liability? Because the way the Consolidated Appropriations Act, the CAA works, the way ERISA works is there's personal liability here because what an ERISA plan is supposed to be doing, plan administrators are required to ensure that plan assets are spent, I think it's prudently. Reasonable costs and without conflicts of interest.
When I asked this question, how do I avoid personal liability? The first thing that you came back with is get your data and, you know, take that a step further, I think, what I'm inferring you mean there is get the actual numbers, not some discount.
I'm had a conversation with Jonathan Baran and one of the things that he made really clear, I thought was super insightful is that it behooves many, many people when employers are trained to buy discounts. And there's this whole set up so that employers think what they need to purchase is discounts.
So this is what you're talking about with this data hostage situation. If people are like, here's the discounts, and then all of the rest of the data is hostage, then everything that you just said could potentially be happening. We had Cynthia Fisher on the show. She's talked about a case in, I think it was Arizona, where the provider was paid $800,000 and Cigna and MultiPlan took 2 million or something, right? Like the spread pricing is not like, oh, 80 cent. It's like huge money here.
You mentioned Tiara Yachts versus Blue Cross BlueShield. There's, there's a lot of them that are flying around right now where the plan sponsor ultimately is the one, I mean, they've been holding the bag for years, probably from a financial standpoint, but now they're holding the bag from a legal standpoint.
[00:14:48] Dave Chase: Yeah. And it's just plain old common sense. I mean, I've been in business a long time when an organization has a customer and they're proud of the value they're delivering to that customer. They bury them in data. Look at all the great things we're doing.
I mean, it's just so clear that all the, going back to the earlier discussion of excuses, excuses, excuses, you know, I used to talk with my kids when they had excuses like, Hey, the job you know of the foreman of the excuse factor is filled up. You don't have that as a career option.
So you just see, you really see that all throughout healthcare. Everybody's got excuses except the people who are delivering value. And you've heard about the Nuka story. I mean, it's just incredible. Like, oh, they could make excuses about medical deserts and all those sorts of things, but the real value creators just don't make excuses.
[00:15:40] Stacey Richter: Yeah, that's probably a good quote there. The real value creators take responsibility and accountability. They don't make excuses. And if there isn't the data to even have to make excuses about, that's even better.
[00:15:52] Dave Chase: Well, and we had Tufts University did a study of the plan grades we do, which is where, how we score plans. There's about 40 questions that we ask. And now we've got between two and 3000 of these plan grade reports. The single most predictive item of a high performance plan was they had unfettered access to their claims data.
We provide the guidelines in the open source resources. But you can also look at the draft language for the Marshall Hickenlooper bill called The Price Tag Act that just was announced recently.
It actually spells out very clearly what you need to do and they're trying to make that a legal requirement at that level. But you don't need federal legislation to do the right thing. That just will make it easier.
[00:16:40] Stacey Richter: It also would be a lot easier to your exact point, you get an independent TPA. If you're working with the right partners, things become a lot easier. Now, I did do a Summer Short with Elizabeth Mitchell who talked all about how sometimes in certain areas of the country it is very difficult to find the right partners just due to, you know, catch and kill where there's a great partner and then they get bought and shut down, right?
Like, so there's a lot of things that are going on where if you have an industry and you have entities that have the market power, the regulatory capture, that some of these entities in our industry have, then inarguably is tough in certain areas. But the points that you're making are, this is how you do it.
There's a little foreshadowing that is going on here. I just wanna point out. We talked about RFP and now we just talked about Plan Grader, so, just saying.
Okay, so Question 3. My pharmacy costs keep climbing despite PBM, Pharmacy Benefit Manager “guarantees” .
How do I tell if I am being systematically overcharged? So we've pivoted a little bit. The earlier ones were more on, I'm gonna say the medical side of the house. Now we're talking about pharmacy benefits.
[00:17:56] Dave Chase: Yeah. Once again, you have to be really, basically take the position that you do in every other area of your business and take control of procurement and define the rules.
You had Scott Haas on a previous episode. The sort of things you wanna look at is have net cost be the focus after all fees. Don't be looking at gross savings percentages like we talked about. You know, rebate guarantees, often hide spread pricing and retain manufacture revenue. And if you look at the full chain of custody of the dollars, there's offshore GPOs and all this mumbo jumbo.
But basically when you get to net cost at the end of the day and you have access to your data, that's what you want to do. But you gotta be very careful about specific calculations that are hidden that would otherwise expose hidden markups. And once again, access to data is vital in this situation. And when you're blocked for that, that's a really good idea that you're gonna be overcharged.
Require PBMs to show actual ingredient costs versus what they charge you. Get line item disclosure of all manufacturer payments. These are the sort of things that best practice procurement experts do. Fortunately there's enough track record that there's a real cookbook or recipe you can follow on that.
[00:19:19] Stacey Richter: Let's go down a couple of things that you said there, and just reiterating the original question was, my pharmacy costs keep climbing despite my pharmacy benefit manager saying that they're gonna deliver this number of guarantees.
Or this is the amazing rebate package I'm gonna get, or whatever. So there's all these promises that are being made, but yet my pharmacy costs keep climbing. Or you know, and I'm hearing this one a lot, the specialty pharmacy finger wag, right? Like, oh, you have so much specialty pharmacy, which again, I'm not necessarily doubting the veracity of some of this stuff.
I think what we're pointing out though is there are underlying games that are being played under the cover of darkness, which exacerbates any existing structural situation.
So the big point that you're making again, I think is just, you know, the pharmacy version of what we were talking about earlier. Get your data and data doesn't mean the discount number, get the actual net unit cost.
We had Paul Holmes on the podcast talking about this. We had Scott Haas on the podcast talking about this. We had Chris Crawford on actually recently explaining the problem with guarantees, so you could go back and listen to that if you're interested. But you know, again, it pretty much boils down to access to data, access to those underlying costs.
Luke Slindee actually gave a very big rundown about what all these just random, like WAC, AWP, like what all those words mean and why they're sort of meaningless. So the three underlines get the data.
[00:20:50] Dave Chase: Yeah. And we've seen, I think it's the counts up to something like 50 different revenue streams PBMs have created. And unlike the TPA scenario, there are a lot of a lot more independent PBMs that can definitely serve the market. No matter if you're in a small town in South Dakota or if you're in Manhattan. You really have no excuse there because there are some good folks.
Again, seizes control of the process. That's what's expected as a fiduciary, and more and more there's a recipe to follow to do that.
[00:21:25] Stacey Richter: It's interesting, Mark Cuban just stood up in front of, I don't know if you saw this Dave. Mark Cuban was standing in front of a very, very large gang of folks who advise employers and he asked, how many of you here have a client or have advised a client to use an independent, transparent, pharmacy benefit manager? And like one of 'em raise their hand.
And you see stuff like that and then you see things that are flying around. For example, right now, just about how some of the larger benefit brokers are taking $7 a script getting paid by their large PBM for every script. Like I mean just, or like the Osceola County lawsuit, where the school district sued their benefit broker for basically doing the same thing.
Like the benefit broker was making, I forget how many hundreds of thousands on the contract and they're making millions of dollars because every single time a teacher went to pick up a script, the employee benefit consultant got paid seven bucks or 10 bucks or something like that.
You start thinking about stuff like this and you're like, okay, get the data. Because you never figure that out unless you have that data and they're gonna try to hide it because wow, their pocketbook would be affected.
[00:22:36] Dave Chase: Yep. I mean, there was the whistleblower case that's in play with a broker and their compliance had said, Hey, we've gotta report this stuff. And it was a huge sum of money. I think it was like 61% of their revenue of that office was coming from rebates and various fees.
[00:22:56] Stacey Richter: Oh, Ann Lewandowski talked all about that whistleblower lawsuit where it was the TPA. This EBC had a TPA arm. They took the pharmacy rebates. They took the rebates from their clients, $20 million and put them in their executive bonus pool. Here's the thing though, none of their customers figured this out.
It was a whistleblower lawsuit where their head of compliance was like, I just can't with this.
[00:23:19] Dave Chase: I mean, the thing that I have not come up with a better analogy, but having observed this a bunch of times now, when the employer finds out what's been going on, it ends up being like the business equivalent of finding out a spouse cheated on you.
Like these people that you had this trust in. And you know, that probably took you to some great ball games and any number of things to do that. It's brutal.
And the same exact thing happened in the retirement arena like 15, 20 years ago. And if you talk to the people who were in that area, guess what? A lot of the status quo folks just disappeared, right?
They went away. It's a completely different set of market leaders and so that's the real opportunity for the people doing it right, is anytime there's one of these once in a career shifts, there's big winners and big losers. And so we love working with the big winners. They're great. They do great work, and they're absolutely out there.
You just gotta be careful about who you choose to work with.
Open Source Tools and Resources for Employers
[00:24:20] Stacey Richter: Okay, Dave Chase, you said a couple of things during the course of our conversation that I wanna circle back on. Starting with, you used the word open source and you used the word RFP, request for proposal. What's going on there?
[00:24:32] Dave Chase: Yeah. I mean, we're lucky in a way that healthcare is always like 15 years behind everybody else. So it's not a new idea that if you want to transform an industry, open source is the way to do it.
Yeah. I hear this expression even in healthcare, nobody ever got fired for hiring IBM referring to the big carriers. And I'm like, well, you know, dot, dot, dot, until they did. And so what we believed from day one was if we could prove that we could have much easier repeatability doing the things like a Rosen Hotels or a Pfeiffer Inc. are doing. If we could prove we could do that thousands of times, large companies, small companies, rural, urban, private, public, every corner of the country, it would be pretty hard to say, You guys just got lucky.
And if we could do that, which we're now at, we had to open source that, I mean, it's really amazing. Yeah, the, the cost savings is nice, but the secret is you pursue the highest quality and you know that's great, primary care centers of excellence and whatnot. You get the cost savings for free.
If you could put the health outcomes of these high performance health plans in a pill bottle, it would be the blockbuster drug of the century, like cancer care type of thing. And any decent person wouldn't keep that from others.
And so that's why we actually created a nonprofit called the Nautilus Health Institute. We've had people like Chris Deacon help us build resources. Marilyn Bartlett and Leah Binder on the board.
I mean, it's really, to use a old baseball expression, it's the Murder's Row of the industry, like just the best of the best are pouring their intellectual property in and saying like, “Hey, if you will organize that, I'll pour my brain into it as long as you make it available for free.” That's the idea with open source.
And so it's some work of course, to organize all these, this information, but that's what we've done with Nautilus. So it started with the Advisor RFP, like here's how you do it. 'cause people always say, where do I start? And I say, you gotta work with the right advisor, consultant.
And then the most important contract is the TPA contract. So that was the thing that Chris Deacon helped us a ton on. And so that was one of the first deliverables. We also have open sourced technology around data because yes, you gotta have the great procurement methodology leading to the best contracts, but you gotta prove it in the data and actually do that.
Having a data platform is super helpful, and so we saw just repeated, redundant investments that point solutions are making that they'd probably have to invest about $3 million to do it, right? To actually take in that data and clean it up, augment it, analyze it, and that wasn't actually what was differentiating them like, that's dumb.
You know, in the rest of the world, there's open source projects that make that a shared investment. And so we did that as well. And so far it's about $4 million of direct investment between the all the contract and data use guidelines and a data platform. And then the next big deliverable is the PBM Field Guide, which is gonna be available at RosettaFest.
And so we really have this kind of annual cycle of major updates with these open source tools. And you know, if you got a case of insomnia, you know, go dig into these. But in all seriousness, you'll look at 'em and go, wow. These folks sweat the details and none of the details are particularly rocket science. It's just a lot.
And so that's where trying to make that easier to operationalize has been a big focus of ours. But it's really a great way to kind of level the playing field and also rise the tide for everybody.
[00:28:28] Stacey Richter: And you said they are available at nautilushealth.org?
[00:28:31] Dave Chase: Yep, exactly.
[00:28:32] Stacey Richter: Nautilushealth.org.
All these links by the way we will, of course, as usual, put in the show notes and if you go to nautilushealth.org, then you can find amongst other things, this RFP template, open source. You can find the TPA contract that you mentioned. PBM Field Guide is coming. You'll see that launched a few go to RosettaFest, amongst a myriad of other things.
And I think to your exact point, like some of the stuff not rocket science, but you know, we had Claire Brockbank from 32BJ on the pod talking about the RFP that they put together. And I know you work quite a bit with the folks over at 32BJ. You know, she was just saying there's certain things you don't figure out until you get gamed and then you're like, “oh, that's what they're up to.”
I mean, we are dealing with entities that whatever we wanna say about them, they're incredibly smart and they're incredibly good at figuring out how to achieve their fiduciary objective, which is to shareholders. Let's just not forget that. So, we kind of need to make sure that we are amassing the same sort of intelligence on the side of members and employees, at least to make it somewhat of a fair fight.
[00:29:47] Dave Chase: The nice thing is once you start doing that, other people jump in. Mark Cuban, he's an employer. They are open source in the hospital contract and just kind of feeding this open source trend. And I know a past guest of yours was Dawn Cornelis, like truly one of the world-class experts when it comes to claims data and payment integrity.
And Dawn saw what we're doing was like, you know, she's towards the end of her career and she's like, I always want to pour my brain into Nautilus and make it available to everybody.
We've always known, even in some of the more vilified corners of the industry, people are good people. They're trying to do the right thing, and what we've done is just provided an outlet for a lot of these great people to share that, whether it Claire Brockbank and basically all of the Relentless Health Value guests are the types of people who love sharing how to do it.
And we're really grateful for that.
[00:30:44] Stacey Richter: Dave Chase, is there anything I neglected to ask you that you wanna mention right now?
Event Invitation: Join Us at RosettaFest
[00:30:48] Dave Chase: We would love to have people join us at RosettaFest. It's the only event that I know of that cuts across all the industry silos. It's got the real payers of healthcare, employers, and unions.
It's got the benefit pros, it's got the solutions and the biggest group right up there with the benefit pros is clinical leaders. We can't do it without the clinical leaders. So it's pretty evenly split across those four buckets for the thousand plus people who come. So we'd love to have people join us, certainly in person, but there's also a virtual option.
Closing Remarks and Listener Testimonial
[00:31:22] Stacey Richter: Dave Chase, thank you so much for coming on Relentless Health Value today.
[00:31:25] Dave Chase: Thank you.
[00:31:26] Cynthia Fisher: Hi, this is Cynthia Fisher, patientrightsadvocate.org. We subscribe to Stacey's podcast and we've learned so much from her podcast with all the incredible individuals she interviews on healthcare and the opportunities to affect change for the better.
I suggest everyone listen to these great podcasts that Stacey provides. So well informed for all of us engaged in healthcare.