To listen to the episode or read the show notes with links mentioned visit our episode page.

Introduction
[00:00:01] Stacey Richter: Episode 444. "Two State Healthcare Laws That Often Don't Go as Planned. We are talking about CON, Certificate of Need laws, and COPA, Certificate of Public Advantage Laws." Today, I speak with Ann Kempski. 

American Healthcare Entrepreneurs and Executives You Want to know. Talking.  Relentlessly Seeking Value. 

Unintended consequences is a thing. ERCowboy wrote on Twitter a while back, in any complex system, the likelihood of unintended consequences vastly outweigh the predictability of intended ones. Today, we're talking about two state laws where this is apropos CON, Certificates of Need laws, and then COPA, Certificates of Public Advantage. Turns out states actually have pretty much power to impact the competitive landscape in their state. They have a lot of levers they can pull. States really can make a difference in terms of improving real competition on value and on cost and quality.

So these two laws are in a way their attempt to do so. Before we kick into what's going on here, I think it is important to point out that these laws on their face aren't an obviously an overtly terrible mistake. This isn't like equivalent to accidentally putting chapstick in the dryer. 

There were good people who spied a problem and had an idea for how to fix it. I'm reminded of something I read by Nicholas Kristof on a totally different topic, but he wrote, "The central problem is not so much that the effort was unserious as it's more focused on intentions than on oversight and outcomes". And that pretty much sums up, I think, the gist of what's going on here.

And I can say that because here we are in a position to Monday morning quarterback. So I've invited Ann Kempski on the pod to point out what hindsight may reveal about these well intentioned efforts, the CON and COPA laws.

Understanding Certificate of Need (CON) Laws

[00:02:08] Stacey Richter: First up, let's talk about Certificate of Need laws or the CONs. Currently, we have 35 states and Washington, D.C. that operate CON programs with wide variations by state. I'll link in the show notes to the National Conference of State Legislatures, that has a good overview of each state's laws. Why did these laws originally get put into effect? They got put into effect to cut down on supply driven demand that was considered to potentially raise total cost of care.

Because in healthcare, unlike Econ 101, more supply doesn't mean lower prices. In the real world, if you have more supply, volume goes up and total cost of care goes up too. So it could be considered good thinking to limit the amount of supply.

Problems with CON Laws

[00:02:57] Stacey Richter: Except there's four problems that wind up happening often enough, which is why some states are busy repealing these CON laws.

We cover these four problems in the show that follows. Spoiler alert. What happens a lot of times is that the big get bigger. Consolidated entities have an upper hand, and we all know, consolidated entities are generally not known for their competitive prices or their desire to rationalize volume. So, yeah, we dig into this and parse it out into, as I said, four main problems.

But this is most commonly where it all winds up, ie, total cost of care does not, go down. I have included links in the show notes that Ann Kempski shared with me, including a statement from the Federal Trade Commission and Department of Justice detailing the anticompetitive effects of state CON laws.

There's also a link to a document written by a former FTC commissioner that highlights how state CON laws can inhibit competition. And then lastly, a systemic review of 90 studies that find the costs of CON laws exceed their benefits.

Exploring Certificate of Public Advantage (COPA) Laws

[00:04:02] Stacey Richter: Okay, so let's move on to our number two state law that often does not go as planned.

And this is the Certificate of Public Advantage or the COPA laws. Approximately 19 states have them. And these laws attempt to immunize hospital mergers from antitrust laws by replacing competition with state oversight. The idea here is that a state tells the FTC to stand down and gives their seal of approval to a merger to stop it from getting scrutinized for antitrust violations.

So, like, a big dominant health system gets an okay to buy a rural hospital. Meanwhile, everybody realizes this will lead to a situation where there is a dominant health system and that dominant health system will reduce competition. But the state may choose to do this because public advantage, as in the "PA". in COPA, Certificate of Public Advantage. But they'll do this because the state has decided that the public advantage of allowing the possibly problematic anticompetitive merger to move forward, the public advantage is a bigger advantage than having competition. Hmm. What could go wrong here?

Well, several things that Ann Kempski discusses in the show that follows. The Federal Trade Commission strongly advised the states against enacting these laws. There is a link to this article that was on the FTC website in the show notes.

Guest Introduction: Ann Kempski

[00:05:25] Stacey Richter: I was so thrilled to get the chance to chat with Ann Kempski today, who knows so much about these topics.

Ann Kempski is an independent healthcare consultant with a background in the labor movement, advocating for healthcare workers and purchasers for many years. Ann Kempski collaborates with clients to strengthen primary care, enhance union health funds, and reduce commercial prices. She often partners with academics from Hopkins, Johns Hopkins, to analyze hospital transparency data for insights into market trends.

My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. 

Welcome to Relentless Health Value. 

[00:06:00] Ann Kempski: Hi, Stacey. Great to be here. 

[00:06:02] Stacey Richter: Well, it is wonderful to have you here. 

In Memoriam: Suzanne Delbanco

[00:06:05] Stacey Richter: Before we jump into the episode, we've had a loss in our community. We've had actually several, one of them being Marshall Allen, another one being Suzanne Delbanco.

And I know that you worked alongside of and really admired Suzanne. Do you want to just talk a little bit about Suzanne and what she meant to those trying to transform healthcare and payment? 

[00:06:29] Ann Kempski: Thank you, Stacey. Indeed, Suzanne was a kindred spirit and a real inspiration for me and many others. She founded two very influential nonprofit organizations, first the Leapfrog Group and then second Catalyst for Payment Reform, which is dedicated to empowering purchasers to be more effective purchasers in the healthcare marketplace.

[00:06:53] Stacey Richter: And to hear Suzanne, I did interview Suzanne on Relentless Health Value in 2019 and the name of the show, so apropos based on what you just said, was "Underestimate Employers at Your Peril". So please go back and listen to that and look into other things that Suzanne has done. She leaves a big legacy. 

[00:07:12] Stacey Richter: Show today. Talking about policies with unintended consequences. Someone has a good idea to solve an actual problem. There is a recognition that there is an issue of some kind and somebody has a way that they see by which this issue can be solved for. But then it doesn't go as planned. So today, I would love to talk with you about two policies.

Let's just kick this off. What's the first policy that we want to be talking about here? 

Deep Dive into CON Laws

[00:07:42] Ann Kempski: So we're going to start with state Certificate of Need laws. Probably if your audience has heard of these, some may know them very intimately, but they've been around a long time.

They're still on the books in 35 states. Mostly they were created at the inception of Medicare and Medicaid back when we were actually doing cost-based reimbursement particularly for hospitals and other facilities. And out of budget concerns and concerns that we would see a proliferation of unnecessary hospitals or unnecessary equipment inside hospitals and it would be duplicative in communities and that would drive costs.

The feds actually encouraged the enactment of these Certificate of Need laws. So you literally as an entrant into the market or a current market participant who wants to start a new facility. You have to go get a Certificate of Need and demonstrate need in the marketplace. 

[00:08:37] Stacey Richter: So Certificate of Need, these are often called CON laws? 

[00:08:41] Ann Kempski: Correct. Yes. 

[00:08:42] Stacey Richter: And they're actual laws? 

[00:08:43] Ann Kempski: Yes. 

[00:08:44] Stacey Richter: You said they are still in effect in 35 states. So am I inferring from that that they used to be in effect in more states, but they are no longer? So some states are getting rid of these? 

[00:08:56] Ann Kempski: Yes, that's correct. And it might surprise you, there's really big states.

Some big states like California and Texas no longer have Certificate of Need laws. Other big states like Florida and New York still have theirs. 

[00:09:09] Stacey Richter: I can see why this would seem to make sense to put these laws into effect. Like I remember reading, and this was a while ago, I remember reading an economic study about Florida, like supply and demand, right?

In a normal marketplace, when supply goes up, then prices come down. The hope was that if you get as many MRI machines in Florida as possible, then the price of MRIs would go down and therefore I guess total cost of care would go down. But what they basically found was the more supply there was, the higher the total, you know, if you have an MRI machine, you use it.

So the total cost of care started rising and obviously some, not all of these MRIs were appropriate. So the quality of care didn't necessarily go up either, but the cost exploded. 

So I can see why the thought was, well, we can't have that. Let's make sure that if we're putting in these new pieces of equipment and new technologies, that there is actually a demonstrable need. 

[00:10:14] Ann Kempski: You're absolutely right. And even though we no longer have cost based reimbursement, fee for service is alive and well.

It's thriving, right? And so fee for service we see for many years, lots of the Dartmouth Atlas, I think is the most famous sort of research out there, which really shows that there is supply driven demand in healthcare, right? Encouraged by fee for service and frankly encouraged by the fact that consumers don't, they don't know if they need an MRI, right?

So they're taking the advice of their clinician. And sometimes that advice is also influenced by the machine they might own or the reimbursement under fee for service for an MRI. 

[00:10:55] Stacey Richter: So that the situation that I just described in Florida, the name for that is supply driven demand. 

[00:11:01] Ann Kempski: Correct. 

[00:11:02] Stacey Richter: Was this something that wasn't just limited to Florida? It sounds like it's given the number of states that put these CONs laws into affect. It sounds like this was something that wasn't a secret, legislatures across the country were faced with these ballooning supply driven demands, and, you know, leading to high fee for service costs, right? Because Medicaid, I guess, that's why the states were concerned about this, or maybe the state health plans.

Yeah, the states, particularly on the long term care side, states very much want it and still want to manage the number of long term care beds that they approve under their Certificate of Need because they assume that they will be occupied by patients who will eventually be Medicaid eligible and therefore impact the state budget.

So absolutely good intentions here and good reasons for wanting to manage the supply and have a process for managing the supply. 

Could you just explain the relationship between states trying to manage long term care beds and CON laws? 

[00:12:06] Ann Kempski: Depending on the scope of the CON law in a state, it could cover everything from what we were talking about. 

MRIs and the purchase of a new MRI and where that can be placed, does it just have to be in an inpatient facility, can it be placed in an outpatient facility, all the way up to long term care beds and kind of everything in between, dialysis beds even or dialysis stations. The thinking being that this is a way to manage costs at the front end by, as you say, managing the supply.

[00:12:39] Stacey Richter: What I'm understanding is the Certificate of Need laws, the CON laws get passed at the state level. And then what is required as, as you said earlier, just confirming my facts here, what you said earlier was that an applicant probably has to fill out a form, right? Like I believe there's this many patients, potential patients in this community, or there's a population of this amount and we know that the prevalence of something, dialysis. Needing long term care is this many per hundred thousand or whatever it is. So therefore, we see that there is a need for a new insert, some facility or equipment that we want to put in the community. Then that goes to some committee or something, like in state government.

[00:13:26] Ann Kempski: Correct. The law usually lays out the criteria for evaluating need. And sometimes some states, for example, North Carolina, actually every year or two, they create a report, a public report that describes need. And mostly it's driven by demographic data, as you can imagine. Different population centers are growing, rural areas may be losing population, and that becomes the foundation for this either state employees, good hardworking civil servants, who then try to look at the applications for need that come in based on the state report or state plan, if you will, or there is an appointed board or commission that reviews the applications. And that's also very common in many states. And often these boards or commissions are selected. Sometimes the governor appoints them based on a certain amount of expertise.

Imagine having the confidence that you know that this community needs just one PET scan, not two. I mean, that's kind of hard even in this day and age to really be confident that we know, we can actually forecast accurately how much technology, what types of technology are needed in a community. 

Obviously you need expertise to review these applications. The problem comes in when some of these experts also have conflicts, they may have be an interested party in an application or if not a direct interested party, they may be associated with the trade association that is interested in perhaps overall protecting the interests of the current members of that trade association as opposed to welcoming new entrants that might want to come into the market.

[00:15:14] Stacey Richter: So, we teed up the why here, which sounds reasonable, like you want to curtail total cost of care, you don't want it to be a just complete free for all relative to people making money off the backs of taxpayers, essentially, right, like, you can see why these laws were put into place for patients getting taken advantage of also.

Issues with CON Law Committees

[00:15:38] Stacey Richter: So you've teed up two problems that have wound up happening when you try to get a committee and we just, we just had a show with Brian Klepper a couple of weeks ago where we talked about the RUC, the RVU scale, I forget what the actual acronym is, but it's the committee that figures out how many RVUs per procedure, right?

This sounds like another example of that really, where you have a committee that's trying to figure out what the needs of the market are, as opposed to having a market driven approach. 

So this is problem number one. And then the second issue is conflict of interest. You do have in the healthcare industry, the regulatory capture, as it's called, when you have an industry that becomes very politically powerful.

You have people going back and forth between politics and industry, like how many people who work at, like the FDA, then go into industry. Do you think that CON certificates of need laws result in the committees approving too many facilities and then we get supply driven demand that drives up prices? Is this the market distortion that happens or what's going on here?

[00:16:45] Ann Kempski: That actually is not our problem. We don't have too many facilities being approved. What we generally have are the incumbents. What this process does is it empowers the incumbents who've already gotten one Certificate of Need to create a hospital. It may have been 20, 30 years ago, but they are able to be advantaged when they want more beds or they want to be the ones to add a PET scan.

And they have the lawyers, they have the resources, they can get in front of the Certificate of Need Committee faster in a more prepared way than an upstart facility. But what happens is, incrementally, the incumbents tend to get their applications approved. And when you are limiting the supply, when you're saying, well, our plan only allows for one PET scan in our community, what you've done is you've said to the incumbent, you get to grow your market share.

And for the guy who didn't get his application in fast enough, it's asking a lot. It's asking a lot of the civil servants, it's the last asking a lot and get it wrong. Or even if you kind of get it right. By advantaging the incumbents, what you do is you help them grow their market share. And in the case of it being hospital based and not outpatient based or office based, you also expand the opportunities to, for example, impose facility fees on a new piece of equipment.

And perhaps if you had approved that piece of equipment in an outpatient setting, you or a setting that was not hospital sponsored, if you will, you could have avoided that facility fee and given a second option to the consumers and the purchasers in that community for getting a PET scan. 

[00:18:37] Stacey Richter: If you have an incumbent in that area, they probably have more regulatory capture, right?

They probably have more influence. They probably donated some more political campaigns. They are a large entity in that area that lots of people work for, right? So there's conflicts of interest, which then leads to, I mean, these are not inextricable, right? 

The second thing that you mentioned, which is that incumbents wind up with a big advantage. That they obviously can take advantage of in a number of ways. One of them is they already know everybody on the committee, because I'm sure it's the same committee that's evaluating, you know, it's not like you've got a different committee for every single need. So they just met with these people three months ago to talk about something, right? So it's not their first day at the rodeo. 

Whereas if you have a brand new entity that comes in, it might be theirs. They don't know anybody. They don't have any relationships with anybody on that committee. So I definitely can see how this starts to become an issue where the big get bigger. And anybody who is trying to come in and be an upstart in that area and challenge the incumbents winds up getting shut out.

So our three things that have wound up happening as a result of CON laws is number one, the committee is the market. Number two, conflicts of interest start to roll. Number three, incumbents get bigger for the reasons that we just talked about. But it sounds like number four, it's almost like if someone had to ask Kodak if it was okay to have digital cameras, that you wind up with a situation where the incumbents would have so much power that of course they're not going to enable ASCs and forego their facility fees.

Of course, they're not going to enable somebody to stand up remote patient monitoring and do hospital at home interesting things or, you know, anybody doing anything which is going to ultimately reduce the ability of those incumbents to make the amount of money that they are making because it doesn't matter if they are tax exempt or not.

We see over and over and over again. That consolidated entities, prices go up. Last I saw a study, it was several years ago. Prices go up and there's no measurable improvements in quality. So incumbents getting bigger doesn't help. But here's my last question on this one.

Repealing CON Laws: A New Approach?

[00:20:55] Stacey Richter: If you get rid of the CONs, and it sounds like there have been a lot of states that have, do you go back to the original problem, supply driven demand? So are states simply getting rid of these CON laws and then they're like, you know what? The original problem was actually not as bad as the ones we created, so we'll just scrap it. Or are they learning lessons and putting in laws which don't have all the problems that we have just talked about?

[00:21:23] Ann Kempski: Great question. What I would say is, and first of all, I should mention that South Carolina just recently essentially repealed its CON law. So we'll have another natural experiment, so to speak, where we can observe what happens in South Carolina over the next few years. But I would say that what we see, you know, Texas has no Certificate of Need law.

It can be a bit of a wild west in Texas. You know, the freestanding EDs became a really big thing in Texas. Now, you could say, gee, they're terrible. They stay out of network sometimes with health plans, but in a big state like Texas, where huge swaths of the state are very underserved, is it better? And if there are investors that are going to put their own money at risk to open a freestanding ED?

It doesn't even have to be investors. If another health system says, gee, we really actually want to serve the community adjacent to us. Let's put a freestanding ED. I would say that, in my opinion, if they bet wrong and actually we don't need this freestanding ED, well, that's investors who've lost money.

They guessed wrong. But there are no taxpayer dollars at risk here, really. I mean, there may be some unnecessary care that happens, but we know that unnecessary care happens even in settings that are well regulated in our health system. So I think we shouldn't be fearful of perhaps new facilities that may not make it, that end up closing after a while. In other markets, we do allow this. 

[00:22:58] Stacey Richter: Not going to get into freestanding ERs staffed by PE backed ERs staffing companies and the pros and cons there because we could talk about that all day. But my takeaway from all of this is that in a volume driven industry, such as healthcare under fee for service, You make more money, the more services you provide.

And in a, in air quotes market, that's not really a market, you have all these weird kind of not market mechanisms that are going on here. No matter what you do, there's probably going to be unintended consequences.

There's bad stuff that happens with these CON laws. There's potentially bad stuff that could happen if you repeal them. And the question is kind of like, I guess, what's a lessers of evils, etc. And if we're thinking that total cost of care is price times volume, and if you put these CON laws into place and the incumbents get bigger, then you wind up with prices that are really high.

I mean, that's sounds like the net net of what we've been talking about here. That you probably actually could have increases in volume if the prices were lower. Yeah, I mean, it's a conundrum, but there's a bunch of facts that people can be taking on board at this juncture. So let's move on to our second state reg with unintended consequences or state law with unintended consequences.

What do we want to talk about next?

Introduction to COPA Laws

[00:24:19] Ann Kempski: Certificate of Public Advantage. 

Another, yes, not to be confused with Certificate of Need. And there's about 19 states, so fewer states have these laws on the books compared to Certificate of Need laws. And they're very interesting laws because they're enacted kind of in anticipation that they might be needed or they're enacted to deal with a very specific transaction or proposed merger that is coming up in their state. 

And what the laws do is they attempt to kind of immunize a merger or an acquisition in a market in a state that would otherwise get the attention of antitrust regulators. And, and I want to say that I think states absolutely have a right to do this and competition shouldn't be the only criteria that you care about.

You know, you may say, geez, we're really losing our rural hospitals, we're really losing our maternity services. This big system over here in this urban area says they'll buy a smaller system that has some rural hospitals. It will lead to a dominant market situation, but it'll preserve our rural hospitals.

[00:25:32] Stacey Richter: Let me just recap there. What we're talking about here is a Certificate of Public Advantage, sometimes called COPA, if I'm not mistaken. So these Certificate of Public Advantages, again we talked about the Certificate of Need, this is not that, this is a Certificate of Public Advantage. These are enacted proactively or reactively, it sounds like.

Because the FTC, the Federal Trade Commission, is worried obviously about competition, so maybe the FTC is going to not condone some merger that clearly leads to some sort of monopolistic situation. So the state is thinking to themselves, hmm, we better get ahead of this because if, unless this dominant system in our state takes over the maternity services in some rural community, which is losing money hand over fist. So, you know, if any independent entity bought that, they'd clearly shut it down because it's losing money. There's a lot of rural hospitals that are in this pickle, right? So the state is thinking to themselves, we'll let this big hospital buy these rural facilities even though we know it's monopolistic, because we believe that if this big dominant hospital system does buy the, that's, that's their only hope. They're going to come and save these rural hospitals and we're going to let them be the savior of these rural hospitals, even though we are aware the FTC might frown on it because it's clearly monopolistic.

[00:27:01] Ann Kempski: I'm very sympathetic to the state perspective here and the state's rightly so think, well, we're closer to the situation. We're accountable to the voters of our state. And we're trying to, you know, we're trying to make the best of a bad situation here and we're not just going to rubber stamp this, we're going to create an oversight process.

So very often what the state law does is it puts in place a process. Either it's often shared by the health secretary and the health and human services agency and the state attorney general that will work together to create oversight and the oversight after the merger is allowed to go forward.

It usually includes a very formal written agreement that the party is agreeing to be obligated for. It might include levels of charity care. It might include keeping the rural hospitals open. It might include trying to monitor what happens to prices.

Challenges with COPA Laws

[00:27:58] Ann Kempski: There's not a lot of COPAs out there. They are, they're not like Certificate of Need laws where applications are coming in all the time.

These are fairly rare. But when you look at case studies at how well they've worked, unfortunately what happens in practice often is for a few years there's resources put into the oversight, there's data that's collected, and then the resources aren't there anymore or the data and criteria that were originally imposed kind of have outlived their usefulness and really it's other services you want to protect and those you didn't protect and so they're being curtailed. So most of the research on the COPAs also suggest they don't really accomplish what is originally the intended goals. And again, now we have a lot more price data than we had before in some of these COPAs that happened say, you know, 5, 10, 15 years ago.

But what, there's been a scary, at least from my perspective, a scary case coming out of Louisiana where a federal judge has essentially said to the FTC who wanted to get involved in a merger happening that no, the COPA essentially does immunize this merger and the FTC has no role to play. Now, we'll see if the FTC appeals this, but it's an interesting situation in Louisiana where the goal, the public advantage that the state officials have decided outweighs the competitive consequences is they want to really strengthen their medical education system and make sure that there are the opportunities and the settings for training future doctors for Louisiana.

And so they're allowing a big merger of teaching entities in the state. And again, may all work out fine but probably what the state is doing is advantaging teaching hospitals that are known expensive settings for care and we just want to make sure that that doesn't happen at the expense of other care options in that state where there are more affordable options for care.

We want to preserve the academic mission but not have it curtail other options for care in a community. 

[00:30:16] Stacey Richter: The state is saying not everything is capitalism has its flaws for sure and getting capitalism and healthcare, putting those two things in the same sentence leads to all the issues that we see, you know, private equity, etc, and consolidation and people who are more concerned about profits than patients, right?

Like that's a whole thing. So a state is basically saying, look, we're okay with this monopoly for a bunch of really good reasons. But what I'm understanding you say is that if a state goes ahead and does this, that there are certainly a lot of potentially unintended consequences. The same ones that if you get a textbook and you look up monopoly in the textbook, you're going to find as its downsides, which is why monopolies tend to get broken up by the FTC because bad things are happening.

So if a state chooses to do this, they are really taking on a great and ongoing responsibility to be watching and making sure they are addressing what is going to be the downstream consequences this year, next year, but also five years hence. And if a state chooses to do something like this, but then doesn't take on the commensurate responsibility that is going to be required to keep an eye on that, then it could go badly It is what I'm hearing you say.

[00:31:33] Ann Kempski: Well said, Stacey. And just like there's an encouraging sign with South Carolina repealing its Certificate of Need law, there's an encouraging sign right now in Indiana where there is an effort to have two hospitals merge under a COPA arrangement. And the employer coalition in Indiana has stepped up and spoken out and expressed a lot of concern about what the impact of this could be on prices and options for care choices for the employee populations. This is coming from a very activist employer coalition. You may know Gloria Sachdev, she leads that coalition. She's sort of the founder of the RAND study on hospital prices. So when she says she's concerned about hospital prices, she knows of what she speaks.

And what we need is to have more voices like employer voices. Right now, there's such a vacuum. There isn't the formal representation of the consumers, the patients, the employers often in these situations. It's really the provider voices and state officials and good civil servants just trying to make the best of a really challenging situation.

And part of the challenge is that there are these enormous systems now that are calling the shots. So what we also have to do is really strengthen voices that right now are very often not heard.

[00:33:01] Stacey Richter: Yeah. I mean, we're talking about immense entities with immense lobbying power, with lots and lots of money, lots of PR campaigns. So I definitely hear what you're saying that this is definitely a conversation with two sides to it and, you know, both need to be balanced. Probably the answer is somewhere in the middle, like everything always is, but if it starts leaning too far in either direction, you can get yourself in some of the pickles that we see you across the country.

Conclusion and Final Thoughts

[00:33:31] Stacey Richter: Is there anything that you want to add here, Ann Kempski, in sum?

[00:33:36] Ann Kempski: I guess I would just add that this is hard. I don't want to imply that I think this is easy, but we really, we're running out of options. The options we're going to have left pretty soon are going to be, like, price caps, right? They're going to be going back to looking at, like, Maryland and its all payer global budgets for hospitals.

That's where we're headed, because we really are going to face both on the public budget side and the employer budget side, we're going to have a reckoning. I don't know the answer for creating more of a sense of urgency and seriousness around paying differently so that we're not just encouraging volume and price increases.

[00:34:20] Stacey Richter: Ann Kempski, if someone is interested in learning more about your work, where would you direct them? 

[00:34:25] Ann Kempski: I'm sporadically active on LinkedIn. 

[00:34:28] Stacey Richter: Ann Kempski, thank you so much for being on Relentless Health Value today. 

[00:34:31] Ann Kempski: Thank you for having me, Stacey.

[00:34:33] Rob Marty: This is Rob Marty, and I'll be the first to admit that working in healthcare can be stressful. I have my good days, and I have days where I feel like our broken healthcare system is here to stay. On bad days, I find hope by listening to the Relentless Health podcast, and I feel as if Stacey is speaking directly to me when she reminds us we are all part of a tribe.

We are not alone in our pursuit of high quality, cost effective, accessible, and inclusive healthcare. You can help someone like me find this podcast and join our tribe by leaving a review on iTunes or Spotify, subscribing to the newsletter, and, most importantly, inviting others to join the tribe by sharing the podcast with them.

You are a changemaker and a valued member of the Relentless Tribe. Thank you so much for listening.