EP450: When Your Health Plan Is $9 Million in the Hole, Who Are You Going to Call? A CPA. And Tell Them to Bring Their Spreadsheets, With Marilyn Bartlett, CPA, CGMA, CMA, CFM

[00:00:01] Episode 450. When Your Health Plan Is 9 Million In the Hole, Who Are You to Call A CPA. And Tell Them to Bring Their Spreadsheets. Today I am speaking with the one, The Only Marlin Bartlett, About Going from Bankrupt, To a hundred and twelve million dollars in about three years.

[00:00:40] Now with Marilyn Bartlett, You Can Find It On The Website. My very first meme ever. In this meme, I picture

[00:00:46] that Olympic silver medalist shooter from Turkey who showed up in a t-shirt and his hand in his pocket.

[00:00:52] Versus the others with all their fancy equipment that turns out may or may not be necessary.

[00:00:58] Regardless, over might swear up and down that complexity requires even more complexity and plenty of expensive geared

[00:01:04] shoot straight. Point being, it's amazing what it's dedicated CPA with the spreadsheet and their eye on the target,

[00:01:10] can accomplish in the real world when they just do their thing and follow the dollar. And with that,

[00:01:17] Marilyn Bartlett has answered the chat. Marilyn Bartlett isn't called the Queen of Health Care for no good reason

[00:01:22] and nobody is joking when they say this. She was probably the first person or one of the first

[00:01:33] sucked out of the wallets of taxpayers and employers and plan members and into the pockets of the health care and

[00:01:40] insurance and consulting industries. She is a through and through numbers person but also deeply

[00:01:45] cares. She is truly a senior stateswoman in our field. Let's start from the beginning here, but you'll have to listen

[00:01:51] to the interview that follows for the end. And most of Marilyn's really sage advice and words of inspiration

[00:01:57] for any of you, for all of us, trying really hard to fix health care in any day of the week taking two steps forward and or five steps back.

[00:02:07] It's what Mike Tyson was talking about when he said everybody has a plan until he gets punched in the face.

[00:02:13] And yeah, I say pretty confidently that everyone in the relentless health value tribe trying to fix health care has been there at some point or another.

[00:02:21] So here's where I begin the conversation with Marilyn Bartlett today. One day in 2014 or 2015,

[00:02:28] Marilyn was mining her own business as a CFO at a regional TPA firm about ready to retire

[00:02:34] when the state of Montana reached out. They asked if she would consider being the plan administrator for the state employee health plan, which was

[00:02:41] turned out headed for bankruptcy. Marilyn took the job and she took the state health plan from $9 million in the whole. They're in debt, $9 million

[00:02:52] to $120 million to the good. Well, meanwhile, plan members got better benefits. Think about that, $9 million

[00:03:02] to $120 million in the good. In fact, the plan had so much money in 2018 when Marilyn left that the state took some of

[00:03:10] hits a pay for other things in the budget. This is truly mind-blowing. I mean, get a CPA with our eye on the ball

[00:03:16] and this is the difference that is possible to be made in a state health plan. It also just needs to be said

[00:03:22] that the same state plan, the one that was going bankrupt? Clearly had seen over $100 million of taxpayer money

[00:03:28] exit stage laughed and wind up in the bank account of their vendors. Now might be a good time to mention something that

[00:03:34] Christine can wrote about the federal employees health benefits program. This is a 55 billion dollar program

[00:03:40] once again funded by taxpayers. As per an OIG audit, there is no written policies or procedures over approval and payment of funds to the carriers via

[00:03:51] ACH. Wait, what? This is just one example, along with a whole lot of other things that kind of make you go,

[00:03:57] hmm, can a CPA with a spreadsheet please get in there and do your thing? In the conversation that follows,

[00:04:03] I ask Marilyn to tell me what she did in roughly three short years to do her thing and save the state of Montana

[00:04:10] over $100 million while improving benefits of the state workers. And she tells me short version, she created a why. That's step one.

[00:04:18] Step two, she looked at her spreadsheet some financial analyses and quantified the situation. She was able to identify a few big hairy problems, which she then hit fast and hard with solutions.

[00:04:31] This is going to accomplish a couple of things if you do this find a solution for a big enough problem. First, to create a quick win and quick wins are needed to get some momentum to get started.

[00:04:40] Second, she knew that by solving big hairy problems the solutions would have an outsized impact given the scope of these original problems.

[00:04:48] This is kind of strategy 101 and then step three, she dug in on assembling the right team with the right skills to make it through what amounts to a change management process. I'm going to say,

[00:05:00] what in Marilyn not do in those three years, she did not get captivated or sidetracked by any I'm going to call it transformational theater, which is not easy because a lot of transformation theater has more glitter than a Las Vegas show and is really hard to look away from. It says magical is most magical thinking.

[00:05:20] Also, Marilyn stayed the course in the face of what I am sure were many opportunities for personal gain that would have not been a win-win for the state of Montana or its employees.

[00:05:33] To emphasize how one should not take this for granted, I was talking to a benefits later the other day and you know what she told me? She said she always goes with this one carrier every year because if you go with that one,

[00:05:45] when you get invited to their box at the NFL games, you can go out on the fields afterwards. I mean it's really fun to meet the players. Unfortunately for so many in positions of power when doing the right thing by taxpayers and or plan members stands between them and box seats, the right thing gets escorted out of the building.

[00:06:05] mentioned in this show we have core up-sol and clear Brock Bank who both will be featured in upcoming shows about RFPs and best practices and how they can go right and also occasionally take a left turn.

[00:06:18] I also promise in the show to put links in these show notes two episodes about pharmacy benefits and pbms which I will do.

[00:06:24] I might think of some others but you'll definitely see links to these shows with Paul Holmes, the one with Mark Cuban and Farun Williams and also AJ Loyakano.

[00:06:34] My name is the Syriaccer at this podcast is sponsored by a Ventria health group.

[00:06:39] Marlin Bartley, welcome to your relentless health value. It's really great to be your safety. Really appreciate your invitation.

[00:06:44] Here you are happily I'm not your retirement. You had the state of Montana employee health plan $9 million in the whole effectively.

[00:06:56] What was it about the circumstance that gave you the confidence that you could fix this?

[00:07:03] I immediately went to the website because the plan used to pose their financial state and sign immediately dug into the data and I saw a lot of opportunity.

[00:07:14] As you were scanning those financial documents, what were just the things that jumped out at you? The medical trend was out of line numerous points of loathings, numerous little add on vendors that I knew could be some quick hits.

[00:07:30] The pharmacy benefit, it was not a transparent pass through it. I could look at the amount of rebates coming back compared to what they should be.

[00:07:41] So there were a lot of metrics I was familiar with and I saw a lot of opportunity because the health plan was not meeting those metrics.

[00:07:50] You followed the dollar and when you followed that dollar, just based on patterns you'd seen in the past, you're like there's a lot of ways here.

[00:07:58] That the taxpayers of Montana are currently funding and you know those dollars are now not going to the state employees as intended they are going to other parties.

[00:08:09] That is well said. The state asks me to come or interview, I prepared my analysis and some quick fixes, some longer two fixes, some novel ideas.

[00:08:21] I also knew that since it was a largest self-funded plan in the state and it also had government money in it, that that was going to give me some bigger leverage to make some changes needed.

[00:08:34] So you also realized that by taking this position, you would actually have enough power to affect the rates and the rates and non-coding core.

[00:08:48] So you have to have a mass and power in the marketplace to be able to pull certain things off that you might want to pull off. So you also made that assessment right up front.

[00:08:58] So you're like, let's do this thing.

[00:09:00] Exactly what happened.

[00:09:01] I definitely wanted to dig into some of the quick stuff before we get into the longer terms but before we even do that and I guess massive spoiler alert here.

[00:09:11] But when you left, when you resigned your posts, what had you achieved? We started our efforts in early 2015 with that projection that reserves would be at minus 9 million and by 2017, our reserves were 112 million to the good.

[00:09:29] What way? So you went from negative 9 million in the whole. Yes, to 112 million in the black. Yes, we did.

[00:09:39] What you're saying is just striking in about 10 ways. So I'm going to attempt to contain myself and actually say one or two things co-genly.

[00:09:49] It's not like anything was fundamentally different from 2014 or 2015 when you began until 2017. Right, like you could probably very,

[00:10:01] incredibly look back on 2015 and say that taxpayer funds being wastefully spent. You have all of this taxpayer money that it's probably going to for profit entities or even not for profits, but basically that is not being used for the stated purpose, which is to take care of the the state of Montana employees.

[00:10:22] There's just millions and millions of dollars that are being wasted. You're absolutely right. And our goal was to enhance benefits and still the employees have not had any premium increase since 2015.

[00:10:36] Let's talk about how you went about this. You had mentioned that there were a couple of quick wins and you also said medical trend, which I know is is a harder to tackle and then you also said pbm rebate.

[00:10:46] So let's start with the fast stuff. What were those quick wins that you were just like, let's just take care of this, you know, this week.

[00:10:53] And that thing's that we kind of what happened. I immediately dug into the contracts and looked at the spanned versus the results. We had five well as programs.

[00:11:03] I immediately terminated for them, but we coordinated it with the members. So we did that really quick and that's a 5.5 million right off the top.

[00:11:14] We analyzed it closely and reached out to the members. It went really smoothly. So that was a quick hit that we got rid of that.

[00:11:22] The other thing I did was take in looking at the contracts was I expired the consulting firm we had. We were not getting the benefit for what we were paid.

[00:11:34] I also re-aligned a lot of things the staff was doing. We were overstaffed.

[00:11:40] And I could see that the stuff that you're just talking about when you see it in hindsight, it's like obviously. Obviously we would not have.

[00:11:50] I mean, who would have five wellness vendors? It's just that the chances of them not being overlapped and redundant in some ways is just feels very slim.

[00:11:58] I will ask you this question though. As you were doing this, how could you have been so confident that you weren't in some way diminishing access to care.

[00:12:09] Montana is a large state a lot of rural. How could you be so confident that by removing some of these point solutions that you weren't accidentally diminishing access or quality of care?

[00:12:19] What we found out was not many members for utilizing the services at all. Now one product was fully injured with a carrier for behavioral health and they would not provide us any of the information.

[00:12:33] We, the leading know what members were using it. We just knew that these we were paying. So we were able to do a mass nail to the employees and say if you're using these services could you please contact the health center or a nurse we had on staff.

[00:12:51] And they were able to help transition them and we didn't have one single fallout for now.

[00:12:57] First of all, you did a comprehensive analysis. Just where are we? You followed the dollar. You figured out where a bunch of the dollars were going perhaps wastefully and then honed in on those opportunities as your your quick wins.

[00:13:10] And anybody that has had anything to do with any sort of change management approach knows that that's how you start a change management approach in addition to figuring out what the why is and making sure that that is clear and communicated. And I think the why in this case just you know the fun just going to go bankrupt is pretty sufficient.

[00:13:28] So yeah, identify the problem you follow the dollar. You figure out exactly what the plan of action is going to be here and what the quick wins are then you.

[00:13:38] Vetted that solution and you're doing that by actually communicating with members and working with them to ensure that there is no diminishment of access or quality and they can largely tell you. I mean it's easy enough if no one's actually leveraging the services for effectively nobody.

[00:13:57] But the ones that are using those services they know I mean probably a no other space of anybody's corporate discipline would you go and ask the vendor how they're doing like you would go ask your employees it's interesting how you.

[00:14:12] So vetted the solution as your third step and then you had the power to put what you wanted in place exactly and it worked to really well.

[00:14:21] So those I think are good examples of the quick stuff where the state was in complete control you had the contracts you didn't need anybody else's cooperation.

[00:14:28] And you also mentioned medical trend was a little bit out of control here so I know this is a very long story that has lots of twists and turns but what was the plan there to control medical spend.

[00:14:43] I think as a CPA one of things I did was what we call a split variance was the trend based on utilization was it based on price most overall it was price.

[00:14:56] I got information from the actually to find out where our plans been was 43% of that were the Montana hospitals about 20% was the pharmacy benefit.

[00:15:11] So I knew it like I could hit those two areas we would get the savings we needed.

[00:15:16] Total medical cost to a plan is going to be volume times price you did the assessment to determine like is medical trend rising because all of a sudden our plan members are getting tons more services and what you determined was no that's not the case it's actually prices have gone up.

[00:15:35] And as you just said medical costs are 43% of the plan so that is a very relevant place to start.

[00:15:44] I think so too and that was 43% were just the Montana hospitals but we had 48 critical access hospitals in 11 acute care hospital.

[00:15:53] We looked at the acute care hospitals first because they were 87% of that 43% sure so if we could get those costs down we knew that that would help.

[00:16:06] That was our big effort we compared what our claims runs were for those hospitals as a multiple of Medicare plus we were headed towards no longer basic reimbursement as it discount off of the charge master and both of those being secret and can change it anytime to doing a cost plus now that's an account for you.

[00:16:32] We like cost plus so I wanted to do Medicare plus we did that analysis we saw where the hospitals came out and at the same time.

[00:16:42] I was digging into the Medicare cost reports that 90s the audited financial statements doing organizational charts and developed the very beginnings of what is now the National Hospital cost tool can know.

[00:16:57] What that hospital would need for me to break even we decided our approach with the hospitals and be data driven.

[00:17:04] We would have the data we would share it with the hospitals but we'd keep it to data driven we terminated our contract with the carrier TPA we had.

[00:17:16] We did an RSP we said exactly what we wanted but then we left it open if you have other ideas or different approach you can talk about that too.

[00:17:26] It was interesting because we had a re well we had no respondents and only one that they would do what we wanted.

[00:17:33] I just want to point out that we do have a show coming up with Claire Brockbank who digs in deep on how to do an RFP and shares a lot of the same kinds of thinking so if you're really interested in RFPing then please do listen to that show it's coming up in a couple of weeks.

[00:17:50] I think the interesting thing that you're saying here Marilyn is you started out your hospital initiative by figuring out what you wanted the plan to look like like what your whole strategy was like you figured that out.

[00:18:04] And then the next part is you know what I have to have a TPA and so who's willing to work with me he didn't just immediately go talk to hospitals there was an intermediate stop where you went and found your TPA partner as your first for a well we knew that we didn't have the negotiation skills that might be needed so the TPA that we chose definitely had their provider relations department and we're on board with our strategy.

[00:18:33] And could help us with the contracting because me ended up with separate contracts reach hospital and then some ambulatory surgery centers.

[00:18:43] So we relied on their expertise once we had it we went to two of the facilities we did not want to do price setting I had a legislature that was very adamant they did not want price caps and they did not want price setting.

[00:18:59] So we were doing individual contracts for no balance building and each contract was different with the rates but that process was insane on every single one of them.

[00:19:11] So everything would be built at a multiple of net care they were caped as far as increases which were dependent upon the Medicare payman increase or CPI whichever was a lowest for medical.

[00:19:24] We wanted it across the board including the fusion drums in patient outpatient we wanted it across the board because we don't want to just carve out one little bundle and see the prices of the web in other services we then started negotiating.

[00:19:40] And we went to two hospitals that were already in that range they were kind of called out as the more efficient hospitals and we started working with them.

[00:19:51] And we also thought it was a great to do it one in Billings a large city that has another hospital and one in Brazil a large city that has another hospital.

[00:20:00] And once they signed on we were able to then get some momentum started.

[00:20:06] I just want to stress again that if we're thinking about how do you roll out a program and do the change management which is required we talked about quick wins in the context of just the whole program.

[00:20:20] Rich large meaning let's find some quick wins to save money and just roll those out because we can do that quickly which gains us momentum.

[00:20:28] This is kind of another version of that all right so for our let's save hospitals medical trend which is 43% of our whole plan.

[00:20:35] Let's get a quick win by working with the hospitals that we know are probably going to be amenable to working with us and then as you said it again this gives moments and we can say that we've succeeded.

[00:20:47] You know so for any doubters that are in the in the vicinity we can be like look this works don't say that it can't work with hospital because we're already showing that it can.

[00:20:56] I know this whole getting the hospitals on board is a very very long story which is fraught on a number of different levels because at the same time that you're lobbying to get a cost plus you know get a percentage over Medicare they are coming in saying that they can't possibly do this and also their major employers so therefore they have their own power base and leverage.

[00:21:21] Just really at the top level Maryland is there any just kind of summary word of wisdom that you might have for somebody who is trying who might be in the middle of the whole.

[00:21:35] I need to work with hospitals and they have zero interest working with me right up front once the idea was conceived and when I started assessing.

[00:21:44] I knew I needed to pull the right team together and I would need support so we worked with the governor and real key to this was the budget director.

[00:21:56] So I like an app to let CEO and a CFL of the corporation the director of administration who was my oversight totally on board.

[00:22:05] We brought in the union leadership because we needed their support in selling this to employees.

[00:22:13] We also I was required to report to the legislative finance committee quarterly while I was putting this in place and update them so there were a couple of members that that body that we included in our group to really get the right team together.

[00:22:31] So when I look at the right team I think that I needed that support and I'm sure every benefit and administrator out there in HR person would probably echo what I said because I knew we were going to be lobbied heavily and the governor would be lobbied.

[00:22:48] The budget director would the legislature would and I needed a support team to carry our message and have our back and help us.

[00:22:58] And then the second thing I did was I needed we needed vendors that were on our team we needed vendors that were clearly loyal to us.

[00:23:07] So I did fire the TPA and we hired the one that agreed to work with us.

[00:23:14] I fired the PDM and we found a good transparent past that would work for us and then a new consultant company.

[00:23:24] Okay, so I think you just said something that was really powerful there and I said to you, you know like what is the one thing?

[00:23:32] What is the one really big piece of advice word of wisdom that you might have for somebody who is trying to work with hospitals and you said get their 18 around you.

[00:23:41] You ticked through who is so necessary to be on this team and if I was going to sum it up, I would say you have to have again it's kind of this whole power thing you have to have people that you know you need to support you otherwise you're going to get undermined and you said the governor and important government people which could be like in the private sector to the CEO and CFO.

[00:24:01] So you have to make sure that you're thinking through right like who do I need to have on my team because if they're on the other team it's got a peer problem.

[00:24:10] What you're saying has a lot of really important lessons you got to set up the why you got to understand what your problem is you got to follow the dollar you got to do some quick wins but the one rings to rule them all I guess is get the right people around and I might also just add to that people with a really strong sense of why.

[00:24:30] Spines of steel a lot of conviction because as you're kind of alluding to you're getting hit from all directions with why we can't do this and just status quo and there's money that's involved here.

[00:24:46] So there's every dirty trick in the book that's getting tossed at you so it does take a really strong conviction and an ability to march through the the mailstrom of attacks.

[00:25:01] That's exactly right and the other thing we did was when we have this right team together we looked at where we may be needing some help and I think you know my strength is as an account and.

[00:25:14] Loving to review and and do contracts RFPs follow the money.

[00:25:21] We knew that we needed help on the benefit side the clinical side too and I didn't have that on the staff at the time nor did.

[00:25:31] We're any of the connections really viable to change and so we hired on a consulting basis of retired primary care doctor in Helleneth who really knew Montana a new primary care and new the health side of it.

[00:25:48] We also hired a communications consultant we needed somebody that could help us and really support us through the change management process communication with employees the media and help guide us in map.

[00:26:03] And then I also hired an independent pharmacist is the consultant in Montana to help me understand a little bit better about the retail pharmacy side and the member impact.

[00:26:17] So we rounded out our team with some of the you know special areas that we knew we're missing within our key team I think that was all very very necessary.

[00:26:28] What I really like about talking to you, Marlin you're showing what the road map needs to be which is inclusive of this right team and who should be on that team making sure you have all those bases covered in real experts because some of the attacks are going to be will do you know this to be true.

[00:26:45] And try to undermine so recognizing that that is going to happen just put together the right team of your own experts there is a playbook here this can be successful.

[00:26:56] I think you're right and another thing is we did it quickly when you think of it because we really started this in 2015 and by you know by the time I left into live 2018 we had reference face contracts in place with all of the hospitals.

[00:27:14] We had moved to transfer past through pbm I'd keep CBS out of the network because they would not match the pricing we needed.

[00:27:24] We got rid of those duplicate contracts we enhanced our onsite clinics and even even this was probably even bigger challenge was I wanted off of the state.

[00:27:37] ERP system it was big in our cake we moved to a cloud based.

[00:27:44] The NFC enrollment and industry system and that's said 1.5 million annually.

[00:27:50] I wanted the plan to always have access to their data.

[00:27:54] So we don't really have time to talk about this stuff that you did on the pharmacy side of the house but it does mirror we have had guests on the show like.

[00:28:02] Paul Holmes we had Mark Cuban talking we have had I can put in the show notes a list of shows that have been about curtailing and controlling pharmacy spend and as you said that was also.

[00:28:15] All initiative because it was 20% what did you say was 23% of your overall spend.

[00:28:20] It was about 20% and when we were done we realized that we had saved 23% by all measures this was really successful and I just want to restate that you started out 9 mil in the whole.

[00:28:41] So with no diminishment of benefits to plan members that is what is possible here like you think about how much money was slashing around.

[00:28:52] Not going to its intended purpose so you can see why with the class action lawsuits and stuff it's just that is a lot of money so.

[00:29:01] You left you go and what happens not to for our group here but there is a risk based capital measure it basically says do you have enough research the magic number to the state is you are doing really well it you can have 300% when I took over the plan it was well below that.

[00:29:22] But when I left it was at 822% so we were very very well funded now when I left in 2018 I left behind the next steps for reference space pricing which were to go work with the hospitals we knew there were some issues we wanted lower rate.

[00:29:42] Possibly some shared savings of different ideas when I look at what happened was by successors did not follow through with those particular plans and they also changed the transparent past through clinic model which automatically cost 2 million more a year.

[00:30:03] They also started adding work point solutions back even with that additional spending that went on after I left the reference space pricing the pharmacy all those things we put in place work holding that number down but then I do notice it in 2021 the plan was still over funded.

[00:30:24] So the that our BC number again when I left was 1822 but it was 169 so double what it needed to be.

[00:30:34] So the plan was doing very well very well funded but in 2021 I think the direction came from the administration and governor's office to change the whole plan they went ahead and did an RSP and ended up through challenges and stops.

[00:30:53] They did end up moving to lower but traditional plan with a large carrier those reference space pricing contracts are gone.

[00:31:01] But luckily the pharmacy benefits still does well and some of the other items that we did put in do you have any insight into the cost of the plan did it go up.

[00:31:12] The cost have gone up but they have not been public with me information I don't have anything since December 2022 there was messy jean going out that the plan was about to go broke but that was proven incorrect.

[00:31:27] So I'm not really sure how the plan has done since then the contract that they are in that I have reviewed is a pretty much standard carrier plan.

[00:31:38] The first effort they put in place was to do a retro active review of claims so they would get to the end of the year and look back and reprise sampling acclaims to make sure they hit hit targets of a multiple of Medicare.

[00:31:53] I personally don't like that approach because I think it's the member that suffers because when you do have those contracts in place any member out of pocket to co ensure and search deductibles is based on whatever that contracted radius versus when you do a retro active look.

[00:32:11] The plan made receive a little bit of money back in their out in cheese so I don't know how that analysis came out that's not been made public either.

[00:32:20] Marlin Bartlett is there anything that you kind of want to say in summary here and just to kind of recap we talked about like what's starting out at the very beginning making sure the wise established using the fundamentals of change management which you know sometimes I say the fastest way home is the long way around.

[00:32:37] Right like you have to do all of these things because failing to consider what the strategy is here making sure we've got the right team getting some quick wins.

[00:32:47] Talking members doing the communication rate making sure that the quality of care isn't being diminished at the same time you kind of got to get through all of these different steps but.

[00:32:56] Marlin you have a huge presence and the amount of inspiration I think that you have given over the years that you've been involved doing these kinds of things is substantial.

[00:33:06] What do you just want to say to the relentless tribe?

[00:33:09] Well thank you peer kind words.

[00:33:10] I'm let want to say to planted administrators their leadership you can do this and actually we had fun.

[00:33:19] We knew we were going to get hit we were going to get slammed I was going to be called names and things written about me but we did it we knew our focus was the right thing.

[00:33:31] Well can we get that money out of the middleman out of the system and how can we get it back because the intermediaries the TPA insurance company side the payers is that employer taxpayer in number and we knew that we could.

[00:33:48] Get it back and you know one of the neatest things about it was just before I left the union gave me an award in banked in so many people out that union function said I didn't know the health plan changed.

[00:34:02] I just know I have great benefits so that was the best best compliment is that what we were able to do was make a rate system changes and not impact members but help them.

[00:34:15] And you can do it you really can do it and I think a team of the leadership the HR the benefits plan you can do it that is probably the perfect way to end on that very inspiring no Maryland Barley thank you so much for being on relueless health value today.

[00:34:32] Thank you.

[00:34:33] This is Sean Griminger president and CEO of the National Alliance of Healthcare Purchase or coalitions if you like this podcast I strongly recommend subscribing and leaving a review.