EP475: Is This a Moment or a Movement? With Peter Hayes

[00:00:00] Episode 475, Is This a Moment or a Movement? Today we hear the viewpoint of Peter Hayes. American healthcare entrepreneurs and executives you want to know. Talking. Relentlessly seeking value.

[00:00:24] I was talking to Peter Hayes, my guest this week, and I said, Peter, you post a lot about many, many different topics on LinkedIn and elsewhere. If you had to roll up all of your posts into a few main, I don't know, change making vectors or forces of change, roads to Damascus, what would they be? And, you know, do you want to come on the pod and tell the tribe here what you're thinking?

[00:00:49] And Peter said, I would love to. So this show is going to be a top down kind of let's try to get a handle on said major forces of change and how those forces have swirled together to create the place that we are now. So most of this episode, I'm going to strongly suggest Relentless Health Value tribe members who tune in frequently. There's not any, oh, wow, what a revelation probably that's going to happen in the show today.

[00:01:16] And to be frank, that's kind of the point. It wouldn't be a major force if you all weren't aware of it now, would it? The goal here is to figure out how to organize so many posts about so many different things on LinkedIn. There's so many of these micro moments, maybe I'd call them. How do we organize them into a manageable number of strategic fundamental goings on that we all can wrap our brains around?

[00:01:42] That was my ask of Peter. And that is not easy because it's a valid question. A lot of times when talking about health care transformation, is it a moment or is it a movement? This show is, again, what Peter Hayes thinks the movements are. The thing is, though, it is surprisingly hard to discern what the forces of change actually are.

[00:02:05] What we often experience as a big dramatic inflection point has almost always been gestating for a while. This creates an opportunity for us all here in the tribe, because if we see the changes early or even better, spark the changes, an inflection point can really be a strategic boon. And let me tell you, I want everyone listening to have a strategic advantage over those who, I don't know, maybe are a little bit less concerned with putting patience before profits.

[00:02:34] But yeah, usually inflection points have been a long time coming because forces of change have been battering away for a while until they finally break through. I say this to acknowledge we've been talking about tipping points and the total cost of health care simply cannot get any higher. We've been talking about this for probably decades.

[00:02:53] But Peter says right now he firmly believes we have a force majeure of bridges too far, of obvious over the line activities that offend normal people's sense of justice and fair play. Peter believes we're at a really unprecedented place right now. So even if there's some starts and stops, some too bigs to fail, like, for example, some of the lawsuits are getting thrown out because it's legally unclear who the, in air quotes, aggrieved party is.

[00:03:21] Yeah, too much of this country is feeling like an aggrieved party. So it's only a matter of time. This is the major takeaway from the show today. Peter's view of how three main forces in the ecosystem all braid together and reinforce each other and have created a kind of inexorableness that something's got to give.

[00:03:41] And part of the equation here is just and I'm mentioning this because we keep talking about it is a brutal lack of trust that's really pervasive across so many parts of the industry. Patient to health care system, clinician to health care system, et cetera. As you listen to the show, definitely consider the shows from earlier with Dr. Kenny Cole and Dr. Christine Hale about high cost claimants. These shows are another view into this exact basic topic.

[00:04:09] They also show what trust can bring us if we earn it. I'm kind of thinking it could be cool to do shows like this periodically where we get different people to answer the question. What are the major forces of change? How are you rolling them up and what is your assessment of where we are now in the journey of transformation? If I get enough of you who are like, yeah, that's a great idea. I probably will be less likely to forget about it. Peter Hayes, my guest today, is technically at least retired.

[00:04:37] He was director of benefits at Hannaford Supermarkets for about 25 years. He's been on the advisory boards of Express Scripts and Definitive Health, among others. He served on two health care reform commissions in Maine, appointed by two different governors. He headed up the Purchaser Alliance in Maine. My name is Stacey Richter and this podcast is sponsored by Aventria Health Group. Peter Hayes, welcome back to Relentless Health Value. I am glad to be here. Thanks for having me back.

[00:05:03] One of the things that I really appreciate that you're doing in your productive retirement here is being very active on LinkedIn and highlighting just so many issues. So I have to admit that one of the reasons why I invited you to come back is just to try to get your assessment of all of these things that you talk about so frequently on LinkedIn.

[00:05:27] What are the ones that you feel like are adding up to this unique moment in time or this new tone and urgency that you have mentioned? So I think for me, as I've spent 30 years in the health care space, I've been somewhat frustrated just about how hard it is to change some of the things that are out there that are driving all the things we're frustrated with. I do think we're at this unique tipping point. It's sort of the perfect storm of events.

[00:05:55] I think there are three things that have really reached us to that tipping point. The three major things are changing public opinion. Two, transparency. The fact that we're really starting to get some information about our health care delivery system, both from quality, costs, equity, has really ignited sort of lots of voices in the space to really call for some changes. And then regulation increasingly is going to play a role.

[00:06:23] How states are leading the way to find some answers to how we can make health care better quality, more affordable, better access. So I think those are three things that are all colliding pretty quickly that is really going to drive this change or transformation that we've been talking about for years. I'm going to be cynical for a moment. We've been hearing about the tipping point, right? Like we've been hearing now it's the moment. Health care cannot become any more expensive. Oh, my goodness. It has reached 15 percent of the GDP, right?

[00:06:53] Like we have heard this for literally, I'm going to say at a minimum, a decade or more, probably more. So these are fighting words.

[00:07:04] I think we should definitely dig in on why these three factors of which you speak are just so unique and so compelling or have reached such a critical mass that after all this talk, now is the moment. And the first thing that you said was changing public opinion. And just to weigh in here for a sec, this one is actually, we have never really had that before.

[00:07:35] I don't think, to your point, I've really ever seen the public this fired up. Yeah, I agree. And I absolutely agree that we've all been having these conversations for decades now, but not talking about the right things. When I said it's a perfect storm, sometimes it takes just an event to really ignite the issue. Unfortunate, but I was really surprised by the reaction to the assassination of Brian Thompson at UnitedHealthcare.

[00:08:02] LinkedIn just exploded with people talking and realizing we have gotten to a point where something has to change. And what really shocked me is I have a young son who just recently graduated from college. And I kind of asked him what his peer group reaction was. It was shocking that many felt, yes, it was unfortunate, but it was deserved.

[00:08:25] And I think that really has sent, it's just been the symbolic message that people can really grab a hold up and say something is just really wrong. And I'll take that on the public engagement piece, kind of a couple of things tied to it. One, what's as a follow up to that, it's the first time that I've seen the board of directors at UnitedHealthcare started to demand that UnitedHealthcare be accountable for what they're doing with denials and some of their audits and other things.

[00:08:52] Two, it's the first time I've seen physicians really starting to speak up and say they're just not comfortable where things are. There's an interesting stat where in 2020, both the public and physicians had about a 71% trust level in hospitals and care. In 2021, fast forward, only 40% did. That is a huge drop in sort of public and physician confidence in our healthcare delivery system.

[00:09:19] Hi, I'm Chris Crawford, CEO and founder of RxSafeCard. If you love the Relentless Health Value podcast like I do, be sure to follow their LinkedIn page and join the conversation about the topics every week. Thanks so much for listening. There are a number of things you just said, as you mentioned, the Brian Thompson assassination. And it is horrifying to think vigilante justice at any level is okay.

[00:09:46] At the same time, it's like the lid got blown off the pressure cooker. It's almost like citizens of this country looked around and started sharing stories. And then it just almost seems like it's become now it's socially acceptable to start talking about your stories. Everybody realizes everybody else has a story like, hey, that time I went to the ER and got charged and yada yada blew out my credit cards. You know, like these stories are becoming so commonplace.

[00:10:13] And I think that everybody just all of a sudden realizes how common they are, which just accelerates the trend. 60% of Americans have medical debt. So it's becoming a real affordability issue. And it's actually gotten to the point where a lot of consumers are foregoing preventative medications and services and other things because they can't afford them. Physicians and other health care professionals.

[00:10:35] We had Kamal Bajaj, Dr. Kamal Bajaj on the pod, talking just about the number of doctors and people who work in a hospital who do not trust that their leadership has their back. You put all of these things together and in the court of public opinion, now we have a trial. That matters more to legislatures. We also have transparency going on, which I also could see being accelerant. And that's the second thing that you mentioned.

[00:11:01] Yeah, I think the transparency piece is really powerful. And I think there's some real staggering things that have come out of it. 60% of the time, the cash price is less than what your insurers are actually negotiating on your behalf. So for instance, in Maine, there's a hospital where the cash price for a knee replacement is $15,000. But the carriers are paying $45,000 on that same procedure.

[00:11:29] So I think those things are all starting to kind of come together into a, you know, as part of that perfect storm. An average person knows this now. Like an average person, like my parents' buddies in their senior community, one of them was giving me a lesson in how he goes to the Google. He goes to the Google and he types in cash price for insert drug name here and he can find it. That is what is meaningful in this exact moment in time.

[00:11:56] That just it is now public consciousness that sometimes it is cheaper to pay cash on its face. That is both a revelation and also a kind of paradigm shift in people's brains. Like that is happening right now. A couple other things on transparency I'd just like to mention too. Brown University came out with a model. It's the hospital payment cap simulator.

[00:12:22] But for any state in the country, you can look at what hospitals are being paid for medical services that you and I are paying as individuals in the commercial market. You can look at what they're charging as a percent of Medicare. Courts are starting to say that a fair and reasonable price is no more than 200% of Medicare. This model will look at the state health plans in every state and tell you what the savings would be if you moved from what they're paying, the state health plans, to 200% of Medicare.

[00:12:51] In May, the savings to the state health plan is $47 million a year. It's a 25% reduction. It's the price. It goes back to Yulia Reinhart in the 70s. It's the price is stupid. Two, on transparency, there's a lot more evidence about life expectancies. People have always heard U.S. has the best health care system. But if you look at some of the other countries, we're dead last when you look at life expectancy. So in the U.S., our life expectancies are going down.

[00:13:21] Average age is 78. The other European countries are at 84 years. Patient safety still remains an issue. Leapfrog rates hospitals on an A to F scale. If your hospital is rated C or lower, you have an 88% higher chance of not walking out of that hospital. That's unconscionable to me. 30% of hospitals get a failing grade of C or lower. You know, that's an opportunity. And again, we've talked a lot about the physician trust.

[00:13:49] So those things are all conspiring to ignite the consumers and really start to ask questions. With the transparency, you can start to see how much they are charging for medical services and drugs. So even consumers who are just, you know, like I don't have time in my life. I'm way too busy to worry about other people. Those individuals, they have medical debt. We had Dr. Wayne Jenkins on the pod. 41% of commercially insured patients or members were delaying or foregoing care due to cost.

[00:14:18] As we like 50% of people aren't taking drugs because of some cost issues. At the same time, we have plan sponsors and other large purchasers getting some transparency through more forthright contracting terms. And the power that comes from those who choose to act on this revealed information, which is bigger than price transparency. There's a lot now possible for plan sponsors to know about how their money is being spent or squandered by their vendors.

[00:14:46] It starts to be clear how much money Medicare Advantage carriers make from our tax dollars. What is it like 70 or 75% of at least UHC's revenue comes from taxpayer funded government programs. Also, there's a growing interest in transparency and like who actually owns the physician practices because, you know, PE buys them and tries to conceal itself a lot of times as the owner. As we talked about last week with Yasha Sweeney Singh, it's becoming just much more clear to average folks how much money.

[00:15:14] Some of these entities, including hospitals, carriers, PBMs, etc. Are making off the backs of sick people or old people or disabled people. And as aforementioned, taxpayers and many find it really unpalatable. So all of this, I definitely can see can easily turn into a flywheel because all these various transparencies that wind up with the public kind of getting a bead on what's going on.

[00:15:40] Can in a way impel purchasers maybe to do things they previously thought were optional on behalf of members and patients. So yeah, for sure. I think we have a flywheel of factors that can coalesce their impact here. Yes. And actually to your point, 30 to 40% of what we're spending is for non-direct care. That's going to all the intermediaries, administration costs, margins and others. That's a huge number. Yeah.

[00:16:07] So despite the complexity, the problem is very simple. And when you have the transparency to see that problem, it becomes all the more crystallized. The third thing that you said here is regulation as a component in all of this. What did you mean? So we talked about changing public opinion. We talked about transparency. And now we're talking about regulation. Many employers, 50% of them aren't even aware of it.

[00:16:32] But 2021, the Consolidated Appropriations Act to me is just an earthquake to the healthcare space. And what it really says for the first time ever that the chief executives, the board of directors, anybody that touches the health plan has personal and corporate fiduciary responsibility. If they are not using the benefit dollars of their employees and family members to the highest and best use.

[00:16:58] For the first time, you're actually getting some executives at different organizations really starting to ask questions. And so if you take it to its full extent in Maine, we have a hospital that's doing, as I said earlier, knee replacements, high quality by CMS star ratings for about 10 to 15,000. There's another hospital in Maine, not very far away, that's doing that same procedure with lower quality for 75,000.

[00:17:23] So presumably what this law starts to say, if your employees are going to that higher cost hospital and you can get it done at that lower cost hospital with higher quality, you are personally responsible for making that benefit decision. And all of a sudden, now you're getting the boards of directors and CEOs and CFOs actively engaged in making sure that they're buying healthcare services efficiently. And I think most states have some type of litigation in process.

[00:17:51] There have been a bunch that have already circulated through the courts. They haven't, the courts at this point, haven't really ruled in favor of the employees, but many are speculating sooner or later it's going to come. The legislation was really modeled after what happened in the 401k industry. And so I think that's another component here where finally executives are starting to say, gee, why is there such this unwarranted price variation and quality variation that exists? It's always been there.

[00:18:19] And now all of a sudden I've got personal risk. We're not using good due diligence and prudence in how we acquire benefits. And I think that's going to absolutely change the world. It also applies to consultants. There are a lot of times consultants have gotten as much as 30 or 40% of their revenue on back-end revenue flows that come from the health plans or other intermediaries. And all of a sudden, if that's there, the consultants have to disclose how much revenue they get, both indirect and direct.

[00:18:48] And then the plan sponsors and executives are going to have to justify why they may be paying a much higher price for those services. And I think really all of a sudden you've got the physicians engaged, you've got the public engaged, and now you have C-suites engaged. The third component here of this crescendo of underlying factors is the Consolidated Appropriations Act passed in the very, very end of 2021.

[00:19:13] It's now clarified that the CAA also requires PBM disclosures and I think TPAs, third-party administrators. And I kind of liken it, I'm going to say, Peter, to me, it's been a little bit less like an earthquake and a little bit more like peeling an onion. I agree. Because, you know, like it first came out and people are like, my plan's fine. And then you have these disclosure forms. First, they sort of gave it the side eye. Yeah, so true. Right?

[00:19:39] And now they're kind of creeping in and starting to realize just how much money, you know, for example, there was just a whistleblower lawsuit that was filed the other day where there was a broker who was taking 61% of its client plan sponsors pharma rebates. What? Wow. Oh, stay tuned. Actually, there's going to be a show coming up with Ann Lewandowski where we dig into that whistleblower lawsuit. Yeah. This is news. This is news.

[00:20:09] And then you get other plan sponsors who are looking around thinking, what? And the reason why these lawsuits are failing right now, and I had a long conversation with Al Lewis about this, is because there's a question mark, who is the aggrieved party? So like, if the plan sponsor is paying, as you just said, the knee replacement example that you just gave, one hospital, good hospital, good quality, $15,000 for the knee replacement. Other hospitals, $75,000. The question here is because the plan itself is picking up the difference.

[00:20:37] So it's the plan itself that's paying the extra $60,000. And no one has yet connected the dots between, hey, if your underlying costs go up as a plan, then members are actually aggrieved next year when their premiums go up. Like, that connectivity has not been connected yet. The second that that happens, yikes, is all I can say. Yeah, no, I agree.

[00:21:01] And I think when the Department of Labor put this in place, they kind of informally said they're going to tread lightly in the first couple of years. But again, I said earlier that this was kind of modeled after the 401k industry on all the hidden fees that a lot of administrators had. And they treaded lightly. And then there was just a case which connected the dots, as you suggested. And there was a huge sort of financial consequence of that to the organization. And that was the wake-up call. So I think you're right.

[00:21:31] It's kind of flying under the radar now. You have consultants telling a lot of plan sponsors, oh, there's nothing to see. But the speculation is at some point one of these cases is going to hit. And then, as you suggest, then it's going to be chaos for a bit. But I think that's on the horizon. I just don't know it. So we have three factors, as you talked about, that underpin a lot of, for example, the posts you highlight on LinkedIn.

[00:21:56] And they definitely create a bit of a trifecta that may add up to a perfect storm. That is the changing public opinion that there is unrest. Most members of plans may be more aware of the fact that they can go, you know, vis-a-vis any of these cash places and get a drug cheaper. Like, members are figuring out that the plan sponsor's plan is enabling stuff like this to happen.

[00:22:23] And then they connect the dots because of transparency to like, oh, somebody's taking money here. Like, somebody's making money. Like, why is it three times more expensive on my plan than if I just go to and get it off Amazon or Mark Cuban or any of these other places? You start having public opinion changing. And then you've got regs like the Consolidated Appropriations Act that sort of validate some of the transparency and also create this flywheel. What's in the middle of the flywheel?

[00:22:50] Like, if we were going to sum up these three factors into just like one force majeure, what would it be? I think we've talked about it and touched on all of these things as we said. It's kind of the perfect storm. It's a bridge too far or bridges too far. When you have a system where the actual people that are providing the services, clinicians, providers are unhappy, patients are unhappy, and it's unaffordable, it's all coming together. And I think the big issue is just this erosion of trust.

[00:23:19] We as a country are really starting to look at all of that. How do you reestablish trust in some of these organizations? You've just got enough people. You've got this critical mass of people who are like, wait, we've got an issue here. And it's all culminating with a lack of trust, which in and of itself is a huge problem. It's like that Winston Churchill quote, which I'm remembering off the top of my head. Americans will eventually figure out the right answer after they've tried everything else.

[00:23:44] So if we think about, all right, now we've got this eroded trust, which has wound up transpiring because we've let it go to this point. If we start thinking about the possible solutions and next steps, like we're in a trench here right now. How do we get out of it? How do we restore this trust? What happens now? It's the trillion dollar question. For the three trillion, four trillion, right? Yeah, true. I think that trust piece is really, really important. And I think that quote you have of Churchill I love, and it's spot on.

[00:24:14] I think a lot of us have believed for years, there's always been the flavor of the month. Oh, an HMO is going to drive all these savings. The, you know, Accountable Care Act is going to drive all these savings and make things better. Point solutions, the disease management and wellness and other things. I think, you know, where we are on Main Street is none of those things have really worked. And so what we need to go back, and it goes back to the top of the conversation,

[00:24:38] what we need to start thinking about is what's the root cause of the problems and how do we start to solve those? And again, I come back to look at fair pricing. We should have standardized affordable prices. Is healthcare a utility? Utilities are described as the basic necessity. Maryland has had a price regulation on hospital services for decades or more that has been effective.

[00:25:01] And now you see eight states that are really starting to move ahead on state regulation that's going to do things to improve price controls and other things. And there are Connecticut, Maryland, Mass, Nevada, New Jersey, Oregon, Rhode Island, Washington. On the prescription drugs, there are 11 states that have formed public accountability boards. You know, Colorado, Maine, Mass, Minnesota, New Hampshire, New Jersey, and others. So I think a pathway, because they are virtual monopolies, they're too big to fail.

[00:25:31] They're too big for any individual market force to change them. We really need to start thinking about effective regulation at the national level that's going to level the playing field. As I'm parsing what you just said, one of the things, and Chris Crawford said it most recently on the pod, if we want to think about how prices wind up becoming fair, it's not just transparency, it's also competition. True. If everyone's like, whoa, the price is too high. Okay, now what? You have to have a layer of competition.

[00:26:02] Otherwise, it's just the price is high and wow, that sucks. And then you start thinking about, well, how do you bring competition into a market that is too big to fail? Where you have these entities where every time, you know, a competitor moves in, it gets bought or the whole catch and kill. That is happening right now, which basically means that a market has become unbalanced. It is no longer a market. It is dysfunctional. The FTC was created to ensure that the market is fair.

[00:26:30] And there's many places in the country that it's currently not. So generally speaking, there has to be some level of regulation. It seems like states are picking up the torch here and maybe a little bit more nimble. They're trying to figure out these affordability boards and doing a whole bunch of different things, some of which I understand are going quite well. There's issues elsewhere. We're in that moment where policymakers need to have the bandwidth and the agility to learn.

[00:26:59] There's a really interesting podcast, Econ Talk, you know, because economists talking is something I can't stay away from. It's like a magnet. But anyway, it is something I think is fairly unappreciated that you can't just make a policy. The end, right, that those policies need to evolve just like a business is going to evolve its product.

[00:27:19] So when you have these entities that are too big to fail, that are regulated by policy, it's going to necessarily need to be some sort of evolving effort there. But there's just so much opportunity. You know, like Dr. John Rodas is our independent director at QC Health, and he is a former hospital CEO. He took his hospital from I think it was like a C leapfrog grade up to an A. And the one thing that he says, if you go to a C hospital, you're twice as likely to die, I think.

[00:27:48] Yeah, 80%, 88% higher chance of having a fatality for anything you go in for. Which is like, think about that. 88% more likely to have a fatality. And there was no incentive, like no money in trying to level up the safety at his hospital. Yeah, actually, we had a, I said earlier at the top that I was the CEO of a purchase for a client. So we had a talk with a hospital in this state, the CFO, who actually said aloud to a room,

[00:28:16] there is no incentive for increased hospital safety because they actually earn 30% more revenue if a patient has a complication. Said it out loud. What I'm taking away from this, states are on it and it might go well, it might create kind of its own issues, but you have eyes on it very astutely right now. There's a great need. There's enough unrest at the state level that states are really digging in. Oh, I'd agree with that.

[00:28:43] I mean, a good example going back to LeapFrog and this discussion around a utility. Can you imagine if we had an airline that had a 92% or an 88% higher chance of having fatalities due to preventable errors? We wouldn't allow them to fly. It's really interesting that we allow hospitals to operate with that type of defect rate when it's preventable and fixable. We need to fix those types of things to really get at some of the issues we're talking about.

[00:29:10] Right. So a number of things going on at the state level from regulation to maybe there should be a utility. Not to bury the lead on this one, but we just had Arkansas with a bunch of states right on its heels forbidding PBMs from owning pharmacies. These are big, big changes in some cases that are happening. We mentioned earlier like Maryland. I think we're at a point where what we need are some good demonstration projects, if you will. States are great laboratories to try different things.

[00:29:39] I mean, I can go back to when I was a benefit manager and LeapFrog first came out, we had some of the most unsafe hospitals in Maine in the country. And we collectively came together as purchasers and the state to say, we're going to emphasize hospital safety. And we changed copays and deductibles and other things to reward those hospitals that were doing the right thing. About two years ago, the governor accepted a word for Maine having the safest hospitals in the country. So I think we need to look to different models in different places.

[00:30:09] States are a perfect laboratory. And then that might build a momentum that we can find the best fit solution that we can start to implement nationally. It's gotten to the point where it's going to take, at least I feel, some national sort of level of the playing field around expectations and conflicts of interest and other things. So I think it's going to be a combination of federal and state collaboration that starts to drive to some of these root causes that we're finally getting back to. What's really causing some of this to happen?

[00:30:38] We're paying four times more for health care in this country than any other industrialized country. It's the prices. We need to figure that out. Got it. So my takeaway from all of this, this last part of our conversation is that at the state level, states can act as sort of laboratories. And this is kind of what I was saying before, that policies need to evolve. A little trial and error here. This is just such a multivariate. Hey, newsflash, health care is very complicated. Lots of people have their fingers in the cookie jar here.

[00:31:07] So it's not necessarily a straight line between we're going to do this and this is going to be the outcome. Lots of really smart people are going to try to figure out how to game the system. So it's hard to be smarter than some of these incredibly deft individuals. The takeaways that I'm gathering here are if you do things at the state level, maybe and maybe it's just the state responding to voters or maybe it's the business community in that state. You know, the other thing that begs to be said here is that health care is local. So some things you just can't scale.

[00:31:36] So there are actually probably things where the ultimate goal isn't to roll them out across the country. The ultimate goal might be to figure out how to enable maybe even counties at a time. Like there's some really successful stuff that was done in North Carolina where basically the whole thing or we had Dr. Bo Raymond on from Ochsner in Louisiana, where even within their service area in Louisiana, there was different needs and different things that worked or didn't work.

[00:32:03] So, you know, part of this could be just like, how do you empower a local market, whatever geography that comprises to do what they need to do? So make a lab, figure out what good looks like. Then others can learn from those experiments. And then you also had brought up Europe. So there's probably also lessons there. A really important point you just made that that health care is local. And again, I shared that I was involved in a purchaser alliance here that included the state health systems, physicians, businesses.

[00:32:33] And we could do things collaboratively that really solve some of these root causes. This has to be done as a village. How do we get in our communities all the parties in the room? There'll be tons of stuff we can't agree on, but let's find those things we do agree on and try to come up with something that starts to address that. Everybody has to be at the table and hopefully we'll find the middle ground. Seems to be a lost art in this country at this point, the middle ground. Yeah, the middle ground, the elusive middle ground.

[00:33:01] But to your exact point, like there's plenty of things where incentives are wildly misaligned. But just because those misalignments exist doesn't mean there aren't some things that everybody can throw their backs into. And that's generally speaking, those are the quick wins. Just because we can't do some things doesn't mean that we can't come together in other places. Peter Hayes, is there anything I neglected to ask you that you want to mention here?

[00:33:25] No, I just appreciate you so eloquently restated or actually interpreting what I was trying to say. So I think at least there's some middle ground I think we have found on ways that we can move forward. Hopefully others will take the lead and move their communities forward. Peter Hayes, if someone is interested in learning about the work that you are doing, where would you direct them? Probably the best place might be just my LinkedIn profile at this point. I'm retired and still doing consulting work.

[00:33:55] Welcome any and all comments and glad to assist in any way. Peter Hayes, thank you so much for being on Relentless Health Value today. Thank you. Hi, this is Scott Conard. One of the highlights of my week is when Relentless Health Value comes out. I love to listen and then to think, who can I send this to that it would bless them and tremendously help them think through and solve a problem they're dealing with. It's, again, one of the highlights of my week. And I hope that you'll join me in appreciating and sharing Relentless Health Value. Thank you.