UPMC Physician Resources
Improving Medication Use: Innovations from an IDFS
UPMC Chief Medical Officer, Dr. William Shrank, discusses how the features of IDFS lines up to deliver better care at lower cost and better management of the members and the patients that are served.
Upon completion of this activity, participants should be able to:
- Explore how benefits design impacts adherence
- Describe how complexity impacts adherence
- Describe how medication reconciliation impacts hospitalization
- A Public-Private Partnership for Proactive Pharmacy-Based Outreach and Acquisition of Needed Medication in Advance of Severe Winter Weather. Lurie N, Bunton A, Grande K, Margolis G, Howell B, Shrank WH. JAMA Intern Med. 2016 Dec 5. doi: 10.1001/jamainternmed.2016.7208.
- Association Between Patient-Centered Medical Homes and Adherence to Chronic Disease Medications: A Cohort Study. Lauffenburger JC, Shrank WH, Bitton A, Franklin JM, Glynn RJ, Krumme AA, Matlin OS, Pezalla EJ, Spettell CM, Brill G, Choudhry NK. Ann Intern Med. 2016 Nov 15. doi: 10.7326/M15-2659.
- Medication adherence and healthcare disparities: impact of statin co-payment reduction. Lewey J, Shrank WH, Avorn J, Liu J, Choudhry NK. Am J Manag Care. 2015 Oct;21(10):696-704.
Dr. Shrank has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
- Consultant: Johnson and Johnson
All presenters disclosure of relevant financial relationships with any proprietary entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients is listed above. No other planners, members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships to disclose.
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Release Date: 2/20/2017 | Last Modified On: 2/20/2017 | Expires: 2/20/2020
It's a really great pleasure to be here with you all today. I assume I'm the newest guy in the room, I've ben here a little less than 3 months; but I can tell you that in my 3 months all of my hopes and expectations about the culture and the environment here have been reaffirmed.
In my background I've spent some time in academia, I've spent some time working in the Federal Government at the Innovation Center at CMS and at CVS working with providers moving toward taking more risk. And at least in those latter two settings a big focus was to try to understand who is ready to actually make this move from volume to value, who is ready to truly transform the way they deliver care, who is ready to start moving towards a view of how we deliver better care at lower cost for the populations we serve? And in both of those last two jobs I had - I interacted a lot with health systems and with payers across the country and there was really one place that stood out, there was one place whose mission was so closely aligned with bringing providers and a payer and a community and accelerated efforts around population health management and better use of data to truly transform care. And the opportunity to join you all here at UPMC and to be part of this, this journey that we are all on together is really, really an honor.
So I'm going to talk today a little bit about the medication piece, in part because that's the piece I know best having worked at CVS and being a researcher in the Division of Pharmacoepidemiology and Pharmacoeconomics I spent an almost bizarre amount of my career to date focusing on prescription drugs. But it's a good case study, it's you know getting patients to use their medications appropriately is at the core of how we manage our most vulnerable, our most complex patients, it's at the core of our ability to address suffering and the deep challenges that our most risky patients face. And it is a perfect example, a perfect example to demonstrate how the features of an IDFS really line up to better deliver better - to deliver better care at lower cost and better manage the members and the patients that we serve.
So just sort of at a high level, we talk a lot about medication cost. Generally we are talking about how much the medication costs when you try to buy it. But there is a lot of costs associated with medication use that are - that represent a massive amount of waste and of spending in the U.S. The cost associated with nonadherence to essential chronic medications, the estimates are anywhere from 100 to $300 billion a year wasted because patients don't adhere to highly effective, very low cost generic medications for cardiovascular disease, for diabetes, hypertension, hypercholesterolemia, congestive heart failure and there may be no better way to promote, to deliver, to reduce unnecessary costs than by helping patients adhere to generic medications for important chronic conditions.
At the same time we have problems with overuse, overuse with opiates in particular, it's a national epidemic. it's one that's garnered an enormous amount of attention here and all around the country and there is a substantial cost there. There is substantial cost associated with the complexity of medication use particularly in our vulnerable elderly. And when you start putting all these pieces together you realize that the medication story is more than just the rising costs of prescription drugs, but actually working together to deliver the right drug to the right patient to make sure that they don't get the medications that can harmful, that we encourage them to adhere to those highly proven medications that have been shown to work are critical, critical central strategies for us to deliver better care at lower cost for our patients.
And it's interesting to think about the fact that there is sort of a good trend and a bad trend here. It's not all going in the same direction. On the one hand we all recognize that only about half of the patients adhere to their medications as prescribed, the evidence is overwhelming, there is literally thousands, probably tens of thousands of papers that demonstrate clearly the patients only adhere to about half the medications that they are prescribed. And the downstream costs are enormous. At the same time we are talking about the rising costs of prescriptions drugs, in particular this new problem around specialty medications. Specialty medications can be extraordinarily effective and at times they can truly cure a previously uncurable condition. But the cost of specialty medications is rising at a rate that really hadn't been preconceived as a possibility, about a third of prescription drug costs today. Within the next 2 years about half of prescription drug costs will be specialty medications, on the order of $200 billion a year.
And we are starting to see specialty medications that aren't meds to treat rare conditions, they are medications to treat hepatitis C with 3 million infected Americans at $100,000 per treatment. You can just do the math in your head pretty quickly, it's pretty extraordinary. Or PCSK9s, this new injectable cholesterol medication at $14,000 a year that is eligible for many more than 3 million patients. As you start to see these specialty medications that are being available for much, much larger pools of patients it really highlights the fact that we need very thoughtful strategies around how to address that rising cost as well. So we have sort of two, we have sort of the good trend and the bad trend. The good trend helping to improve adherence to the essential meds, bad trend trying to make sure that we reduce unnecessary spend when it's not providing additional clinical benefit.
This is all happening in a really unique landscape, one where arguable the most transformative time in healthcare in any of our careers. The way in which we deliver and more importantly the way in which we pay for healthcare has changed enormously over the last couple of years. We are no - we are really aggressively moving away from this pattern of paying for volume, increasingly rewarding providers for delivering better care at lower costs. The CMS expectations of hitting 30% advance payment models in this year has been exceeded, beat 50% in 2018. MACRA is essentially a value based payment model, increasingly private insurers are moving - are also aggressively getting into this space and encouraging and developing contracts, risk based contracts with providers that are putting more of the financial risk both for the quality and for the care and for the costs of patients on those providers.
The landscape is changing drastically and it means that providers who are thinking about cost and quality have to, have to think about how their patients are taking their medications. It means they have to think about what their patients are doing between the visits to the doctor. It's not just prescribing the right medication to the patient, it means making sure that between those visits to the doctor the patient goes to the pharmacy, they take their medication every day, they refill their medications, that those medications are doing precisely what they are supposed to do. It's the surgical intervention for the medicine practitioner.
But we do have a secret sauce here as an IDFS, we are the payer, we are the provider, we are working together hand in hand. We have - we on the payer side have a great deal of data, you on the provider side have a great deal of data, and when we work together whether it's around care pathways, whether it's around sharing of data, whether it's around clinical programs there is so much more that we can do as a partner to really drive better medication use, less waste, better outcomes, lower cost. And that's what we'll speak to today. So first we'll talk about some of those, that first section of the good trend, how we are going to get patients - how we are going to work together to get patients to adhere to essential meds that we know are effective and useful for them.
First just one thing to get out of the way is there is - continues to be some sort of concern in the marketplace about the equivalence of generics. We did a systematic review and a metaanalysis of all cardiovascular drug randomized trials comparing branded and generic cardiovascular drugs and found absolutely no difference. We published this in JAMA in 2008. We also looked at the very same articles, I'm sorry the very same issues of journals where these papers had been published and they overwhelmingly were filled with editorials from experts saying well I'm not so sure that that's true. So there is some sort of mixed messages out there, we'll get to more of them in just a second. And it matters, it matters in terms of adherence. Generics in our typical formularies generics cost less, more affordable drugs, patients tend to adhere to them better and we have clear evidence that when patients are initiated on generics as compared to preferred or nonpreferred brands within the same class after controlling for all of the other features we see better adherence. And not only do we see better adherence, we see better clinical outcomes.
This is a paper we published a couple of years ago in the Annals where we looked at patients started on statins who are high risk and who were either started on a generic or a brand of exactly the same molecule. The patients that were started on the generic had a substantially improved adherence, but most importantly much better clinical outcomes, 8% reduced composite end point, less acute coronary syndrome, less stroke and less death, all statistically significant.
But part of the challenge here is around perceptions and this is a great opportunity for us at an IDFS. So when we surveyed patients to ask them their perceptions about generics overwhelmingly they said generics are less expensive, overwhelmingly the did not believe that generics cause more side effects, not a lot of concern that brands are more effective. They generally felt that generics are a better value than branded drugs. But when you ask them should more Americans use generics, over on the right, yes, they all said more Americans should use generics. But if you ask them would you rather use a generic it looks a little different. And it does highlight the fact that there is still some gap. I don't know what it is. I don't know if it's this vision of like the generic at your grocery store with the white you know bag and the black letters. But there is an opportunity for us to work together, both the health plan and the providers, to better educate our patients and really improve comfort with these medications.
And this is just the tip of the iceberg. So about 10 years ago there was this massive generic cliff about - for small molecules, the generic cliff that's about to happen is in the area of the biosimilars. It's going to be - there is a huge number of patents of specialty meds that are nearing expiration, the opportunity for biosimilars will be enormous. it's not going to be the same kind of marketplace where there is a whole ton of small molecule competition with a really rapid drop in price, it's going to be a much deeper, deeper partnership between the plan and the provider around developing care pathways, encouraging the right medication to be used, agreeing that we can exclude some medications and increase volume to other medications so we can really deliver the best quality at the lowest cost for the members and the patients that we serve.
There is a lot we can do about benefit design. This on the health plan side this is relatively easy for us to do. So we did this study a couple of years ago when we were working with Aetna. We randomized about 6,000 patients who had a heart attack to one of two arms, either to get all their heart medicines for free or usual care. We powered the study on clinical events, we also looked at costs. And in patients that got their drugs for free there was a modest but statistically significant improvement in adherence anywhere from 4 to 6% by class of drugs, by aces, ARBS, beta blockers, that is supposed to stay statins, sorry this got a little screwy.
Health outcomes again statistically significant, 11% reduction in vascular events and revascularization, 14% fewer major vascular events, 15% less cardiovascular death, a positive clinical outcome from giving away those medications for free and that was all statistically significant. The spending was not because we could not create a study big enough to be able to power it on costs. There was a modest $600 increase in pharmacy costs as we paid for both more drug and the co-pays, but on average saved over $6,500, $6,300 medical costs, over $6,000 per patient. Aetna saved over $6,000 per patient as a result of the intervention.
It speaks to the fact, this was again this was not statistically significant. The New England Journal when we reported it required us to report it s budget neutral. On the same day that we reported it in the New England Journal Aetna announced to the Wall Street Journal that it's being scaled nationally, again highlight some of the sort of gaps between academia and sort of how business decisions are made. But it really speaks to the fact that we working together with you can work, can design benefit designs that make more sense, that eliminate financial barriers for the most effective and most cost effective drugs, delivered better care at lower cost.
And it also raises the possibility that we can do more, we can be more creative. This is I think kind of a crazy study that a scientist at MIT did and he had a bunch of healthy undergraduate students and he gave them electronic shocks to inflict pain on them. And then he gave them one of two placebos, one of which he said was really expensive and really new and like totally the fanciest newest most expensive; the other was a very well proven low cost generic. And then gave them those placebos and then again inflicted the electronic shock and when patients had received the really expensive, really fancy new placebo they had much less pain. And it speaks to the fact that just eliminating cost sharing may not be enough, there has to be more around engagement. Increasingly there is a huge, huge amount of literature coming out around rewards, around positive reinforcement, around loss aversion that leverages behavioral economics to try to as part of the benefit design to try to encourage adherence, and we are again in a perfect position to be able to test and spread those approaches.
Another area is the complexity of medications that our patients take. I think every one of you has a patient or a family member where you can't possibly imagine how they administer their 24 drugs every day. You wonder what their kitchen table or their bathroom medicine cabinet looks like. My relatively high functioning parents have amber bottles all over the house. And it is a big deal. The complexity that our patients address when taking their medications is a very, very big deal and it's not just the number of meds, it's not just the number of doses a day, it's how many pharmacies you get it from, how many doctors are prescribing, how synchronized are the refills? Are you making 10 trips to the pharmacy every 2 weeks? Are you spending half of your time going back and forth to the pharmacy to get your medications? Or are you getting them all on the same day?
So we looked at the relationship between a whole host of these complexity measures and how adherent patients are and it is a massive, massive association. Obviously it's not causative, it's just an association but those patients with the most complex therapy have a very, very difficult time taking their meds. And this is something for us to understand and this is definitely an opportunity for us as a payer/provider to work on strategies whether it's mail order that provides different kinds of packaging, whether it's working with our retail colleagues to synchronize prescriptions at the point of refill, whether it's us working together for those patients that are receiving medications from many, many doctors to try to simplify the process of sort of determining what the right medication regimen is. We as an IDFS are perfectly positioned to solve this.
There is a great deal of literature about the possibility of leveraging health IT to support better adherence to chronic medication therapy. These are all things we are doing today at UPMC. We are leveraging smart phone technology to provide reminders and text messages, we are partnering with Telehealth to engage patients at home hopefully to move towards more direct observed therapy of their medications. We are tracking all of these in our infrastructure, our UPMC Health Plan infrastructure so that we are all aware of the kinds of touches and interactions we are having with our patients, but technology is one more place that we can leverage.
I personally am really, really interested in the power of social connectivity and peer support. We did a systematic review and there is no question that if you had - just being married doesn't get you, doesn't improve your adherence; but if you are married to somebody who is engaged in either how you deliver the medication or provides emotional support or ideally both it can have a very, very big, a very big impact on adherence. When I was practicing general internal medicine and I saw a patient with an adherence problem I always asked them to find a buddy in their family, somebody to help them to move adherence from an individual sport to a team sport.
And you know Miguel is a perfect person to be here in the audience for this discussion but it's not just peer support from family or from friends, increasingly more and more patients are getting their support online. They are getting them from social networks. This is a study where we looked at the 15 most commonly used sites for diabetes on Facebook and we qualitatively characterized the 15 largest threads about the discussing diabetes care and found a really extraordinarily rich environment where patients are talking to perfect strangers about their greatest fears, their deepest challenges, offering very precise clinical information and getting a great deal of emotional support. The one problem we found is there was some promotion, about a quarter of the posts were promotional in nature and that's something that a UPMC based site could address. But Miguel has taken this on and he's created a site that allows his patients to interact with each other hopefully offering a little more oversight so there isn't as much of the promotional activity and creating a safe place for patients with a similar clinical experience to interact with each other to learn, to improve. And again this is a nice example of a speciality medical home collaborating with a health, with the payer to try to deliver better care, better care for our mutual patients.
Another area is around identifying patients at high risk. We have a lot of data, we have a lot of data from a lot of sources and there is a lot that we can do with that data to understand who is at risk of not taking their meds. There are literally dozens, many, probably 100 different published models predicting nonadherence. The best models are the ones that turn out to be the simplest. The best predictor of whether or not someone is going to adhere to their meds is looking at their use, their most recent use of those meds, their patterns of meds, their trajectories of medication use. We compared this model to neural networks, to machine learning, to boosted regression, to all of these you know - we worked with Watson, we worked with everybody to try to figure out if there is a better - the most precise way that we could predict whether or not someone was going to adhere to their meds is looking at their actual trajectories of medication use.
We now have - we have acquired a company recently called RxAnte that leverages a design like this and has a series of outbound messages, proactive messages to try to improve adherence in those patients at the greatest risk. And again this is another place where the IDFS has allowed us to both make the right investments, leverage our data appropriately and really intervene proactively to promote better medication use.
So this is the other part, this is the part around how do we get patients to use less or use better rather than to adhere to what's being prescribed? And again I think, I hope you'll agree that the IDFS provides a really rich environment for us to be able to do that. So one example is around medication reconciliation. Our patients when they are being discharged from the hospital are incredibly vulnerable and their medications almost invariably were changed. Sometimes they were changed just because the formularies are different in the hospital. Sometimes they were changed because their disease progressions changed meaningfully. Sometimes they just have a different name of a medication that's you know very similar to what they were taking previously at home. They go home with this new slug of medications, they don't know what's the new, what's the old, what to get rid of. It is arguable the most - it's one of the really truly confusing times the patients face in the care of their complex conditions.
This is an ideal time to intervene, this is something that we do across UPMC both on the provider side and on the Health Plan side, but the more coordinated we do this the better we'll be. We did a study with Aetna where we used insurer claims to identify high risk patients. We then contacted those patients at home either telephonically if they were sort of modestly ill, in person for the most ill. We got about a 50% reduction in readmissions in 90 days, I'm sorry in 30 days, and a substantial reduction in total cost of care. The ROI was enormous. What did we say, 4.9 ROI. This really speaks to an area that we have to work together and we do work together, we have to work together to keep getting better.
Another opportunity for us is really just around how we develop our formularies. We partner extensively in the development of our formularies, both the hospital formularies with Health Plan participation. The Health Plan formularies have a great deal of provider participation. And if the more we can move towards reduced, encouraging the use of generics which we know help make medications more affordable and help patients adhere, but even more importantly how to steer patients toward one versus another of equally effective branded medications so we can negotiate better prices and we can deliver the same quality of care at a much lower cost we can work together. So by really restricting formularies in a way that's guided by you, that's guided by the providers to make sure that we are not actively, we are not reducing access to something patients absolutely need.
In this study, it was something that we did at CVS, we did just that. We did a really good job of communicating with patients about the fact that a formulary change was happening. There was minimal disruption, there was better long term adherence to chronic medication therapy and there was extraordinary, extraordinary reductions in cost. A big target for us has to be opiates. I think probably - who here in the last week hasn't thought about the opiate problem at least once? None of you. 13% of the prescriptions we fill on the Health Plan side are for controlled substances, and a lot of the patients that are filling them are filling multiple types of controlled substances.
And this is a case where the IDFS, our partnership, the partnership of the Health Plan with the providers offers a truly unique and I think unrivaled way for a partnership to really reduce unnecessary use. On the one hand there is a lot we can do around formularies and around sort of the rules around prescribing, clinical protocols that we build with you around how to achieve - how to achieve better prescribing patterns. Second, at the point of sale leveraging the PDMP, the Prescription Drug Monitoring Program data and being much more crystal clear about how to reduce inappropriate use in patients who are potentially taking harmful doses. But last and I think the most important is how we work together around sharing data. We, the Health Plan, sends the emergency room data in a program called Heads Up about everyone's opiate use and if someone has substantial amounts of opiate use there is a flag that helps that emergency medicine physician make a more informed decision about what to prescribe, how to prescribe, how to manage that patient.
And data mining also allows us to interact and proactively reach out to patients across the system and as we talked about earlier more and more we are looking for ways to deliver substance abuse treatment along the continuum of care to try to get more and more patients that need it into the appropriate therapy. And I think you know as we start pulling all these resources and efforts together it definitely appears to be something that's different than what you can get in virtually any other system.
So Steve and I have talked a bit about collaborative utilization management. It's a profound interests of ours and a direction we promise we wan to go. And particularly as we are partnering more deeply with you and you are focusing more and more on how you want to deliver the best care you can to the patients you serve at the lowest possible cost our goal is to work with you and have you help us create those clinical pathways, have you help us define the best ways to care for your patients that will reduce variability, that will deliver the best care at the lowest costs. We want to give you data, we want to give you data that shows you where there is variability, where there are opportunities, how - you know specific targets where we can work together to reduce unnecessary use. And increasingly we want to be more strategic with you. We want to think about opportunities in a choosing wisely kind way, opportunities that we can work together on specific clinical problems where we realize there is more use, or more inappropriate use or more unnecessary use than there may need to be, and that that partnership just by stating it and by agreeing to it and by building a structure around it could have a really big impact on reducing variability and delivering the kind of care that we want to provide.
At the core of a lot of this movement is a lot of these efforts to deliver better care at lower cost is how we pay for care. And advanced payment models, shared savings, risk based contracting between the plan and the providers it's always an evolution. It's always a process. There is always - it's never perfect at coming out of the gate, but there is a sincere and profound belief that if we work together on this, if we get these kinds of models right we can deliver better care at lower cost. We are - I can tell you from having visited health systems across the country when I worked at CVS and also during my time at CMS we are different here. We are very advanced in terms of what we are testing and how we are testing. The specialty medical homes are unique and advanced. We are doing a bunch of bundling. We are very aggressive in terms of our shared savings models and we are thinking about the next step, how all of these pieces start to fit together.
It is important to note that if you are a provider working in one of these settings it does change the way you think about medications. It changes the way you think about it here that's for sure. You want your patient with heart failure to take their meds, and you want to work with your health plan if your health plan has a predictive algorithm and proactive outreach that can help you. Similarly, if you are at risk for the costs of some of these really expensive meds you want to make sure that you've thought through what the algorithms are, what the clinical pathways are to make sure that the right patients are getting the right drugs at the right time. So I think this you know down the road this is ultimately going to be one of the really key drivers by aligning all of our financial incentives to get us to a place where we are delivering the best medical management that we possibly can.
This is an area of particular interest to me and I've talked to a bunch of people in the room about this already. I think we all agree the problem of rising drug prices has reached a fever pitch, it's part of the national Presidential campaign. There are a broad array of very sort of draconian solutions that are being promoted by our politicians and by think tanks. We are eager to try a bit of a different approach, one that's more based on partnership rather than for example having the government negotiate the drug prices.
At the core today there is no partnership between the purchaser - or there is little partnership between the purchaser and the seller. The seller is just trying to get the highest acquisition costs they can, the purchaser is trying to figure out whatever leverage they have to try to reduce that cost. What if we moved the model and changed it fundamentally and said we are going to pay you for the value you produce. If your drug, if your hep C drug is curing hep C for a large number of people and it's averting millions of dollars of downstream healthcare costs that's worth more than the medication that really, you know that offers marginal benefit for a specific patient at the end of life let's say.
So there is a growing body of work in Europe around how to develop these kinds of models, models where payers reward the manufacturer. There is oftentimes sort of a population based payment and then additional rewards or additional withholds based on the results that are delivered by the medications themselves in specific populations. We think that we are perfectly aligned, we are perfectly setup to be able to be a leader in this space. We have a progressive payer, perfectly aligned, you know well aligned with providers that deeply care about how you manage or how we manage our patients. We have some of the greatest clinical experts in the world in each of the clinical areas that we'd be pursuing that have all the credibility that we'd need to be able to make the argument about how - to sort of come up with a model that would be irrefutable from a scientific standpoint. We have the right kinds of research infrastructure both at UPMC and at the University of Pittsburgh to design and evaluate the model. And I believe if we work together with you we can test a handful of these and really try to move this model forward.
Our hope is that by doing this A, we will reduce drug costs a bit, but more importantly it will change the nature of this discussion. Instead of us versus the pharmaceutical company it's us partnering with the pharmaceutical company. If we are able together sharing data, you know working on a population together, deliver better outcomes, keep people out of the hospital, avert other healthcare costs I think we'd all agree we'd be willing to pay more for that kind of a service. So this is still early, this is not begun - this hasn't started to happen yet but this is an area of great interest. I think there is a lot of interest across UPMC and it's going to be fun to think about how we bring that together into an organized way.
The last think I want to talk about is our commitment at the Health Plan to learn. So we have a research group at the Health Plan called the Center for High Value Healthcare. Historically it's a group that pursued external research funding, might have been successful with PCORI and with some foundations to test innovative models and have that sort of credibility that they have external funding to test models around behavioral health or around better management of childcare.
Increasingly we realized that if we area going to be as cutting edge a plan and an IDFS as we want to be we need to bring a really high level of evaluation, assessment and learning to every new program we implement. We are going to start this off slowly and build up resources over time but the goal is if we are going to try a new shared savings model we shouldn't wait a year or two years to see how it works. We should be looking at results every month, we should see how we are doing. We should see if we need to make midcourse corrections. We should understand if there are certain procedural things or implementation issues that are stopping - that are keeping us from being as successful as we want to be. We want to make sure that we are not confusing bad implementation with bad ideas. We want to make sure that we are learning as fast as we can. And we still want to publish the results of all of our - all of these efforts. We want to disseminate them. We want to publish them even when they are not all good because it's by doing that that A, we build our own credibility, B, we help move the - we help move the field, and C, we really establish ourselves as the leaders in this space around delivering better care at lower cost to our members and our patients.
And as I look out in this room I'm hopeful that this kind of a structure which matches or mimics a lot of what happens in a health system amongst researchers that you see some synergy here and some opportunity for us to collaborate, and some opportunity for us to pose or present or consider experiments, tests that we'd want to pursue together as Miguel, as many people in this audience have before. We are interested, we are eager, we have to be able to be responsive and interactive with each other. We have to build a sense of open communication and be responsive and sort of engaged with each other's beliefs about how we can both get better. And only by doing that will we be successful. So I'm hopeful that sort of this talk and all of this positive momentum around the payer/provider partnership can help open up those lines of communication even further.