How are Built-in Supply Networks (IDNs) shaping the way forward for healthcare, and what position—if any—does value-based care nonetheless play?
On this episode, I sit down with John Marchica, CEO of Darwin Analysis Group, to debate how IDNs are reworking affected person care. We additionally study the continuing challenges of value-based care and why it continues to overlook the mark on enhancing affected person experiences, bettering inhabitants well being, and managing prices. We additionally discover the rising affect of AI in bettering healthcare effectivity.
In case you’re a healthcare chief searching for insights to navigate these complicated modifications, you received’t wish to miss this podcast. John’s experience presents a novel perspective on how physicians, well being techniques, IDNs, payors, and PBMs can align to enhance affected person outcomes and operational effectivity.
I extremely advocate listening to our podcast in its entirety for extra in-depth protection of this comparatively new enterprise mannequin.
Be aware: The next uncooked, AI-generated transcript is offered as a further useful resource for many who choose to not take heed to the podcast recording. It has not been edited or reviewed for accuracy.
Stewart Gandolf Hello, everybody. We’re interviewing John Marchica, who’s an previous buddy of mine, having been on my podcast earlier than. And I feel I have been on his. And it seems we’ve guitars in widespread, as you may see. In case you’re watching the YouTube model we each have. His workplace is on a golf course. I dwell on a golf course. Now we have numerous widespread past the healthcare stuff. So welcome again, John. Good to see you.
John Marchica Thanks for having me.
Stewart Gandolf Oh, I adore it much less coverage, or the day man, that is what we’ll discuss as we speak, however not likely that. Into the dialog later.
John Marchica Weave in rather less, Paul, after which somewhat discuss your keyboard over there. I’ve not made the soar to convey my certainly one of my keyboards into the workplace. I feel I’d most likely drive everyone out if I did that.
Stewart Gandolf It is humorous trigger my all my consumer calls. Everyone brings up their guitar nearly like I do not know no less than 80% of time any person refers to it. No one brings up the keyboard one particular person has, and it is a synthesizer. It is a good keyboard. It is not like somewhat plinky factor that my children used to play after they had been enjoying music. anyway. So we’re gonna discuss one thing fully completely different. 1st of all, John. You understand, assuming that you realize, the listeners as we speak have not all been 100% in crimson. Hearken to the final podcast we did with you a few years in the past throughout Covid. Inform us about Darwin analysis group. What do you do? And, by the way in which, why is it, Darwin? Let’s begin there.
John Marchica Good query. So Darwin analysis group, we’re based mostly out of Scottsdale and our kind of lens of focus. Our analysis space focus is in organized healthcare supply techniques of every type. We name them IDNs, massive doctor teams, massive most cancers facilities. You understand, in all places that any person has determined to place all of this collectively beneath some type of holding firm. And we analyze these techniques. And on the consumer facet, most of not all, however the general public that we work with are within the life sciences. Who’re making an attempt to grasp the modifications in healthcare. So I kicked this off. I’ll get into somewhat little bit of my background, I am certain, with a few of these questions, however I kicked off the LLC n 2,010. So formally, we’re. I suppose, nearly 15 at this level, though I’ll say the first 5 years, and when you return to while you had been beginning, Stewart, you may bear in mind the times, or who is aware of? Perhaps you identical to. After which you’ve an organization, and all these staff, and all this cash comes.
Stewart Gandolf Lengthy, lengthy, slog child. It is like.
John Marchica Lengthy slot proper? So these 1st 5 years was like, if I might afford to herald any person for half time from some company, to assist me out with just a few issues. So. However anyway, in order that’s our focus. I spend most of my time. If I am if I am not interviewing or speaking to folks within the area. It is studying about it, making an attempt to grasp the modifications. And one of many issues that I simply love about what I do, and I wager you’ll most likely agree with me on what you do. Is that the truth that there’s a lot change happening for therefore lengthy for so long as I can bear in mind. It makes this type of work fascinating. You understand. It is not like every thing is boilerplate, and also you’re simply you realize, identical factor 12 months after 12 months after 12 months. There’s all the time one thing new, as a result of healthcare is so dynamic, in order that a part of it I like.
Stewart Gandolf I completely agree. And it is humorous, as a result of, you realize, for us, we have needed to reinvent ourselves a number of instances. That is why we’re all nonetheless right here. And since we would not be proper, we have modified our mannequin a number of instances. And yeah, it is wildly completely different than it was within the previous days for us. And you realize I’ve a crew. Now that I’ve all the time had good groups, and this one simply is the smoking greatest crew prefer it’s wonderful. And it is but it surely’s, you realize. Okay, guitar analogy metaphor. We’ll convey that in proper now.
John Marchica Alright!
Stewart Gandolf Yeah, I am going to let you know like, I take advantage of this with shoppers loads, and it is actual. It is like good musicians play with different good musicians. And so, I discover that in advertising and marketing the very best expertise needs to be with different good expertise, and you may’t. It is actually exhausting while you’re beginning, as a result of, like you might be actually sensible, however the expertise needs to be with different expertise moreover simply the founder.
John Marchica So true.
Stewart Gandolf Yeah.
John Marchica Yeah, it is so true. After which to your level about reinvention so early on our 1st kind of market analysis report, you realize that you may. You can purchase off the shelf. Was in house well being care and our second one, and I actually thought this firm was going to be all about ACOs and worth based mostly care supply. And like, that is what folks wished to learn about. And look. I do know we’re gonna most likely dive into that as possibly a subject to speak about. However There’s it is nonetheless related. It is simply that I really feel like on the analysis facet, no less than in these early years. I used to be somewhat bit early on stuff. You understand what I imply. It is like I noticed, oh, that is gonna be fascinating. Individuals are going to wish to have a look at this, and we’ll go down this rabbit gap. After which people would say, Yeah, effectively, house well being that it is hasn’t actually come into its personal but. It is nonetheless untimely to speak about. You understand that type of perspective, and it took us some time to type of calibrate on. You understand, the built-in supply community or the built-in well being system is kind of being. I do not know the unit of study for lack of a greater time period to attempt to sound sensible. You understand, the unit of study is the IDN. and that is once we actually took off. So it. It occurs proper? I imply, you gotta reinvent.
Stewart Gandolf Effectively, it is easy to be a pioneer, however then you definitely get arrows in your again. So it is prefer it’s like, but it surely’s additionally good to be there, as a result of afterward it will get loads more durable. So simply briefly what? Inform me somewhat about your background, and the way you got here up with this concept that you simply talked about earlier your background. I am simply curious previous to this, and we’re gonna soar straight into this in a second. However.
John Marchica Certain.
Stewart Gandolf Yeah.
John Marchica So once I obtained out of college the first time I minimize my enamel at Abbott, so I used to be a Pharma man, as a result of the division that I used to be in later grew to become AV after they type of cut up the corporate aside. And I used to be there after which from there. I I had the entrepreneurial bug. You understand what that is like, Stuart. So I had the bug, and I began a medical training. Firm known as fax watch that I ran for about 11 years, after which I bought it and went to go work on a PhD. And in Dartmouth’s type of interdisciplinary program. And that is kind of vital to the narrative as we speak, I feel, as a result of had I not had that kind of pit cease for five years, and the place we had been, you realize, in our doctoral seminars, like inventing worth, based mostly care fashions and testing them and type of simply going backwards and forwards with different college students. I most likely would not be doing what I’m as we speak. However that point that I you realize, I all the time joke about this. I mentioned, most guys, they’ve a midlife disaster. They purchase a corvette. Yeah. I went off and labored on a PhD. And you realize.
Stewart Gandolf Poor man!
John Marchica Poor man you realize.
Stewart Gandolf I am certain there’s assist for you someplace. Would not the automobile higher been extra enjoyable.
John Marchica Corvette would have been approach. Extra enjoyable, and I most likely would have picked one thing much more enjoyable than that. Perhaps. Perhaps a Ducati or one thing. However anyway, I being uncovered to that type of pondering and like understanding the place healthcare was going and searching on the economics, wanting on the coverage implications. Trying on the outcomes and epidemiology, you realize, type of scientific epidemiology the place we had been going, the vital areas to give attention to. I simply obtained. There’s like that second wind you get, you realize, generally halfway in life. And so beginning this firm, as I mentioned, early on it, was looking for our footing and what I wished to give attention to. However you realize this simply since you wish to give attention to one thing proper, chief, gonna get arrows within the again proper? But it surely’s actually what {the marketplace} needs and what’s most wanted, what individuals are prepared to pay for what they wish to know. And on this enterprise the largest query. Effectively, there is a bunch of query marks. However one of many greatest ones is, you realize. What concerning the built-in supply community. What about this kind of mannequin of care? And in some circumstances mannequin of cost as effectively? it looks like there’s a variety of motion during the last decade or two on this space, a variety of mergers and acquisitions. A number of the greater getting greater and appears to be the place the place, no less than from the life sciences, perspective, the place they’ve essentially the most questions, and the place there’s a variety of change taking place. And in order that’s the place we ended up. I suppose you realize the opposite approach that I’d describe it kind of in a non-healthcare approach, Stuart, is I get to jot down, I get to do talks and keynotes, I get to learn loads and like, take into consideration how and construct fashions. I’ve kind of constructed this firm to do all of the stuff that I love to do.
Stewart Gandolf I adore it.
John Marchica You understand what I imply. So it is prefer it. It is type of labored out that Darwin. And so, by the way in which, you probably did ask concerning the title.
Stewart Gandolf Yeah.
John Marchica So the doing I get to do a variety of what I love to do. Additionally, as you realize, you do not get it. You aren’t getting away from doing a few of the issues you do not love to do, simply because we do not love to do them. So there are these duties as effectively however On the time once I return to that kind of 2010 timeframe. and having bought my firm and dealing on a PhD. And I did not point out marriage. The first marriage did not go so effectively, in order that one ended and there was a variety of change. And so, I used to be fascinated with evolving kind of like, what’s my subsequent step? The place am I going? And that phrase evolution type of saved? So, it is kind of a nod to that, regardless that I do not assume that that Charles Darwin 1st of all got here loads earlier. However he wasn’t fascinated with self-actualization, and you realize Maslow’s hierarchy When he was speaking concerning the idea of pure choice. However that is type of caught with me, and it type of goes to your level earlier, which is, you realize, about making an attempt various things and reinventing your self, as a result of when you do not, you die.
Stewart Gandolf Yup!
John Marchica You will make it.
Stewart Gandolf Completely pure choice. Superior. Okay? So let’s go into the you have talked about the built-in supply community, and I’d love you to take a second, simply to outline that to a few of the viewers who is probably not as acquainted with that. After which I might love to listen to a few of the widespread themes and tendencies that you simply’re seeing.
John Marchica Certain. So what I like to consider is, I begin with the premise of kind of a holding firm, you realize. of an entity that, and it may be in any completely different type of trade, proper? However only a holding firm that has a variety of curiosity and within the, within the healthcare world, that kind of moniker IDN or built-in supply community. It additionally means built-in well being system. It means a variety of various things to completely different folks. And it is type of turn out to be this catch all to explain one thing massive that is delivering care. However actually it is a holding firm the place there are various levels of the power to ship care. So that you may need a system that has a few hospitals and possibly a doctor group. and so they all are beneath the identical umbrella, and you realize the medical doctors and the doctor group are referring to the hospitals for procedures, and possibly they’re contracted. Or possibly they’re even employed. And in order that’s an instance of a small supply system or IDN. And then you definitely type of go to the opposite spectrum, and also you have a look at a corporation like a Kaiser or an Intermountain or right here in in Phoenix? like a banner. Considered one of these organizations, the place they haven’t solely the hospitals and the doctor teams. however they could have a house healthcare wing. They may have clinics. They may have partnerships, for like pressing cares. Perhaps even with a few of the retail teams they might have their very own specialty Pharmacy and infusion websites. So any approach that you concentrate on healthcare might be delivered. After which, if you wish to add on to that with like a Kaiser, the insurance coverage element of it, too, proper? So organizations like Kaiser had their roots in managed well being care. Then it is like cradle to grave. I neglect who they used to say that about was it, Sears? And, after all. what’s.
Stewart Gandolf Life cycle.
John Marchica Yeah, proper? So that you had the life cycle speak proper? So however that is and so a variety of the dialog that folks have when making an attempt to grasp these teams is, you understand how many, what number of other ways are they delivering care, and the way really built-in are the other ways of care. For instance, you’ve an issue that will get recognized by your main care, physician, that physician sends you to a specialist. The specialist determines that, you realize. As an example that you realize you’ve a non-threatening cancerous lesion in your face, and that is obtained to be taken care of. And so then the derm sends you off to surgeon that handles that. And possibly when you’re within the Kaiser mannequin by work. your insurance coverage is Kaiser, and so that you go to a Kaiser facility, and also you see initially a Kaiser main care, physician. Then you definitely see a Kaiser specialist and also you get a process most likely in an outpatient setting in a Kaiser clinic proper? And the diploma to which everyone is aware of what everyone else is doing. And there is some planning and forethought and a few measurement on the again finish. So fairly typical administration enterprise administration issues. That is a technique that we assess whether or not a healthcare supply community or IDN or healthcare system is superior or not so superior. How effectively are they speaking? How superior are they Technologically? and so a variety of these sorts of questions we ask, as a result of. you realize, there are some that assume that if we undertaking out 5 years, 10 years, no matter, that ultimately we’re gonna have, like a handful of those massive supply networks which are simply, you realize, as we speak, relying on the way you measure them. There are 600-700 of them throughout the US. You understand. Perhaps we’re gonna find yourself with a half dozen to a dozen which are gonna be dictating how care is delivered and paid for within the US. So you will need to take note of them. In case you consider that that is type of the place issues are trending, no matter The place they’re really going. So does that make sense, so far as clarification, something you’d add to that by way of my definition. I imply. That is the way in which that I have a look at them.
Stewart Gandolf No, I adore it, and I feel we talked somewhat bit offline about it. You understand we work with a certainly one of our shoppers is a, you realize, kind of neighborhood hospital, 500 beds. And it is making an attempt to do type of a variation at a clinically built-in community. However that is not likely the identical factor, as a result of they do not have that degree of group. And that is simply it is a robust mannequin. And, you realize, going again to that instance, they’re in a serious metro space. And you realize, there’s now, well being techniques throughout them. And so you realize, that is what individuals are working about on the well being facet. Proper effectively, what number of of those unbiased hospitals will survive? After which and then you definitely get into issues such as you talked about infusion. Now we have an infusion consumer. And so, like, you realize, there’s pure development of okay, you have obtained gastroenterology. What concerning the infusion? Or referring them out to an infusion heart. Do you, you realize, have an affiliated ecology like, how does all these things match collectively? And you realize you have come from a cottage trade of, you realize a whole bunch of various gamers. The non-public fairness owned and in addition bigger well being system owned techniques that you realize, we’re all hoping there’s some economies of scale and efficiencies by doing it that approach, you realize, like versus, you realize, sea of a whole bunch of various unbiased suppliers. In order that’s ex to me. That is fascinating for you watching it out of your standpoint effectively, inform us about a few of the tendencies you are seeing now with, you realize, possibly bearing on all of the stuff we simply mentioned like.
John Marchica Yeah.
Stewart Gandolf That each one work.
John Marchica Effectively, I feel you realize the overarching development. I do not understand how many individuals would agree with me on this. Perhaps that is simply my bias. However I’d say, the overarching development that we have been seeing over years is that this notion of worth based mostly care, and the triple intention and issues like that. That means paying for the standard of the outcomes somewhat than the variety of companies. You understand, we’re in a price for service world. Proper? So I’d say that beneath every thing that is happening, or possibly it is above relying on the way you need. Your image isa motion to get extra worth out of healthcare. Proper? Would you agree with that? I imply, it is simply. That is what we have been making an attempt to do. You can say we are saying like. There’s all this inefficiency within the system, all this waste and if we might simply get extra environment friendly and smarter about how we do issues and give attention to the outcomes, as a result of I imply, give it some thought again within the day. I do not know what you had been doing at the moment, however to illustrate, you realize, early nineties, late eighties. Once I was simply beginning to work, you realize, type of changing into an expert the every thing was managed Well being care, and that managed care.
Stewart Gandolf Yeah, for certain. Like good everyone and.
John Marchica And everyone oh, managed care, and you realize, and in some methods folks may need been proper to be afraid, as a result of managed care. Look that their instrument was simply the scalpel. Their instrument was to say, we’re simply gonna deny care. And I am over generalizing, clearly. However that is that is the knock on conventional managed care. We’re simply gonna not pay for issues, and if we do not pay for issues, then we’re worthwhile and we’re holding down healthcare prices. Effectively, that is ridiculous, when you actually, if you concentrate on it. Yeah. And so you realize, some people got here alongside it is largely credited to Don Berwick, and he says, You understand, it is not simply him. It is a few different guys, too. However from the IHI got here out within the early 2000s and mentioned. You understand, we wish to enhance the well being of populations. And we wish to enhance folks’s expertise with care. we additionally wish to maintain the road on prices, and we wish to do all that on the identical time. And triple intention, proper. And so folks mentioned, Effectively, that is loopy. You possibly can’t try this as a result of we’ve this previous notion. or I do not know when you even know if it is previous. Perhaps it is an American notion. However we undoubtedly, I feel equate value with worth. Proper? The simplest factor is you realize the BMW. Versus you realize a Honda or Peugeot, or one thing, or after which above that, you bought your Maserati’s and all these fancy sports activities vehicles. folks say, effectively, I will pay 200 300 grand for a automobile, as a result of I get XY. And Z. And so they affiliate that pleasure or the worth. However while you discuss healthcare it actually type of breaks down, and I feel the largest motive why is we’re speaking about life and dying on the finish of the day and high quality of life once we’re round. And so the results of selections round healthcare are a lot greater than client items, and a few of the different issues that we, you realize, do make our pricing fashions on that it is exhausting for us to get our arms round, and I feel I do not know you assume, Stuart, however I feel it turns into much more difficult while you’re making an attempt to pay for worth while you’re making an attempt to place a greenback quantity or making an attempt to say, Okay, effectively, that is the end result that we would like, and we wish to pay for that versus. You know how that we do pricing as we speak.
Stewart Gandolf Effectively, it is yeah. It is so exhausting, and, you realize, just like the I do not know if we talked about this final time, John. However I, you realize, first obtained. I’ve all the time been as a client concerned with affected person expertise, however I used to be invited to talk at Cleveland Clinic about somewhat over a decade in the past about affected person expertise on their massive symposium. They had been, they had been actually main that my buddy Jim Rolando, has been on our podcast a bunch. And so like. That is one complete class that you realize. Again then a variety of nonetheless however again then, particularly lots of people, together with medical doctors like I do not care in the event that they like me. It is like no, it is lacking the purpose proper? It is somewhat.
John Marchica Proper.
Stewart Gandolf After which the concept of you realize preserving the associated fee per affected person down. That is you realize, that goes again to managed care. However then bettering the well being of inhabitants. That is like, okay. Now, that is loads. After which we begin fascinated with, you realize, once we talked about this kind of factor prior to now. And I podcast with numerous suppliers and completely different folks. You understand, I all the time take into consideration allergy symptoms and bronchial asthma. And so you realize, it is like. It is extra than simply giving the suitable inhaler. It is like, when you go to their home. It is, you realize, particularly on decrease earnings facet of this. and so they’ve obtained canine and cats, and it is dusty. And it is all working round. And you realize, like, there’s only a you realize, you’ll assume that is actually apparent. That is gonna assist your child. But it surely actually is not apparent to lots of people. And like, How can we try this? And who’s gonna pay that invoice. However who’s gonna pay the invoice within the emergency room like there’s loads proper.
John Marchica It is loads.
Stewart Gandolf However we all know all of us agree. The emergency room is a nasty thought, however so when you do not wish to pay, you realize, $20,000 for that go to. Perhaps there’s value sending a social work over there to assist them clear it up on occasion, or and I am there isn’t any simple reply. That is actually complicated. And a large number so yeah.
John Marchica It is out of. It is out of the field like I bear in mind years in the past. What was it, Montefiore? placing air-con items right into a sure space within the Bronx, the place there have been excessive bronchial asthma charges. After which, you realize, you hear about like meals cooperatives that a few of the well being techniques do. And a few of the housing work that Kaiser and a few of the different techniques have achieved for homelessness. So it is like Penny clever and pound silly. Proper? We’re gonna lower your expenses right here. But when we do not make investments on this over the lengthy haul, it is gonna come again to chew us. And so I feel that is the place a variety of that pondering comes from. Like, let’s handle a few of the root causes, or the, you realize, get on the root. However that is not how well being on the whole. That is not why folks get into healthcare, or what medical doctors practice for, or nurses practice for. Proper? You understand, it is so. It is it makes forces them to be type of out of the field. And so they’re pondering.
Stewart Gandolf Effectively, I get, you realize, in speaking to medical doctors, as I usually do particularly again once I was main seminars for them, like each week like I used to do. You understand, I’d all the time ask even essentially the most kind of establishment medical doctors on the market who felt like something is simply speaking about Socialism while you mentioned, Would you design the healthcare system the way in which it’s now, when you began from scratch? Oh, no.
John Marchica Proper.
Stewart Gandolf Who would? Who would try this? Who would design the healthcare system from scratch the way in which it’s now, even like I am certain there’s folks on the market listening to this. Who would say I do. However most individuals I do know even essentially the most conservative establishment type of main people are like, yeah, no, that is most likely not the very best mannequin ever. And that’s, you are proper concerning the coaching. It is like, you realize, issues like palliative care. For instance, no one needs to do palliative care. You wish to get the affected person higher. You wish to do 1, 3 and get them higher. And preventive is not very thrilling but, you realize, if we’re making an attempt to take a look at the broader inhabitants, and you realize, broader prices, it is we’d like to consider that. So let’s return to tendencies like, what’s the excellent news and unhealthy information? Let’s body it that approach like because you began this, and learning this significantly, like what issues are like, oh, thank God, that is lastly working. And what issues like. Why is that this nonetheless an issue? I might like to know. What are your ideas? There.
John Marchica I’d say couple of issues again to the tendencies. One of many disappointments for me I might say at this level is the everlasting uptick in telemedicine. and that if, once we’re popping out, when you bear in mind and I am certain we talked about this beforehand popping out of Covid, and through Covid there are lots of people who did heroic issues with telemedicine to have the ability to preserve care being delivered in the course of a pandemic and a lot switched to that. And you realize there was modifications in reimbursement to permit for extra telemedicine. It obtained folks to the place you realize. Proper place proper time, proper? Proper? That that these type of con conversations effectively, seems, folks wish to look on their telephone or on their pc and have a go to. It’s extremely handy for them. There was a variety of hype and a variety of we wrote loads about it right here. I am certain you probably did, too. And you realize right here, as we sit in mid in the direction of the top of 2024, I’ve obtained like an enormous yawn, you realize, like, effectively, what actually occurred? How a lot did it actually take over? How a lot did the cost mechanisms actually modify for this? How a lot do you know? And so I do not assume that it is remotely realized its promise. Not simply because we do not discuss it as a lot as we speak as we had been just a few years in the past. Alternatively, one thing that does present a variety of promise. And it is most likely, I mentioned, there’s the overarching development, but it surely’s most likely the primary development is the adoption of AI into numerous parts, each component actually, that you may consider in healthcare? It looks like any person’s testing this out. however the introduction of AI into not simply scientific resolution making or scientific assist, however in inhabitants, well being. The monetary sphere. In communications. I imply. It touches so many various areas that it is clearly to in my thoughts the most popular development we have tried to not write about it. There’s a lot on it each single week that is popping out on AI and I feel you realize it is type of I do not know. I suppose everyone kind of says that is to a point that the jury is out. I do not assume that folks assume the jury is out like AI is gonna be gone in just a few years. It is extra like. effectively, now that we’ve this new expertise. how can we refine it? The place is it? Good? The place is it not so good. And I feel a few of the largest techniques, and even a few of the extra medium sized teams on the market. And doctor teams try to determine this out in addition to the Googles and the Microsofts and the Apples of the world. I am nonetheless type of in that sport, so.
Stewart Gandolf So I’d. Let’s go right down to that somewhat bit. I might like to get your suggestions on the next. So by way of healthcare and the applying. I am simply. I can. You understand, with our place on the Web, I see a variety of issues. I hear a variety of issues. I get pitched a variety of issues proper? And so some issues have been pitched not too long ago is AI for the needs of taking routine. New affected person calls, you realize, making an attempt to assist them navigate or scheduling an appointment or following up with sufferers for routine issues. And I am speaking voice, not that is not simply textual content or e-mail. The A enterprise capital based mostly firm did some work and was exhibiting that the AI physician that that they had created was doing a greater job of diagnosing sufferers than the human medical doctors. As a result of you realize, the factor about AI is no less than in idea, you may management prefer it’s happening a sure protocol. It is not vulnerable to human error or bias. Proper? It is like, step 1, 2, 3, 4, 5 will all the time be the identical. After which, if they are saying this, and that’ll all the time be the identical. So these are 2 areas. Then you definitely have a look at value management, and you realize, kind of accounting you have obtained issues like looking for, possibly hidden clues within the information the place sickness may be in a sure neighborhood like these are just some examples like, do you hear about any of that stuff? Or is there different stuff like, the place do you see the largest, commonest, possibly teams of purposes.
John Marchica I, so I am certain I do not speak to as many of those folks, however I’m certain, like on the monetary facet. For example, in simply getting higher and smarter with coding proper and possibly figuring out. Did this affected person come? Did we code this correctly, and the type of flags that may assist out which are income producing probably for that system. So I am certain there’s a variety of that happening. We simply do not see it as a lot the place I see it essentially the most is in pop well being and scientific resolution, assist and the entire realms of what they might most likely match, like 50 firms with choices on this space. That type of fall beneath that. However you realize, again to your level about does the who makes the higher resolution. I imply, look, I I am not. Gonna get right into a matrix dialog about you realize the place we’re headed with machines. But when you concentrate on. you realize. how does a physician or nurse how do they? How do they make selections? And do not they type of undergo? Perhaps not consciously, or possibly consciously, if it is constructed into the HR. However kind of a call tree of their heads. Proper? I see this. Meaning cannot be this. So I will go down this path. And that is type of the way in which I feel they make these selections, after all, vulnerable to bias. And generally these biases. I feel we name that studying and knowledge might be a very good factor that possibly we have not fairly marshaled within the AI age.
Stewart Gandolf Yup!
John Marchica after which it is kind of on the flip facet. The unhealthy factor, from what I hear, no less than in simply kind of just like the ChatGPT realm of AI, that if it does not actually know the reply to one thing, it could actually make one thing up and sound actually good. together with references.
Stewart Gandolf Yeah.
John Marchica Proper. Do you bear in mind? The story was that the lawyer who had ready some? I do not know. I do not bear in mind, but it surely was comparatively not too long ago, within the final 12 months or 2 that every thing turned out to be made up, even the references, and that had been put into the case regulation. So. I am very cautious. You understand what in our world AI is nice for brainstorming, not so nice for information.
Stewart Gandolf Yeah, for certain. Going again to you mentioned there a minute in the past, like, so I feel you talked about you realize, inhabitants well being planning. And so I am gonna throw a situation on the market to you and inform me if that is one thing you have seen, as a result of particularly with kind of the IDNs. However like, if I take into consideration okay, if I am wanting as an thought. And the place do I wish to have precise bodily amenities for care? That is a posh resolution. There’s transportation points. There’s, you realize, the demographics of that space. Bodily limitations, psychological limitations to completely different areas. Have that, too. You understand. Are we going to steal from different places that feels just like the type of place is absolutely, actually complicated that I’d most likely would not depend on AI. However I simply wish to know what AI has to say. Hey, is that an space utilizing it? It looks like it could be pure for the type of work you are doing, or no less than speaking about.
John Marchica Once more. then we’re. We additionally should watch out right here, too, Stuart, as a result of I do not know when you’ve seen this, but it surely looks like every thing nowadays is falling beneath the AI moniker.
Stewart Gandolf Oh, it is a gross sales factor.
John Marchica So when you’re speaking about, I developed an you realize, an Excel algorithm that maximizes the potential for visits traded off with socioeconomic blah blah blah and traded off with all these different variables that is already being achieved. And I’d assume, yeah. And also you and I might sit down with our screens and a spreadsheet, and possibly fill out a fairly respectable prediction simply on that. So I do not know if AI is definitely in that world. However I feel you realize finally it is gonna come right down to I imply, there’s some moral points. However I feel proper now. As a result of look, I do not assume on stability, there’s some techniques that do fairly effectively, however on stability with the expertise that we had obtainable 5 years in the past, and 10 years in the past. I do not assume that these well being techniques are maximizing their efforts in inhabitants well being and figuring out the suitable sufferers proper? And so the newer applied sciences hopefully can assist out with that. However they carry once more an entire host of different issues. So I suppose my type of a awful reply, Stuart, truthfully. But it surely’s, you realize, it is type of it relies upon. After which I requested the query, Effectively. is it actually AI, or is it simply good analytical pondering that constructed a mannequin that may be a good, predictive mannequin.
Stewart Gandolf Yeah, that is completely.
John Marchica Not the identical factor.
Stewart Gandolf Yeah, effectively, it undoubtedly has a variety of intercourse attraction. Like I mentioned, there’s and I can see purposes and all of the stuff we mentioned. And however yeah, on the finish of the day. you realize, we’re we’re determining it is not going wherever. It is actually useful. In a variety of methods, the you realize, organizing the notes for the podcast my, you realize, the author that is gonna go summarize this assembly between you. And I’ll most likely use AI simply to get a begin. She’s not gonna do it that approach. However that is you realize, a part of. We use these instruments in any approach we will. So I wish to return to one thing you alluded to a minute in the past, and my canine by the title is Pirate, and it is nationwide converse like a pirate day. So there’s that proper. He is talking proper now. It is Pirate in Spanish, really. However.
John Marchica Did I begin.
Stewart Gandolf These of you which are listening to the precise recording right here. However let’s discuss worth based mostly care. And also you did not point out the kind of disappointment with that. So I might say, worth based mostly care has been round now for a very long time, and once I speak to folks, you realize leaders and clinicians privately, like, yeah, what I imply. It is there. However you realize, I assumed it might be loads greater by now, identical to I assumed we would all be driving flying vehicles by now, and that hasn’t actually occurred the way in which we thought it could. So, you realize. Give me a way of I requested you earlier offline. You had a solution to this like, what’s the penetration of worth Care? Is there a share? How do you quantify that? The place is it now? The place is it going? You understand all that type of stuff.
John Marchica So it is actually fascinating. It is a query. Some type of this query is one thing that I have been asking in analysis interviews for effectively, over 10 years, and to your level. It has been round a very long time, I feel, I mentioned. 10 or 15 years or so. The ideas have been round longer than that. I imply, we had been having our conversations again in class in ‘06 and ‘07. So it has been round some time. I feel there are good causes for this, however I do not assume that it’s actually met the promise, no less than kind of like the place folks thought that we might be, and I am going again, and I do not bear in mind if I discussed this final time. But it surely’s actually. It was a extremely type of a seminal second for me. I am going again to. you realize, 2013, 2014 timeframe round that point, as I mentioned, once I’m making an attempt to determine the place this firm was gonna go and what we had been gonna give attention to. And I went to a variety of the conferences again then that had been actually centered on worth based mostly care and ACOs, and you realize some IDN stuff, too. And the folks again then. So you work 10 years in the past, these conferences had been on a scale comparatively small to ones that we usually consider. However they’re specialised conferences. So possibly say, there is a thousand folks there, possibly 750 folks there, and these are like, these folks drank the Kool-Support. They had been completely. you realize, a billion p.c behind worth based mostly care and wished to speak about what they had been doing. And a variety of these guys, I wager, appeared loads like your shoppers. So there are a variety of doctor teams, a variety of actually sturdy, like entrepreneurial physicians that had been shifting their organizations on this path, possibly to your level, placing collectively, clinically built-in community on prime of every thing. Carry different medical doctors into the fold. However each time I learn a paper. you realize, each time I see one thing come out. Avalier does a you realize? An evaluation of ex-government program and healthcare. And the way they did. And I simply, I simply wanna yawn, proper? The numbers…
Stewart Gandolf Inform us what you actually assume, John, inform us what you actually I adore it.
John Marchica However I imply I simply I it doesn’t suggest that I am not a fan. It doesn’t suggest that I do not assume it is cool, and that we should not be shifting to extract extra worth. And there is not waste and blah blah. I get all that, and I am on board. However and you realize, you have a look at it this fashion. So. and that is what I noticed 15-20 years in the past with the ACO mannequin. You’ve gotten a scenario the place you’ve an entity. Let’s simply say an enormous doctor group. They go to Medicare, and so they say we wish to be an ACO nice. You probably did all of your paperwork nice and at our core. As a corporation, we comply with the triple intention. You understand we wish to enhance the well being of populations, cut back value, so on, so forth. And as a part of this settlement. Medicare says, sorry I will perform a little fast 101 right here. I am going to attempt to do rapidly. Medicare says, here is your finances. Here is how a lot cash we expect you are going to spend. Discuss to us in 18 months, how a lot cash that we really reimbursed you. and if there’s financial savings there, I am actually simplifying this. But when there’s financial savings there, we’ll share in that financial savings. And so to illustrate it is 50/50 cut up we mentioned you had been going to spend. you realize, 100 million {dollars} on care on your sufferers. You solely spent 90, and so there is a 10 million greenback distinction. And so let’s cut up that 10 million. We’ll offer you a doctor group. We’ll offer you 5 million nice and we’ll preserve as the federal government will preserve 5 million. and that is kind of a shared financial savings mannequin. And we might discuss danger. And you realize, high quality and different issues that go into it. However that is kind of the essential gist, proper? And so. However when you break down, when you have a look at that 5 million {dollars}, which looks like loads. And then you definitely say, effectively, based on our constitution. 60, 75% of that must be reinvested within the group for expertise, for improved care, and all of that proper? So now you are 5 million {dollars}. Now you are right down to, to illustrate even one million, which might be extra sensible proper as soon as you have achieved all these different investments and to illustrate that you have you realize just a few 100 physicians in your doctor group, or to illustrate you are an IDN. and also you’re coping with, you realize. a whole bunch of thousands and thousands or billions in that affected person income general, and you have, you realize, 2,000 docs beneath which are beneath wage, and one other 2,000 that you simply’re contracted with quantity, proper? So it begins to look actually small. And the doc that was in that follow or a part of that community. A part of that ACO seems at and says. Okay, effectively, I upgraded all my pc techniques. I needed to rent 2 extra folks that I did not have earlier than, as a result of I’ve obtained to handle this course of, and so they should have somewhat extra expertise than the opposite person who that I had as an workplace supervisor. So I’ve achieved all of this. I am additionally seeing extra sufferers as a result of I discovered find out how to turn out to be somewhat bit extra environment friendly. and I simply obtained a verify for $450 from the ACO.
Stewart Gandolf Woohoo!
John Marchica Proper?! So I I am making an enormous deal out of this. However when you have a look at the numbers and look a few of these convening organizations that put collectively the bundles that do the bundle funds and a few ACOs. You understand, there’s one in Florida that 12 months after 12 months appears to have 50, 60 70 million {dollars} in share financial savings. They appear to be killing it. However what’s the web impact? The one factor that I’ll say at this level. I am dying to listen to what you assume to Stuart on this level. However the web impact, I feel, at this level that is optimistic, has been an general change in perspective. And I’ve mentioned this from the very starting concerning the ACO mannequin and worth based mostly care fashions on the whole that if you may get folks to shift their pondering from. I am gonna lower your expenses as a result of I am gonna simply not approve this process. I am gonna minimize prices versus I will give attention to outcomes that can result in financial savings if I do the suitable issues like preventive care and a few stuff you talked about. Effectively, if there’s that shift in perspective that helps us in the long term. I feel that is a very good factor. However so far as the precise outcomes that I’ve seen, and by way of actual impression on the associated fee facet of issues. Not loads.
Stewart Gandolf Yeah, so it is humorous, like, we had been concerned. you realize, kind of tangentially with one of many pioneering ACOs. And like a variety of these actually did get arrows within the again proper? And so, yeah, I did not comply with it. I do not comply with this wherever almost as shut as you do, however I do know a quantity pulled out, and so they introduced ones again in, and that that is an entire factor. And now you are achieved with the Authorities loads to that complete story approach past the scope of this name. However you realize, I do bear in mind. And at the same time as not too long ago as we’re speaking to a serious well being system in Florida not too long ago. In case you simply come again to love find out how to preserve you out of the emergency room like, that is the massive driver. I feel that appears to be like, okay, virtually talking, no less than from the advertising and marketing facet. How can we do our half? It is like, let’s preserve them wholesome, and particularly. After which, when you’re wanting on the 80/20 rule that Pareto precept, like, okay, usually preserving folks wholesome is like, okay, it is bold and broad. However you realize, often gonna discover 1% of any inhabitants goes to be accountable for 50% of the outcomes. Let’s take into consideration that and work out find out how to rely. Maintain them out of the emergency room may be a approach to do that, however I so I am going to put that apart, after which going again to why, I like the way in which you simply broke that down by way of the numbers. Understanding the medical doctors, I do, boy, that may be lower than a collective shrug like, Wait, I misplaced cash. I misplaced some huge cash proper? Precisely. Oh, you realize, ethically, I like this. However, man, I am working actually exhausting. So I suppose then, like, to illustrate, you realize, there’s election coming. You are now that they appoint you because the Czar of this matter, which they might you realize loads.
John Marchica They might.
Stewart Gandolf So what would you do like? How’d you make issues higher? What are you able to do? What’s sensible objective? What’s like? Not a practical objective?
John Marchica Effectively, boy, there is a there’s one other hour or two on this podcast. That we might, that we might hold forth about this. I’m for non-political, non-ideological causes. As a result of I will preface that as a result of for some motive, if I say this, then everyone’s going to take it politically. I feel some type of, for lack of a greater time period, a Medicare for all is finally the place, as a nation, as a society the place we’ll have to be.
Stewart Gandolf Yeah.
John Marchica And I say that with you realize, understanding that particularly from the world that I got here from, and that I grew up in, that is like a serious heresy to say one thing like that proper?
Stewart Gandolf Yeah. It is the one firm ever.
John Marchica Yeah. Yeah. However when you actually, when you simply kind of take out, you realize that no matter political nonsense that you have heard during the last 20 or so years, or 30 years, or no matter you realize, and you concentrate on it. Numerous the inefficiencies that we do have in healthcare don’t have anything to do with or cannot. We won’t innovate our approach out of it. Essentially. The inefficiencies which are there are structural, and one of many greatest ones I imply, we might discuss. You understand, PBMs proper on the Pharma facet we will discuss PBMs, and whether or not that is a market distortion. If it is a good factor or a nasty factor. However there’s so a lot of these items that I feel we would clear up a variety of issues with, and I am going to offer you a extra tangible instance. Why, I say this. we would clear up a variety of issues by having a extra unified cost construction and never having to introduce the idea of competitors in the way in which that we do as we speak, like the way in which we’ve it now with the Inexpensive Care Act. And you realize the previous Heritage Basis, you realize. Mannequin that grew to become Obamacare. It is a good interim step, but it surely’s not. I do not see it as being the top objective and the instance that I used to be going to make use of. We did a undertaking for a consumer that was and it is a Pharma consumer that was seeking to primarily implement a a refund assure for throughout the board for all of their merchandise. Have we talked about this? I imply, I am making an attempt to assume we have had a dialog. I do not assume that we’ve and so mainly, if our product does not work. if we’ve one thing that lowers ldl cholesterol, and your ldl cholesterol just isn’t being lowered. If we’ve one thing that’s purported to develop hair in your head, and it does not develop hair in your head no matter. And clearly I am utilizing less complicated examples. But it surely turns into rather more tough while you’re speaking about coronary heart assault, dying, most cancers bunch of different issues. However that is the worth proposition that when you use our product and it does not work, we’re gonna offer you a refund. And so the 1st so very a lot so, a pure worth based mostly contract. The objective is, you need these higher, affected person outcomes and never simply higher. But when there is not a optimistic end result that’s anticipated. Then do not use the drug, and we’ll offer you your a refund. And in its very easiest type. so excellent instance of a price based mostly settlement. The issue is, effectively, the first query is, who will get their a refund? Does the affected person who did a copay get their a refund. Does the IDN that has the affected person beneath their care get their a refund? Does the payer, which can or is probably not the IDN get the cash again. And oh, by the way in which, what if they are a Medicare affected person? They are not. And what if their Medicare and so they’re a part of an ACO or their Medicare and their Medicare benefit. And also you begin happening this highway. And also you see within the feedback that we obtained spoiler alert folks did not prefer it. So I did about 30-35 interviews with folks. and ran by this mannequin with very educated folks in healthcare. And you realize who’re delivering care or paying for care. And it was nearly universally panned. And a variety of it needed to do with this query of Effectively, how do you who will get the cash? And one of many suggestions that I gave to our consumer one of many optimistic suggestions, ought to they wish to go ahead with. That is what I mentioned was, or what our the place our firm landed was. This type of mannequin is simply going to work in a Kaiser or a Geisinger, or you realize any well being system. If you are going to do it in a well being system and never simply with a payer, it is obtained to be achieved in a well being system the place they’ve the entire value of care beneath their umbrella. So they are a payer as effectively. in order that it makes monetary sense for them to trace these outcomes. They may have the power to trace the outcomes higher, however in any other case making an attempt to it simply turns into so tough to implement, and in order that the method of measuring all of this prices greater than any potential financial savings might presumably be, with a variety of headache concerned.
Stewart Gandolf Yeah.
John Marchica So.
Stewart Gandolf Additionally, you’ll take the inducement for the pharma, for instance, out like approach we’re gonna spend all these billions of {dollars} to develop a drug, and we might not receives a commission. In order that makes it exhausting, too. That is a that is somewhat barrier to entry like, Okay, you go try this. Then.
John Marchica Yeah, and he.
Stewart Gandolf And you will by no means ask.
John Marchica Even when they stand by their product. And so they say, Effectively, we all know our product is nice. There’s the potential upside for that firm proper? As a result of their opponents that are not beneath this settlement. Effectively, possibly whoever has that worth based mostly settlement says we’ll use extra of the product the place we all know that there is this a refund assure.
Stewart Gandolf Yeah.
John Marchica Proper, and so possibly they might develop their pie somewhat bit extra. However that is why I say that. You understand, once we’re speaking in these phrases, I actually really feel like, and if it is not a single cost kind system, then it is one thing somewhat bit extra that approximates what I talked about earlier than, which is a fewer variety of well being techniques to have the ability to kind of management the pie.
Stewart Gandolf So excellent. I that is actually fascinating. In order we wrap up a pair extra issues and we’ll reserve it for the subsequent time.
John Marchica I have never put you to sleep but, Stuart? Ha ha
Stewart Gandolf I like these things. It is like I like something. It is like, ahead fascinated with healthcare. And you realize, it is like, it is vital to maintain the imaginative and prescient of what is attainable and never get to kind of downtrodden, as a result of.
John Marchica Yeah.
Stewart Gandolf Fairly glacial instances like, for all of the modifications. There’s some issues which are such as you mentioned. It is like going again to what I mentioned a short time in the past. Would anyone design it the way in which it’s now? As a result of with that creates all these different unexpected, you realize, unanticipated penalties. And you realize, it is prefer it’s you may completely get political there, too. However you realize it is like, generally issues evolve. It’s important to begin over or work out one thing. As a result of when you’re doing incrementalism ultimately, it stops working. And that is, I feel, type of the place we’re in some methods. So I am going again to the pharma and life sciences. You understand. How? How does Pharma view concepts by way of. you realize, analysis or different partnerships like, what’s pharma fascinated with? They’re paying, and so they should care so like what are a few of the conclusions there.
John Marchica So the old fashioned mannequin nonetheless exists of how firms market and promote their medication. So if we simply have a look at the pharma element of the biotech kind of element of life sciences. The old-fashioned approach is, you’ve a gross sales drive, and then you definitely go ship in a rep to go see a physician. They speak to that physician concerning the product. They educate the physician, and so they “promote” that physician proper. And that mannequin for pharmaceutical advertising and marketing labored for lots of years. not a lot anymore. And there are a variety of causes for that. Considered one of them is that I feel the trade kind of shot themselves within the foot. within the nineties, and the and the early 2000s. by hiring armies of gross sales, reps. and doubling down and tripling down and quadrupling down on sure doctor workplaces, the place sooner or later they simply type of threw up their palms and mentioned sufficient with the onslaught of reps. Proper? So there was that dynamic. However the different dynamic, which is possibly much more vital. is the acquisition of those doctor workplaces by IDNs. from non-public fairness, from Insure, from like Optum, I imply, what are they as much as? 100,000 medical doctors, or one thing like that? At this level, so United Healthcare, Optum and in these circumstances, after post-acquisition, nearly by definition, the entry will get shut off as a result of these techniques wish to management. or these PE teams or these insurance coverage firms wish to management, how their physicians and their nurses and everyone else, how they spend their time, and the very last thing they need them doing is spending time with gross sales reps, so that they instantly will shut off entry. And so the query that has been on Pharma’s thoughts, I feel, most likely for over a decade at this level is okay. If now, because the enterprise is shifted to those massive doctor teams and these IDNs and all of this. How can we preserve advertising and marketing our stuff? proper? We won’t simply depart it to the peer reviewed journals and allow them to determine this out on their very own, or determine this out on their very own at conferences. So how can we market our stuff? In order that the first response which they did I do not know 20 years in the past, plus is to say we’ll bypass all of this, and we’ll pour oodles of cash into direct client promoting. Proper? You can not watch TV at this level for any length of time past 5 min and a business break with out seeing a drug. Industrial. They’re in all places.
Stewart Gandolf Yeah, yep, proper.
John Marchica In order that’s 1st factor. And we’re gonna create demand by having sufferers go into the physician’s workplace and demand our product proper, and that, I feel, is fairly efficient. However then the opposite factor they mentioned was, is, effectively, how can we align our salesforce to work higher on this new atmosphere. After which and I feel what a variety of them have What they’ve provide you with is extra of an account administration mannequin the place they’ve extra skilled folks constructing relationships and having conferences. And so, as an alternative of getting 2,000 reps. And I am oversimplifying right here, possibly they? They’ve 25 account managers and 100 reps, or one thing like that. however the query is, and the battle is, when you have a look at Pharma from an IDNs perspective, from a, or an enormous doctor’s group perspective, they nonetheless have the detrimental ideas. They nonetheless have the. They bear in mind the armies of reps coming in and disrupting their workflow. So that does not go away in a single day. Then the query is, okay, effectively, what worth are you do you? Are you able to convey to us. Do you actually convey to us? And the way can how can we work with you in type of a special approach? By the way in which, I do not assume IDNs are asking that query. I feel Pharma is asking that query of what they’ll do for IDN.
Stewart Gandolf Sure. Yeah.
John Marchica After which making an attempt to, you realize, have the query come from the IDNs? As a result of once more, so far as the well being system or the massive doctor group or the massive most cancers heart. What they perceive the life sciences to be is a check mattress of innovation, analysis, scientific trials, issues like that the place they’ve the capabilities. And all of that is sensible. Okay, Pfizer’s growing a brand new drug. We wish to be on board with that. We wish to be one of many websites or one of many companions in in in evaluating that drug. So I feel, the place we at the moment are is type of at a at a standstill. And I swear I didn’t intend for this to come back throughout. It is gonna sound like I am providing you with the massive wind up for a promotion. I do not imply it like this.
Stewart Gandolf Oh, please God!
John Marchica Do not imply it like this.
Stewart Gandolf No, no, please promote your self. I need somebody to name.
John Marchica I am simply so we’re within the means of we’re launching a nationwide Id and engagement examine. one thing that we did within the wake of Covid for about 18 months. And now we’re type of restarting that the atmosphere is completely different. We’re not asking questions round Covid as we had been earlier than. However we’re actually making an attempt to get at this partnership or collaboration or engagement piece that identifies the win for the affected person. for the well being system and for the Pharma firm. What does that seem like? What’s working collectively on one thing on a undertaking collaboratively do to enhance affected person outcomes? And
Stewart Gandolf Thrilling.
John Marchica it is thrilling. It is a massive query. And I feel that is type of the place Pharma is as we speak. I feel there’s a variety of head scratching. I feel some folks, mentioned the widespread chorus, that that I get on a regular basis Stuart, is the wins that we’ve the WINS. Not WINDS. The wins that we’ve are very uncommon. We are able to level to at least one or 2 partnership collaboration agreements. No matter you wish to name it, and possibly a price based mostly bit element to that the place we will all say that we had been profitable, that the sufferers turned out higher. The system was proud of the outcomes, and us as a life sciences or Pharma firm. We ended up successful out ultimately as effectively, too, very, very uncommon. So we’re within the means of launching this. We’ll be fielding, doing all of the analysis in Q 4, and are going to be releasing our leads to in January. So fairly excited.
Stewart Gandolf And prepared. While you’re prepared. It’s important to come again.
John Marchica Alright!
Stewart Gandolf And I feel that is intriguing. So this has been a I like. This has been a really kind of mental ahead wanting, which is to me is absolutely enjoyable, proper? There is a each day stuff. And for us that is one thing that I will not. I like fascinated with the place issues are like, I mentioned. Strive to not be despondent for some issues which are actually tough to alter, and nonetheless discover daylight within the opening. So. as all the time, John pleasure. Thanks on your time. In the present day we’ll speak once more.
John Marchica That is nice, and I gotta say, Stuart, one final shout out to you since you make this really easy. You actually do, and it is not. It is not simple. I hope, that I am simple on my visitor, too. However you you are simply. It is such a pleasure. I might come on and speak to you on a regular basis. It is such a pleasure doing this. And it is it is due to what the way in which that you simply go about it. So I actually recognize that, and thanks for having me.
Stewart Gandolf You are welcome.
