Payor Contracting Part Three

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Richard: Welcome back to Agile&Me, a Physical Therapy leadership podcast series. Again, I have the pleasure of welcoming back Mark for part three of the Trilogy on Payor Relationships. Welcome Mark.

Mark: Thank you very much, Richard.

Richard: So I bet you never thought you'd be part of a trilogy.

Mark: I did not. So this is exciting.

Richard: So in the previous couple of podcasts, we talked about the high level contracting, generally for outpatient therapy clinics and what the contracts needed to include, or you need to look out for and some of the specifics about contracting generally. But I thought about what might be helpful is talking on this episode about the mechanics, the strategy, but more so the process of actually negotiating or renegotiating, shall I say, a contract, because as a private practice owner, one, if you actually find your contract, but then once you found it, it's really, how do you go about changing it? And we'll assume that, hasn't been done for a while and it's time to update the terms and all that. I assume part of that is the price. So if that's okay, I'd like to kind of focus on that today.

Mark: Yeah, sure. That sounds like a good place for number 3 here. So the general process, it's an easy process, so to speak. It might take you a little while, but the general process I have down in four steps. So I have that you want to send a formal written request to the payor, and that can either be an email or an actual snail mail letter. That goes to the payor. Some payors will require it to be a formal request on letterhead. So in either case, you'll need to initiate it by a formal request to change the contract. Then you'll want to wait for the response from the payor representative. You want to read through that response and start dialogue to get the desired changes made. And then four, you want to establish the effective date of the changes that you're able to negotiate. So those were the four steps that, , I came up with. And of course, within each of those steps, you have different things that you need to make sure you have.

Richard: Yeah. Sounds easy, doesn't it? Whether you actually have a positive outcome or not, probably the harder part, shall I say, yes.

Mark: Exactly. Yes.

Richard: Okay and what we're talking about here is commercial payouts essentially. So let's assume that we want to renegotiate with insurance X and it hasn't been looked at for a while. We got to dust off the contract. We found it. , if we haven't found it, I assume the first before the formal request is we'd actually have to ask for a copy of the contract.

Mark: That's exactly right. And so even before that, taking a step back, you want to make sure that you understand the contracts that you do have out there. Okay? So, one of the best ways and easiest way I can think of is to actually read through your EOBs. And look at the bottom reason codes at the bottom and they'll explain contractual adjustments that have been taken. And so that should be your first key that, okay, this payor says that I have a contract in place. And so that can help you build that list so that you can reach out to the payors that you don't have contracts for and find out what has been agreed to in the past. Or if they're just saying there's a contractual Contract in place, and they're just taking a contractual adjustment just because no one's going to ask them about it after the fact. So I think the 1st step is to go through and make sure you understand which payors are saying there's a contract. And then the next step would be to track down provider reps. At those payors so that you can get the copies of clean contracts and fee schedules so that you understand what the parameters of those contracts are and what rates you're supposed to be getting based on those contracts.

Richard: Correct me if I'm wrong, it's not unheard of for you to ask for a contract and actually the payor doesn't even have one available and that then opens up the negotiation in itself, correct?

Mark: Yes, and I would imagine that it accelerates the negotiation because they are paying you at a rate that they can't justify. So I think I want to add that, just because you don't have copies of your contracts, that doesn't necessarily mean it's a disorganization issue on the provider's part. A lot of times we'll sign a contract and you have to ask for that contract to be sent so that even after they supposedly signed it, you don't automatically get a copy. You have to keep that in the back of your mind that you need to get that copy. So that you have a copy, a clean copy of it for your files, because they don't automatically just send you one all the time.

Richard: And that's interesting in itself, isn't it? You sign a legally binding agreement, and they don't even send you a copy of it. Well, who would have guessed?

Mark: Right.

Richard: Okay, so let's assume that you have the contract now, and then you've reviewed it. And obviously you want to renegotiate based on some, some term or condition. And you mentioned that the formal request is the first piece. So with the formal request, who does it go to? What's included in it or needs to be included in it? And then anything else about that communication?

Mark: Yeah, so, with your request in the back pages of your contract, usually close to the signature page, it will describe for you where any notices need to go and where any notifications that you need to make to the payor, and then any notifications that the payor needs to make to you, there will be actual physical addresses of where those articles of mail need to go to be official as part of the contract. So that's where you'll find out where you need to send it. And when you're drafting the letter, you're going to want to put your practice information. So you'll want to add your tax ID number, your legal name, perhaps your NPI number, perhaps your physical address, and then in that body of the text, you'll want to describe what you want to negotiate. So whether that's rates or language or both, you can make that formal request. You can come up with a per diem rate that you feel is acceptable. For your practice or a percentage increase to the current fee schedule, but you want to spell that out in your letter and then, of course, sign it by a representative of the organization so that it's official and that should get the ball rolling for you.

Richard: So in the initial formal request, it actually is quite detailed. It's not as if it's kind of like dating where you reach out and say, hi, my name's Richard. I'd love to chat with you. What's your name? It's much more, I have an agreement with a contract with you, and these are the terms that I want changed and very specific. Is that true? And then is that your starting point? Is that really the stake in the ground? Or how formal is this as a formal request? And how detailed should it be?

Mark: Yeah, so to save time. I would be as detailed as possible and justify why you feel that you deserve better rates. And so, in saying that, and needing that for your letter, there are a few things that as a provider, you need to be on top of as well. So, 1 of the things that you'll want to know, you'll want to understand your clinics, KPIs, your key performance indicators. So you want to know what the cost to treat is. So that you have a basis to understand what's a fair rate for you and what's a rate that's going to allow you to keep the lights on and grow your business. You also want to know the cost to bill or rebuild claims, because that's a true cost. And if a company is making you resubmit over and over, that's shipping away at whatever margin you're able to get. With your contract. So I think it's important that you're drafting these negotiation letters. I think in everybody's time. I think it behooves us to try to shorten the time frame and to add as much information that's going to get them to say, okay, yeah, this guy's serious. He's done his homework. We're going to negotiate a rate and get them up somewhere. Maybe it won't be what you're asking for, you want to ask as high as you feel comfortable asking so that you can always work back to a reasonable number that's going to get your targeted increase that you're looking for.

Richard: So two things, and essentially one is no point schmoozing. Basically, from what I understand, there's no point in kind of ingratiating yourself. And secondly is to ask for more than you perhaps, Willing to accept because ultimately I assume it's negotiating. I assume it's bartering at the end of the day. I can't imagine very often. You'll get put in a formal request and they'll agree to all your terms immediately.

Mark: Yeah, it's rare.

Richard: So, but I would also assume that you don't want to be outrageous in regards to your request. So for instance, if you are reimbursed, let's say $60, and there's no point saying, I want $200 for a visit.

Mark: Right. But certainly if you compare to other payors around you that you're getting paid for and you're seeing some paying you 95 or a hundred dollars, I'd ask for a hundred dollars. And see what happens, and they can always say no, but I think that's a good starting point.

Richard: Are you able to give the audience perhaps an idea of where that starts, how you come up with the starting point for reimbursement? So in that formal request, when you say, I would kindly request a reimbursement rate of X, is that a benchmark against something? Your kind of starting point.

Mark: Yeah, so oftentimes I'll look at the number of units that we're building, and then price that out using Medicare as a baseline. I know that a lot of the payors will base their rates off of Medicare, a percentage of Medicare.

So, we're still using the same baseline. We're just looking to get at least 100 percent of Medicare, but generally, if we can push that to, 1, 15, 1, 20 percent of Medicare, that's that much better. There have been payors that I've seen pay at 140 percent of Medicare, but they're few and far between. But certainly, I think basing it on Medicare gives us something, to attach our, our justification to and then also the hope is that Medicare will continue to increase their rates even slightly, which builds in a cost of living increase that we can talk about later about getting a higher one for us specifically, but I think that's a good place to start is to to price it out at Medicare and what we should be getting at a Medicare rate. And then building off of that.

Richard: I think some listeners might think, perhaps we should be a comedian here because the irony, the true irony is Medicare used to be one of the poorest payors and the Medicare rate, I don't know if it's relative or real. I think it's probably relative. I suppose it has gone down 30 percent in the last 10 years, and it used to be one of the poorer payors. But, ironically, now we're using it as perhaps a benchmark or a starting point to negotiate rates, even though Medicare rates have basically taken a complete hammering. So, food for thought there, if nothing else, I suppose. So staying on the formal request, essentially, we are outlining what we want, and oftentimes it's to do with reimbursement rate, I would imagine. What other things might you want to include in that request?

Mark: Well, you certainly want to look at your administrative costs. So if you're finding that you have to bill, send claims multiple times, if you have to send in additional documentation that you've already sent several times, all of that stuff adds to your cost and chips away at the margin. So you want to make sure that anything that you can negotiate for your better is something that you want to consider to do.

Richard: I don't know if this is relevant for smaller entities, but for instance, credentialing and then we mentioned, I don't know if there's any way of negotiating. I suppose there's definitely the idea of the term of the contract if it's not evergreen or I assume there's lots of other little things that perhaps need to consider within that formal request as well.

Mark: Yeah. So one of the things about keeping very in tune with your practice and the KPIs, but you want to look at your adjustments in your bad debt. And figure out where it's costing you money. So things like providers, not credentialed. If you're finding that a payor has a higher number of write offs based on credentialing, then you can justify it. And you can say, look, you guys take 6 months where everyone else takes 30 days or 45 days to credential, which again, I guess, is a comedy routine as well. But the point being, if it's taking them 2 extra months to credential you. That's a cost that you're bearing either through scheduling and inconvenience to the patient, their members, or you're writing things off that you shouldn't have to write off because you do have qualified providers and it's just their paperwork and their process is slowing everything's down. We talked about the missing documentation. If you keep knowing that you're sending this document documentation in and that payor, for some reason, you're seeing a lot more write offs based on that, if you're seeing registration errors, if you're seeing timely filing, those are things that perhaps you can get expanded that if timely filing is 60 days. Maybe that's something you want to push to 180 days because that takes them a while. It takes you a while either to get your documentation or secondaries or whatever. There can be a lot of reasons that it's slowing it down. And you just need that buffer that other payors are giving you that you can justify them giving it to you as well.

Richard: And I assume in the ideal world, you try and negotiate the amount of time for payment as well, down to the lowest amount of time as possible, or at least, at least to a time frame that is comparable with other payors.

Mark: Yes, correct. And then most states have a law on that that usually it's like 45 days of receiving a clean claim. Now, if they're pushing it out, because they keep saying, you don't have a clean claim, then that's another issue that you can talk to them about and negotiate about. But generally speaking, you want to be in tune with what the state guidelines are for prompt payment from a payor and make sure that you're holding them accountable to those rates.

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Richard: Anything else that we need to cover with regards to the formal request?

Mark: No, I think that that pretty much covers it. I think that it hurts you if you're putting too much information in there. So, I think a good guideline is to keep it to like a page so that they're not going to just not read things and skip past it. And then certainly, when the negotiation starts, then you can add a bunch of additional information and send them justification and that's when you want to send a lot of information to them.

Richard: So an essay is not going to help your case at this point.

Mark: Not generally, yes.

Richard: All right. Okay. All right. So the second part, as you talked about, is waiting for the response. So this was really interesting to me. I know we've chatted about this as well. So contractually, are they obligated at all to respond in a certain time frame. What is probably common? And how long should somebody wait? Because if you don't as a payor, if you don't want to do anything, then you just don't respond, that's the easiest way of not doing something is just don't even engage, but tell me a little bit about this waiting game.

Mark: Yeah. So typically speaking, when you're doing your initial request, usually they'll give you 30 days that they'll get back to you within 30 days with a response, and usually they'll tell you that however they respond to your letter, so if you send it an email, generally, there'll be a form letter that comes back an email saying we've gotten your request and we'll be in touch with you within 30 days. You certainly want to make sure that they're holding you for 30 days. So I would put a tickler in my calendar that I'm calling them a day 29 and saying, hey, I'm just checking in to see where you're at with that. And when we can start negotiations. And then go from there. If you're not getting a response that that from them that I'm certainly continuing to Track down whoever I can just to get that response and to start the negotiation because like you said you do not want to allow them not to respond because it's costing you money every day and it's saving them money so there's not really an incentive for them to come to the table. But certainly as a partner in a contractual relationship, I think they're obligated to give you a timely response and a timely negotiation so that you can figure out what you can get.

Richard: So obviously, when they respond, they could respond in a number of ways, or if and when they respond, let's assume the positive and they do respond, good intentions, they can basically say no, they can say yes.Which either probably well, certainly just saying yes is probably rare or they can say yes but let's talk. So, in your experience, what are the types of responses you have? Um, and how do you deal with each? So first off, let's say you just get a response. That's basically a point blank. What can you do?

Mark: Well, you have several options. I mean, you could just sit back and say, okay, well, they said, no, I tried and that and that's it. You can continue to go up the ladder. It depends who responded to you. If this would be a provider relations person, then I would say, okay, we'll go to contracting directly then on who the contracting director of contracting is or the VP of contracting or provider relations and push your case if you truly feel you're not being consulted. Fairly compensated for the quality care that you're giving that I think is you're, you're obligated to yourself to continue with the process. And a lot of times there are, or there have been times where you just do it 3 times and then all of a sudden they're like, okay, yeah, we'll take it. They assume that if you're not going to do it the 1st time or the 2nd time. Then they've won and you'll just continue to treat their members because you feel that you have no other option. But sometimes if you hit that third or fourth request, then they just want to get done with it and move on and have you stop pestering them. So that's typically the route that I would take is that I would continue to find someone in the organization that's going to hear you and then make that justification.

Richard: So essentially, saying no is easy, isn't it? And yes, I firmly believe that a squeaky wheel gets the oil to a certain extent as well. If it's a fair and reasonable request, right. If they are reimbursing less than what the cost of the visit is, I don't necessarily think it's fair. And I'm sure you don't think it's fair that we just roll over and acquiesce, right. Even though some, I'm sure some entities they expect will, and they do, because they don't want to pick a fight. I wouldn't say fight, but certainly pursue it further. So it's a follow up. And I assume a lot of these nodes are just standard template nodes as well. So they don't make any effort with regards to that. So it's follow up and then perhaps escalate as well, essentially.

Mark: Right, right, because you'll never get them to justify their rates to you.

They'll never come back and say, here's why we're paying you so low. It's usually a form letter saying thanks, but we've done our homework and we're not changing anything. So usually that's what the form letter is. But you don't need to stop at that. You can continue to push and push and push until the CEO tells you and then you're like, okay, well, maybe I don't have an option here.

Richard: Well, I assume the option is at that point is you either accept it or you walk away right?

Mark: Yes.

Richard: Okay. If it's a yes, that's easy. So we don't really need to necessarily talk about that at the moment. They dispute the request, but they at least open the door. So then what tends to happen there?

Mark: So then they will offer you some kind of an increase, if they haven't set a flat number and you've reasonably justified why you deserve more. Then typically they'll meet you somewhere in the middle of your original request. and I think it's imperative that you understand how you differentiate yourself in the market. So if you make even the slightest case for an increase, I think it gives you a better shot than just saying, I want more money. Because a lot of times the person that you're dealing with is going to need to have something to show whoever makes the decision on their end. If you're not talking to the decision maker, any information that you can provide makes their job easier. But I think it's important that you can point to things that are like customer reviews that you get, NPS scores that you have, services or different expertise that as a provider can provide that your peers cannot.  If you have someone 30 miles away, that's your nearest participating competitor that can make the case that they need you in-network if you have a large portion of the market share, you're seeing a ton of their members that gives you some leverage in this too. So understanding your business well, we'll help you with your negotiations.

Richard: And this is my naivety, I'm a clinician at heart, so I have a fairly negative perspective unfortunately on payors and that's unfair, but with regards to the people you tend to deal with regards to payor relations and the payors, does it tend to be adversarial in nature or is it collaborative?

Mark: It can be either. I don't think they go out of their way to be collaborative. They say they do, but if they want to be more collaborative, I think they give you more avenues for contacting them and communicating with them over the past 10 or 15 years. They've slowly gotten away from the dedicated reps for people. They've given them larger territories with more providers to deal with. So they say they want to be collaborative. But I think at the end of the day, are we going to give you the money or are we going to keep more of the money? And so I think it becomes a little bit more adversarial when it comes down to the dollars.

Richard: Yeah. So dialogue, how long can it go on for, what's the best strategy? So they've opened up dialogue and where do we go? How long does it last? What direction does it take? How should you kind of continue it to optimize the outcome for the provider?

Mark: Yeah. I think you want to respond quickly and you don't want these to drag on. You want to get paid as quickly as possible and part of the issue with negotiations is how long does it take them to load the new contract or the new agreements in. So you have to keep that in mind as well that if it's going to be a 30 day load or 60 day load or whatever you want to get that stuff taken care of. And started so that you can get reimbursed as fast as possible. What I found is that typically the payors don't want these to drag on either. So you're going to get to an answer, a final answer rather fast. I would think, and I would say that after that, maybe initial 30 days. After an initial 30 day window that they've asked to review your request, I would think that within the next 3 to 4 weeks, you should be able to have some kind of a final idea of whether it's going to be approved, or if there will be changes, or if you're going to have to decide if you want to stay in-network or leave network or whatever. But generally speaking, I would think that it shouldn't drag on more than like a 60 day process.

Richard: So I assume after the response to the formal request, that's really when you can then increase your communication and justification so you can have this whole slew of information to help build your case or justify the additional amount when you're negotiating backwards and forwards.

Mark: Yeah, correct, because after that initial submission that you've done into the mailbox, the general mailbox or whatever, you're going to be assigned someone to actually do the negotiation. So then you'll have a name to to actually talk to to send stuff to. You have an email address. Generally, you'll have a phone number. And I would stress that as you're collecting these phone numbers and email addresses, make a Rolodex of some sort and keep the phone numbers handy. Cause you don't want to lose track of these folks when you need something done, it's a lot easier to pick up the phone then rather than wait that first 30 days, if things aren't working out. You'll want to be able to actually talk to a person to negotiate right out of the gate. And I've had a lot more success when I'm talking to a person than just sending a blind request.

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Richard: What else, with regards to the negotiation phase, what words of wisdom do you have in that component?

Mark: Yeah, so we talked about knowing your business inside and out, and having a good handle on the things you can affect your processes, making sure that You have your processes taken care of and in place so that you're sending claims efficiently, but there are some outside things you want to consider as well. So, obviously, inflation is a big thing. So you'll want to have some resources that are going to give you. Kind of inflationary impacts over the course of the time that you've had that contract in effect. So, for instance, if you had a contract that took effect in 2012, you'll want to do some research to figure out what the inflation rate was over that same 9 or 10 years that we're talking 11 years now. I've seen 30 to 40 percent increase in just inflation. So you'll want to keep that in consideration as you're looking at your rates and justifying your rates to say, Hey, look, inflation over the course of the last 11 years was 40 percent and you're still paying me what we originally agreed to. So that's a big thing. The other thing is to figure out how premiums have gone up. In that same time period, if you see that the premium overall for payors has been about 45 percent or 47%. I think it's very fair to say, okay, well, you guys got your rate increases over the last 12 years. Why shouldn't I be getting some rate increases as well? I'm actually doing the heavy lifting. I'm actually working with the patients, getting your members better. I think it's only fair that some of that premium increase that you've enjoyed should be coming my way as well. And I think just in general, what your peers are doing, have you had some providers, some physical therapy providers in your area, cancel? Do you have some employer groups that have changed insurances and they've gone from an Aetna to a United Healthcare or vice versa? And so you have an idea of, okay, well, United has taken a hit because a big factory closed down or decided to go somewhere else. That might be good leverage for you to say, Hey, You need me in here to continue to offer services to the existing employers. And if they're growing their business, trying to grow their business, they certainly need providers in the area. So I think it gives you a little bit of leverage there.

Richard: Let's say we've successfully negotiated. I use the term negotiated probably in very broad terms. If I say we've reached an agreement with regards to perhaps adjusted terms and conditions. Interesting to talk about effective dates because to me, it's if you ask, if you give somebody a pay raise, for instance, they expect it to take into effect within the next pay period, a couple of weeks or possibly a month, but it doesn't really quite work that way. Does it with payors? They seem to take a little bit longer with regards to loading up changes, correct?

Mark: Yeah, correct. Now, there are some that will fast track it. And I've dealt with some that are like, if we can sign it this week, we can have it by the end of the month. But then, then there are certainly ones that say, okay, well, it takes 45 days to load a contract. So this will push you out to June 1st or something like that. So, You certainly want to try to get those in as quickly as possible and the effective date as quickly as possible. One option could be to hold claims if they give you the effective date of tomorrow, say, and then you, you say, okay, well, I'll hold claims for 30 days, but you have to take that into account as well, because that's, that's costing you money. So you have to use that as a last resort, but that's certainly an option for you if you can do that, you might be able to get a faster, effective date. You just might have to wait for payment.

Richard: That all sounds great. How often should providers look at their payor agreements? Obviously, let's say you've made a slight change.I'm sure that no change is probably that significant where you wouldn't want to at least go back within a reasonable period of time. But how often should you reach out to payors?

Mark: Yeah, so I would say that you should review your contracts at least annually if you haven't made any cost of living adjustments, any escalators in those the benefit of adding cost of living adjustments. You can spread that out over a 3 year period so that every year you're guaranteeing yourself, a 3 percent raise or a 5 percent raise, whatever you can negotiate and in that regard, then perhaps I look at it every other year or so, because I know that I'm getting better rates every year. And what those percentages are, but if you only are able to get 3 percent increase, get the rates increased one time. Then I would say look at it every year and see about increasing those every year. See if there's things happening in the environment that you need to increase your race for. You want to look at them periodically, but certainly I don't think you want to put them away for 5 or 10 years and then dust them off and reveal them because your best opportunity to continue to get those increases is to make sure that they're either built in or that you're constantly looking at them periodically to increase your rates.

Richard: The last thing I'd like to perhaps talk about is the decision to terminate contracts. And I believe that this should be done more. I believe that this sends a message to payors that the providers have been squeezed enough by certain payors and the reality is this in the past, health care was cross subsidized, so essentially the poorer payors got away with it based on the fact that the better payors were really subsidizing care and really taking advantage of goodwill of providers, be those hospitals or individual independent providers, but with rates coming down relatively across the board There isn't even that opportunity to cross subsidize, even if we believe that it's fair and reasonable to do so. So ultimately we're going to have to call contracts. And I think it's happening already, not at the pace or the rate that I think is necessary. How do you go about ending a contract?

Mark: Right, so you need to make sure that you understand the contract and understand the termination clauses in the contract. A lot of times, there will be a period of time where you have to give notice and that might be 90 days. For 120 days, in our past podcast, we talked about limiting those termination timeframes and you want them as short as possible, but say it's 90 days. So you need to make them aware that you're going to be terminating your contract and the effective date will be 90 days out a lot of times in the contracts that will talk about needing to continue to treat patients even after the termination until that patient can find another, in-network provider. So generally speaking, 90 days is long enough that you have enough time for the patient to find someone else in your region. I guess the only time that might come into play is if there isn't anybody, if there isn't anyone else in your region. And again, that's not good business on the payor side. If they're letting you walk away and they don't have adequate network coverage for their members, but generally, those are the 2 things that you want to make sure of. And then once that 90 day time comes, you want to make sure that you've notified the patient. And let them know that that's what's going to happen. Sometimes the insurance companies will want to make that announcement to their pay to their patients and their members, but certainly as a provider, you are able to make those announcements as well. And should you're the 1 building the relationship with the patient and the member and. Explain to them exactly why you're getting out and what's not working and because they should know they should know where their premium dollars are being spent or not spent.

Richard: Have you ever had the situation where you put in notice, essentially formal notice of, of termination and then for payors to come back to you, or is that really unusual, should I say?

Mark: It just depends on the payor. A lot of times, that has happened in the past, and it was like a game of chicken, who was going to blink first. And ultimately, the payor came back and said, okay, well, here's where we can meet you in the middle. And generally, it was sufficient enough to have us stick with it because we like treating their members. We like the volume coming in and now we're getting a better rate. But there have been other times where the payor has enough density in the market and they just say whatever, unless our members are going to complain, we're fine with them finding someone else. We really aren't concerned with the relationships they built. We just don't want them complaining to us. So if they're okay with moving to a different provider, then we're okay with you leaving.

Richard: So, ultimately, if you don't think that you're going to win, if you decide to pick a fight or play chicken, ultimately. Any final words of wisdom for our leaders and listeners who are, , many independent private practices or the actual or aspiring PT leaders as it pertains to payor relations?

Mark: Yeah, I would just say that it's imperative that you do understand your business and that payor contracting is more important now than ever with the decreasing in or stagnation of reimbursement rates across the board and the rising cost to bring in great therapists and, and So you're getting pinched on both sides.

So I think it's imperative to really have an understanding of your contracts. I think it's imperative that you call the ones that are not working for you, even though you might feel that you're losing volume in the long run, it can save you money. It can give you opportunities to get better paying patients, better paying members into your clinics and fill that void that you think will be there. But certainly that is something that you need to be aware of and really take a focus and understand.

Richard: Well, thank you so much for your wisdom, Mark, as always, really appreciate chatting with you and I've certainly learned a lot more from this chat. So thank you.

Mark: Thank you, Richard. Always a pleasure.

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