Ep 10. Navigating hospital/physician direct to employer contracting, truly value-based care

As the cost of healthcare continues to rise, more employers are turning to direct employer contracting and self-insured models to take control of their healthcare costs. But how do these models compare to fully insured arrangements? And what are the key considerations for health systems, PBMs, and employers looking to engage in value-based care?

Welcome to Value Health Voices, where we bring health policy and healthcare finance to life in a way that's accessible, engaging, and informative. This is episode 10, where we'll talk about direct-to-employer contracting and the growing trend of health systems working directly with self-insured employers.

Why does this matter to us? Well, given rising healthcare costs and the need for alignment between providers and payers, there are a lot of advantages to having direct-to-employer arrangements. Whether it's the opportunity to have more say over health plan design, increasing employee wellness and productivity, or addressing concerns about the costs of medical care, these are all advantages to the employer. For the providers, they have the potential to offer significant financial and non-financial benefits, the most obvious being greater access to patients and perhaps a more predictable revenue stream. We'll get into all these topics and more on today's episode.

That's a great overview, Amar, and we are very pleased to have Ned Laubacher with us. Ned is an expert in all things value-based care and in direct-to-employer contracting between health systems and employers. Ned is CEO of his advisory firm, Health Spectrum Advisors. Not to date you right off the top, Ned, but you have had a long career with over 30 years of experience in various healthcare leadership roles, including serving as regional CEO for acute care hospitals, COO for a healthcare consulting practice, and CEO of a diagnostic imaging network. With Health Spectrum Advisors, you have extensive experience advising both health systems and employers directly in this space. So we're very excited to have you with us today.

Thank you. So nice to be here.

Self-Insured vs. Fully Insured Models

Amar and Ned, in preparing for this episode, we know there are many directions to take this subject, but we would be remiss if we didn't at least set the stage first. Before we dive into the details of direct contracting, we'd like to help our audience understand some of the differences between what it means to be self-insured and what it means to be fully insured. Ned, I'll leave the word to you.

Great. Well, health insurance provided by employers to their employees and family members is a key human resource benefit. The bifurcation between fully insured and self-insured comes in on who bears the financial risk for the cost of care that those employees and family members seek.

During the course of a year under a fully insured model, the employer buys a package of health benefit plans from a health insurance company. That prepackaged plan is priced so that the health insurance company, who bears 100% of the financial risk for the cost of that care, has a provider network of physicians, hospitals, labs, and imaging. They have stop-loss insurance, they have claims processing, and they have a pharmacy benefit manager. All of that is prepackaged.

Those premiums reflect that a health insurance company does not want to lose money. They don't want the cost of the care that those employees and family members seek to overcome the premiums that the employer is paying for that fully insured package. So they price those premiums pretty high.

Now the reverse is true. Under a self-insured program, that employer steps in the shoes of the health insurance company. They customize the health benefit program that fits their employees' needs and their employer's needs. They don't need a health insurance company to bear the risk; the employer does. So they need claims processing. They need to be able to access a physician network, a hospital network, and a lab and imaging network. They need to be able to buy stop-loss insurance to protect them from high-cost drugs, high-cost medical claims, and sometimes what they call shock claims. So they have more control over the design of the health benefits offered to their employees and family members, and they have greater access to the underlying data.

Navigating Administrative Complexity

That's a great way to start just to set out that difference. I've noticed in interacting with entities and companies that there is some degree of fear regarding the administrative complexity of taking on the responsibility for being the payer.

I got a compliment on the word complex because healthcare is extremely complex. When you're outside of the industry looking in, like an employer and an employee family member, complete glaze over occurs. The process of knowing whether an employer is buying health benefits that are low cost, high quality, and valued by their employees needs a good understanding. It needs data to understand whether the health benefit program and the vendors that are providing the care and stop-loss coverage are working in a value-based approach.

Low cost, or at least reasonable cost, and very high quality with great expected outcomes—all of that is terrifically complex for an employer to figure out. As we'll talk about, that employer, particularly self-insured employers, has a fiduciary duty on behalf of their employees to provide a valuable health benefit package. In order for them to get past that complexity and understand what's going on to determine the value of those health benefit programs, that's a very challenging task.

And so that's why you would say it's almost necessary to have that third-party administrator.

Not only that, but you need to balance out whether that third-party administrator is efficient, has low errors, and makes it easy for your employees to pay their claims and get prior authorizations. There are some TPAs, or third-party administrators, that do a great job and others that don't.

I'm smiling because as you were describing that, Ned, TPA reputations are fairly consolidated and fairly well known around the country. We're not going to say who's great or who's not. We're not here to advocate for anything, but the reputations precede themselves in this particular segment of the insurance business.

I want to go back to the complexity too, if I can. If you think about an employer in any industry, payroll and health benefits are going to be probably the top two expenses in that company's financial statements. Now those two programs are managed typically through the human resources department.

All other operating expenses—utilities, professional services, rent, capital decisions that impact operations—are run through finance and supply chain. They use a very rigorous RFP and procurement process for every decision they make. Deregulation in the energy sector just opened the door for a very rigorous process for selecting utilities. That does not happen with the number two operating expense, health benefits.

The Evolution of Direct-to-Employer Contracting

I think this might lead us into the next thing we wanted to ask you about, Ned, and that is the evolution of direct-to-employer contracting. My sense is that there is a growing realization on the part of the C-Suite that they need to own this. Maybe we're still in the early days, but we're somewhere further along the track in C-Suite understanding that this is their responsibility. One, because it is such a high expense, but two, for the fiduciary responsibility you talked about. You don't hand that off to the head of HR. That's your responsibility. Is my impression on track?

Your thinking is on track. I think the adoption of specific strategies that employers are taking is not well entrenched yet. Let me go back in time a little bit. You gave me a 30-year career; I'm actually at 36 years plus some additional even before that.

I shaved off 20%.

Yeah, old, old, old. Back in the early 90s, companies like Disneyland, Toyota USA, and Matsushita USA had big operations in Southern California, and they had a lot of workers get injured. As a hospital leader, I had three ways to increase my patient volume. One, contract with health plans at rates that were good for us. Two, increase the number of referring physicians. And three, work with self-insured employers because they had an ability to direct care.

It was that third strategy that we took to heart back in the 90s when we approached Disney. We, the hospital, approached the employer and said, "Look, instead of us waiting for your employee who's injured through a worker's comp case to potentially come to us or go to a competitor, we're going to set a clinic up on your campus for return to work. We're going to keep track of your employee and return them to work quicker and at a lower cost."

We then added more services to these clinics to keep those employees productive so they wouldn't take off work. Think about today's worksite clinics; we were doing that back in the 90s.

Let's move forward a little bit to 2010 under the Obama administration when the Affordable Care Act was passed. The Affordable Care Act, and I'm sure you each read that from cover to cover.

I refresh it every time and again. It's just like Harry Potter. I keep rereading it. I can't get enough of it.

They created the Centers for Medicare and Medicaid Innovation, CMMI. CMMI has spent over 12 years testing over 50 different payment methodologies that tie the level of payment to a hospital or a physician to quality metrics and cost savings. In many cases, Medicare shares some of the savings back to the provider. So the bundled payment programs, ACO programs, medical home programs, and advanced primary care programs are some of the 50 different payment models they've tested since then.

While CMMI is testing these models from 2010 through 2025, employers, in particular the self-insured employers, saw their costs increase dramatically. So we've got CMMI at work tying payment to quality and cost savings, and we have rising healthcare costs on the employer side. Then in December 2020, this new act was passed called the Consolidated Appropriations Act. It said many things, but chief among them, it said we are going to require self-insured employers, health insurance companies, and PBMs to report to us specific costs surrounding medical and pharmaceuticals offered through health benefit programs.

That reporting goes to three federal agencies: the Department of Labor, the IRS, and Treasury. It's pretty significant having three federal agencies have this data. At some point, that data is going to become public, and now we're going to have more data transparency.

Fiduciary Responsibility and Litigation Trends

It was after 2020, if I have it correct, that we saw this explosion in litigation, primarily of the self-insured employer being sued for breach of fiduciary responsibility. I presume it was the data transparency requirements from 2020 on that made it possible to pursue these kinds of suits. Do I have that right?

You have that right. The Consolidated Appropriations Act and the burden of these significant rising costs year in and year out meant a lot to bear. Healthcare benefits costs rose between 3.5% to 25% each year depending upon where you were fully insured or self-insured and your risk experience.

That Consolidated Appropriations Act made this data more available, and you started to see lawsuits of either single employees or groups of employees against their employer, like Johnson & Johnson or Wells Fargo. We go back to the PBMs because the underlying issue in those litigation cases was that the employer contracted with a PBM that was not serving in their fiduciary best interest, particularly regarding the cost of generic drugs.

When you think about a PBM, they have three formulary classes that they bill certain drugs out at: generic, brand, and specialty drug. Specialty drugs are really high cost. I can give you an example of a case in which an analytic firm I am very well familiar with worked with a self-insured employer to analyze their pharmacy claims for a year. That PBM charged the employer and the employees 450 times in one year for a generic drug being billed as a specialty drug. That generic equivalent price was about $12. The specialty drug on average was about $7,800. That's about a $3 million swing.

That's crazy. This gets back into the pitfalls. It's the responsibility of the firm to see that they are transacting with actors who are not leading the self-insured employer to breach their fiduciary responsibility. Some of these cases, like the Kraft Foods case or Johnson & Johnson, we could talk about a lot of them. I think the Johnson & Johnson case actually was recently thrown out on a technicality, which is a side issue, but it will probably be brought again.

Critical Success Factors for Employers

You brought up PBMs, Ned, and we will probably come back to them. But for those who might be listening and wanting to have a sense of why there is a growing impetus to save money by becoming a self-insured entity, what are some of the key critical success factors from the perspective of the employer? And then after that, we'll get into the perspective of the health system.

To demystify the complexity of the healthcare industry and make working with a hospital partner, physician partner, or digital health company more business-like, we start with an employer checklist.

Step one is the right data. That's going to be the claims data for the medical and pharmaceutical benefits that are run through the employer's health plan for the year. You typically use a third party to collect this data because the data is not clean and you need expertise to cleanse it, enrich it, and then analyze it.

Step two, that analytics team needs to identify the cost drivers and the clinical risk profiles for the employees and the family members covered under the plan. If you take a hundred employees, there are going to be five to ten of those hundred that are really going to drive some very high-cost medical services and drugs. You need to know who they are and why. If there are aspects that can be controlled, such as somebody whose diabetes is running amok and they're going into the ER every month, there are ways to intervene and manage that diabetes so the ER visits come down.

Once you identify the costs and the risk drivers, then you can identify opportunities for intervention. As you learn through this, that employer is going to identify more and more opportunities. In order to do so, they have to develop clear goals and performance metrics beyond a typical Medicare cost savings and quality metric. There's efficiency management of those high-risk and emerging-risk members. You need to verify that those patients are adhering to a care plan.

There are gaps in care. For example, not having a colonoscopy as a male age 50 and above. We're the hockey sticks; we have no claims until we hit age 50 and we have our first colonoscopy and all hell breaks loose.

We have member-reported outcomes and member-reported experience. These are very unique aspects for performance goals. And then financial toxicity to the employee: can they actually bear the expense of the medical services being prescribed for them? These are new aspects that, as an employer, you need to be ready to collect the data on and analyze. Then, of course, you need to engage the entire management team to commit to this type of program.

Types of Direct Contracting Arrangements

Ned, to shift gears a little bit, for our listeners who may not know all the different types of direct-to-employer arrangements, maybe you can talk about the single-service arrangements versus the more concierge types versus the on-site clinics you were alluding to versus bundled payment arrangements.

That's a great question. When you understand your data and the risk underlying your employees, you begin to identify where those opportunities sit. Maybe all your diabetics are well managed, but you've got a lot of hypertensives or those with significant sleep apnea issues. If you're a trucking company and your drivers suffer from sleep apnea, that's not a good combination. It's going to depend on what the data tells you your biggest opportunities are for improving the health of your employee base.

For the trucking company, you're going to want to bring a third party in to understand where the best opportunities are to help manage sleep apnea for your workforce. There are disease management programs, and typically these are experts in OB care, sleep apnea, hypertension, diabetes care, and other chronic diseases. Mental healthcare is a big, growing disease management effort that employers are seeking help with.

There are also care management companies. These are individuals who work with your employees so that if they have to have a surgery or they have a chronic disease, they are looking holistically at that individual to make sure they're seeking care appropriately. Any gaps that exist, they're working with the provider network on the other side to close those gaps.

Now there are also carve-outs, and we talked about PBMs. I always say if you're a self-insured employer, a PBM is a gift that keeps on giving. You can select different PBMs than the incumbent one you have. You can put out an RFP with performance metrics, and you're going to get markedly different responses in terms of how they manage cost and formulary.

You brought up selecting the PBM, and I wanted to ask you about this in particular as it relates to pitfalls from the perspective of the employer just accepting the package deal that's served up to you by the TPA and not pricing around. That's how you get down the road of some of those cases you were talking about earlier, right?

That's right. Additional employer solutions could also be worksite clinics, which keep employees and their family members seeking care close to the employer base, either on the campus or near-site. It increases productivity, so folks don't have to take a half-day or a full day off.

Then you have hospitals and employers working together for procedures and surgeries. That can either be a transaction, like just a knee replacement exclusive to a hospital, or it could be a 90-day episode. So all pre-surgical, surgical, and rehab over a 90-day period is then carved out to that hospital partner.

Quality Metrics and Shared Savings

You had mentioned earlier around shared cost savings and quality. I thought maybe you could talk a little bit about how some structures around that shared cost savings work that providers can also access, as well as what quality metrics are sometimes built into these models to promote value-based care.

Let me start with the quality metrics first because the shared savings is still new for employers. It's not for Medicare because that's how CMMI created their payment models. Medicare would take 2% to 3% off the top, and anything left over that provider could receive as an incentive payment. That's not necessarily the norm in employer direct contracting yet. It can be included, but it's not the norm today.

So it's typically just a price. And that hospital actually needs to know its own operating costs in order to make a margin on that price.

Right. So let's start with the quality metrics. Medicare started with 32 quality metrics in their bundle payment, and ACO went to 72. But a lot of these are process steps. Did I do this check mark? It's not necessarily outcomes, quality of life, or financial toxicity. Quality starts now to be a limiting metric. It's one of many. Did my employee get in to see a specialist within a reasonable period of time after being diagnosed with a new disease? How quickly does that happen? That's not necessarily a quality metric.

Typically a quality metric is: was there an ER visit within the next 30 days after discharge from a hospital? Is that really quality? Maybe that person really needed an ER visit. It doesn't necessarily mean something bad happened.

We sometimes have the "next third available appointment" as a quality metric in oncology.

Yeah, that's a good, robust one. And you know, Ned, about the ED visits or other admissions, they can happen for other reasons. It's not necessarily a failure of the cancer care. The water gets muddied and the data are dirty, and therefore you get dinged when it had nothing to do with it.

Yeah, they call them "all-cause ER visits" and "all-cause readmissions" back to the hospital. It doesn't necessarily have to tie back into the previous diagnosis or previous treatment. Those are quality metrics, but are they the right metrics for performance? I think it's limiting. I think we need to get into efficiency. We need to talk to the members about their experience and have a Net Promoter Score. We need to talk about their expectation for outcomes and quality of life before and after. We need to talk to them about the financial toxicity of accessing these services. It's really incumbent on us to pay much more attention to performance metrics that are broad-based.

The Health System Perspective

I kind of wanted to come back to the health system perspective because that's where Anthony and I sit. What's in it for the health systems? Intuitively it makes sense to me that there's a reliable revenue stream through the patients that are coming in through these employers, but maybe you can expand on that.

It is a great reason right off the bat. You want an assured volume that you can trust coming in because it's up to your own performance and your relationship with that employer. To make it work takes organizational commitment here, both for the employer and the hospital.

If you can play in that game, you don't have to deal with a lot of the complexity that health plans and network arrangements through health plans have in terms of billing, denials, underpayments, and delays. You just need a third party to process the claims that are already agreed to. So the administrative complexity over the revenue cycle and billing process goes away. Not entirely, but the games that health plans play for denials go away.

So overall you would say the administrative costs on the provider side with managing these direct-to-employer relationships is less than the administrative costs with dealing with utilization management, prior auth, and back-end denials. It's less cost to the hospital.

Great summary. I completely agree with that.

That's a world Amar knows very well. I do too. Everybody in cancer care does. Ned, is there a metric where health system CFOs or CEOs can say, "Okay, our cost structure is at such and such percentage of Medicare reimbursement, so we can do these contracts"? Is there something you could point to as a guidepost?

Let's take a step backwards first before we get into the cost structure. If I'm a hospital in conversation with a self-insured employer to direct contract for, let's say, a 90-day episode involving knee replacement, I need to understand whether I'm already capturing that volume. Why would I want to shift it to a direct contract?

There are reasons to do so. Lock it in. Keep that employer attached to you so you don't lose volume to a competitor, and you become the innovative partner of choice for other employers. But the economic analysis is a little bit different if they're now working on a relationship with an employer where we're only getting half or a third of the current employee base. Those employees are being scattered and going to competitors. You have a lot of upside to gain to capture their employee base and redirect that care. If you take it from 30% to 60%, that's a heck of an economic gain.

It seems my impression is that if you are a hospital system operating in a tough payer mix environment, where your percentage of revenue that is Medicare and Medicaid is on the high side, getting this right and consolidating the self-insured in your market has a huge competitive advantage.

Your audience may be familiar with the American Hospital Association statistics that on average about 80% to 85% of all US hospitals lose money on Medicare, and an even higher percentage—above 90%—lose money on Medicaid business. So if you're sitting on 70% Medicare and 10% Medicaid in your market, which by the way I did for about five years, you would die to get more employer-insured business coming through your doors.

Setting Rates and Understanding Costs

Since we are speaking of payer mix, where are the average rates set? Are they set closer to the commercial payers or are they set at a certain multiple of Medicare? Where are providers setting these rates for these 90-day episodes?

It's a good question. The one that makes every hospital leader nervous is Medicare. Medicare plus 25 scares people. If you're losing money on Medicare and you're saying Medicare plus 25, what you're saying is I'm going to get a 15% margin on this business to try to offset all the other expenses I have. That's losing money.

Medicare is an established baseline. There are health plan offerings right now for self-insured employers that are aimed at basically Medicare-plus models. It's attractive from a marketing standpoint, but you may not necessarily have long-term hospital partners because they may go out of business.

I think what Medicare had shown through the bundled payment and the ACO is that there are market averages that can be incorporated with commercial or health plan claims data. That combines Medicare and commercial reimbursement in more of a representative market base. That's a better starting point.

The third way is you just look at your own claims experience. You may work with an analytics company that provides regional benchmarks for a knee replacement. So Medicare might cost $36,000. The commercial health plan might cost $48,000. Somewhere in that range, you're going to have some wiggle room. But then it's back to the hospital CFO to say the cost for us to deliver that knee with the implant cost, OR time, and rehab is $40,000. So now you're working with an $8,000 margin between $48,000 commercial and $40,000 costs. I think the important piece is really knowing how to narrow that gap and define it before you enter a negotiation.

Common Pitfalls to Avoid

That's really helpful. That tees up a topic I really wanted to ask you about, which is getting some clarity on common pitfalls to avoid in direct contracting. You just answered probably the number one pitfall for health systems, which is underpricing services without an understanding of true costs. Are there other pitfalls you could point to?

We mentioned one before: the lack of organizational commitment. "Oh, this is just a pilot. It's one program among many." HR is a busy place. They have all these other benefits that they're managing, and they don't really know the skill set to manage a healthcare program. You need an expert.

I know of a food company in central Pennsylvania that has a woman who's a dynamo. She is an expert and has direct contracts, expanded those, and worksite clinics. She's killing it because she has taken the time to get a master's in everything she does. That organization is fully committed. The hospital on the other end has to have the same commitment.

I would imagine another pitfall is the contract language and the exposure of the system to liability, as well as making sure that it's clear that providers can exercise independent medical judgment.

You are exactly right. You don't want to step in the shoes of being an insurance company. You want to avoid those licensure regulations and cash reserve requirements. So you do need to be very careful about that language.

But here's the thing. Health benefits in the US has never really been under a rigorous procurement process. Think about all the group purchasing organizations out there for every industry. Even Pittsburgh grew FreeMarkets, a huge commodity-based international open auction and reverse auction site. Why aren't health benefits in the contract language reflective of an auction process?

Any sort of gag clauses that the Consolidated Appropriations Act sought to remove need to be addressed. A self-insured employer has reasonable access to their own claims data, but there are several contracts that employers entered into with their claims processing TPA that restricted them from using that data. In an RFP process, those gag clauses would be identified and removed.

I think we need to get into the rigor of buying health insurance through an RFP process and transparent open auction marketplace. We also need to have a very concerted data analytics platform. It just doesn't stop at medical and pharmaceutical care. There are other human resource programs like workers' comp, safety programs, and retirement programs. When you start to integrate that data together, now you're talking about a human capital management platform identifying risk areas so that you can mitigate that risk. There's only one dollar and one member.

I think your last commentary there, Ned, is the fruit of a total mastery of the subject and seeing all the connection points in every aspect of all the players on the field. Should we come back to PBMs, Amar?

PBM Transparency and Market Disruption

I wanted to make sure we hit on it again. We talked about PBMs, choosing your own, and the particular legal cases resulting from PBM failures. I wanted to ask you about Cost Plus Drugs. That's on the tip of everyone's tongue. Where does Mark Cuban's startup fit in this whole world of self-insurance and PBMs?

We used a term earlier: an employer assumes a fiduciary responsibility to provide a health benefit program that is value-based. Cost Plus Drugs and others like them are very open about their pricing structure. Their formularies are set. There's no manipulation. There's no charging an employer for a generic drug as a specialty drug 450 times in a year. There are no games. A drug cost is a drug cost. That's what Mark Cuban's Cost Plus Drugs does. It removes a lot of the games.

By the way, who regulates the PBMs? Every industry has some sort of regulator.

We hope there's some regulatory stuff happening on the state level, but very minimal.

They regulate themselves. The administrative fees charged to manipulate average wholesale price (AWP) two times, 20 times a day—they charge administrative fees for changing the prices of their own AWP. Spread pricing, where the PBM charges the employer $50 for a drug and then they pay the pharmacy $10, means they keep that $40 difference for themselves as profit.

And throw you a little bit of rebate.

They throw you a tiny rebate if you qualify based on volume. PBMs lack transparency. Cost Plus Drugs' business model is transparency. I think that fundamentally is a different business model. If you're a fiduciary employer trying to prove the value of your health benefits to your employees, and hopefully not in front of the DOJ or the IRS, then you have a lot of incentive to go out to the market in a rigorous procurement process and identify those players that drive value for your plan.

He probably didn't realize that this was going to happen when he set out to create Cost Plus Drugs, but in the Johnson & Johnson case, several of the exhibits submitted were the prices that their employees were paying for drugs compared to Cost Plus Drugs, which was like $20 versus $4,000.

Future Trends in Employer Health Benefits

I think the conversation around Cost Plus Drugs takes us into our final topic, which is the future. Ned, if you had a crystal ball, what trends do you see emerging in this space, and which providers are best positioned to succeed?

That's a loaded question. We talked about the speed of adoption self-insured employers are making to access their data, analyze their data for risk and cost drivers, and take appropriate action. I do think in the next five to ten years, it's going to be more commonplace for self-insured employers to have rising experts within their ranks managing the health benefit program and working with analytics firms.

Right now most HR benefits professionals work through a broker to price out health plans, TPAs, and PBMs, and then bring you a package deal. While you have the control to customize, you're working with a broker to do it for you. Transparency in data, identifying risk, and being able to manage that—employers need to be able to do that. If they're going to still rely on a broker to do that, that's a tough call.

Maybe another thing may be finally breaking down the insurer or TPA side throwing up HIPAA as a reason not to share their data. They used to charge the employer to access their own claims data.

There was an attorney, a federal judge at some point too, who was helping an analytics firm and made this analogy: When you go to the grocery store, you're buying all these things and you get a line-item receipt of everything you bought. They're not charging you to provide that receipt. A third-party administrator who's processing claims on your behalf through an ASO agreement is charging you for your own receipt of all of the medical and pharmaceutical expenses you paid for because you're self-insured.

He used that analogy, and when they said, "Well, that's our policy," he said, "I don't care about your policy. I'm going to get 100 employers who contract with you together and we're going to have this discussion again. Do you want that?" Slowly, the health plans started to remove their fees and provide this data.

This is interesting. This is daily life for you, Ned. It's not for me nor Amar, so we really wanted to peer into the fine points of this issue and get a sense of where it's all going. I think we've covered a lot of ground, from PBMs to pitfalls to critical success factors from both perspectives. Amar, are there other things that you think we want to call out for our audience?

No, I think this has been really informative. I only learned a lot of this researching this episode, and I think it's going to be very informative to some of our listeners who are outside of the C-Suite. For those in the C-Suite, hopefully, they got some helpful tips out of this episode. Thank you so much for joining us, Ned, and we can't wait to have you back.

It was so fun. Thanks so much, guys.