Tuning Healthcare, Episode 7: Reevaluating Care Delivery Approaches Post COVID-19

Joe Ruth, the Executive Vice President and Chief Operating Officer of Sparrow Health System

In this latest episode of Tuning Healthcare, Joe Ruth, the Executive Vice President and Chief Operating Officer of Sparrow Health System in Michigan discusses the impact of COVID-19 and recovery approaches in a post-pandemic world. He also talks about the importance of advancing value-based care strategies, moving from fee-for-service toward managing the entire premium dollar, and investing in the right care that drives happier physicians, happier patients and better outcomes.

“I think fee-for-service has been a challenge for a long time. When you get paid for what you do, and again, most of that payment is on the back end of very high, very expensive procedures and towards the end of life. If we can reposition the spend towards more preventative medicine, being more connected, providing greater access to our patients, the care will be better at a lower cost. There’ll be a happier physician involved, there’ll be a happier patient involved. … I think as healthcare providers we have an opportunity to really reset what we think is important in how best to care for patients.”
– Joe Ruth, the Executive Vice President and Chief Operating Officer of Sparrow Health System

In this episode, Joe and Lumeris Senior Vice President Nigel Ohrenstein discuss:

• • The impact of COVID-19 in Lansing, Michigan (Note: this episode was recorded on Tuesday, April 14, 2020)
  • How the course of the pandemic across the country illustrates how healthcare is local
  • A patient-centered, phased recovery approach for coming out of COVID-19
  • How owning and operating a provider-sponsored Medicare Advantage plan can drive broader population health efforts
  • The importance of managing the entire premium dollar that allows investment in the right care, allowing for higher provider and patient satisfaction

Recorded: April 14, 2020

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• Read Transcript:

  Nigel Ohrenstein: I’m joined today by Joe Ruth, the executive vice president and chief operating officer of Sparrow Health System in Lansing, Michigan. In this episode of Tuning Healthcare, Joe and I will discuss the impact of COVID-19 in Lansing and how a critically important implementation of social distancing has helped them offset a major crisis in Lansing; how this crisis has further illustrated that healthcare is local and [the] difference in response [from] Detroit to Lansing and other parts of the country; and as they think about the future of Sparrow, how critical it has been that they have invested in a health plan, PHP, and launched the Medicare Advantage plan and how you need to move away from fee-for-service and take responsibility for managing the entire premium dollar. Join Joe and I as we tune healthcare.

  Nigel Ohrenstein: Joe, thanks for joining me today. Truly unbelievable times in healthcare. Before we delve into COVID-19 and the impact to Sparrow and Michigan more generally, would love to just learn a little bit more about how you got into healthcare, obviously a Michigan native and spent a lot of your career there, but how did you get started?

  Joe Ruth: Actually, purely by accident: a summer job. Had an opportunity, I worked on the loading dock of Saginaw General Hospital. Saginaw, Michigan is my hometown and one of the most enjoyable and also excruciatingly difficult jobs I’ve done. The Gordon Food truck would back up and offload 80 pound crates of food that you had to throw onto the back of carts and things like that. My first real experience inside a hospital kind of from the inside out and so unloading the trucks and pushing supply carts and leaving big gashes in walls of hospitals was my first introduction into that. Second summer I had an opportunity, actually had an opening in the business office so I got to see from the business office side how those things kind of came together. After I got out of college I said, “You know, that was a really incredible experience. Its own little community, its own ecosystem.” So I started down that path really through finance, and now more on the operating side.

  Nigel Ohrenstein: That’s great and I see a Spartans jersey in the background. Is Michigan [State] football the true love?

  Joe Ruth: Michigan State sports of all nature. I think we were robbed this year of our NCAA Basketball charge that we usually make but yeah, living in East Lansing and a part of the community, we do live and die by our Spartans. Hopefully football season will be allowed to move forward this fall.

  Nigel Ohrenstein: Yeah, it’s truly unbelievable just the impact of COVID-19 across the board. Obviously as you know I’m from England and we’ve had a prince, we’ve had a prime minister, soccer players, as well as everyone who we would consider sort of ourselves regular people. The impact has known no bounds. Talking of COVID-19, how are things in Lansing?

  Joe Ruth: Some of this flattening of the demand curve has played out here in our community compared to others. We have certainly taken care of our fair share of patients but we haven’t seen the huge and overwhelming spike. It’s been more of a steady and consistent flow.

  Nigel Ohrenstein: So Joe, it’s fascinating often how little we seem to know about this virus. On the last episode of Tuning Healthcare we had Aneesh Chopra who spoke about the daily inadequacies that we have as a country as it relates to public health. Even if you know well within the Sparrow Health System who’s being admitted and who has COVID-19 and what the demographics of those people are, the ability to transmit that data in a meaningful way to the CDC for them to look at patterns and the like is obviously a failure of our public health system. Within Michigan itself, it’s fascinating how localized it is. I’ve done that drive from Detroit to Lansing many a time. It’s no more than an hour and a half yet Detroit seems to have a lot of COVID-19 and Lansing, as you just articulated, seems to be doing okay. What do you put that down to?

  Joe Ruth: That is the question that we all keep asking ourselves. I do think that the adoption of some of the social distancing played out differently in different communities. [It has] been fascinating to see some of the cellphone data that comes out and it’s basically showing who’s staying home and who stayed a little bit more mobile. I think kudos to our community. I think they took that really seriously and locked things down pretty early pretty tight and I think other communities were a little bit slow on the uptake. Just one of a million contributing factors. I think in retrospect we’ll understand this so much better than what we are understanding in the moment. I’ve heard a whole bunch of theories in terms of what went on in Detroit, large conventions, people from out of the state coming in, a lot of people touching different aspects of the community as at least theories. Perhaps some benefit for some of us that live in more mid-sized communities. Sometimes we lament the fact that we don’t have all the restaurants we want or things like that but I also think that Lansing being the state capitol, when the governor, who’s actually from Lansing gets on TV or sends out an edict and says, “This is what we need to do” we may be a little bit more compliant than others just by that location, as well.

  Nigel Ohrenstein: Yeah as I said, fascinating and if that truly turns out to be the case that the main reason is effective social distancing it’s going to be an interesting study in how we deal with these things in the future, right and obviously if we have the right data we can social distance locales rather than states, which obviously from an economic perspective would be far better. Talking about the economic impact, what is the economic impact to Sparrow? Obviously you’ve stopped elective procedures, you don’t have the tidal wave of COVID-19 patients. I’m sure it must be difficult for you.

  Joe Ruth: Yeah, if I could though, one other key point that I think has been hugely beneficial to our organization, we have an incredible clinical laboratory as a part of Sparrow. It’s actually one of the top 25 busiest labs in the nation and we have some incredible scientists working in that laboratory that actually helped us get to a testing standard and level where we weren’t dependent on others providing us all of the materials to do so. I think we have also been able to test with much shorter turnaround times. Four hours instead of four days or 40 hours or whatever it played out. I think our ability to actually identify and isolate patients early on in the process also served us extremely well here in Lansing. To the question of the economic impact, still trying to figure out all of that but like you say, unfortunately in healthcare right now, much of the payment is for procedural work as opposed to medicine work and that’s really the care for these COVID patients, end up in a hospital bed under intense scrutiny with lots of physicians and nurses and anesthesiologists and respiratory therapists caring for them every moment and those types of cases typically aren’t recognized as a high resource consumption and therefore reimbursed at a much lower rate than say, an open heart procedure, an orthopedic procedure.

  Joe Ruth: And so, as we shut down early, again I think Sparrow was an early adopter in slowing down and then stopping elective procedures, we certainly decreased our daily census by probably 150 to 200 patients per day on any given day. Those are typically the things that pay the bills in healthcare. So tallying all of that up, certainly some of the federal money that has come our way has been helpful but doesn’t come anywhere close to back filling that gap. I think we’ll look back on this and try to figure out what that deficit is but Sparrow was very fortunate going into this crisis having a very strong balance sheet and has been able to weather the storm. There are certainly a lot of friends that I talk to across the country that are incredibly concerned. One, getting through this and then really what their capabilities are on the backside.

  Nigel Ohrenstein: Let’s elaborate on that a little bit. Thankfully for Sparrow, as you said, a strong balance sheet. What do you think happens to systems, the ones you’ve spoken to, that are not as well managed or are in a rural area that never afforded them the luxury of building a stronger balance sheet? What happens to those systems?

  Joe Ruth: Yeah, I think it’ll be a gamut of responses. You really hit on an appropriate topic. I think rural healthcare is one of those really challenged areas. Sparrow has four community hospitals in our region, one of which is really, really struggling and if they weren’t a part of the system would have probably closed their doors many, many years ago and I think this will really put an emphasis on those types of small community providers all across the nation. There’ll have to be some consolidation. If they’ve been trying to remain independent, I don’t know that they’ll be able to do that. All of us are going to have to rethink our strategic plans, our capital investment plans. Healthcare [has] been a pretty challenging environment financially for the last handful of years and then to take a big chunk of working capital away from health systems, a lot of these things I think will come to a screeching halt and you certainly have to reprioritize. There’ll be programs that get closed and I’m very fearful, probably many hospitals will get closed at the back end of this.

  Nigel Ohrenstein: Stay on the rural hospital scenario because if a hospital closes in certain metropolitan areas there are choices, right? It’s potentially not the end of the world for patients in that region, but in a rural area, that might be the only hospital that’s within quite a distance for those patients. What happens in that rural community? Let’s assume that the large players who are within reach decide, “Our balance sheets been damaged by this. We’re not in a position to go buy additional hospitals.” Does the government have to come in? Does the state come in and have to try and prop it up? What happens to the rural hospital in the scenario where they don’t have the balance sheet and they don’t have someone who’s willing to come in and merge with them?

  Joe Ruth: I think there are a handful of rural hospitals that never took advantage of the Critical Access Status that was granted probably about a decade ago. We actually have one of those hospitals as a part of our portfolio, as well. Critical Access creates some additional reimbursement, that certainly helps things along. For those that don’t have any support from a system or systems willing to come in and support, I think the inability to access care locally will have devastating impact to those communities. In some communities, one in particular that we just built a new hospital in not too long ago, it’s the lifeblood of those communities. The mayor was on the hospital’s board and said, “If we don’t have access to healthcare and if we don’t have good schools, we will not have employers and our community will continue to shrink and go away.” I think it’s multifaceted from the health of that community to the economic health. Local hospitals and healthcare systems play a vital role and I know there’s been a lot of conversation about the affordability of healthcare and now we’ve turned around and are pouring trillions of dollars back in to fight this pandemic.

  Joe Ruth: And so, I hope there’s a rebalance of that conversation to say, “What is the totality of the role that these community hospitals play?” Again, many of these hospitals that have an emergency department and that’s really a patient’s first stop on getting care, getting stabilized and should they need something more tertiary, quaternary, an access point then to get them to the right place for the right type of care and again, without that people will be driving 30, 40 minutes, 30, 40, 50 miles just to get to that first ED, let alone to the end destination for them. In so many of those things, that time is the difference between life and death.

  Nigel Ohrenstein: Yes and in addition to the medical impact, obviously there’s also the economic impact. One of the things that I’ve always admired about Sparrow, the system and also you and your colleagues is you’re so connected to Lansing. It’s an integral part of who you are and the community you serve and probably for the people of Lansing, Sparrow is an integral part. And so, how do you see the economic impact to a city like Lansing? What are you seeing around the community? The sort of not buying impact of the virus to sort of non-medical industry?

  Joe Ruth: First and foremost there’s been an incredible thing that happened here in Lansing. We have an economic development organization that brought together a lot of manufacturers and things that just wanted to help. Some of them have retooled their operations to provide manufactured face shields, they’ve reached out to other folks that are helping to create disposable gowns. There’s been an outpouring of community that wasn’t necessarily healthcare-related that have actually come through to do that. There’s a local paint store that had some N95 masks and they said, “Hey, they’re sitting on our shelves. We obviously aren’t going to be using them any time soon. Can you come over and pick up a couple of cases?” There’s all of that in totality but certainly the small businesses are in a world of hurt. Restaurants and things like that that run on a very slim margin. Again, smaller communities probably it’s a little bit easier to rally around them and buy local and get your takeout food from your favorite restaurant and things like that. There will certainly be businesses that won’t make it through this. Sparrow is trying our very best to make sure that all of our caregivers are gainfully employed and if not, able to access some of the government support systems. We’ve taken people whose normal role, say imaging, radiology, not as busy. We’ve repositioned some of those caregivers and they’re now our screeners at all of the entry points into the hospital.

  Joe Ruth: They’re asking us the COVID questions and taking our temperature and if we pass we get a little ribbon that goes around our name badge so that we can go into the premises and things but as our own almost ecosystem, we run the gamut, as well. We have an incredible health club that’s a part of Sparrow and all of that has been obviously shut down. It’s not as easy to reposition those people and so they’re being challenged by that. We’re making as positive a decision as we can each and every day. We’ve avoided the massive layoffs, we’ve avoided the massive pay cuts. If this were to go on for months and months I don’t think that that’s a possibility but we’ve tried to make sure that our physicians, even if they aren’t able to work in their practice, that we position them in part of our surge plans to maybe go to an alternate site of care and be able to take care of patients. We’ve instituted virtual visits. We had actually planned a large launch of a virtual platform in May and in the moment pivoted, dropped a couple different products into the community specific to COVID screening and conversations and got them up in the matter of weeks.

  Joe Ruth: And so, it’s amazing what you can do when you run out of all other options. I hope some of that level of innovation and ingenuity actually carries on and over in a post-COVID world because we’ve done some incredible things that we would have all told ourselves, “There’s no way we could possibly do that that quickly and do it well.” There’s a lot of great learnings that will also come out of this crisis.

  Nigel Ohrenstein: Yeah, undoubtedly. As you, let’s turn our minds to coming out of it because one of the concerns that we all have is we weren’t prepared, as you mentioned before, around testing others. Thankfully Sparrow was but as a country we were less prepared in some of these areas. One of the concerns is do we have a plan to come out of it? As a chief operating officer, executive vice president at Sparrow, I’m sure it’s something that consumes you every day and maybe every minute of every day. As you sit here today, what are your top three priorities that you’re focused on as you think about coming out of it? Obviously let’s assume you put in place the fire extinguishers that you need to make sure that you deal with the fire if it, hopefully it doesn’t spike in Lansing, but if it does it sounds like you’ve put that in place. Thinking coming out of this, hopefully a couple of months’ time, what are the top three priorities that you think of for Sparrow?

  Joe Ruth: Funny you should ask. We just had a really long conversation this morning with our senior leadership team. We have been all hands on deck in terms of standing up incident command and really taking care of the community and the data is starting to show, when you start talking about doubling rates and things that we’re all now becoming experts on, statistical analysis and predictive modeling and things, we do think that for our community we are starting to see that curve not only flatten, but turn down. And so, we’re talking about the restart. What does that look like? We couldn’t just say tomorrow, “Hey, back open for business.” Not by any means. We’re going to actually start to be, as deliberate as we were standing up incident command moving cases out of the health system we’re going to be equally deliberate on this restart. So we’re going to start talking to our physicians about the prioritization. Who haven’t they been able to see? Who haven’t they been able to treat and how do we start to bring that back online? Not knowing, we will still follow the governor’s orders in all of this so the current orders are through April 30^th so I think we at least have a couple of weeks to think through what the restart is.

  Joe Ruth: And we should also be preparing that if it isn’t that May 1^st time, what does it look like after that? No magic bullet but I think it’s really going to be focused on the people most in need. We have seen a lot of elderly patients not coming in to see their doctors, not talking to their doctors. You’ve probably seen on the national news the number of deaths at home has skyrocketed across the country. Certainly in big cities like New York and even in Lansing where the statistics play out. We’ve seen people arrive at the emergency room too late to save them with cardiac issues and we’re trying to now be proactive, to call out to all of our patients and reassure them that if you’re needing to come in, come in. I think we’re going to start with those key services first. I think we’ll certainly do that within the primary care, which is kind of that first line of defense, get that stood back up, open and available both on a face-to-face basis and more on the virtual side of things as well and slowly bring things back on.

  Joe Ruth: Can’t do that too quickly because if there is a resurgence or rebound that would put a lot of people at risk. If you talk to me in a couple of weeks I’ll have a much better plan than I do in the moment. That’s really been more of a new thought for us than anything else.

  Nigel Ohrenstein: As you think about that, rolling recovery for want of a better word, rolling renewal of service, sounds clear to me from what you just said, which is wouldn’t have expected anything else from you, Joe, focused on the patient first. Which of the patients that are in need? Obviously at the same time you have to marry a clinical model with a business model. What are your thoughts about are there going to be ways to recapture some of the lost revenue or do you just feel there’s just going to be a hole that you just won’t be able to recapture?

  Joe Ruth: I think there will be a predominant hole that we just won’t recapture. Something that is more elective, say a hip or knee replacement, the people that were scheduled to have those I assume will still want to get that done. Typically, people don’t often schedule cardiac cath events, they usually show up in the emergency department in great distress and again, I think there are some people that have missed out on that. So there will be a hole; there’s just no doubt about that. There won’t be nearly enough federal money or state money to ever fill that back in but some of it will certainly be caught up. The oncology area, we have a fantastic cancer center and again, not able to treat and take care of all of the people that they want to in the same fashion. That will certainly come back online sooner than almost anything else.

  Nigel Ohrenstein: You spoke about telehealth and how you had a rollout in May, figured out how to roll it out much quicker. Do you see that playing a bigger role going forward for the Sparrow physicians and the patients being more willing to accept that as a mode of receiving their healthcare?

  Joe Ruth: Both patients and physicians are probably struggling with that right now. It was something that we hadn’t jumped on like many others had. It hasn’t been a huge adoption rate, which we’ve seen across partners in the state when we’ve asked and so I think it’ll be just another access point but I don’t know that that will, certainly it will pick up pace. I think it will have a stronger adoption rate than it had on its own but I think it’s just going to be one more issue. It certainly won’t fix all of those problems and our physicians like the video aspect of it. It’s still not the same for them to be able to, especially for some of their fragile patients to really look them in the eye, take a look at them from head to toe and see where they’re at in their care. We’re hopeful, like I said, we’ve learned a lot. We’ll be better video visit aficionados when we go full blown in May but I don’t think that that will overtake the in person visit any time soon.

  Nigel Ohrenstein: Let’s switch topics. Sparrow has been a leader in population health strategy, been a leader in Michigan, you’ve had a health plan, PHP, for many years. You recently decided to expand into Medicare Advantage. We obviously at Lumeris [are] fortunate to be your partner in that part of the health plan and the endeavor to deliver an excellent MA plan to the people of Lansing and the people that you serve. Tell us a little bit about Sparrow’s population health strategy and how the MA plan fit into that strategy.

  Joe Ruth: Yeah, that has been one of certainly the more exciting developments for us as a health system. I think as we understand both the delivery of healthcare and the financing of healthcare, hospitals are typically a little bit lower on the food chain as it relates to the total premium dollar and if we’re always going to be beholden to somebody else we didn’t think that that was in the best interest of ourselves nor our patients. Medicare Advantage was one of those marketplaces that we didn’t really have a presence and we knew that we could make an impact. We get to now take a look at the whole premium dollar that comes in for the Medicare patients and perhaps reposition that in better fashion. If we have better preventative care on the front-end, say through our cardiology practice, that maybe we actually start to avoid those emergent cardiac cath procedures, open heart procedures because we’re catching the disease earlier in its path and intervening earlier, be it with procedural work or medicine and things.

  Joe Ruth: And so, that’s the exciting part for us. I think it really puts us where we think we belong in the health system is helping our patients get the best care, the more affordable care and that was a big driver in our strategy. Our health plan has always been really well received but we didn’t always reach all of the marketplaces that we wanted to and Medicare Advantage opened a door. Those patients are already in our community, they have choices and as we attach the Sparrow brand to that offering, the Sparrow brand held really strong. So many people chose to join our health plan because it wasn’t only PHP that they might have known while they were employed but just the trusted Sparrow brand and we’ve seen that in Lansing and we’ve partnered with another health system called Covenant in Saginaw, Michigan that we put their brand onto their product with the exact same response from their community. I think again it comes back to healthcare is incredibly local, who is trusted and I think the faith that our community and our region has in Sparrow was both answered and rewarded with this Medicare Advantage product.

  Nigel Ohrenstein: Brand undoubtedly is a key factor to differentiating an MA plan and the brand of Sparrow, as you said, is second to none in the Lansing area as Covenant’s brand is in Saginaw. Of the 107-odd provider-sponsored plans that exist in the country, most underperform. PHP on the other hand has been in recent time, it is successful. What do you put that down to?

  Joe Ruth: I think it’s the marriage of not only the plan but our population health platform and our employed physician group. So much strength and focus around that. We actually started down the pop health road before we really turned our attention to PHP. We organized our physicians, both primary care and specialty, into a clinically integrated network and really started looking at how we improve the way we delivered care, putting ourselves in [a] position to take on risk and to take on delegated responsibilities that plans often held. We had a running start with that and then married with a health plan that is literally just two buildings down. If the health plan has an issue or if we have an issue with the health plan, they can’t hide from us. If somebody’s health plan is hundreds of miles away over that distant phone line, it’s really connectedness and the teamwork. We see this as a holistic endeavor and so we remind the health plan from time to time: “Stop acting like a health plan” and we also remind our physicians from time to time: “Stop acting like this isn’t part of the family.” We’ve had those conversations over the year to where we are right now a very mature integrated group. I think that’s going to distinguish our performance from so many others.

  Nigel Ohrenstein: Yeah I think that’s right. You spoke about the ability to manage the entire premium dollar, which obviously for a health system moving up the premium dollar is, I would argue is so important. As fee-for-service comes under pressure; to me, one of the ironies of the COVID-19 crisis is that many health systems felt there was safety in fee-for-service and actually what they’re finding is there actually might not be safety in fee-for-service and therefore I would look at it and argue taking greater control of the premium dollar was not only wise but maybe will be critical for health systems. That’s obviously my perspective. How do you see it? Sort of the impact of COVID-19 on what we broadly talk about as population health, which I define as health systems moving up and managing populations, and as a result of that, taking control of more of the premium or premium equivalent dollar. Do you see that will make you move faster? I’m interested in your perspective for Sparrow and then also what you think more broadly for the industry?

  Joe Ruth: I think it will have a huge impact. I think fee-for-service has been a challenge for a long time. When you get paid for what you do, and again, most of that payment is on the back end of very high, very expensive procedures and towards the end of life. If we can reposition the spend towards more preventative medicine, being more connected, providing greater access to our patients, the care will be better at a lower cost. There’ll be a happier physician involved, there’ll be a happier patient involved. Where fee-for-service I think really kept people locked into almost that treadmill effect, right? If you needed more money you had to do more things. Not the right things all the time, just more of the same thing. And so, I think as healthcare providers we have an opportunity to really reset what we think is important in how best to care for patients.

  Joe Ruth: And so yes, I think that it’s a conversation we may now get to have with employers, that we may now get to have with others, too, in light of what they’ve experienced for their employees through this crisis. There’s a lot vested in the old fee-for-service world and so many will hang onto that for as long as they can because that’s probably to their benefit but I think even as a health system we see the, quite honestly, the need to employ more and more physicians where that used to be another variable. We’re all under the same economic tent and we get to have different conversations about how we should go about providing care and now if you add the premium dollar into it, how we spend that collectively where there was a lot of competing interests for that conversationally prior to that. There’s a lot changing and as we said about the impact, I think some of the smaller private practice physician groups are probably struggling just like any other small employer. A handful of folks that are dependent on that fee-for-service money to pay for that and now they’ve literally all been out of work for about 30 days.

  Joe Ruth: And so, we’re doing what we can to help support them in this time of need and transition, as well. Things like if they rent space from us we’ve given them a rent holiday for at least a couple of months knowing that they don’t have any income coming in. Things like that. We’ve really been trying to reach out and provide them with the resources, as well.

  Nigel Ohrenstein: Great. Joe, I’d like to end with what I call the quick fire round. Just a few quick questions. Best piece of advice you’ve ever been given?

  Joe Ruth: I always say typically in many situations you have a choice that you can either choose to laugh or to cry and I always make sure that I choose to laugh. I think humor and laughter is a great course of medicine and I always make sure that we keep doing that even in the heat of battle. I think it makes a huge difference.

  Nigel Ohrenstein: Couldn’t agree with you more on that one. When you’re not supporting Michigan State sports, what do you do to relax, have fun?

  Joe Ruth: Well in Michigan certainly some of that’s weather dependent. I do love to play a little bit of golf. I wish I was good at it but I at least enjoy it and I love the fresh air. I love to travel, I love to get out and get around. In the winter months I prefer to travel somewhere warmer and we’ve got two college-aged daughters that have returned to the nest, not necessarily of their choosing but we have a wonderful family and so even spending time together there throughout that time, either going to visit them or having them come home is all part in parcel what keeps us pretty busy.

  Nigel Ohrenstein: Joe, thanks for joining me today. Thank you for continuing to be a great partner to Lumeris. We appreciate it and we hope that you stay safe and well in Lansing and we look forward to a day when we can continue this conversation in person.

  Joe Ruth: Thanks, Nigel. Great catching up. Thank you very much.

  Nigel Ohrenstein: Thanks for joining us for this episode of Tuning Healthcare. It’s incredible to have the opportunity to speak to people like Joe and his colleagues who are at the front line of saving us and protecting us during this incredible time. Don’t forget to follow us on your favorite streamer and place take a moment to rate us, as it helps others find this podcast. Stay safe and please join us next time as we look to further tune healthcare. This is Nigel Ohrenstein in New York.