Tuning Healthcare, Episode 8: Positioning a Sustainable Long-term Strategy

Mike Englehart, Senior Vice President for Medical Groups and Ambulatory Strategy, Trinity Health

In this episode of Tuning Healthcare, Mike Englehart, Senior Vice President for Medical Groups and Ambulatory Strategy at Trinity Health System shares his insights on the current healthcare crisis and what health systems must do to create a sustainable long-term strategy. He recently served as the interim CEO of the Mount Carmel Health System in Columbus, Ohio. Prior to that role, Mike was the President and CEO of Presence Health in Chicago.  He was also formerly an Advocate Health Care leader where he was the President of Advocate Physician Partners.

“But if your heart is, ‘Yeah, we really do believe that population health is the right thing to do,” then your capital dollars will start to be spent more on ambulatory, technology, medical group physicians, ASCs, because those become cost effective ways in a diversification of your portfolio. And the conversations you’re having with the payers and the employers are critical because that’s where you get rewarded for doing the right thing. And if you don’t ask and you don’t sit down at the table and try and find those new opportunities to share risk, give a little bit of protection as you go into risk, but ultimately take the training wheels off and go all in, you’ll stay in a fee-for-service world as long as you need to, until you’re forced out of it.”
– Mike Englehart, Senior Vice President for Medical Groups and Ambulatory Strategy, Trinity Health

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

• How a national health system like Trinity Health is thinking about revenue recovery in light of COVID-19
• Why revenue diversification is critical for a health system’s sustainable future
• Risk-based models and how payers, employers and providers can align to create a better health experience for consumers
• The expansion of telehealth and virtual care
• The balanced strategy of delivering healthcare locally across a national system
• How Medicare Advantage plays into Trinity Health’s strategy both now and into the future.

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• Read Transcript:

  Nigel Ohrenstein: On this episode of Tuning Healthcare, I’m joined by Mike Englehart. Mike is a Senior Vice President for Medical Groups and Ambulatory Strategy for the Trinity Health System. He recently served as the interim CEO of the Mount Carmel Health System in Columbus, Ohio. Previously, he was the President and CEO of Presence Health in Chicago and spent seven years at Advocate where he was the president of Advocate Physician Partners. Given these different roles, Mike brings a unique vantage point and perspective to both current healthcare crises and future strategy. In this episode, Mike shares with us how Trinity is thinking about revenue recovery and how critical revenue diversification is for them. He also talks about how do you manage a health system the size of Trinity in 22 states with such dramatic variance, both through a pandemic and out the other side and how critical Medicare Advantage is to the future of their health system. Join Mike and I, as we Tune Healthcare.

  Nigel Ohrenstein: Mike, thanks for joining me. Really appreciate your time. It’s obviously been a difficult time. How are you and your family holding up?

  Mike Englehart: You know, we’re doing pretty good. We’re all back underneath one roof so that’s neat. We have four kids and one out of college, one in college and two high school students, so it’s interesting having them all together. So all things considered it’s going fine.

  Nigel Ohrenstein: That’s great to hear. And you probably, like we are, I’ve got three high school kids. We’re running sort of a little WeWork facility. Everyone’s on Zoom calls or work calls or high school classes all around the house. At lunchtime the kitchen gets absolutely destroyed as everybody piles in for lunch and then leaves to go back to the other part of the house.

  Mike Englehart: That’s exactly right. Yeah, thank God for the internet because I’m not sure how we would have handled this.

  Nigel Ohrenstein: Trinity, obviously one of the best known health systems in the country, truly national, right? I think you’re in 22 states, but at the end of March, you guys announced your results and I think it was $173.5 million loss and that was just due to coronavirus then. What does the number look like now? I mean that was the beginning of coronavirus, we’re now two more months into it. What does that number look like now?

  Mike Englehart: Well, you can imagine that the impact of taking away elective procedures and probably 40 or 50% of the volume, it’s had a profound impact. We’re not yet done with … We’re in the middle of the fourth quarter now, so we’re coming down the home stretch so the number hasn’t gotten any prettier. April was a tougher month than March and I think that’s universal for all health systems because really March we started … Most health systems, unless you’re in New York at the heart of it, most of the other health systems were starting to feel it in March, where elective cases got shut down some point in the month of March, where April really marks a full month’s worth of the experience. And so it has not been pretty. We have received federal dollars. We’re grateful for those, but truth be told that puts a small dent in the impact this has had on Trinity and any other healthcare system. So April was a very tough month and May is going to be better than April we think, but not significantly. It’s nowhere near where we want to be or need to be.

  Nigel Ohrenstein: Yeah, I can imagine it’s enormously tough. So how are you thinking about a revenue recovery?

  Mike Englehart: The way we’re looking at it right now is we’re doing a major outreach to all of our patients, our members. We have a relationship, we call our patients members. And what we have found is that although elective cases are now coming open, have been for the last couple of weeks, the month of May has really started about the middle of the month. State by state, we’ve been walking into opening up elective cases. There’s still this education that needs to occur, whether it’s going to see a primary care physician, a specialist or a procedure/surgical case that was postponed. So we’re having to do a tremendous amount of outreach and that is happening both locally and we’re assisting from the system office in the talking points and the outreach campaign. Because the patients, the consumers, the members are really saying, “Do I need to do this? Can I do this other ways?” And so while elective procedures are turned back on, it’s a slow uptake, is what we’re seeing right now.

  Nigel Ohrenstein: Yeah, it’s an amazing situation in that consumer confidence really is going to, in my opinion, is going to be the driver here, irrespective of whatever a governor says or does, right? It’s going to be consumer confidence that drives how quickly people go back to doing anything, not just back into hospitals which obviously gives them the highest level of concern. I know you like to play golf. The analogy that I was discussing with someone the other day is that your coach could teach you how to hit a one iron every day of the year, but if you don’t have confidence hitting it when you’re on the course, you’re going to skip that club out of your bag.

  Nigel Ohrenstein: And so that’s sort of a little bit how I imagine people feel about health systems right now is like, “Well, if I can skip it, right, I probably will right now.” Which is frightening for sort of the long-term impact. What do you think the long-term impact will be of sort of people skipping their care?  Because elective procedures carries a pretty wide gamut, right? I mean, it’s an odd term, right? Elective. Because some of them truly are not elective, right? So what are your thoughts about the long-term impact to people’s health, public health? We’re obviously highly focused on the Coronavirus, but…

  Mike Englehart: Yeah. I give you two points. One I would say that it’s going to take us months before we understand, if not years before we understand, the impact because the postponement of an elective case, and we’ll just use a simple, a knee replacement. People can muscle through and get through and extend and wait for three or six months if they’ve dealt with that. I think the larger concern that we have is that there’s been a disruption in the relationship and maintenance of people that have diseases, diabetics, CHF, COPD, and then the delay or postponement of going to see their physician whether it’s for the annual well visit or just going in for a checkup could postpone the diagnosis of issues. And so it’ll take a while before we appreciate what has transpired, but I had two things that happened to me.

  Mike Englehart: I was serving as the interim CEO down in Columbus at Mount Carmel for Trinity and one of our radiologists said to me, he goes … This was at the end of March. He said, “In the month of March, I diagnosed two ruptured appendix. That does not happen that these people came in to the emergency room with a ruptured appendix, within a lifetime of a radiologist you might have that happen one or two times in your career. I saw two of those in the month of March.” And he’s convinced that these patients waited and tried to get through the pain because they’re so concerned about coming in to a hospital or emergency room because of the perception, concern of what this means.

  Mike Englehart: So I think there’s a lot of delay of treatments and wishing away some of the symptoms that have appeared and we’re seeing a lot of people that have passed away because of heart attacks and they might have had an opportunity to potentially, under normal circumstances, maybe make different decisions, but decided to postpone and delay or hope that something was going to get better and in reality, it didn’t and they missed some of the early signals. And so that’s what’s troublesome and concerning to us. And we’re seeing and hearing that, not just at Trinity, but across the country, other health systems seeing the same thing.

  Nigel Ohrenstein: Yeah. We’re hearing the same thing as well. It’s actually frightening and one of the problems from my perspective is that we’re all focused on this one number, right, which is COVID-19 deaths, right or COVID-19 cases. And there’s no way, as you said, because it’s going to take us years to figure it out, to sort of put the other number up there, right, which would then lead to sort of an opportunity, as you said, to educate the people that actually you might be doing more harm to yourself than good by staying home and not getting that… let’s see which is obviously very, it’s frightening, as you said. So Trinity being such a large number of markets and it’s urban, rural, really must see the gamut of sort of Coronavirus responses and issues. Can you give us a little peek into what are some of the differences you’re seeing between some of the different locations?

  Mike Englehart: Yeah, that really is true. Because we’re in 22 states, every single day, at least now it’s Monday through Friday, but there was literally every single day, an update where we would report out all of the findings, everything you can imagine. It was an incident command center and we were tracking the prevalence of cases, obviously deaths, supplies…and it’s really interesting. We’ve been on the East coast and so we have ministries in the new England area, in the New York, Albany, up in Syracuse, and then we go all the way out West to Fresno, which has been hit pretty good, but Boise has been relatively quiet, and Iowa where we have a joint venture with CommonSpirit had been quite quiet for a while up until probably the last two to three weeks. And obviously Iowa, Nebraska both been in the news because of the incidence. So it’s interesting.

  Mike Englehart: And obviously we’re here in Chicago and with Loyola and Mercy and Gottlieb and so we have seen waves. We have seen the concern and rather significant impact it’s had and we have shuttled and moved some of our staff, our nurses and some doctors have actually gone from some safer areas into the heart of some of the surges to assist us. And so we’ve done a lot of that borrowing of staff and moving them across the country and that’s been a great assistance, but it’s been remarkable.

  Mike Englehart: And one of the hardest things to do is to do the forecasting and I think we’re getting better and better as the country is as well, but in areas like New York and when I was in Columbus, we were prepared to stand up convention centers and thank God, we never had to do that, but if it didn’t get under control, it was headed that way. And so people are like, “Well, it’s not that big of a deal,” because the convention center wasn’t opened up. And it’s like, that just goes to show you just how unique this pandemic is and how it can really extrapolate rather quickly, or it can bend or flatten quickly with some pretty common sense approach. And that’s what’s made the difference.

  Nigel Ohrenstein: And as you look at the ministries, let’s take some that are more rural, do you feel that you’re going to have to either prop up or potentially sell some ministries and then simply on the flip side, are you looking in and saying this might be an opportunity to acquire some in locations that you think will be desirable because then there will be hospitals that are struggling?

  Mike Englehart: I think what I would say is that Trinity, like any good health system continues to evaluate its portfolio and I think what we were looking at before COVID was, too often we believed that the hospital was the only way, well, it was the primary way that we provided care to a community. And prior to COVID, I think we were all coming to the rationalization that there were some markets where it might be more advantageous to provide a medical home, a large ambulatory behavioral health focusing on some of the comorbidities, and so we were in the process of doing some portfolio management. I’m not sure right now that acquisitions are on the forefront. I think what we’re continuing to look at is how do we stabilize and start to find out what the new norm is.

  Mike Englehart: We don’t believe at Trinity that, we don’t even use the language we’re going to return to our pre-COVID. We think that this is going to have a fairly long impact and we need to be cognizant of the fact that it’s unlikely that things will return to where they were. I think that some things have changed for the long-term and for the future. And so I think it’s more about stabilization and looking at more ambulatory than it is acquisition. Although, who’s to say in six months, if things don’t change and other opportunities present themselves.

  Nigel Ohrenstein: Right. So, you’ve hit on a topic that is sort of central to everyone who thinks about sort of where healthcare’s going which is site of care. And so I know that Trinity’s been involved in a lot of sort of telehealth opportunities. How much has that grown over the course of the last two, two and a half months?

  Mike Englehart: It’s been dramatic. We were always in favor of it and our regions probably moved at their own pace and then when obviously COVID kicked in, it became a, I think it was the patient, the consumer, the member, that said, “I’m okay with this.” Now it’s not the right solution for all patients, but if you have an existing relationship, it turned out to be a godsend and I think it’s the new norm. And so that’s a perfect example where we literally right now are averaging north of about 35 to 40% on any given day of all of our primary care visits are digital health. There are some ministries that gets as high as 55 or 60. And so we believe that we need to keep that as somewhere at least around 30% or greater as the new norm.

  Mike Englehart: We believe it’s the new channel in which many members are going to want to interface with their doctor, not all the time, but it certainly is efficient. It can be effective and I think we believe at Trinity, that over the next two to five years, I think a lot more risk will come to the patient and to the provider. And if you take risk, one of the great tools that can be leveraged is telehealth. And so it has to become a core competency. It’s got to be a new way to bring new members into the family and it’s also a great way to check in and keep people healthy and on the right track.

  Nigel Ohrenstein: Yeah couldn’t agree with you more. I sort of think about all the people in the supermarket that choose self-checkout. They’re sort of the first in line to prefer telehealth.

  Mike Englehart: Great example, yeah.

  Nigel Ohrenstein: So risk, you hit on an interesting topic. I’m assuming when you say risk you’re meaning financial risk, but for outcomes was that the, how you using risk?

  Mike Englehart: That’s right. Yeah. That’s how I’m referring to risk. Whether it’s taking cap, I do believe… Trinity has always been an early adopter in all of the ACO programs and to the extent that we can do commercial, we’re in. And we also have an MA plan, a Medicare advantage plan, and in Columbus, which is now moved out to Boise and headed to Iowa and to New York. And so we believe that that is the holistic way to take care of a person and we believe it’s the way of the future. And so that was pre-COVID. I think that COVID only confirms that decision, because I think it’s causing everyone to take a step back and say, “What’s the best way to care for someone and what can we afford going forward?”

  Nigel Ohrenstein: You’re preaching to the choir here. Actually I just finished writing an article about how do you recover revenue, and really focusing in on how many health systems thought fee-for-service was sort of their protection, right? And “As long as I keep building buildings and filling the beds, I’m recession proof.” But we’re actually… true maybe, but the hospital’s systems were recession proof, but we’re clearly not pandemic proof, right? So, the safety in fee-for-service is, to me, should be more obvious than ever to a health system that this is not a sustainable long-term business model. And so it’s interesting to hear you say as such a senior leader in such an enormous health system that it sort of confirms it for you as well.

  Mike Englehart: Well, I agree with your analogy. I think the tricky part has been, most people would say, “Yeah, it would make sense that we build enough hospital beds to care for patients, but it feels right and it’s probably the right thing for the long haul if we got compensated for keeping people healthy.” Everyone will say that. But what they’ll say is, “but until the tipping point is achieved, I still have to keep my health system moving forward.”

  Mike Englehart: And I think for the same reason telehealth has taken off, Zoom has taken off and WebEx is, and all of these things, I think that COVID, I think we will look back in five years and say, “It really did push things over the top.” And it takes a little while, but once things become the new norm, they just become hardwired in. And I just believe that if I’m an employer right now, and we’re as a country sitting at between 15 and 20% unemployment, I think it’ll be interesting to see how fast the economy comes back. But the employers now are going to have to be extraordinarily smart about how fast they believe they can build their business back up. Some will take off because they’re in a sweet spot right now in the economy and others are concerned and have to be thoughtful about how they bring people back to work.

  Mike Englehart: In that environment, the employer will also say, “What are my obligations as far as benefits are concerned to my employees? And payer, what are you going to do to make this a better model for me?” And then you bring the providers in and we’re at the table and we’re having a different conversation.

  Nigel Ohrenstein: Yeah, no, I think that is true. Actually, I was, it seems like a lifetime ago now, but I was at J.P. Morgan at the beginning of January, which is sort of the annual pilgrimage, which I don’t love, but it’s highly efficient because I get to hear from a number of health systems in one go, meet a lot of people that it would take me months to do. So I do it and I think it must’ve been about my, maybe my 10th year in a row maybe that I’ve been out there and it was stunning to me how, I sit a lot in the not-for-profit health system track and listen to the presentations there.

  Nigel Ohrenstein: And it was stunning how many health systems would get up and tout that their population health, which is such a nebulous term, but their population health capabilities for 20 minutes of their 30-minute presentation and then one of either two things would happen. The CFO would then get up for the last 10 minutes and actually talk about how they’re losing a lot of money and they’re actually still 99% fee-for-service, or it would be someone who’s truly doing something, and as you said before, has an MA plan and they’re actually looking to be a little bit more innovative. So how do you move a system like Trinity with so much disparity of region, of payers, of people you serve? How do you think about that?

  Mike Englehart: I had the opportunity to work at Advocate and I thought that Jim Skogsbergh and Dr. Sacks always said listen, “One, it’s got to be part of our mission and we’ve got to live it, breathe it, talk about it, think about it.” So it’s got to be there in your mission and your strategy. And then the second area is, show me where you’re spending your capital dollars and tell me how you’re talking to the payers and the employers. When those three all start to line up, you can’t go faster than the market will allow you. But if your heart is, ‘Yeah, we really do believe that population health is the right thing to do,” then your capital dollars will start to be spent more on ambulatory, technology, medical group physicians, ASCs, because those become cost effective ways in a diversification of your portfolio.

  Mike Englehart: And the conversations you’re having with the payers and the employers are critical because that’s where you get rewarded for doing the right thing. And if you don’t ask and you don’t sit down at the table and try and find those new opportunities to share risk, give a little bit of protection as you go into risk, but ultimately take the training wheels off and go all in, you’ll stay in a fee-for-service world as long as you need to, until you’re forced out of it.

  Nigel Ohrenstein: You mentioned before your stint as the CEO of Mount Carmel Health System, obviously a highly regarded health system in Columbus and I know, prior to that, you were the CEO of Presence Health in Chicago. And so as the CEO of a health system within the Trinity network, I’d love to learn a little bit of insight from you in terms of where did you have local authority versus what’s national, particularly as you think about responding to post COVID-19, and then I’d love to delve a little bit into … you touched on it before, I’d love to go back and talk a little bit about MA, but let’s start with the CEO of a health system within a broader network, where do the battle lines get drawn?

  Mike Englehart: Yeah, well what I’ve come to appreciate at Trinity is that they’ve got a very good model. The regional CEO has a tremendous amount of authority. But as it pertains, ultimately there is a Trinity board and the regional boards do have fiduciary responsibilities that are given to them from the Trinity board, so they do have responsibilities. It is not an oversight so there is real substance to the board. So the regional CEO has the responsibility to work hand in glove with their local board, but then there’s obviously policies and there’s strategy and capital and all those decisions are made through the system office but it’s done in a very transparent, thoughtful way as far how we set budget, how we spend capital, how we roll out our strategy. We were in the midst, we made a commitment to convert to Epic. We had been on three or four different EMRs, and we made a decision about 18 months to two years ago that we were going to convert to Epic.

  Mike Englehart: And we were literally in the midst of rolling out Epic when COVID started to hit us up in Michigan. So I would say that the way that Trinity has it set up is, it’s got to be this way because of the size being in 22 states, that you have to give the regional CEO a fair amount of control. But we have a standard matrix as far as the quality indicators and our balanced scorecard is the same, but Trinity is a firm believer that healthcare is delivered locally, and we have to afford the regions some flexibility and autonomy so that they can respond to market dynamics, but the underpinning, our mission or values, those are consistent across all of Trinity.

  Nigel Ohrenstein: And as the CEO of Mount Carmel, how did it differ how you thought about value-based care, how you thought about managing populations, how you thought about running the hospital system with the fact that you did have, as you mentioned, MediGold, which is, I think the market-leading MA plan in the Columbus area. How does that change the way you operated as a CEO compared to sort of your other experiences as the CEO where you didn’t have a plan?

  Mike Englehart: It was actually really, really interesting because all the other, whether it was at Advocate or at Presence, we dabbled in MA and we did all of the ACOs, but when you’re an MA you’re all in, and when you own the plan with 50,000 lives, you really have to be thoughtful. What was interesting and fascinating was, there were still, even within Mount Carmel, were times when there was a disconnect about what was MediGold’s role versus the hospital and you can imagine we tend to be more hospital-centric. And so if readmissions and length of stay debates occurred between MediGold, then the hospital administrators, and it’s like, “Look, we do the right thing all the time, but don’t think we’re going to do the right thing for the patient and we’re going to do the compliant thing.” But there was a lack of understanding about what it meant to run an MA plan.

  Mike Englehart: And I think we made a lot of progress and there’s some really good leadership at the MediGold team and they just needed to get to the table to explain how they’re progressing, steps they’re taking to help their members stay healthy. And it’s enlightening because it gave people a different viewpoint. So I found it fascinating. It was, I think, a really interesting opportunity to see, really a 360 viewpoint of running a traditional health system, being adamant about population health, and, Oh, you are carrying risk. And MediGold had been performing and continues to perform quite well in helping Mount Carmel perform financially well.

  Nigel Ohrenstein: And you mentioned a few minutes ago about how you’re looking to expand MediGold to three or four more states. Take us a little bit through that strategy. What’s the thinking there?

  Mike Englehart: One, it’s our plan so [it’s] we believe we’re in the best position to roll out an MA plan in a thoughtful manner that is set up for the member to be successful and for our health system to really be the beneficiary. MediGold is a great chassis and while there still is additional opportunity in the Ohio marketplace, where we have critical mass in some other states, we see opportunities to introduce an MA plan where we can take advantage of the last several years of taking risk on and saying, “All right, we’re now going to graduate. This is a multi-year journey so that we can grow an MA plan, but the market is not dominated yet and we see an opportunity to bring in a MA plan that is run by a health system that will allow us to be successful and really push the envelope.”

  Mike Englehart: So we’re excited. We’ve picked these markets strategically because of the market dynamics, the MA penetration, our reputation in the marketplace and it’s not a one year. You look at it through three and five year windows, but we’re excited about it. Again, it helps with that tipping point, Nigel, when we talk about, and so this is a further … One, we just think as a country, we do need to move deeper into MA. It just makes a lot of sense. It rewards the right … There are things that could be tweaked about it, but it does directionally move us where we need to go as far as total cost of care. Number two, it’s a diversification of our portfolio and I think that’s incredibly important as we look forward because that’ll inform how we invest capital dollars and invest in doctors and nurse practitioners to help people stay healthy.

  Nigel Ohrenstein: Yeah. So I couldn’t agree with you more. I’ve spent a decade researching and studying every sort of value-based care model out there and I haven’t seen a sustainable model, sustainable being the key word without an MA play. It’s, as you said, really astutely, it rewards doing a lot of the right things. It rewards operational excellence, it rewards quality, right, it really has, in many ways, the most thoughtful of programs that have ever been put out by the government. And in addition has had many years to evolve and improve itself. I think we could all, with everything, sit down and come up with another 20 ways that we think it would be better. But I think it’s fundamental to a sustainable strategy. So why don’t put a plan in, I know you said where you have critical mass being a key area, but as you think long-term [and, given the] and I don’t blame them for this, the payers look to protect their own business model, why not put a plan everywhere you have a ministry?

  Mike Englehart: Yeah. I would just simply say that standing up an MA plan in a new state is no small undertaking. It’s a big lift as far as education, the state requirements. It’s a long process so I would just simply say, we’re not done. We’ve just started and we’ve identified, we want these to be successful. And so we have to move at a rational pace, but I don’t think we’re done with just these three additional markets. I think we will go further, but this will keep us busy for the next two years or so. But we believe that we have an opportunity to go further with MA, whether it’s our plan or really going deeper in with and pushing the envelope and other marketplaces.

  Nigel Ohrenstein: Yeah. It’s, as I say, I think it’s a great strategy, as you said, both in terms of enabling the system to manage populations, diversification of revenue, controlling the premium dollar, as opposed to, as we see now in pandemic times, really being at the whim of other people determining how and when you get revenue, which is, in almost any business, right, in any industry, you look to have as much control over your revenue as possible, right? And if you don’t, you’ve got to rethink your strategy and it seems that you’re doing that well. So I’d like to close Mike with what I call the quick fire round.

  Mike Englehart: Sure.

  Nigel Ohrenstein: So, best piece of business advice you’ve ever been given?

  Mike Englehart: Run to problems. You’ll learn more from those opportunities than anything else.

  Nigel Ohrenstein: And I think I’m guessing I know the answers to this one, but how do you relax, have fun?

  Mike Englehart: Family, some exercise, and you can find me playing golf whenever I get a chance.

  Nigel Ohrenstein: That’s great. And then finally, if you could change one thing about healthcare, what would it be?

  Mike Englehart: I would love to see the velocity of change be allowed. I think we burden ourselves with regulations that are 20 and 30 years old and I think it’s a barrier towards a progressive movement towards more efficient care. I understand the government’s role but I think the pandemic is reflecting that when we need to, we can change and I think that that is long overdue in healthcare.

  Nigel Ohrenstein: Great. Thank you. You know what’s fascinating to me about having the opportunity to chat to you today is that you spent seven years at Advocate, who many people consider sort of ahead of their time, as you think about managing populations and everything that goes with that which is so easy to say but so super complicated for those of us that are sort of executing on it day in, day out. You bring the CEO perspective. You’re an obviously senior leader in a national organization, national hospital system, and so the different perspectives you bring to the table and the different vantage points you’ve had over the last 15 odd years, and to bring this now, I think it is an amazing opportunity for Trinity to have leaders like you leading them into this next generation. And as we come out of this pandemic, having leaders that both understand the need to focus on today’s execution, but also keep an eye on the strategy, which you clearly articulated through this conversation is heartwarming. So Mike, thanks for taking the time today.

  Mike Englehart: Well, thank you for the opportunity. Stay safe and look forward to talking to you again.

  Nigel Ohrenstein: Great. Thank you. Thank you for joining us today. Please following us on your favorite streamer and don’t forget to rate us as it helps others find this podcast. As we get deeper into this pandemic, I hope you and yours are staying safe and healthy. Please join us next time as we tune healthcare, this is Nigel Ohrenstein in New York.