ACAP Coffee Break

Chris Palmieri, Commonwealth Care Alliance

November 13, 2020 Association for Community Affiliated Plans Season 1 Episode 1
ACAP Coffee Break
Chris Palmieri, Commonwealth Care Alliance
Show Notes Transcript

Commonwealth Care Alliance President and CEO and ACAP Chair Christopher Palmieri joins Meg for the inaugural episode of the ACAP Coffee Break to discuss his journey from aspiring law student to Safety Net Health Plan leader, how his plan has responded to the COVID-19 crisis, and what he looks for in emerging health care leaders. Find Chris' book recommendation here: 

Hello and welcome to the first episode of the acap coffee break with Meg Murray, a new podcast from the Association for community affiliated plans. Our first guest is Chris Palmieri, the President and CEO of Commonwealth Caroline's in Massachusetts. Chris is also the chairman of a caps board of directors. Here's acap CEO Meg Murray to get things started. Welcome to the first acap coffee break where we will be speaking with the CEOs of our safety net health plans. We're going to talk about leadership both in the industry and among their, their staff and their companies. We want to hear their  stories about their career influences, and we want to hear more about the innovative new passive they're forging to build healthier communities both in this time of COVID. And just generally, I'm your host, Meg Murray, I'm the CEO of the association of community affiliated plans. And today we have the pleasure of speaking with Chris Palmieri. Chris is the President and CEO of Commonwealth Care Alliance in Massachusetts. It's a not for profit community based plan dedicated to improving care for people who are dually eligible for Medicaid and Medicare. It's a very unique plan with a storied history. And they're very lucky to have Chris there. And we're lucky to have him as the chairman of acap as well. So Chris, welcome to our first podcast, we wanted to hear from you about why didn't you go into healthcare to begin with, there's you know, you're a very talented man, you could have gone into any industry, why did you choose healthcare? This is a great question. And thank you for having me. So, truth be told, I tried really hard not to go into health care and a little bit of background. My, my mom is a registered nurse. I have three siblings, all of which are significantly older than I am. The closest is 12 years older, and the one that's the oldest is 17 years older than me, all of them are, are still in healthcare. My oldest brother at the time that I was going through college was a nursing home administrator. My sister was in nursing home administrator, my other brother
who has a physical disability, he spent his entire career working in food service in a nursing home. And I think what led them into health care was my my late uncle owned some nursing homes, and they followed in his footsteps. And I tried very hard to be an attorney, which was my passion. And I started out on a journey in political science and English, which I thought would prepare me well for law school and two years into my undergraduate education. I sort of panicked, and I called my oldest brother and said, I'm really worried that I'm not going to get into law school in two years, and I'm going to be sort of in a situation where
I may not be employable. And we grew up fairly poor. And, you know, economic considerations were important and me running out of money to continue to finance my education was of great concern to me. So he, like great older brothers do have we had a meeting and I'm, you know, here I am 20 years old, and he's 37. And he said, Have you thought about health care and sort of told me all about what he was up to, and his world and I decided to I transferred from the school I was in, which was the Utica campus of Syracuse University, and ended up going to Ithaca College,
also in upstate New York, because they had an undergraduate Healthcare Administration program. And, and ironically, ithaca, was a program that that also trained nursing home administrators, and in particularly prepared people well to take the New York State nursing home licensure. And when I got to Ithaca, that was not of interest to me, I decided to put together a curriculum with accounting and finance courses that I thought would prepare me well to work in a managed care organization. And at the time, I remember the Dean of the School, I'll never forget this called me into his office, he had my entire profile they must have done when I was going through my admissions process. Some researcher I provided them information on who my family was and what their careers were. And he said, you know, as I look at your curriculum and what you've put together, it looks like you're going to not be a nursing home administrator, you're going to try something else. And I said, I was at the time I was really interested in managed care, and in potentially working in some type of care delivery organization like a hospital, and he said, managed care is a fad. And, and unless you want to work on the on the west coast, I don't think that's really going to be a place that will create employment for you.
But he also said the decision is yours and the college will support it, although we strongly discourage the direction you're going and I continue to tell that I go back to Ithaca College.
A lot and I tell that story a lot, because that became a very motivating force in my life and and I ended up I ended up pursuing the path and you know, now here I am working in a value based purchasing type organization or managed care organization. So, and I think it, I think it worked out well. Yeah, worked out well, and you've actually been led to have are a cap plan. So what what drew you to the safety net health plan side of managed care. And actually, Meg, I think it's three, because I work I also lead I led home first, which is now part of elder plan, it was
one of our three firms, we have a bunch of them at a camp, I know, I'm happy to be in that in that crowd, and happy to have the the experiences that I did, right after college, I had a mom that really wanted her son to come back to upstate New York. So of course, she helped me get an internship. In fact, I think she found the internship, unbeknownst to me, and it was at a very large, multi specialty physician practice that was taking global risk. And this is again, in the mid 90s, when when very few organizations were taking global financial risk on managed care populations. And in particular, they were taking risk on Medicare and Medicaid. And they were not doing very well financially. And I had the opportunity to work with the CEO at the time, who was a great person just moved to upstate New York from Montefiore Medical Center in New York City, to lead this organization. And he took me under his wing, and I essentially was, their their analytics person, for this large problem that they had. And really, in terms of looking at the data, I wanted to learn about the populations that that they were serving, and sort of what were the drivers for the the financial results, as well as there was a lot of quality issues. And at this point, we were looking at vaccinations for children. And, and the gaps and in kids having good, good health. And, and at the same time I had I just finished an internship before I took that position, working in a diagnostic and treatment center, which is essentially it's like a federally qualified health center, and really felt I could help the populations. So that was my start. And, and I stayed with it. I mean, they this, this physician group really wasn't a safety net organization. But then I went on at a very young age to build a small organization that was in upstate New York that worked in the same category as as elder lan, and VNSNY, in New York State's manage Long Term Care Program, and did that and, and really the whole concept of taking individuals that would be normally living in nursing homes and allowing them to live at home, and addressing the needs that they would have around personal care services and activities of daily living and getting meals prepared at home, and getting care coordination. And all these things, as we know today
are really addressing the social determinants of health. But that was not a term that was in vogue 25 years ago and stayed with it, I just the value to see what you can bring to an individual who is reaching a point of their life where they do need some supports, but also cherish living in the community and living potentially the home that they may have lived in their whole life, the supports that you can provide someone to continue that that really was what hooked me. And,
and I've stayed with it in a variety of different ways throughout my entire career. So you were at Elderplan, and then at VNSNY the health plan in New York. And then most recently, now actually, it's been almost five years has it that you've been in CCA
it'll be five years on the first of November is my anniversary. So I, I was interested in sort of, I guess, spreading my wings. And I was still in my late 20s. And looking for opportunities in much larger cities than where I was in upstate New York. And, you know, 9/11 had happened, and which was a very traumatic time for our country. And and I watched so many people, you know, sort of leave New York City because they were scared and the tragedy that had just ensued, and I had an opportunity to actually go at that point and work for a company that was in the same family of companies as elder plan. And it was also an organization that coordinated care for nursing home eligible people that lived in the community. And I took that opportunity and I was one of the first airplanes that was back in the sky. In I guess it was September, early October of 2001. And when a job interview, really liked the organization, I got to meet
At that time, David Wagner, who is, you know, now, the ceo and has spent his career there. And it was an interesting time. I mean, it was about, you know, again, coordinating care for people that needed the services, but at the same time, many of many of our employees and their families and the people that we were caring for were either negatively impacted by 9/11 or perished in in the, the situation where the towers had come down. So it was a, it was just a remarkable time to be in health care. And it really, it taught me so much that experience and I was you know, I was able to gain a lot as well as, as well as give a lot and there was some incredible visionaries. Eli Feldman, who is a he's an icon in in long term care, in healthcare, and certainly in New York, but in the country, and Maxine hochhauser, are two people that really, they spent a lot of time with me and trained me and, and I think really prepared me well, while I was still at a young age. And, you know, as you said, from there, I ended up getting to visiting nurse service of New York. But I took a stop in between at amerigroup Corporation, which was the, at the time, the largest publicly traded Medicaid managed care organization. And they serve moms and kids in several states. And they were looking to diversify and wanted to get into things like Medicare Advantage and managed ltss. And that was my, that was my role in the organization. And I had a crossroads, I was presented the opportunity to go to their corporate headquarters, which was in Virginia Beach. And, and probably if I if I had a chance to do it again, and maybe I would have done it, but I didn't want to leave New York and I wasn't able to stay and do the work that I was doing. So I left the organization after about a year and a half. And it was fortuitous, because I had found the visiting nurse service of New York
in 2005. And at the time, and still, I think today, they're the nation's nation's largest homecare provider, that's nonprofit, and they serve somewhere between 80 and 100,000 people a day. And they wanted to get into being an insurance company as well. And they hired me, I was employee number one of their Medicare Advantage division, and spent 10 years there and moved up and became the ultimate the CEO of their health plans. And, and it was we were serving about 40,000 people at our height and in the organization were 22,000 employees. And we're very, very well equipped to serve the most vulnerable New Yorkers.
Because we had the ability to coordinate care, and we also had a very large workforce that could go into the homes and provide the nursing care and coordinate all of the social determinants. And it was that was also an incredible experience in my career. So you've talked about your progress up the ranks, what do you look for when you're hiring staff, maybe young staff coming into the industry? What what are the characteristics that that you look for when you're hiring? Yeah, it's a great question. And I would say, I would say there's a there's a few things. So first of all, I I certainly prefer to work with individuals that are people you want to spend time with people that have nice personalities, we had a saying and remedy. When you when you met someone, is this someone who could go on a camping trip for a weekend? You know, we're sort of stuck in close quarters without all the traditional amenities? And, you know, so that's something I always think about, and I think it's, it's sort of comical, but it's in the back of my my head. I mean, one is just Can Can you lead and uncertainty, and that's something that I think we see in healthcare more and more is things don't go the way you hoped they would or the way you thought they would. And how does someone respond? When there are uncertain times?
Do you have calm under fire? So you know, we're always in I feel like high pressure situations, either, you know, dealing with the consumers that that we serve, and are the safety net for these are folks that have they have significant health care needs, and they're touching the healthcare system, each and every day. And that can be very stressful if the delivery system is, is not functioning the way you hope to serve your, your consumers or the regulatory climate or whatever it may be. Can you stay calm in those situations, and do not sort of bring more
intensity to assist situation that you're trying to de escalate? Do you have self awareness? So do you know sort of where you stand in the world, you know, if you were to put a mirror up? What do you see? And do you know that or do you just always see yourself I think I think sometimes folks that have less experience, see themselves in a very different light that is reality. And reality obviously is how everybody else sees you. So if you have the self awareness and understand what you're not only what your strengths are, but what your weaknesses are, can make you a better a better you not only obviously in the employment world, but in life in general. I think the
Last thing is just to have the willingness to get to get the job done. And it's you know, this these are not, I think roles in healthcare are not about you in your chair from nine to five, or you know, now are you on zooms from 7am to 7pm, it's about are you are you able to get things done. And that's really important for people. And I think oftentimes, people still lose sight of that. So those are some of the things I look for, in particular.
And certainly, being able to become in a time of uncertainty is really important right now with COVID. And I'm curious, what are some of the things that you did with the staff at CCA? Is you move to the virtual world and dealt with the pandemic that started in Massachusetts? What were some of the management changes that you made within your organization? No, it's it's a, it's a really, it's a great question. And something that, you know, as we think about what is what is COVID going to end? Or what are going to be the lasting impacts? Or is there going to be a second wave? You know, I'd say, first of all, back in March,
you know, we, we moved everybody home almost immediately, and we had never had our entire workforce, working remotely for more than 24 hours, that was due to inclement weather. And now, they've been out for about 215 days. And our systems have responded flawlessly. And I'm thankful for that we've spent the last five years making some significant technological investments. And those are paying off. But you know, so first, it was about the safety of the staff and our members. So how do we get? How do we get people in the best environment? How do we make sure that our staff are equipped to do their job, so we sent everyone an IT setup, which is either laptops or main, you know, heart, heart, hard drive systems, monitors, sometimes multi monitors, if that's what their job requires keyboards. Then we went one step further, and we set folks that that didn't have the appropriate desks and chairs and ergonomically appropriate equipment. So we want to make sure that people are equipped to do the work that they needed to do at home, because we had no idea back in the early days that even this was going to be as long as it is now. And we hoped it wouldn't, but it was and the second thing was we communicated with our workforce in its entirety. Every two weeks, because people had questions, people were scared, people that know how to do their jobs, from from a distance. And we wanted them to know that we were we were there with them, and
provided them the support. And these were live town halls are over 1000 people were calling into each and we allowed them to also ask us questions as being the leadership team. And we'd answer those questions immediately on on the call. So there was no scripted answers, it was really much more candid. So so we we support our workforce, that way we've given our staff
time off, so that they can rest because again, I think I think people early in in March and April, and may, they just never stopped working. They didn't they weren't used to working in an environment where there were really no boundaries, which historically leave your office, you're not working. folks were at home, and they were getting up at six in the morning. And they were working on zooms until midnight. And they you know, a couple people that said, geez, I didn't realize I just did that for 55 days, and, and we needed to help our folks take a break, which we did, and we gave them some mandatory time off. We also paid for our staffs, internet, a lot of our folks like I think the world has been experiencing, not only were they using their Wi Fi, but their children were doing it to go to school, their spouses were doing it. And bandwidth became an issue. And we asked our folks if they needed to to increase their bandwidth, and we paid for that
for a period of time. So it's been a good recipe at the same time. We extended our expertise to the state of Massachusetts. And you know, the one thing is I look back on my own career. You know, I guess there's a benefit to living and working through the the tragedy of 9/11. And then Hurricane Sandy, which occurred, I believe in 2013. And you get experience in terms of how to run an incident command center, how to do business continuity, planning, how to communicate with your workforce. So we immediately went to the state of Massachusetts, which had set up a command center, which is a bunker style way that the state and its officials were going to manage the crises. And we offered our expertise to them. We had no idea if they would take us up on it. But we said you know we have I said to the Secretary I have experience in these disasters, unfortunately but I'd like to help
in any way, and, and lo and behold, the state came to us pretty quickly. And they said, we have a situation with folks in the MassHealth Medicaid fee for service program. And we're concerned that they're going to be trying to access acute care for things that may be a lower level of care, then we have access and capacity to do given all the people they're going to need ventilators and how this is going to escalate. And they originally said, can we can we borrow some of your staff. And we didn't have any staff to loan because our staff were very much fast at work and caring for the members that that were enrolled in our plans, as well as the patients in our primary care centers. I said, Who is going to run this operation, which they hadn't really even figured out yet at the time what it was going to be? And they said, We don't know. And I said, Well, I will offer to run it for you. If you can get the staff and they six hours later called back it was a it was a call at 11 o'clock at night with somebody that was designated by the Secretary to lead this part of the operation. And in conjunction with FEMA and MEMA, we decided, and the state decided that they were going to set up six, isolation and recovery centers, which we're going to be at six hotels that the state was leasing. And then we're going to have as covid positive individuals that did not need a level of care. That was equivalent to the acute care hospital, but needed to be in a place where they could be cared for. They wouldn't contaminate others a place where their families could go if necessary. So we ran out with 600 beds, we have, we have one facility still running today, it has about about 18 to 20 people in it. We think that those will be remobilized if there's a second wave, but that was an incredible experience. And, you know, I'm more grateful that the Commonwealth called on us and I think the Commonwealth is grateful that we were able to help them on this small piece of of their operation.
Yeah, I saw this morning that the cases are increasing in Boston on the schools had to shut down. I think today, so are you starting to see that play out with among your, either the homeless population, you were helping for the state or your own population? Yeah, I mean, you know, we've watched the numbers, they've been a steady rise. Now, again, the testing is also up. So. So as we test and have more confirmations of positive, some of it's a function of having greater testing and more rapid testing, but the cases are rising here. And we are going to see some regression on steps that we were trying to make forward in hopes of creating some sense of, you know, I wouldn't say it's a sense of normalcy, but it's a way for people to resume some of the activities that they wanted. Yeah, you know, some colleges here, I've had students on campus, some have elected for students to go remote, some of the retail industry is opened.
And all of that, you know, all of that is, is those are all parts of a very vibrant economy, which has been non existent for the last six months. And I think that the tension is obviously how do you how do you can you reopen the economy? And can you can you can you do in a way that safe? And, you know, unfortunately, right now, the numbers are saying something very different. And, you know, the decision for kids to go back home is a it's a big one. And
I think it signifies that we're going to be in for a pretty long haul. I had a conversation with, with the governor a week ago, about some of ccaas thoughts on the future. And and, you know, he acknowledged second wave, I think anyone in Massachusetts would, we don't think it's going to be as as bad as the first go around. But, but it's very serious. And we have to continue to practice social distancing, and wear our masks and not put ourselves into situations or environments that are going to create risk, because this, this does, unfortunately, spread very, very easily and very quickly. Yeah, especially, I guess, among the congregate settings that a lot of people are in the the states are starting to come out with their plans for vaccine distribution. And I wondered if if you all starting to talk to the state about that. And think about that, given your population that will be probably first on the list to get vaccines? We are we're having some conversations about it. I think the conversations are tempered certainly internally as well as
at the state level about what is the vaccine going to be safe? Is it going to be
tested enough for people are people or are people going to voluntarily want it? You know, and that's the other key ingredient here. So I think all these conversations are happening in parallel. This is going to be the fastest we've brought a production vaccine, I think, to the marketplace in history. And that is something that I think I think consumers, they have a lot of trepidation and i think i think consumers and people are going to have to decide, you know, where they stand on that and then will there be enough vaccination back
Seen, I should say, to go around so that people can get it. But you know, our folks would definitely be a priority. Right? Yeah. What about some of the other challenges? It's probably hard in some ways to think beyond COVID. But I know you're always planning well ahead. What, in the next couple of years? What are the other challenges for the the plan?
Yeah, so I think there's, there's a variety of them. So, you know, we do have a presidential election. And we're, I think, all sort of preparing for what the healthcare agenda will look like, if we have another four years of the Trump administration or if we have four years of the Biden administration, and what does that look like? I think there is a desire to continue to move individuals that are covered by the Medicare program into some type of value based purchasing relationship, it seems like that is some level of consistency between either party, although I think how that gets executed will look very different. You know, I want to make sure that we here in Massachusetts, continue to advance the engine, the agenda and the success of the programs in Massachusetts now that they are reaching a different type of scale. And, you know, just to give you an example, Massachusetts has had its senior care options program since 2001. And we have about 57,000 people in it. And that's more enrollees in one state's FIDE snip, than, for example, the entire pace, associations membership in every state. So this has been a great success and the plans here and that can speak for CCA, where we were four and a half star plan, we've always been for four and a half. And our peers are also seeing high levels of quality. So it's a good quality plan and meets the consumers needs. And I want to leverage the experience in Massachusetts. And I frankly, think the administration here does too, to point to it as this is an example of when done right, this can really work. And and I think other states can adopt certain things that we're doing, and the lessons that we've learned Now, over 19 years with the senior care options program. And, you know, I think it is going to be for us challenges of continuing to show that show that success with the administration. And you know, we're seeing now, even with the current administration, there are some things coming out of CMMI that wants to advance integrated care and value based purchasing, and we're seeing the direct contracting model come forward, I think, you know, the challenges for us will be making sure that that continues to happen. The second thing is that, as a nonprofit safety net plan, we are seeing much more industry consolidation than we've ever seen. And I think, you know, there was a lot of consolidation, you know, here to now going all the way back to when I started my career. But there were also more plan sponsors, and now it's happening quicker, I think COVID and the financial challenges on certain organizations it has accelerated and we see certain organizations that are, you know, publicly traded, are getting bigger and have done more acquisitions and integrations. And, you know, I don't want to leave everybody with the impression that the public entities are worried about their consumers, but their ultimate objective is to return an investment to their shareholders, versus I think what the safety net nonprofit plans are, which is really it is about the consumers and making sure that the consumers needs are met first. And I think I think, you know, lastly, we're all going to do this in a fiscal climate that's going to be different than we've ever seen before. We are talking about, you know, how do we Tru up the dollars that have that have been put out by the federal government flow through the states to make sure that there's a health care system still standing when this pandemic ultimately winds down, and you have tax revenue, because the retail is lower than it's ever been? So tax receipts for the state are lower, you have greater unemployment than we've ever seen. So the the economic equation is a very challenging one. At the same time, you see an uptick in people on the Medicaid programs, I don't think we saw we're seeing the surge that we thought we were going to see, but I think it's just it's a timing issue, not a circumstantial issue. So we have to be prepared to serve more people can potentially do that with less resources, less less premium dollars, and we have to be able to do this the same, the same, if not a better job than we've done before. And we may have, frankly, a sicker community. Because they have been maybe they have not, you know, maybe not been hospitalized by COVID. But but they may have been negatively impact impacted. We've had consumers that have not had the access to health care like they did back in February, March before COVID hit and and I think we're going to see a different consumer a sicker consumer, one that has more behavioral health complexities, one that has not getting there, their their routine and maintenance, primary care,
health care, because of the you know, just there hasn't been the right access points. I think that's what we're going to see in 21. And we have to be prepared.
So what would you say to your 22 year old self? Given what you know about our industry in our country? What what what advice would you give to that 22 year old Chris thinking there and ithaca about what to do with his life? Yeah, it's it's, it's, it's actually advice that I still give because I try to access as many of the, the what I think is going to be the next generation of leaders and who is going to have to solve the problems in our country, because I think they're great, and I don't think I'm going to, I'm going to be able to do it in my career, I am in my peer group. So first, it is that they can make an impact in whatever they decide to do, whether it's healthcare or something else. The second piece is that I try to attract to the extent I can I sell health care as an industry, to as many people as I can, because I frankly, think it's a it's a place for employment that is, is just greatly overlooked by a lot of our talent. And, you know, it's before before COVID, it was a $3 trillion industry. And now that's, that's probably up by 30, or 40%. In terms of the way spending is going.
It's It's the largest part of what we spend, as a country on and I think that's going to continue to grow. And I want it i think i think there will be value in attracting as many talented people to look at healthcare, maybe the way I did, although I tried to avoid it myself. When I was in my, my late teens, and then ended up coming back to it, I'd like more people to recognize it as it's a place where they can go and have a rewarding role and work on the things that they've learned in school around, whether it's finance, or marketing or some clinical pathway that they're choosing, or being able to build a business. All of that exists in healthcare as much as it does, and maybe more so now than in banking and the traditional pathways that people want to go into when they're when they're younger in life. So that's, that's sort of where I start, and then I get into, you know, some of the things that, you know, I give advice to my, my nephew, who is 23, and also just chose a path in health care, which I'm very proud of, and to really sort of, you know, think about his career as he looks forward and what are the skills that he will need in sort of his early 20s his mid 20s? And how is he developing those and how is he creating the social and professional networks that will help him and, and continuing to develop himself and that's sort of the the advice I would give one side hopefully would lure someone into healthcare. Hmm. Well, that's great advice. And I will share those with my son who is just starting college, as you know, and hopefully thinking about these things, too. Um, so the last question in the wrap up question is, one we hear in a capper are many of us are bookworms, and we're always looking for good advice for books, both fiction to kind of restore our soul as well as nonfiction to enhance our knowledge. So you will be the first person we've asked this question too. But we are going to start up a list on Goodreads and acap list of books. Um, and so what what should be one of the books that's on our Goodreads, want to read list? Yeah, I'm gonna, I'm gonna give you three. And
I choose books maybe slightly differently than others. So I like to read things that I actually know the authors or have heard the authors and have some level of connection. So the first book is written by Alan Wiener. Alan is a
a corporate, executive and communications guru. So Alan is an executive coach and helps folks with their communication style and strategy. And the book is called so smart, but how intelligent people lose credibility and how they can get it back. And it's a great book, it's a really easy read Alan's a great person, and just a very practical approach. The second one
is by Michael beer. And I just heard Michael,
present to a group of Boston executives, and the name of the book is fit to compete, why honest conversations about your company's capabilities are the key to a winning strategy.
And again, in this one, I think, you know, it is sort of, you know, looking at your, your company, from from the perspective of what reality is not sort of the utopian view that I think a lot of people look at themselves as in corporate America. And then the last one, and this is
someone I've gotten to know over the years, who is better, a friend, a potential investor and some things we were doing and, and really, I look at him as a mentor. And that's Ron Williams, former CEO of Aetna, in his book is learning to lead and also just a great book. And I think I would say all three of them are easy reads and you can read them
all sort of concurrently if you're that type of individual, or you can you can do them consecutively. But they're they're great books to read, and I would recommend all of them. Okay, great. Well, those will be the first three books on our list then. And as part of the podcast, you'll be able to see a link to the Goodreads site and see the other books that our other CEOs have recommended. So Chris, thank you so much for being our inaugural podcast guest. And we look forward to other conversations with some of our other CEOs at acap. So thank you. Thank you, Meg this s was wonderful. And I appreciate those that have spent the time to listen to this to actually to actually do that. So thank you. Thank you to the acap audience. Thanks again for joining us today. You could find Chris's book recommendations on the ACAP Coffee Break Goodreads bookshelf, find the link in the description of this podcast or just head to Goodreads and search a cap. Our next episode features Linda Hines the Medicaid plan president of Virginia premier health plan, here's a preview. I was torn to be honest with you, between being a social worker and a nurse and that was back in the 80s are really settled on wanting to be a nurse feeling that that's where I could really do the most good or what I wanted to do. Don't miss that and more on the next episode of the ACAP coffee break. You can find and subscribe to the cap coffee break wherever you get your podcasts. And when you do give us a shout on Twitter using the hashtag #acapcoffeebreak. We'll put you in a drawing for Starbucks gift card. So the next time you tune in your coffee's on us. Thanks for listening. We'll see you next time.