Addressing Barriers to Care in the American Indian Community and Beyond | That’s Understandable

In this compelling episode of That’s Understandable, hear from Dr. Barbara McAneny—renowned oncologist, former American Medical Association president, and tireless patient advocate—explore the critical healthcare challenges facing tribal communities today. From systemic barriers to cultural disparities, Dr. McAneny unpacks the complex issues impacting tribal health care in New Mexico. She also shares her passionate mission to boost cancer screening awareness and improve outcomes where it’s needed most. 

Transcript

Brendan (0:11): Hello everyone, and welcome to that's understandable, a podcast that aims to make healthcare and science more understandable. I'm your host, Brendan McEvoy, US Head of Corporate Reputation and Digital Communications at AstraZeneca. One note before we jump into our conversation, I will be using American Indian throughout this episode to broadly refer to a population made up of 574 tribes that go by multiple names, including Alaskan, native, Native American, indigenous American, or their tribal name. In using American Indian, my intent is not to generalize or minimize the individuality or unique experiences of those in the community, but rather to provide consistency in the conversation and avoid any confusion among listeners. Thank you for your understanding. Let's start with a simple but shocking fact, American Indians have a life expectancy that is nearly seven years shorter than the national average. They suffer higher rates of diabetes, heart disease and mental health challenges, and are disproportionately impacted by certain types of cancer, and yet access to timely quality care remains scarce. So why is this the case? It is a result of a combination of historical, structural and socioeconomic factors. About one in four American Indians live below the federal poverty line compared to 11% of the general population, and they receive the least amount of federal funding in comparison to other minority groups across the United States, both contributing to healthcare affordability challenges many American Indian communities also lack sufficient hospitals, clinics and healthcare providers, and face limited resources to everyday needs like running water, electricity in their homes and transportation. Because of these factors, basic healthcare and diagnosis of chronic conditions is often delayed, and thus so is intervention with guideline directed medical treatment. In New Mexico, there are 23 different American Indian tribes, each with their own language and culture. The largest tribe in the state and nationally, is the Navajo Nation. In 2002 the New Mexico Cancer Center was founded to help cancer patients in this community with non-medical related cost. To date, the foundation has distributed over $1 million to pay for patients bills, including rent, groceries, utilities, gas and anything else they might need to learn more about the health challenges that American Indians face and the great work of the New Mexico Cancer Center. I'm pleased to be joined today by Dr. Barbara McAneny, founder of The New Mexico Cancer Center foundation. Dr. Barbara McAneny is a renowned community oncologist, former AMA president and tireless Patient Advocate. She is the CEO of New Mexico Hematology Oncology Consultants, the co-chair of ONCare Alliance and the Chief Officer of Advocacy and Government Affairs for ONCare Alliance. Welcome, Dr. McAneny. 

Brendan (4:00): So we've got a, you know, a big topic to discuss today, so I won't waste any more time and jumping in to do that. But maybe first can we start by telling a little bit about yourself and your practice?

Dr. McAneny (4:16): Yeah, so the practice is actually called New Mexico Oncology Hematology Consultants, and it was started in 1987 by me and a good friend who was Doctor Clark Haskins, and we've grown since then. And we built the first Cancer Center in 2002 and we built the second cancer center out in Gallup, New Mexico in 2007 uh, we've now turned into a multi-disciplinary cancer focused practice with pulmonologists and urologists and others contributing to our work, and we also are now the biggest rheumatology clinic in New Mexico.

Brendan (4:54): Wow. Okay, that's great. So, it's clear then that you have a, you know, a passion, obviously, for this work, and I understand also a passion for serving, you know, this marginalized community that sort of faces so many challenges in healthcare. Where does this, you know, passion, or, you know, what sort of fuels you to do this work? 

Dr. McAneny (5:16) So I've never been one of those people who could watch something that I thought was wrong, and just keep quiet and go around my business, which generally gets me into some trouble, but generally I find that it's worthwhile that someone needs to stand up and say, I will spend my life working for people, where I can be the most useful, where I can generate some good help for people. And as an oncologist, and recognizing that New Mexico is an extremely underserved area, I decided to check it out. But I will tell you that when I got to New Mexico, I fell in love with the place. It was not a sacrifice to come here by any means. It's beautiful, the very variation in population is inspiring, and we cherish our diversity, instead of trying to tolerate it or suppress it. And the climate is the best in the world, the art and the music is wonderful. So I'm not suffering at all by being here in New Mexico. It is wonderful place to live.

Brendan (6:21): That's great to hear. Yeah, it's a place I have not visited yet, but it's definitely on the list, and I think I'll have to get there now with all the great things that you had to say about it. So, in my upfront, I talked a little bit about some of the barriers that the American Indian population, or the Navajo Nation specifically face when trying to ask access healthcare in New Mexico. But could you, either elaborate on some of those, or even speak to some additional barriers that you face with the patients that that you work with?

Dr. McAneny (6:55): Certainly, well, it starts in our entire history, in the US of what we have done to Native Americans, pushing them onto reservations until we find some value to that land, and then pushing them onto other land. So, the Navajo Nation, the Diné people, as they call themselves, are spread across a very large area in western New Mexico, eastern Arizona, southern Utah. And it is, I don't know how to compare it, it's probably about the size of Connecticut, but there are very few services there. A lot of our population does not have running water or electricity, much less internet for telemedicine, as you referred to in your introduction, and the Indian Health Service has been one of the most underfunded health services in the country since its inception. They constantly underestimate the budget, and the Indian Health Service tends to run out of money mid summer, and then when their fiscal year starts in October, then they pay those bills that just sit there. When you look at the comparative amount of money that we spend, for example, on a Medicare patient, it's $15 to $16,000 a year on average. When you look at what we spend nationwide, on average for Medicaid, it's about $5000 to $6000. When you look at what we spend to the Indian Health Service, it is about $4,000 a year. So, they are incredibly under-resourced.

Brendan (8:37): Wow, yeah, that really puts it into perspective. And you talked about, you know, New Mexico having sort of a vibrant and diverse set of cultures when you think about healthcare delivery how do the sort of the different cultural or language dynamics come into play there is that sort of a challenge in terms of healthcare practices, supporting patients? Is it something that is kind of engaged with and sort of bringing in those broad cultural perspectives within the actual healthcare itself, or in the practices? How does that kind of come into play?

Dr. McAneny (9:18): My off-the-cuff estimate would be that about 80% of the barriers that we see are related to poverty, but about 20% are cultural. And by that, I mean kind of hardwired into how the community feels about the American healthcare system. The Diné people learned long ago that when they get their data given to the federal government, it does not work well for them, so they're very skeptical of people coming in to do things for them or to them. That's one of the reasons we do not do well with research in the Gallup office, though, we can recruit 20 to 30 patients. Some months to research trials in the Albuquerque office with the same physicians, because people are not trusting of the system to treat them well, and they have very specific views on their own privacy that  makes it hard for them to participate in trials. So the first thing one has to do is really establish trust, and so they're used to having lot of people come out from the rest of the country, excuse me, and do tasks or do research or set up programs, and then they vanish after a year or two, the program is finished and the Diné are left unchanged, and they do not like that, and so we've kind of taught them to be suspicious of us, because we have not been the best actors in this whole process. So, the first and most important thing that we have done when we built our Gallup clinic was, first of all, we built it because we realized that people were not coming to Albuquerque for treatment. It's just too much of an effort. It's 140 miles west of Albuquerque one way, and when you live on an average income, that's about $22,000 a year, an extra tank of gas is a lot of money. So, we built it out there, thinking that this would be a way that, if you can't bring people to health care, bring health care to people. But the fact that we have now been there almost 18 years has started to build some acceptance that we're becoming trusted, even though the doctors kind of come and go as people retire and we recruit new doctors, they know that the clinic has been there and that the clinic is dedicated to them. The other thing that we do is, when we built that building, we were very careful to incorporate the architectural signals that send to the population that we are respecting and wish to work with your community, your beliefs. We built a thing called a Hogan, which is a traditionally an eight-sided building with that is built with several blessings incorporated into it that the Navajo people tend to use for their own curative ceremonies. And so, we put that on our ground so that you can't miss it when you drive up, because it's a signal that says, you know we respect you and we want to work with you. And we designed it in such a way that it blends in and reflects the community. We also hire locally, which is great for the community, because we pay well and give good benefits, and all those things that good employers do, and we're hiring local people to work in this clinic. The doctors are travelers. Most work in Albuquerque, same problem that you see in most rural areas, where physicians want to work, where there are jobs, in schools and other things, other amenities. But our staff live and work in Gallup. We also have hired Native American staff, not just Navajo, but Zuni and Hopi, which are the tribes that are in that area. And you know that helps get our word out to the community that we are there to help. And I can't say enough about the foundation, because the barriers are so huge that once patients learn that if they're being treated with us, that we will help them with their economic needs as well as their medical and emotional needs that's been a huge ability to build that trust. So, the culture, particularly for Diné, cancer is the sore that does not heal. And, that if you bring the intellectual concept of me together in a sentence with the intellectual concept of cancer, you've made it more likely that that will occur. So screening is a problem there. So, another radiology group put a mammogram machine in a truck to see if they could do better with screening. And what the Navajo women learned was, don't go in that truck, I didn't have breast cancer when I went in that truck, now I have breast cancer. So. You have to think about those things and do it differently. So the Galpin Medical Center has done a fabulous job of bringing in programs and working with the community to help send out the message that some of the cancers can heal, and that we can find them early and be able to treat you, but it requires a long term commitment of working with the community and incorporating members of the community and allowing them to tell us what they want, not just coming in and going, “Hey, I'm a doctor. I know what you need, I know what you want, just do what I say.” If you're going to work with another culture, you need to get over that attitude pretty quickly.

Brendan (15:55): Yeah, there's a lot of important points in there. I was just sort of, you know, jotting down the importance of trust and building that trust, it doesn't come sort of from day one. And it’s really the continuous engagement, the education piece that was interesting almost like by saying something out loud, it is becoming a reality and kind of getting over that sort of the fear, which is compounded within this community. But I think broadly that people are kind of afraid of getting screening in general, because of the potential that they could have something. And then this last piece around kind of meeting people where they are and sort of not going in as that they know it all, but actually really taking the time to engage, understand, and then meet each individual patient where they are. I definitely want to come back to more of the work, both with the clinic and the foundation. But one of the things that you touched on, that I wanted to explore a bit further is around the Indian Health Services. So, it's interesting. You know they are underfunded, as you said, and that obviously comes into play. Are there other certain beyond sort of increased funding going to be any health services. Are there other changes that you believe might be, you know, beneficial to help overcome some of these disparities and challenges that that the American Indian population is experiencing?

Dr. McAneny (17:33): Well, consistent, adequate and reliable congressional funding would be very helpful having your system run out of money every summer, and then we buy chemo every month, we have to wait until the fall to get paid it becomes a cash flow management issue. More money would be helpful and stable money would be helpful. But there are other things as well, and before I talk about them, I want to say that the doctors and nurses and other clinicians who work at the Indian Health Service are amazing. They have learned to do a huge amount of care with very little resources. They're the masters of the work around that they get things done for their patients despite the bureaucracy that's set up. So, part of the problem the Indian Health Service has is that it has been saddled with rules and regulations that require so much bureaucracy that it eats up a lot of the short resources they're given. For example, we deal with prior authorization in all healthcare systems, and that's a huge waste of money and time and resources everywhere. But it's particularly difficult with the Indian Health Service, where they basically have to look at external clinicians like we are external services. They're not providing their own oncologists, but we're there, so they have to give us the equivalent of a purchase order. And so if we say, well, we're going to treat this patient with six cycles of chemotherapy every three weeks, they can give us one purchase order at a time, which means that we are running over there trying to get the next purchase order, which means that if we can't get it, that next treatment is delayed for the patient, which decreases the effectiveness of what we're doing and increases the expense of what we're doing, because we have to pay people to run over to Galpin and the medical center and try to pick up the permission slip to treat the patient. We don't do imaging in our clinic, because we know that the Indian Health Service hospitals rely on their imaging and their pharmacy in their lab, so we didn't want to interfere with what's keeping that important part of the healthcare system alive. But it means we are incredibly inefficient. We can't get a CT scan without going through a lot of permission processes. When we write a chemotherapy medicine, I cannot electronically transmit it to their pharmacy like I could any other pharmacy. What has to happen because of the way their rules were written by Congress was that that prescription from an outside person must go to Gallup and the Medical Center employed physician who must rewrite that prescription on their prescription form and then submit it to the pharmacy. I have primary care doctors who are rewriting cancer chemotherapy prescriptions, which makes me very nervous, and then the patient has to go and sit and wait in their clinic. They schedule everybody to come in at eight o'clock, and then it’s first come, first serve, and then when they run out of time, then they reschedule everybody as the one o'clock patient, and then they sit and wait so it's, you know, no one else does it that way. There's no reason they have to do it that way. They could give people appointment times and not have people spending their whole day waiting. But after my patient waits or has to waste a primary care doctor's precious time rewriting a prescription for a drug they don't understand or know anything about. Then it has to go to their pharmacy, and the patient has to wait again to hand it in. And then the pharmacy, of course, is not going to be carrying a lot of the oral chemotherapies there, so then they have to order it with another purchase order and get the drug delivered to them. You see how the bureaucracy has made it incredibly difficult, right? I would love to be able to contract with them. We have medically integrated dispensing in Albuquerque. I would love to be able to contract with the Indian Health Service and say, you really don't want to carry all these drugs. You know, they're expensive, and if one of them out dates, you're in trouble, right? So let me be your medically integrated dispensing for the oral chemo. I'm not going to start selling eyeliner and diapers, but I would love to be able to get the chemotherapy my patients need to them on the day that they need it. So, I've described that rigmarole to get through, to get anything oral. Imagine if you're doing a regimen where part of it is oral and part of its IV, trying to get those drugs delivered together so that they're the most efficacious is really difficult. 

Brendan (22:58): And do you think that? I mean, obviously it sounds very inefficient, timely. Does that experience from a patient point of view I can't imagine that's a pleasant experience. Does that come into play in patients essentially abandoning care or maybe even sort of being a barrier, if they hear how complex or maybe timely it is. Do you think that comes into play as a barrier for patients seeking care as well, as well?

Dr. McAneny (23:30): I'm sure it does, because there's only so much that anybody could tolerate, right? Yeah, and when you live out on the reservation and you have maybe one or two vehicles that the entire extended family uses, and you're trapped sitting and waiting in a hospital or some place to get something done. Nobody else has the vehicle people can't pick up the kids after school, they can't go to work. They you know, well, these people don't show up to work, you know, it just cascades from there, and it really is going to need some fundamental changes and it starts with an overhaul of the way the Indian Health Service is funded because without adequate resources. But there are places where you can say partner with us. Trust us when we say we're going to treat somebody with six months of chemotherapy. Give us the order to do that so that you only have to do that process one time instead of six times that cuts down on the number. And now they in health service has been told to offer early retirement to a lot of their people. Now we discover that office that gives us our permissions to treat has lost over half of their workforce. The phones they just turn down the volume on the phones ringing so that no one has to listen to it, but there's no one there to answer the phone when we call.  So, we've made it worse currently with this. This cutting that we're doing across the board without any thought to what could we do to improve how we do care. Just let's cut out expenses there. Let's cut out the people who approve the paperwork that allows us to treat the patients, then they've made treating patients less efficient and they won't save money because cancer isn't going to wait for bureaucracy. And these people will get sicker and they will end up getting inpatient care, and that will deplete resources. 

Brendan (25:59): Yeah, a lot, a lot to unpack there. Is there anything else sort of like a from a broader policy perspective? Any sort of policies on the table you're aware of that might help to reduce either any of these barriers, or more broadly to reduce the healthcare disparities that the community is facing.

Dr. McAneny (26:33): They have the ability to do what's called a 638 waiver from probably section 638 of whatever law it is where the tribe can decide that rather than having its money go through the Indian Health Service, they can take the money themselves and use it for the projects and things that they most want to see. And that's back to, you know the arrogance of having someone from outside come and tell you what you need, because I'm the expert and I know what's best for you and giving that money to the tribe themselves, to be able to say, this is what we see our people needing. We would like to take our money and use it for the health care processes we need and that will allow them to get around some of these hardwired inefficiencies that are congressionally mandated for the Indian Health Service. I think that is really a good process and a lot of our tribes are now we call it going 638 and we're partnering with some of them in some innovative ways like our free lung cancer screenings and things like that, which would work with the tribes because that's a very underutilized tool for finding lung cancer early. It gives them the freedom to redesign their own healthcare system in a way that works better. I think that's the easy answer. You know, we could probably talk for weeks about all other things that could go on, but you're not giving it weeks.

Brendan (28:17): Yeah, no, I think that's great. There's a lot there, but it's helpful just to kind of contextualize a little bit about the sort of barriers we talked about early on right, which were around just some of the things, sort of lack of resources to basic human needs within the community. This is more compounded with this for these broader policy funding barriers and so this big mixture of all of these creates a real problem. I think I at least have a better picture, I'm sure that the listeners will as well. I do want to kind of shift gears, because I want to learn more about the work. We've kind of been sprinkling some of it in as we've talked but I really want to get into the work that you're doing, both with the clinic and with the foundation. I'd love to hear more about the success you're seeing, the significant and positive impact you're having, as well as some of the programs in particular the Breathe Easy Lung Screening Program. I love to kind of learn more about the impact that you're having with both the clinic and the foundation, if we can shift gears a bit.

Dr. McAneny (29:39): Well, the clinic had to come first, because if you're going to screen someone for a disease, it is not only unkind, but not very useful and maybe unethical to not have a plan in place to manage the diseases that you find. I'll use breast cancer as an example. The Breast and Cervical Cancer Detection Program gives women free mammograms, but then you don't have any way to get care once they say we found breast cancer. Good luck with that. That makes no sense at all. We didn't start our Breathe Easy lung screening until we had pulmonologists in our clinic and the ability to look over the results that you find from those and to manage them. And it's not just following the American Thoracic Society requirements of how you work up a nodule that you find, which we do, but you find all kinds of things. You find calcium in people's coronary arteries. Well, I'm not a cardiologist, right? And I don't have any cardiologists in my practice, so I need to make sure that we have people we can refer them to and get those patients in to see a cardiologist before they have that we have found cancer sitting in the liver, that was probably not lung cancer. They have clear lung but there is a big mass in the liver, so we have to be able to bring that into the practice and manage that as well. It's interesting that even though policy is that there are not to be copays charged for screening things like lung cancer screenings, people do not trust insurance companies not to somehow figure out how to bill them for it and so by saying this is free you don't have to do that it has made it a lot more accessible to people. We do collect information on people. One of the things that's crucial, as I mentioned, is knowing how to find people once you've got their test result if we just do a CT scan, and they vanish out into the wild, and I don't know how to find them. What have I accomplished? We make sure we have their phone number, their best friend's phone number, their next-door neighbor's phone number, their mailing address, whatever we can get so that we can track people down. And we say this is just so we can track you down and give you the results. I do collect some insurance information, because if they are on in a specific insurance and I find like the liver lesion, I have to know where I can send them to get that biopsy done and it doesn't help their trust in us if we send it to some place that says, oh, you can't come here, I don't take your insurance. We explain to them that that's why we're collecting that information on them. But other than that, X-Ray Associates of New Mexico is our radiology group, and they have volunteered their time to New Mexico Oncology and Hematology Consultants, which is the name of the practice at New Mexico Cancer Center gives a donation of the staff to run the CT scan, the staff to help me write the letters that go out to patients or to make the phone calls, etc. Tim Tokarski from our foundation, as our director, spends a lot of time making sure that we get the right community engagement and partnerships out there so that this is a successful program and I've been very impressed with how well we're doing on that. 

Brendan (34:00): That's great. And the foundation itself how do you secure funding for that? Is that something you look for national partners? Or is it more locally secured? How does that work?

Dr. McAneny (34:20): The answer is yes. Both things locally, we do apply for local grants, and, for example, we built our cancer center to also be an art gallery. The practice pays a curator, but 40% of anything's sold as a tax-deductible contribution to the foundation, and then we have local partners who do fundraisers with us through Tim's tireless efforts and that works very well. But through the Care Alliance group of 32 practices we have created the cancer safety net Foundation. Tim Tokarski is on that board as well, which is great. And our goal there is to be able to reach out to national funders, to be able to do two things, one is to help a lot of other practices duplicate what we're doing in terms of being able to help patients with their economic, non-medical needs, and then to also be able to give grants from the larger foundation down to the smaller one, which has the policies and procedures in place to know that the people we're getting we're paying their bills for, are really the patients who need that. You know they should never pay my bill, but they should pay the bill of somebody who's living on their social security check month to month. So we have those local policies in place, because the practices will know which patient legitimately needs the help, but the practices foundations do not have the bandwidth to go to national entities like AstraZeneca and be able to say, help us manage these patients so that we can get them to the clinic to be treated, and then nationally, we want to raise that money and then give it as grants down to the local foundation, who will then give it as grants to the patients in need got it.

Brendan (36:30): That's great. If we turn and look towards the future a lot of great work in programming is happening, what are you most optimistic about for the future? You know, in terms of continuing to help this population. And do you have any goals that you've yet to achieve with the work of the foundation or the clinic. What is still on that to-do list, if you will?

Dr. McAneny (37:09): Oh, there's so many goals. Well, first of all, the same thing that makes me proud to be an oncologist these days is what is going to help with that. I will give your company and all the other manufacturers a huge amount of credit, the number of new drugs coming out that really make a huge impact in the diseases that we treat every day is astounding to me. Remember, I started out when we had, you know, a dozen drugs, and they were all toxic. Right? Now we have amazing drugs that really make a difference for patients really make them maybe break that idea that that cancer is the sore that never heals, maybe cancer is the sore that does heal, you just have to work at it a bit so. I think that the advances that have been made in the science, and unfortunately, with the NIH cuts, I think that's going to fall more heavily on the shoulders of the manufacturers. I think those advances are the things that give me the most hope. Thank you all for that. Then we've gotta figure out how to get this out to the people who need it. The fact that people have now figured out that you can have a 20% difference in outcome just based on your zip code is a huge factor that we can no longer ignore. It's as good as some of the drugs, right? We need to start looking at the entire process, but I think that we have to work together to recognize that the medical infrastructure, practices like mine and pharmaceutical manufacturers are not going to be able to solve poverty in this nation, but maybe we can take care of the patients in front of us. Maybe we can work together to make sure that we get those drugs out to the people who need them, that we can work to come up with some innovative ideas like let me be the dispensing pharmacy for the people that we serve out on the reservation, and not make the Indian Health Service spend their budget trying to find these patients and stock drugs on their shelves that might outdate. We could be a lot more efficient at treating patients. And I like the idea of pathways of figuring out, okay, what do you need to do to get the patient from first phone call to on treatment? If I got to pick a quality measure, that would be one of mine, first visits to on treatment, that's our efficiency measure. I would love to, I mean, I could go on for probably years about this, but really, it really is going to take people getting back to the roots of understanding that the reason that we do what we do is to try to help patients who are sick. And it is not our goal to make insurance companies into fortune 500 companies. We've gotta look at where we have the waste in the system. And I would not do this with a chainsaw, as you probably figured out, but I would look at the waste of the system as who is excessively profiteering off these drugs. We know that 50% of the cost of an oral drug is added on by a PBM after it leaves the manufacturer. Why do we do that? I've got lots of lists you don't have time for me to go through my whole list of things that I would like to fix about the US healthcare system. And I think the other part of it would be just like the Indian Health Service needs funding, independent physician practices are the most efficient way to get cancer care to patients at home, because cancer is becoming a chronic disease, and you don't manage that at a tertiary referral center, you manage it close to where people live, so you can be integrated within the community. We have to fix the physician fee schedule because if we don't fix that, you're going to find that more and more physician practices suddenly become part of 340B hospitals, because that's the only way we can survive. And I think one of my fears and one of my concerns is what the affect the inflation Reduction Act is going to do both on your ability to manufacture drugs and create new drugs and my ability to exist to deliver them to patients. There you wanted a positive end note, but I think the positive end note would be if, if the industry can pull together with the physician community we can start to look for a new process to get these amazing drugs to the patients who need them.

Brendan (43:07): Yeah, that's actually a great point to end on, right? It's going to take not just one entity to help to solve it. It's going to take public, private partnership, a whole host of a variety of stakeholders to come together to really to make some improvements, and even with that, they'll still be challenges for sure that continue to need to be tackled. Believe it or not, we are just about at the end of our of our time together. I know that the conversation goes quick right? Before I close, I did want to leave an opportunity. I think oftentimes, when you have a conversation like this there's so many thoughts. I know there's thoughts going through my head. I'm sure there are with yours as well. I want to make sure I left an opportunity for you to share. Is there anything else still burning on your mind that you want to make sure that you share with our listeners today before we close?

Dr. McAneny (44:08): I think the basic point is that everyone in this country deserves the best cancer care they can get and that we each play a role in delivering that. I'm hoping that we will partner on some of these projects. Let's create more foundations like ours and practices all across the country. Help us get the cancer safety net foundation up and flying so that it can help manage these patients, so that they can take advantage of the advances that your company and other companies have made in the science, because if they can't get there because they don't know the drugs exist. Or they they don't have the gas to put in their tank to get to their appointment, there's not much we can do to help their cancer. We've got to focus on getting this delivery system working properly and recognizing that we can't just sit in our ivory tower and say, well, I'm a doctor. If you come to me, I'll write you a prescription. Or you're in your ivory tower of I make great drugs, good luck getting them to patients. We've got to work together on that absolutely well.

Brendan (45:33): Dr McAneny, thank you so much for taking the time to speak with me today, for sharing your insights, your ideas, your perspectives. Really informative conversation.

Dr. McAneny (45:44): Thank you for asking me

Brendan (45:47): and to our listeners, thank you for joining us on this episode of That's Understandable. Until next time, be well, be healthy, be understanding.