Coordinated Care and Beyond: Future Trends in Chronic Care

8:00 – 8:45 a.m. Registration and Light Breakfast

8:45 – 9:00 a.m. Welcome and Introductions

• Sarah Dash
  Alliance for Health Policy

9:00 – 10:00 a.m. Future Trends in Chronic Care

• Peter Fise
  Bipartisan Policy Center
• Clay Marsh
  West Virginia University
• Sue Nelson
  American Heart Association
• John Romley
  USC Schaeffer Center for Health Policy and Economics
• Sarah Dash, moderator
  Alliance for Health Policy

10:00 – 10:15 a.m. Break

10:15 – 11:15 a.m. Coverage and Chronic Care

• Mark Fendrick
  University of Michigan School of Public Health
• Rebecca Kirch
  National Patient Advocate Foundation
• Kathleen Nolan
  Health Management Associates
• Hon. Allyson Y. Schwartz
  Better Medicare Alliance
• Julie Appleby, moderator
  Kaiser Health News

11:15 a.m.-12:15 p.m. The Future of Integrated Care for Complex Chronic Conditions: What’s Working, What’s Not

• Bart Asner
  Monarch Healthcare
• Larry Atkins
  Long-Term Quality Alliance
• Sandra Wilkniss
  National Governors Association
• Susan Dentzer, moderator
  Network for Excellence in Health Innovation

12:15 – 12:30 p.m. Closing Remarks

PLEASE NOTE: This is an unedited transcript. Please refer to the video of this event to confirm exact quotes. SARAH DASH: All right, folks, we’re going to go ahead and get started, if you could find a seat. Fantastic. Thank you, all. Thank you so much for being here. My name is Sarah Dash and I am President and CEO of the Alliance for Health Policy. And for those of you who were with us back in April, for our first summit on the Future of Healthcare, you know that we have recently changed our name, from the Alliance for Health Reform. And we’re really excited to be here with you, as the Alliance for Health Policy, here to talk about important policy issues that we all face every single day in our jobs and in our lives. So, welcome today. For those of you who know us, for 25 years, we have been a trusted source of nonpartisan health policy information and convening for health policy leaders, and the health policy community here in Washington D.C. and beyond the beltway as well. And we’re excited to bring to you today the second in our summit series on the future of healthcare. This one is, as you all know, is on the future of chronic care, a really important bipartisan topic with bipartisan action happening in both the House and the Senate. And we decided to do this series in particular, because we really wanted to take a look at the important issues that are facing the country now and into the future. And of course, it’s been an action packed month on healthcare. But the issues that face people who have chronic conditions, those who are healthy, but may eventually get a chronic condition, those issues are not going away and those are the issues that we all have the opportunity to shape here today. So I really want to thank our sponsors for this series. First of all, our annual sponsors, who are sponsoring not just the chronic care summit, but also our summit on the future of health insurance, which we held earlier in the spring, and the summit on the healthcare workforce, which we will organize later in the fall. Anthem, Ascension, and Health is Primary, thank you all. And I also want to thank the sponsors of today’s summit, CAPG, DaVita, Genentech, and Express Scripts. So, we couldn’t do it without your support. Let me, before I turn it over to – before we get started on today’s agenda, which is going to be a full agenda. We’re going to talk about the future trends in chronic care. We’re going to talk about coverage issues in chronic care, and then we’re going to also talk about the best way to deliver care through integrated care delivery, and what that means. I’m going to turn it over to Liz Hall from Anthem, and then to Mark Hayes from Ascension, and then to Kirsten Thistle from Health is Primary to just give a few brief opening comments before we get started with our first panel. Thanks. LIZ HALL: Thank you, Sarah. We really, at Anthem, do want to thank the Alliance and congratulate them for 25 awesome years of really, as she said, digging in and providing all perspectives on really important issues, including the one that we’re going to discuss today. I also want to thank you all for coming out, for being interested in this topic, for wanting to dig in and take it to the next level. At Anthem, we have been partnering with providers to really do all that we can to improve care for our members, to provide high quality, affordable coverage. And we really do think that by working with both providers, and our patients and members, that we can continue to improve and do a better job particularly for those who have chronic needs. I want to thank everyone, the panelists in particular for the insights that they’re going to offer today. We are constantly working to improve and innovate, and we will take away the best nuggets that we can, and try to build those into our programs and services. Thank you so much. SARAH DASH: Thank you, Liz. MARK HAYES: Good morning, everyone. I’ll be very brief. I just want to welcome everyone. Ascension is very proud to be a sponsor of this. Ascension is, if you don’t know about us already, we’re a nonprofit Catholic health system. We’re in 22 states. We have about 141 hospitals throughout the country. We are very, very proud to be a sponsor of this. I mean, how many years have we all been talking about how the key to lowering healthcare spending is managing chronic disease better? And we’ve all been working on it. Caregivers on the frontlines have been working on this for years. But finally, the payment systems are catching up, to enable this to really happen. So we’re really excited about the discussions that are going to happen this morning, and what we are all going to learn from our experts and the expert panels. So, thank you all for being here. SARAH DASH: Thank you, Mark. Kirsten Thistle. KIRSTEN THISTLE: Good morning. I’m Kirsten Thistle and like the others, I’m thrilled to see everyone here today. I know some of us are sick of talking about healthcare, but I’m excited that we have today to dig in, and talk about important issues around chronic disease. Just a show of hands. How many people have heard of the Health is Primary Campaign? All right, not bad. The campaign is run by – it’s sponsored by the eight family medicine organizations in the U.S., most notably the American Academy of Family Physicians. And really, the goal is to showcase innovation and transformation in primary care delivery, much of which is happening with companies like Anthem. We believe that a strong primary care system in America can deliver on the triple aim. And I think we’ve seen time and time again, studies that show the more primary care providers, the better the health outcomes for the community. And frankly, the lower the costs. A study came out a few months ago that showed that for every dollar spent on primary care, we can save $13 in downstream costs. So this isn’t just about improving health. It’s really about showcasing the biggest bang for our buck in healthcare. And certainly, I think chronic disease management is a place where having a strong primary care infrastructure can deliver huge dividends on the backend. So again, thanks for coming out and being willing to continue talking about healthcare after a crazy couple months in Washington, and we’re excited to hear from the panelists today. Thanks, Sarah. SARAH DASH: Great. Thanks, Kirsten. So, I’m going to ask our first panel to come up to the stage now. And as they’re coming up, I’ll go ahead and introduce them. This first panel is going to be on the Trends in Chronic Care that we’re facing in our country. So we’re really excited. We have a fantastic panel with us today. John Romley, who is an Associate Professor at the Schaeffer Center for Health Policy and Economics at the University of Southern California. Welcome, John. Dr. Clay Marsh, who is Vice President and Executive Dean for Health Sciences at West Virginia University. I know I’m not as good as like the baseball teams or the basketball teams. We don’t have music for you or anything, but we’re thrilled you’re here. Sue Nelson, who is Vice President for Federal Advocacy at the American Heart Association. And Peter Fise, Senior Policy Analyst at the Bipartisan Policy Center, which has been doing a lot of work on this issue. So, thank you all and then, I am going to come and join you to moderate the panel. Awesome, fantastic. Well, thank you all so much for being here. So as I said, we’re here to talk about future trends in chronic care. You know, as Mark alluded to, obviously we’ve been talking about this issue for a very long time now. We’ve been talking about the need to prevent and better manage chronic conditions. So, what I would like to ask each of you to do is kind of give us a sense of, what is the country facing, as we look into the future? You know, 25 years into the future, what kinds of trends can we expect? And what are some of the issues that we need to be looking at, as policymakers and people who advise and influence policymakers? And I’m going to go ahead, and just ask you to go down the line, if you would, and start with John Romley from USC. JOHN ROMLEY: Hi. So thanks, Sarah and thanks to the Alliance for Health Policy for the opportunity to participate today, and thanks to all of you for coming. So as Sarah noted, I’m in the Sol Price School of Public Policy at the University of Southern California and also a Senior Fellow at USC’s Schaeffer Center for Health Policy and Economics. And at the Schaeffer Center, we have developed a tool called the Future Elderly Model, which we use to analyze trends, and population health and health spending, and how public policy and medical innovation and other factors impact those trends. And so, with the Medicare program recently turning 50 years old, we used that Future Elderly Model to assess where the program is headed. And so, the sort of demographics are fairly straight forward. We’re going to see a big increase in the number of Medicare beneficiaries with a baby boomer generation retiring. Like our society, the program is becoming more diverse, right? So the share of Latino beneficiaries is going to more than double, and the population is also becoming more educated. So, the folks with less than a high school degree, that proportion falls by more than a half. So that’s kind of what’s going on in terms of what we expect to happen, and what we project, in terms of the simple demographics. Now, in terms of what’s going on with health, we see some good news and some bad news. So the good news is that certain health behaviors, like smoking, are going to continue to decrease. But the bad news is that other risk factors, like obesity, are likely to increase. So we expect between 2010 and 2030, the proportion of Medicare beneficiaries who are obese to grow by more than 50 percent. And the proportion who are extremely obese with a body mass index in excess of 40 to more than double. And so, risk factors like obesity contribute to chronic disease, of course. And so, the burden of chronic disease is going to increase. Diabetes will go up from – the prevalence of diabetes in the Medicare population is going to increase from 25 percent to 40 percent. We’re going to see a similar increase in the proportion of beneficiaries with multiple chronic conditions. So in terms of life expectancy, actually we’ve been pretty successful in helping people to live longer, notwithstanding some of these challenges. And so, we think that for men, life expectancy at age 65 is going to increase by half a year between 2010 and 2030, to a little more than 18 years. And for women by almost a year, to a little almost 23 years. So all of these trends have pretty predictable consequences for the federal budget, right? So living longer, more folks, more chronic disease, and healthcare spending growth has its consequences. We used the Future Elderly Model though to quantify the magnitude of those impacts. And so, what we see is that lifetime spending on Medicare, for someone in 2010, would be about $130,000. And by 2030 would be about $230,000. And total spending with the growth in the population grows even faster, more than doubling. So these numbers are sort of roughly in line with what CBO thinks. And that’s sort of the, I think the big challenge that we face. I don’t think it’s an unrecognized challenge, but in my view, it’s probably one that can’t be emphasized enough. SARAH DASH: Thanks, John. Clay? CLAY MARSH: Hello Sarah, and it’s great to be here. I’m going to take a bit of a different tact and I’ll try to be succinct. But I, like the other panelists, understand that in general, we are increasing healthcare spending at a rate that’s not sustainable. We spend almost twice as much as the next leading country, and we have outcomes that are among the worst in all westernized countries, and in fact next to last. And so, when we look at our future in our current system, it doesn’t look so bright. And I think from a healthcare delivery standpoint, and that’s part of what I do, you know, our purpose and our business model have gone different directions. Our business model is rescue from failure. The more stuff we do to you when you’re sick, the more money we make. But the purpose model is to help you live well, is to help you be healthy. And as I have thought myself, and I could go through how I got there, which is not quite a straight line, but when you start to say that the only way really to save money and improve outcomes in healthcare is to have a healthier population, the question is, what is health? And I don’t think that’s such an easy question to answer. And to me, my own bias is that health is where your biological age is less than your chronological age, where your real age is less than your birthday age. And I think that we have a country that’s getting older younger, as opposed to a country that’s getting younger older. And when you start to look at the things that affect your biological age, then we realize from longevity studies, such as the Harvard Grant Study or the Longevity Study, which follow people seven to eight decades, or from “The Blue Zones,” which is Dan Buettner’s work, where they look at people that live long and well in five areas of the world, that so overeating is certainly one. The only way you can increase survival across animals is calorie restriction. And so, obesity might be a form for us of early biological aging, accelerated biological aging. You know, when people lose weight, you say, “Hey, you look younger.” Maybe you are younger, so we’re interested in that. And the other one is smoking. Cigarette smoking absolutely increases your biological age. That’s been proven. So policies that reduce simple sugars, which drive insulin receptor, which drives obesity and also by the way, drives addiction centers in our brains, like opioids do is probably important. And we know that taxes on cigarettes do reduce smoking consumption, which actually probably also improve biological age. But the other stuff that you find is really interesting, and it’s really human. It’s not so technical. You know, it’s interesting that the things that really are resonant from these long studies are people who have great connections to other people, have a great sense of purpose, and who see the world as abundant, who see the world with gratitude and with hope. And also, the mindset that you bring is important, as it was shown by Elizabeth Blackburn, who won the Nobel prize, that if you are stressed and you feel stressed, no matter what your real stress is or isn’t, then you age faster than if you don’t. So how we see the world influences our biological age, and she measured telomeres to be able to know that. So I think that in our world of separateness, of breakdown in communities – you know, Tom Friedman said that, “The difference in the country is not the coast versus the middle, or rich people versus poor people. It’s weak communities versus strong communities.” And so, we know there’s a term that was created by Robin Dunbar, who is an anthropologist, called Dunbar’s number which is 150, which is about the maximum number of people that you can know very well, because 150 was about the maximum size of a community you could have survived with. Big enough to protect each other, small enough to feed each other. So I think we’re stuck in this evolutionary frame, but our world is really changing. Our communities are breaking down. Sam Quinones, who wrote a great book called “Dreamland” came and talked, and said “He thinks the opioid problem is really a problem of isolation. That we’ve broken down the connections that matter with each other.” And we know that the frame of the social network is really important. You’re more likely to be obese if your best friend is obese, and if your first-degree family member is obese. So I think that a lot of the policy work that needs to be done is starting to understand that really reknitting communities together and starting to connect with each other, to help people have purpose, which to me is oftentimes jobs, which in our state is really quite an issue. The last thing I will say is that Anne Case and Angus Deaton – Angus Deaton won a Nobel prize in ’14 or ’15 in population economics – found there’s a group of less educated white people that were dying at a rate that’s been unprecedented since the peak of the AIDS epidemic, 50 years old, high school education or less. And initially said, they were dying of overdose and suicide and liver disease, all addiction-related problems. Recently, there’s a deeper dive taken. And it turns out they’re really dying of despair and hopelessness, because their life used to be better, and now it’s not. And so, as we look at this population, it’s interesting that other demographic groups, other underrepresented minorities like blacks and Latinos are not dying at a rate that’s any different than before. In fact, they’re living better. And the reason why is, the presumption is that a lot of the people in this less educated white population have seen their lives step down. So they were here, and now they’re here. And so, our perception of our own status and the place that we have in our society becomes really important, too. So I, personally, believe that the really important work in healthcare is the same really important work in community building, and in trying to regain this sense as we had when we grew up. That the American dream was accessible to all of us. I grew up in a very middle-class household in West Virginia with my grandfather and uncle both coal miners, but I think that that is lost on many people today. SARAH DASH: Thank you, Clay. Sue? SUE NELSON: I have to say, every time I stress, I do think about my telomeres. What woman wants to age, right? And it’s like, “Stop doing that, Sue.” So, I’m going to go back a little bit to the demographics. I spent 20 years on the Senate Budget Committee, and my apologies to those of you, who knew me back then, who I said, “No, you can’t do that” to. And when I joined the American Heart Association, the first thing I said was, “Where are your long term projections of the cost and prevalence of various forms of cardiovascular disease?” And they looked at me like I had a hole in my head, because they were academic researchers and they deal with real data. But I persevered and worked with the Research Triangle Institute, to develop a model that would project again the cost and prevalence of several forms of cardiovascular disease: high blood pressure, coronary heart disease, congestive heart failure, stroke, AFib, and then the other category. We continued to be amazed by the results of those projections. We ran them first in 2011, and more recently in January, which is why this – this is our report, in case anyone wants to go to our website – and substantiated a lot of the trends that were mentioned earlier. Cardiovascular disease has been the leading killer of Americans for many, many years. It’s also the most costly disease, but we’re also considered the success story. When Francis Collins talks about NIH research, it’s “look at what we’ve done for cardiovascular disease.” There’s been a 70 percent reduction in the death rate over the last century. And my father sort of illustrates that point. My grandfather died at 49 because he had a heart valve problem. There was no open heart surgery. They gave him morphine. That was the only treatment for heart disease back then. We forget that. My dad with the same problem lived to be 92 years old. So that to me, that’s the cardiovascular success story. But we still are the number one and most costly disease. And as noted earlier, our progress in reducing mortality, morbidity from heart disease has slowed recently. Not so much due to the demographics, which were always factored into our calculations, but due to the rise in obesity, diabetes, all the things that were articulated earlier. So when we did our projections more recently, we found that by 2035, nearly 45 percent of the population would have some form of cardiovascular disease. And the cost of that is astronomical. The cost in 2015, annual cost of cardiovascular disease both the direct medical cost and then indirect cost in lost productivity is 555 billion. By 2035, it will be 1.1 trillion a year. Men tend to be at higher risk for cardiovascular disease, but heart disease is now the number one killer. Women, we’re catching up, ladies. It also exacts a disproportionate toll on racial and other minority groups, accounting for nearly 40 percent of the disparity and deaths in that population. And more relevant to this population, we’re seeing the cost shift to the old-old, to people who are over the age of 65. And in terms of chronic disease, stroke and heart failure were the most expensive chronic conditions in the Medicare program. So given these developments, what does our association do about it? We have a very aggressive goal of improving the cardiovascular health of all Americans by 20 percent by 2020. Not sure we’re going to meet that goal, because of what I mentioned earlier. But we’re focused on four different areas. Number one, federal research. Only five percent of the NIH budget goes for cardiovascular research. You know, we’re not the scary disease. You fund what you fear, right? Everyone’s worried about Alzheimer’s and I understand that. There are no effective treatments. Certain sorts of cancer, no effective treatments. A member of Congress has a heart attack and three days later, he’s back on the House or Senate floor. It’s like, people think of it as not being as scary and deadly as it used to be. So we really advocate for more research, particularly in the area of prevention. Cardiovascular disease is 80 percent preventable. If you just do all the things the American Heart Association tells you to do, you can live a very long, healthy life in most cases. Obviously, there’s exceptions. And genetic research is starting to shine a spotlight on why people like Bob Harper, who attended our Lobby Day two weeks ago, and who is the fitness guru for America’s “Biggest Loser,” suffered from sudden cardiac arrest at the age of like 40. Why? You know, and those are the kinds of things research can still shine a light on. But in the main, it’s prevention. It’s people who aren’t monitoring their blood pressure, their cholesterol. They’re not exercising. They’re not eating right. Nutrition is about 80 percent of the obesity problem. Don’t think that one hour at the gym is going to do it. I used to think that. It’s not going to work. It’s your diet. Eighty percent of it is what you’re eating and the rest is exercise. So we focus on, first of all, advocating for research. We focus on prevention in a variety of areas, which I can get into later. Access to care is critical and that’s why we’re working very hard to preserve the elements of the Affordable Care Act that have been so helpful for our population. First dollar coverage for preventive benefits really, really helps. We did a study recently, or a study was done recently that found that the incidents of sudden cardiac arrest in a district or a part of Oregon declined by 37 percent for people who had insurance coverage. Mortality rates are much higher among people, for cardiovascular disease, who don’t have coverage. Almost twice the chance of dying from a stroke, because when you’re feeling the symptoms, you don’t want to pay for the ambulance. You just take an aspirin or something else, and hope that it goes away. And then, a final area that we’re focused on is delivery system reform. Areas like cardiac rehab, which are so helpful to people, are tremendously underutilized. Only 30 percent of the population really takes advantage of this important benefit. And there’s ways that we can address that through delivery system reforms, but we can get into that later. SARAH DASH: Thank you, Sue. Peter? PETER FISE: Thanks, Sarah. And as Sarah mentioned, I’m Peter Fise from the Bipartisan Policy Center. And I want to thank the Alliance for having this event. I think it’s a critically important topic, not only for ensuring smarter spending in our federal health insurance programs, but better outcomes and better quality of life for patients and their families. So just a quick word, a background on BPC before diving in. The Bipartisan Policy Center’s health project is co-chaired by former Senate Majority Leaders, Tom Daschle and Bill Frist. And our work in the long-term care space is also co-chaired by former Secretary of HHS, Tommy Thompson and former OMB and CBO Director, Alice Rivlin. Our work has primarily focused on chronic care and long-term care issues of late, although we are also involved in a separate initiative in looking at Medicaid policy reforms, as well as policies to stabilize the individual market. But for today’s topic, over the past 18 months, BPC has produced five reports that relate to this issue, in the areas of integrating care for dual-eligible beneficiaries, those who are eligible for both Medicare and Medicaid, Medicare chronic care, and long-term care financing. All focus today’s discussion on the Medicare chronic care piece, but maybe we can get into some of the others during the discussion. So when we looked at this issue, we focused on beneficiaries who were not dually eligible for Medicaid, so they are Medicare only, and had three or more chronic conditions, and functional or cognitive impairment. And we chose this population, because the intersection between chronic conditions and functional and cognitive impairment is a pretty good predictor of poor health outcomes, and high Medicare spending. And these beneficiaries, the average Medicare spend for them is about twice the national average at $30,000 a year. And they tend to have higher readmissions and more ED visits, even when you risk adjust. So, the question then becomes, what are they lacking? And I think one of the key ingredients is non-Medicare coverage social supports and services for these beneficiaries, who look in a lot of ways like dual-eligible individuals. They have similar service intensity or service use intensity, and similar outcomes, similar needs for assistance with activities of daily living. The difference is they don’t have necessarily the same access to those services, because a lot of those services are covered under Medicaid. They’re not covered under Medicare. So when we looked at this population, it’s about seven percent of Medicare beneficiaries, roughly 3.6 million, of which three million are in fee-for-service and 600,000 are in Medicare Advantage. We looked at ways that we can improve the integration of social supports and services that aren’t covered under Medicare, and so we can use that Medicare dollar better. And the primary examples are Medicare Advantage plans and the accountable care organizations, because they’re taking risk for the cost of care of the population. They’re going to have probably the best incentives to integrate non-Medicare coverage supports, because they know that those supports can reduce hospitalizations and reduce ED visits and readmissions, all the types of outcomes that you’re looking to improve on. When we talk about these types of supports, it can really run the range of a number of different supports, as long as they are part of a person-centered care plan and are designed to improve or maintain functional status. But what we looked at closely were in-home meal delivery for low sugar and low sodium meals for like folks with congestive heart failure or diabetes. That meal can help them not have an adverse event and stay out of the hospital. We looked at supports like non-emergent medical transportation, so transportation to a doctor’s appointment, or minor home modifications, like to put in that handrail just to prevent a fall in the home, or targeted case management. All of these services and supports aren’t covered under Medicare, but have the ability to reduce hospitalizations and reduce ED visits. So the good news I think is that in our report, we developed some policy options for Congress to consider, that can help integrate these supports in both MA and in ACO’s and other provider-based organizations that are taking on risk for the cost of a beneficiary’s care. Among other things, CMS could establish quality measures that reward Medicare Advantage plans and reward ACO’s for integrating these supports into their models. And CMS could look at waiving the so-called uniform benefit requirement to allow Medicare Advantage plans to target these types of supports to the specific beneficiaries that are high-need. And not have to provide necessarily the support to everyone in their enrollee population through supplemental benefits. And for the latter point, we found that a Medicare Advantage plan could offer in-home meal delivery, non-emergent medical transportation, minor home modifications, and targeted case management and finance that through only a four to six percent reduction in the existing Medicare Advantage supplemental benefits that are offered to all enrollees. So by having that ability to target, you can get a lot better bang for your buck as a plan, and we think that there are similar incentives that could be placed for ACO’s and providers that are doing this on the hospital and physician side. SARAH DASH: Thank you. And I think we will definitely be getting to some of those issues in the integrated care panel. But I want to pick up on this issue that you raise, Peter and Clay, that you raise, and that really kind of fits in with all of your comments around this idea that preventing and improving the care of, for people who have chronic conditions, involves more than just healthcare, and it’s beyond healthcare. It’s the stress. It’s the community. Peter, you kind of went into how we might consider paying for some of these issues, right? But I’m wondering if we can go into – and since we have some budget experts on the panel, too – we talk about oftentimes kind of the cost of params in silos. So, in-home meal delivery is kind of one line item in the budget. The Housing and Urban Development budget is completely separate. I’m not sure if the health LA’s and the housing LA’s oftentimes get a chance to sit down and talk about the synergies that might exist between their two issue portfolios. So talk about, how do you translate – what Clay, I think you’re raising is the root of some of the challenges with chronic disease as the need for stronger communities, better intersections. I know we’ve seen studies on social isolation and Medicare beneficiaries as well being an issue. Are we looking at this in a holistic enough way, in a policy context? And if we’re not, how do we start to get there? CLAY MARSH: Let me maybe start, and I’ll again try to be brief. So, let me initially reference an article that Atul Gawande wrote that was really kind of a game changer. It was an article called “Hot Spotters” and it was in the New Yorker. And it told this story about an ER physician named Brenner, who basically started to look at his community and tried to identify the hot spots in his community, like crime prevention did. So the idea, if you could identify the really expensive parts of your feeder system, then you may be able to do something in a more targeted way. And you know, this Pareto’s principle, the 20/80 rule, the fact that in complex systems, which is all the systems we live in, a few agents or a few people spend most of the money, right? And CMS at the top one percent of people spend 23, 24 percent of the dollar. The top five percent, 50 percent. The top 20 percent spend 80 percent of the healthcare dollar. And the bottom 50 percent spend only 3.5 percent of the healthcare dollar. So, the more we can push people over to the healthy group, the better. But Brenner identified two tenement buildings in Camden that were responsible for an overwhelming number of emergency room visits that he had. And identified one guy in one of the two tenement buildings that had been admitted to the hospital about 500 times over a seven-year period. And they looked at this guy and the guy weighed 500 pounds, and he was an alcoholic. He was a cocaine user. He was diabetic. He was morbidly obese, weighed over 500 pounds. And every time he fell down, he’d call the because he couldn’t get back up, after he drank or did cocain