Rae Woods (00:02): From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. (00:15): The forces that frankly, many of us have eyed from a distance and maybe with a healthy dose of skepticism, have now arrived. In 2023, we are facing a new era of physician employment with more opportunities for physicians and a new bar for autonomy, plus an arms race for talent and new imperatives for integration. The truth is that these trends matter to everyone, not just the physicians that listen to this podcast. (00:44): So, today I've invited our resident physician experts, Eliza Dailey and Sarah Hostetter, to talk about what this new era of physician employment means for the rest of the industry. Hey, Sarah. Hey, Eliza. Welcome back to Radio Advisory. Sarah, are you aware of the fact that other than me, I don't count obviously, because I host this podcast every week, but are you aware that you are our most popular Radio Advisory guest? Sarah Hostetter (01:12): You did tell me that once and then you told me I had to come less. Rae Woods (01:19): There are a few people who I feel like are coming for first place on, "How often can I come on Radio Advisory?" And you probably know, it's definitely John League. Daniel is up there on competing. He's unfortunately not going to be in our physician conversation today, but there's a couple that are gunning for top slot, for your slot. Sarah Hostetter (01:39): I want to keep the tally. I want to keep the top spot. I feel like this is like a video game, where you go play in an arcade and you have your initials in there and then you leave, and you just wait and hope that you're still on the top when you come back. Rae Woods (02:06): Well, one of the unfair reasons why you're on the podcast all the time are, one is personal and one is not. The personal one is obviously the physician world is very close to my heart. It is my absolute favorite topic to talk about. But also, there is a reason why in the state of healthcare we need to have a lot of conversations about what is happening in the physician landscape, and that continues to be true in 2023. (02:28): In fact, I'm almost feeling like the physician world or the landscape feels maybe especially unstable right now, right? Burnout is high, discontent is high. We know that retention is incredibly difficult, and we've got all these looming retirements on the horizon. We also know that practices are getting bigger and more corporate owned. See, literally any of the other episodes that we've done on this topic. Should we expect more of that in 2023? Eliza Dailey (02:57): I think we should, Rae, and I think it's easy to attribute a lot of the things you just talked about, the burnout, the looming retirements, the discontent, to COVID. But I think the reality is that these things have been at play for a while, right? The pandemic sure didn't help, but I think they stem from deep-rooted structural things about the practice of medicine, who's part of our physician workforce. So, I think we can expect these things to continue in 2023, because they've been at play for a really long time. Sarah Hostetter (03:26): I also think you can't discredit the practice level changes that you alluded to, Rae. It's not just that the workforce has a lot of discontent and they're requiring different things from their employers, but it's also that there are a lot of options for physicians in terms of who they work for. (03:43): So, we are not just talking about ... I feel like I beat this drum every time, but it's no longer a dichotomy between independent practice and hospital employment. There's a huge range of what employers offer and what employers are out there. So, the intersection of a workforce crisis when there are a lot of choices, enables a shift that we've been tracking for a long time, to become a reality. Rae Woods (04:09): And we saw a lot of big deals hit the headlines at the end of last year, but there are some new ones on the horizon or that have happened already in 2023, right? Sarah Hostetter (04:18): Yeah. I mean, everyone obviously knows about Amazon One Medical. I feel like you can't open a briefing without something like that about Amazon One Medical, including advisory boards. We have been looking a lot at the VillageMD acquisition of Summit Medical Group, because Summit is a longtime, independent practice that is more recently private equity backed, and we had been asking a lot of questions around, "Okay, what is the next stop for a private equity backed practice?" It turns out VillageMD was the next stop for this one. (04:50): I think it's really fascinating because Summit brings something different to that deal. VillageMD, who is focused on population health management. Summit brings in specialty care and they bring in urgent care. So, VillageMD is predominantly primary care. So, they're rounding out a portfolio of practices in a way that actually may enable them to advance on some of their population health goals. And Summit is really advanced in terms of how they think about these things in the specialty care space. Rae Woods (05:22): And I don't think we can unwind VillageMD from Walgreens, right? Sarah Hostetter (05:26): Right. Rae Woods (05:26): Which is the big retail partnership there. We talked about Amazon, who's obviously a big retailer. The other one is CVS. Sarah Hostetter (05:33): Yeah. And that's where when you said Walgreens, that's immediately where my brain went is CVS is reportedly eyeing an acquisition of Oak Street. I think what is fascinating is probably five years ago, if you had said, "Okay, what are CVS and Walgreens going to invest in?" We would've said, "Building out urgent care." Right? Rae Woods (05:53): Mm-hmm. Sarah Hostetter (05:53): That's what they're good at, and that's what they started with is building in-house urgent care. Oak Street is heavily involved in the senior care space and in the Medicare Advantage space. And so, that's a switch, that's a pivot. Rae Woods (06:09): Yeah. Sarah Hostetter (06:10): It's hard to disentangle CVS from Aetna. Right? Rae Woods (06:12): Sure. Sarah Hostetter (06:13): So, there's obviously a plan angle here, and I know Eliza's been on the pod before talking about the payvider space, but I think what is interesting is how we think about both of these organizations that started in retail are now trying to play in value-based care with some of these acquisitions. Rae Woods (06:31): And by the way, one of the criticisms from five years ago was, no physician wants to work in retail medicine, right? And now we see the strategies of these organizations being the same, if not more advanced, I should say, than some of the classic strategies in healthcare, moving into population health, moving into value-based care, and so on. Remind our audience why physicians are actually choosing these partners over traditional hospital or health system partners. Eliza Dailey (07:02): For many of them, they see it as a path to growth with a more like-minded partner. So, if we look at Summit and VillageMD, it actually makes perfect sense that they would team up together. Summit has really been looking for a way to scale their population health model, and VillageMD has really the scale and the resources to allow them to do that and really hitch their wagon to. (07:26): It's interesting, because a lot of the physician practices that I work with often talk about this range of suitors is the lesser of two or three evils. So, right, as they're working with health systems, private equity, maybe it's a health plan, another aggregator, there's going to be trade-offs across all of them. I think they feel like they have to make the most trade-offs when they're working with the health system, but I think they're starting to realize that there's no perfect suitor out there, so they're looking for more attractive ones, which tend to be these large retailers or aggregators who are really committed to similar care models that they've begun to stand up themselves. Sarah Hostetter (08:05): But I think in addition, when you talk about the lesser of two evils or three evils, the thing that I hear often from the suitors themselves is, "We are going to maintain autonomy." And whoever says, "We'll maintain clinical autonomy." That's the shtick. (08:20): And I think we are realizing, and physicians themselves are realizing that all of these suitors require some sort of trade off in autonomy. So, how do you find one that best aligned with your interests? Again, another theme that we have talked about is that dichotomy between autonomy versus stability. That dichotomy's out the window with this range of practices. Rae Woods (08:49): I want to ask a blunt question. There's obviously more competition around the physician space than we've ever seen. Should everyone respond by jumping on the bandwagon and trying to buy up and employee doctors? Eliza Dailey (09:02): Short answer is no. I think when you look at the headlines, it's easy to think that this is a buying spree and that everyone's just trying to build up their physician assets as quickly as possible. But when you dig into the deals, some of which we just talked about, they really do make strategic sense. (09:20): It makes sense that Amazon would buy One Medical, really consumer focused, hybrid healthcare platform. We've talked about Village and Summit being a really good partnership. Some of Optum's acquisitions of Kelsey-Seybold and Atrius, those are so in line with their ambition to build a hospital-less IDN. So, I think it's easy to look at all those deals and feel the pressure to acquire more physician assets yourself, but you should only be doing that if they're the right organization for you and if owning physician care delivery assets makes sense for your strategy. Sarah Hostetter (09:53): And you say assets, Eliza, and I think that's an important word to underscore, because when you think about a CVS, a Walgreens, an Amazon, a United Health Group, they are big for-profit businesses and they think in terms of asset acquisition. (10:14): So, I think sometimes we just see language that is different from how we traditionally refer to physicians, in terms of acquiring a physician asset. And so, it's easy to say, "Oh, it's just one more thing that we're globbing on." And that's not to say that some acquisitions aren't out of FOMO or aren't the right decision, but I think especially these big headline deals, when we dig into them, we see principled reasons and principled alignment for where they want the company to go. Eliza Dailey (10:44): And a lot of these companies who are doing these acquisitions are actually out of industry, and these are very successful businesses and corporations, so they have really robust due diligence departments. They know a good deal when they see one. And so, I think we're also dealing with a different type of M&A than we've seen before. Sarah Hostetter (11:05): The other thing that our colleague, John League, likes to say is that when you talk about an Amazon for example, they are used to trying things and they have the money to throw at trying a new solution, and if it doesn't work- Rae Woods (11:21): That's right. Sarah Hostetter (11:21): ... they offload the solution and try something else. Right? And so, that is a very different mindset than what we are used to in practice acquisition, where it is a lifetime marriage versus going out on a series of dates and figuring out if it works out, and if it doesn't, not proposing. Is that a terrible analogy? Rae Woods (11:42): No, I want to continue the marriage analogy, because I actually think it makes sense, right? You're talking about how acquisition or aggregation isn't the end of the journey. Right? When you are at the altar, that's not the end of your journey, it's the beginning, right? It's the beginning to a larger strategy. Have I beaten this to death. By the way, should we say congratulations on your engagement? Sarah Hostetter (12:04): I know, Right? I was like, is this how I announce my engagement publicly to the entire world? Rae Woods (12:07): To the world. Sarah Hostetter (12:09): Or, at least all of your Radio Advisory listeners. Rae Woods (12:12): But on a serious note, right? Aggregating physicians is not a default strategy. It is the means to something that is larger. And Eliza did such a good job of articulating very specific and a very strong purpose that these third-parties are holding sacred. As you're researching everything that's happening in the physician aggregation space, I wonder if you can put a finer point on what success actually looks like? Sarah Hostetter (12:39): Yeah. As we've started to dig into some of the acquisitions and the archetypes within some of these larger organizations that are multifaceted and have multiple types of entities within them, we think the key thing or the determining factor is going to be how well they integrate these pieces together. (13:04): And that's not a new question, right, Rae? You and I started studying physicians how long ago? And we were talking about integration and helping employed medical groups integrate their physicians better, and it has always been the secret sauce is, can you integrate or not? It's just gotten a lot harder. Rae Woods (13:23): It's still probably the number one question that we get asked by incumbent physician groups is, "How do we actually become a unified enterprise?" Sarah Hostetter (13:34): Yeah. I think it gets harder when you talk about a different scale. Right? So, a lot of the splashy headlines lately are nationwide companies. How do you think about integration nationwide versus in a geographic area? But I don't think that's that dissimilar from health system patterns that are branching out into other states. Right? (13:51): We have health systems now that span the Midwest down to the South. The challenge is on a bigger scale, but it's still going to be the thing that makes or breaks, can you get everyone rowing in the same direction, towards what your aim is? So, if your aim is value-based care, how do you get all of your doctors delivering to the standard that gets you there? Eliza Dailey (14:15): I think the other thing that's really different about integration today, is we're dealing with a vertical ecosystem. So, in the past, as the medical group got bigger, it was really by adding on like practices and making the practices bigger and bigger and bigger. Now, the medical group or the physician enterprise is just one part of a really diversified company, in a lot of these instances. (14:42): So, they may have a health plan arm, a pharmacy arm, a retailer arm, and so, that's a whole nother challenge for integration, to figure out how physicians fit into this larger vertical ecosystem you're building. Rae Woods (14:55): So, this is an old problem. It's also a problem that's gotten a hell of a lot harder. What advice then do you have for our listeners? Sarah Hostetter (15:03): One of the biggest ways I've seen integration go wrong is timing. And I think it's really easy to assume that you want to start integrating the second you acquire the new asset. And for some types of assets that may be right, but when it comes to especially an independent physician practice that is being acquired, there is a huge type of culture change that we are thinking about when we go from true independent practice to acquired entity. And you can't just spring that on folks overnight. You need to employ some really best practices around change management. (15:44): I also think on the flip side though, that I've seen it go wrong when people wait a long time. So, you can't just let the organization or the physician enterprise run as it was for two years and then assume we can flip a switch overnight in two years. So, I think it's a really fine balance. (16:05): It also requires a consideration around what is staged, when. So often we see organizations come in and clean house, and that really doesn't work in a physician enterprise, especially again, an independent physician enterprise that is run by physicians. Imagining coming in and we've completely upended the C-suite overnight and put in external folks. So much of that leadership has been critical to buy-in and you lose that if you lose that leadership. So, those are my two pieces, is the timing and also the staging, and what is timed when. Eliza Dailey (16:45): I'm glad you brought up leadership too, Sarah, because I think especially when you have these out of industry folks or these more corporate-feeling aggregators, I think physician leadership and the centrality of the doctors themselves is really, really important. That was a struggle even when it was health systems who are the primary driving force in aggregation, but I think becomes all the more important as organizations are getting bigger and really into the business of healthcare. Rae Woods (18:22): One thing that I'm also hearing through your answers is that some of the old solutions to this old problem are probably still right, like the classic playbook around integration, especially if we think about change management, probably still applies, but are there ways that you would update some of that classic playbook to make sense in 2023? Sarah Hostetter (18:43): Yeah, the part that sticks out to me is, we think about care redesign and historically we have advised that you get some of your other ducks in a row before you move on to care redesign. So, you make sure that you are getting onboarding centralized. You do the EHR. And I'm always going to say, "Get everyone on the same technology." Rae Woods (19:03): Yes. Sarah Hostetter (19:03): "That's going to help. Please do that early." Right? Rae Woods (19:06): Please. Sarah Hostetter (19:07): Please. But I do think the care redesigned section, while it might come a little later, looks a lot different now than it once did. We used to talk about standardization and how you roll out care protocols, as one example. I think that's a thing, but I don't think that you need to assume that the acquiring entity is the one that's going to roll out the new protocols. (19:32): I also think some of the other elements that go in there look a lot different with our current goals. Care team redesign, telehealth protocols, how are we integrating this whole enterprise? Who's going to see what patients over telehealth, and when? How do we think about balancing care pathways with more personalized medicine? It's just that the delivery of care has evolved a lot since we first thought about practice integration. Rae Woods (19:57): It sounds like whether or not physicians help organizations achieve their ultimate strategy or hinder the path to that ultimate strategy, is going to come down to integration. But help me understand how that relates to autonomy. (20:13): Sarah, you kind of teased this earlier, as that being the key currency that today's physicians are looking for, and every suitor is promising autonomy, but isn't that in direct conflict with our goal of creating wholly integrated physician enterprises? Eliza Dailey (20:29): So, I think inevitably there will be trade-offs, but I think there is the possibility, and we see this, where providing physicians autonomy could also be what's best for patient care or in pursuit of the medical group's goals. So, I think of things like schedule autonomy and thinking about when and how physicians work and how that can align really well with when patients want to be seen, whether that's flexing hours or things like that. (20:58): So, I think we often think about autonomy and integration as in complete opposition to each other, but I think there are opportunities to align what's best for the patient, the physician, the medical group, when we really get down to brass tacks. Rae Woods (21:16): I wonder if we should be more explicit about what we mean when we say autonomy? Eliza Dailey (21:21): Yeah, and I'm glad you asked that question, Rae, because I feel like it's this term that we talk about in big ways, and it's kind of this monolith. We have come to think about autonomy in three big different ways. The first is clinical autonomy, which is probably what folks think of most when they hear that word. It is about how I'm practicing medicine, how I'm treating patients when I'm prescribing to them, how I'm working in a team-based care model or doing telehealth or things like that. So, really about care delivery itself. (21:51): Then you also have schedule autonomy, which I alluded to earlier, around when I work, how I work, what is my schedule, what are my hours, what are the things that allow me to also be a human outside of my practice? And then, the last is strategic autonomy, which is more or less important to some doctors, but really focused on, what is my role in this medical group? Do I feel like I have a voice? Do I feel like I can really shape the future of this practice and feel like a vested member of this group? Sarah Hostetter (22:22): And I think, Eliza, you started with clinical autonomy and that's the one that's the most fascinating to me in terms of how we think about it in present day and what we mean when we say clinical autonomy. And I almost feel like we need a trigger warning, because it has assumptions of what clinical autonomy means. Right? Like, clearly this means I'm a doctor, I can practice medicine the way I want to. I can prescribe things, I can diagnose things, right? It's the core function of the physician job, is practicing clinical medicine. (22:53): And so, I think it can be really scary, for good reason, to admit out loud that we will have changes to clinical autonomy, even if we are, we already have them. So, if you look at achieving goals about value-based care, we talked about clinical pathways earlier. Right? If I want to figure out how to do diabetes management, I'm going to work with my team, work with my physicians to figure out, who does it best and how we scale that across the enterprise. Right? That is actually, in theory, losing some level of clinical autonomy. (23:34): And I actually think that if organizations aren't willing to touch that, then they're not going to achieve all the things that they acquired these practices for in the first place. They're just acquiring a bunch of physicians that exist on their own. So, we have to have some level of integration or standardization with how we are practicing medicine to achieve those goals. Rae Woods (23:59): And everyone probably agrees that the extremes have no place in modern medicine. Cookbook medicine has no place in 2023, neither does having hundreds or thousands of doctors that just act like cowboys, that do whatever they want. That also doesn't have a place in modern medicine. (24:16): The difficult problem is, how do you navigate this middle ground and this tension between integrating practices towards a common, I'll use the word again, sacred, strategic aim, while also maintaining enough autonomy that we can keep actually attracting physicians and being the employer of choice? What's your advice for actually navigating that tension? Sarah Hostetter (24:41): Oof, that's a tough one, and I've never been boots on the ground navigating that tension. It reminds me of some conversations that we've had recently, Rae, with a longtime Advisory Board partner and thought partner, Dr. Joe Golbus, and I wonder if it's worth getting his take on this since he's actually done this for many, many years and he's my go-to for all things physician change management. Rae Woods (25:07): Yeah, we might be obsessed with physician research, but none of us are actually physicians ourselves. Sarah Hostetter (25:15): Right. Rae Woods (25:15): And that's a good push to think about how a physician leader would actually respond to that question. And Joe's been doing this for a few decades now. Sarah Hostetter (25:23): Yeah. Eliza Dailey (25:24): Should we call him up, phone a friend? Rae Woods (25:25): He usually responds to my emails pretty quickly. Let me see if I can get Joe's take here. Dr. Joe Golbus (25:33): My name is Dr. Joe Golbus. I recently retired as President of Northshore Medical Group, an employed physician practice of over 1,000 doctors in the greater Chicagoland area. After spending 25 years leading physicians, my advice to leaders and companies that run physician practices relates to the need for some sense of autonomy, or better, engagement of doctors in both governance and operations. (25:57): In an era of widespread physician burnout, the antidote to burnout is engagement. Culture remains a critical aspect of successful physician practices. From an employment standpoint, if physician are treated like employees and not part of the decision-making process, they will disengage. One important way you can make employed physicians feel valued is to engage them in decision-making, so that all can work together on goals and metrics, which then becomes a direct link to accountability. (26:26): Like most humans, physicians don't need to always get their way, but they do need to feel they have a voice and an understanding of why certain decisions are made, especially those that directly affect them and their practices. Rae Woods (26:39): What do you think about Dr. Golbus's answer here? What did you like about what he said in terms of threading this needle between integration and autonomy? Sarah Hostetter (26:49): A couple things stood out to me that he said, one of them is this relationship between involvement in the decision-making process and engagement. When we talk about acquisition of a formerly independent practice especially, we are used to having a lot of involvement in decision-making, right? It's a shareholder-owned, shareholder-governed entity. (27:10): And so, I love the idea of how we get physicians' voices involved in decision-making, and I've spent some time studying how we do that in a way that is not overburdening the system, but helps everyone be a part of it, versus just a W2 or contracted employee that clocks in and clocks out. Eliza Dailey (27:31): The other thing that stood out to me is how Dr. Golbus is speaking about this is in such stark contrast to viewing physicians as assets, which a lot of these corporate aggregators are, as we talked about earlier. And so, it strikes me that- Rae Woods (27:49): Yeah, he said they're humans. Eliza Dailey (27:50): He said they're humans, they're people. And it strikes me that there actually may be more incumbent advantage here than I think we've given credit to in the past. These corporations know how to run a business. They know how to make an acquisition. They might know the right pieces to standardize and integrate, right? But I do think that there's this human element, there's this cultural element, there is this piece of strategic autonomy that we talked about, that's really important too, that I worry isn't being considered enough by some of these big investors and funders in the physician practice space. (28:28): Health systems haven't gotten it right either, that's to be certain. They've worked at this for ages, as we talked about, but I do think at least there's this recognition that that piece of it is really, really important, and there may be some advantage there. Rae Woods (28:42): Or said another way, if you're an organization that has been able to put in practice being a physician-led enterprise, which by the way, I think we would all agree that Northshore Medical Group has done that very successfully for over the last 25 years, at least in Joe's tenure, that that can still be an advantage moving forward, even if it's a fleeting advantage. And you have to also add on some of these other strong business-minded practices that other entities are putting forth today. Sarah Hostetter (29:14): Yeah. The other thing Joe hit on, Rae, that I think is really important is he started to talk about, a little bit around how do we make culture a reality? Because he talked about leadership and the importance of physician leadership, but I think it's really easy to hear culture and think, fluffy, nebulous. But Joe has some really practical advice around how to make culture a reality and live the culture. And we refer to it as a tight, loose, tight model. Where you are setting the bounds around autonomy, for example, as we've been talking about, or around guidelines, as we've been talking about, but you can play with autonomy in between. Eliza Dailey (29:58): And Sarah, I really think one of the classic examples of this tight, loose, tight framework that you're talking about, comes down to physician scheduling, which as we know really is this sacred thing, how physicians are spending their time. Really good example of this is, we say, or physician practice leaders may say, "One of our goals is growth and getting new patients in for visits." And so, all physicians have to see at least two new patients a week. Have a block on your schedule for new patient visits. (30:26): Then the loose part of it is, it's up to the physician to determine when that goes on their schedule, where, based on what makes most sense for them, how they like the flow of their data look. So, there you can see we're really threading the needle between this group goal of new patient growth and also really giving some physicians some autonomy and agency over what their day still looks like. Rae Woods (30:48): We've talked about a lot of changes in the physician landscape, and we've talked about some areas that will leave our listeners feeling vulnerable and probably some other areas where folks are saying, "That's the opportunity that I know I want to chase down in 2023." Before we end this conversation, do you have one or two big things that you want to make sure our listeners focus on when they think about the physician landscape? Eliza Dailey (31:11): I would say, don't underestimate the power that individual physicians have themselves, in influencing care delivery, total cost of care, business strategy. I think with all the M&A we're seeing right now, it's very easy to view physicians and medical groups really as the object of acquisition, but when you get down to it, they're the ones making those prescribing decisions, deciding where patients are going for care. And those are the decisions that matter when we talk about some of these big strategic goals. And so, I think it's important that we really focus at the physician level too, to unlock that power, but also realize how important it really is to engage and retain those doctors. Sarah Hostetter (31:55): Something stood out to me that you said earlier in this conversation, Eliza, around not underestimating the incumbent advantage. And I think it's a different approach to this landscape than we've been taking, or that's been getting the news attention potentially, about all the new types of suitors. And there is a huge advantage that incumbents have, which is that they have been working with doctors for a very, very long time, and they understand some of these change management needs. They've practiced integration. Rae Woods (32:28): Yeah. Sarah Hostetter (32:29): They've not succeeded a lot of the time, but they've had a lot more years of practicing how you integrate a physician enterprise. So, in some regards, health systems and independent groups have a leg up on some of these new providers in terms of how they approach this new problem. And I still think that the winner or the most successful is going to be the group or groups that figure out how to integrate these disparate entities, but I wouldn't count out incumbent providers in that race. Rae Woods (33:00): Yeah, incumbents don't squander your advantage because it is fleeting. Well, Eliza, Sarah, thanks for coming back on Radio Advisory. Eliza Dailey (33:08): Thanks, Rae. Sarah Hostetter (33:09): Thanks for having us. We'll be back whenever you let us. Rae Woods (33:17): I said this at the beginning of this episode, it is no surprise that physician continues to be a top topic on Radio Advisory, and it is not just because I am a legacy physician researcher like Sarah and Eliza. The truth is that the things happening in the physician landscape are perhaps one of the biggest catalysts for change in the industry. (33:40): We have quite a few episodes in our library about the physician landscape, so I want you to go back to our playlist and listen to any of those if you have questions about how changes to the physician landscape impact you, because remember, as always, we're here to help. (34:01): If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcast and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Katy Anderson and Kristin Myers. The episode was edited by Dan Tayag, with technical support by Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston, and Nicole Addy. Thanks for listening.