Rae Woods:
From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods, you can call me Rae. It's no secret that our industry has been rattled by the COVID-19 crisis, but it's actually been a while since we've talked about what that means for the financial outlook specifically. So to talk about the financial realities for health systems and also for health plans, I've brought payer expert, Natalie Trebes, and strategy expert, Christopher Kerns. Hey, Natalie. Hey, Christopher.

Natalie Trebes:
Hey there.

Christopher Kerns:
Yo.

Rae Woods:
Christopher, you do not look like you are dialing in from your home office. Where are you?

Christopher Kerns:
I'm in an undisclosed location. Actually I am in, we call it a little town of St. Michael's, Maryland. I am staying on the water. We are eating lots of crab, drinking lots of Natty Boh, and eating as little Smith Island cake as possible.

Rae Woods:
And generally living the remote work dream. How about you, Natalie?

Natalie Trebes:
Well, I'm just trying to figure out how to get invited to where Christopher is. So I guess I will signup to do more and more work for his team in the hopes that it curries favor there.

Rae Woods:
Yeah, where's my invite?

Christopher Kerns:
Well, maybe like more of my posts on LinkedIn, Natalie, and you'll get an invitation.

Natalie Trebes:
Oh, don't talk to me about LinkedIn.

Rae Woods:
Before we talk about the financial outlook for providers or for payers, I just want to take a moment and make sure that our listeners actually understand the financial realities for both of these players. And I think what I mean by that is the practical differences between how hospitals and health plans actually keep the lights on. Christopher, I want to start with you. What does this look like for hospitals?

Christopher Kerns:
Well, the reality is that hospitals are just far more reliant on cashflow than a lot of other businesses. Healthcare is such a cash-intensive business that we see even minor disruptions in cashflow can be hugely catastrophic for the industry, just because there's so much money that comes in and so much money that goes out the door every month. So even moderate disruptions, such as we saw around the beginning of the pandemic last year, can have pretty significant longterm effects. Even if in the aggregate across the year, there's enough money that comes in. If it doesn't come in in a particular month, that's a real problem. I often like to say that healthcare systems are a lot like sharks, they have to keep moving or else they drown.

Rae Woods:
Natalie, what about health plans, where do they stand?

Natalie Trebes:
Plans are the exact opposite of hospitals in that regard, but the premiums, the revenues come in first, and then the whole game is how do you predict what you are going to have to pay in terms of service charges for the rest of the year. So for them, enrollment is actually a really big input into their financial health. More enrollment means more premiums, and it's actually generally a double whammy for plans because the more people you have, the better you can spread that risk around, and then also the more weight you have to your negotiations to try to get the price down.

Rae Woods:
We're going to be talking about how the COVID-19 crisis has shaped the financial outlook, which means we have to go back to 2020. And if I think about the reporting that I'm seeing in the last year, there have been opposite headlines. There are some narratives that say that providers and plans are going out of business, but then there are others that say the "bad guys," maybe I'll even call them the sharks, are just getting richer. Which of those two narratives is true?

Christopher Kerns:
I'm going to give you a very unsatisfying answer from my perspective, Rae, and the answer is both and neither at the same time. The reality is, it's really just not true to say that financial performance for all providers is the same. There was a pretty big divergence in the last year on the provider side. In fact, we saw an unprecedented level of divergence in financial performance across the year. There are some, because of their ability to constrain costs and capture volumes and capture CARES Act money, that were able to become far stronger across the course of the year and did pretty darn well financially speaking, others just barely kept their heads above water because costs were exploding, they didn't get to capture as many volumes as they would like, and they didn't capture the CARES reliefs that they would like. So there's a pretty significant difference across the board between those that thrived by the end of 2020 and those that were barely keeping the doors open.

Natalie Trebes:
And I also have to say, we have to remember that things that we can easily get data on and easily create headlines out of are going to get outsized attention. So the big publicly traded national plans, releasing quarterly earnings reports, and all of Wall Street looking at those, all of the media writing headlines on those, are going to have this outsize impact on the narrative for plans, but all of the rest of the regional local plans I talked to are in a very different place, both emotionally and financially [crosstalk 00:05:19].

Christopher Kerns:
And I also think you have to think about 2020 in terms of first half and second half. The first half of the year saw across-the-board lockdowns, but they didn't see across-the-board spikes in COVID cases, whereas the last few months of the year saw pretty much universal spikes in COVID volumes, but not necessarily the same level of lockdowns. So in effect, I think the financial realities for plans and for providers were pretty much flipped from the first half to the second half of the year. Natalie, would you agree with that?

Natalie Trebes:
Definitely.

Rae Woods:
So it's incorrect to look at perhaps any year on the whole, but especially if we reflect on 2020, so let's actually take a moment and break down what happened last year. And we've actually done this before, actually around this time last year, we sat down to do financial update podcast episodes on different parts of the industry. And I do think it's easy for folks to forget how scary things were. Christopher, you mentioned universal lockdowns, a lot of folks being concerned about how they could actually make payroll, how we could keep patients out of the hospital and sheltering at home. What did that mean for hospitals in the first half of 2020?

Christopher Kerns:
Well, I'm not going to sugar coat it, the lockdowns were indeed devastating, some would even say catastrophic. There were a number of organizations that were concerned about how they can make payroll, how they can make their basic interest expenses. And in fact, there was a lot of talk, I was talking to a lot of banks at the time who were concerned that the health crisis could become a solvency crisis, which could become a financial crisis. And if that starts to give you flashbacks of 2008, there's a good reason for that. And it's true that the CARES Act stymied that, it really staved off the worst of it. It really did provide a lot of the cash flow relief that providers needed. And by and large, with those 2020 relief laws, not just the CARES Act, but also its follow up legislation, we saw the worst of disaster avoided financially speaking.

Christopher Kerns:
And in fact, when we look at the payback terms for a lot of the loans that were included in the CARES Act, those terms have been eased across the course of 2020 in the subsequent legislation. So most organizations are reporting to us fairly easy repayment of the advanced payments that they got. And of course there were the grants, there were no strings and they led to huge cashflow gains for some organizations, and again, for others, it just barely managed to keep them open and running. One thing I will say though, that is true across the board, we did see pretty significant spikes in costs, labor supplies, technology, all of those spiked, everything became more expensive. And it's true that larger systems tended to do a lot better, not just because they had the ability to secure more CARES dollars, but also because they were able to use their often underused systemness capabilities, moving patients and supplies and labor to different sites of care. So the reality is a lot of them were left financially much better off than their smaller brethren.

Rae Woods:
The story for the first half of 2020 was a very devastating moment for hospitals that required intervention from the federal government, and that helped keep things going. Natalie, you said earlier that the financial practicalities of health plans is the opposite of hospitals. Does that mean that in the first half of 2020, health plans were actually doing well?

Natalie Trebes:
Well, I think we all have to go mentally back in time here. You have to remember, everything was uncertain, capital letters, underlined, April 2020, March 2020, we were wiping down groceries, right?

Rae Woods:
Mm-hmm (affirmative).

Natalie Trebes:
Nobody knew what was going on. And we think about uncertainty in the health plan context, that's their number one fear because they have to predict what is going to get spent for the remainder of the year.

Rae Woods:
Yes, certainty is a essential component of acting as a insurer.

Natalie Trebes:
Exactly.

Rae Woods:
Or that's what they're hoping for.

Natalie Trebes:
So, they didn't know how many people would get COVID, what would the treatments entail, what prevention costs would they actually have to bear, and how many people would need that, we didn't know how much routine care would go away, when and how much of it is going to come back, how many people are going to lose job-related coverage and shift to Medicaid and what individual coverage would look like? So the plans really felt like they were on the precipice of having a hedge between saving up their funds for potential more catastrophe in case things got worse over the rest of the year, and they really did get worse with COVID over the course of the year, and then investing in future health and stability. So you don't want other people's conditions to go untreated and get worse later.

Natalie Trebes:
And also they wanted to give cash to provider networks to pay them in advance, to help make sure that they existed, they didn't want providers to go out of business. So it was a point of extreme uncertainty for them.

Rae Woods:
And then we go to the second half of 2020, we started to get a little bit of better control of the virus, right? We started to be able to answer some of those previously uncertain questions, but any positive momentum that we had over the summer as an industry was met with honestly devastating results in the fall and the winter. We've talked a lot about a basically nationwide surge across the final months of 2020 and what that meant for care delivery, but what did that mean for financial performance?

Christopher Kerns:
I mean, not to put too fine a point on it, but a surge in cases meant spike in utilization. And that means that hospital beds were full, not necessarily the most profitable patients, but for most hospitals, a full hospital's a full hospital, it's profitable. Meaning financial performance looked pretty decent on a month-to-month basis in the last quarter of the year. It's true that without CARES, margins may have actually declined because COVID cases are medical, not surgical. And medical cases just don't have that much of a per-patient margin. But with few exceptions, the so-called long haulers, even COVID patients do carry some margin. And a hospital that is full, is almost always financially sustainable, even if the workload and the emotional stress just isn't. Also important to keep in mind, that in the fall surge, we did not see the same types of lockdowns that we saw at the beginning, surgical cases, ambulatory cases, they were allowed to continue in safe environments. So those deferred services came back. And in the fall, few orgs really had to reenter a lot of those lockdown policies for non COVID procedures.

Christopher Kerns:
So they may have had to move them a lot more aggressively into the outpatient setting, but that's a trend that's been happening for a long time, it's just one that got a giant accelerant, especially in the latter half of 2020.

Rae Woods:
And maybe this is why some of those headlines I referenced started talking about hospitals making money. They were specifically looking at the last half, maybe even the last quarter of 2020. And like you said, a full hospital is a profitable hospital even if it's filled with medical patients, with COVID patients.

Christopher Kerns:
It's not as profitable as it would be under a normal patient mix, for sure. And when you look at the impact on workload, sustainability of the workforce, it probably isn't sustainable over the long-term without some pretty significant changes, but yeah, most hospitals were finding themselves in the black by the end of the year.

Rae Woods:
Natalie, this is not something that most payers want. Payers don't want their members to end up in hospital, they don't want increased utilization. So what did the end of 2020 look like for the health plan side?

Natalie Trebes:
So yes, payers don't want their members to end up in the hospital, but if members need to get care that's appropriate, payers want that to happen. In a weird sense, this was actually good, when you consider the previous few months, it was good for plans in that they again are vindicated from the hedging that they were doing. So it varies a little bit, depending on the type of plan we're talking about, but this is where we have to talk about the MLR or the medical loss ratio, which basically legally says that risk-bearing plans have to spend a certain amount of their premiums on medical care. So if they go under that amount, they have to rebate that back to their consumers and purchasers.

Natalie Trebes:
So the plans are really trying to make sure that they hit their targets, again, back to that predictability. And they want to spend as close as possible to what they had planned on spending across 2020. And so that's really what drove a lot of their willingness to do things like get really flexible on telehealth and pay a parity, provide advanced payments to providers, even give people a premium holidays in certain cases. And so when we look at what happened with those medical loss ratios across 2020, there was a big cratering in Q2. They dropped by six to eight percentage points for all the major plans, but by the end of the year, a lot of that came back. And for most plans, they came pretty close to their targets averaged across the year. So when we look at what rebate payments plans are owing, it actually looks. pretty similar to what they owed in 2019.

Rae Woods:
And that's not what we originally predicted, there were a lot of conversations about, "Oh my gosh, what's going to happen with MLR? And is there going to have to be huge rebates that get given out?" I mean, if I think about insurance policies in general, not even in healthcare, we're talking about that because they were afraid about not hitting target.

Natalie Trebes:
Exactly. And I think we are seeing headlines about huge rebate payments, but they're actually coming from mostly over pricing in the individual market, which are the same as what we were seeing in 2019, so they look pretty similar. They're still big, and so that's where the headlines are coming from, but they're not related as much to changes in utilization across the year from COVID.

Rae Woods:
And you mentioned earlier that utilization isn't the only thing that matters. You mentioned that enrollment is actually a big driver of financial success for plans. And we do know that payer mix pretty dramatically affects finances on the provider side. So what actually happened to coverage and how does that factor into this conversation?

Natalie Trebes:
So, 2020 was one of the biggest coverage shift years we've seen. As of April of this year, employer enrollment is down by about 14 million, Medicaid enrollment is up by about 8 million, and then individual ACA exchange enrollment is up by about 1.5 million covered lives. And so that gap between commercial drops in public sector, including the ACA market gains, has really narrowed a bit from the height we saw over the summer due to policy interventions and economic recovery.

Christopher Kerns:
On the provider side, I got to say though, it's very bizarre what we saw, payer mix was surprisingly stable. You'd expect that with those huge drops in commercial enrollment, that Natalie just mentioned, you'd see some sort of effect in the payer mix that was coming into hospitals. But when we looked at the data from across 2020, it barely budged, at least in the aggregate here. And when we start looking into the reasons for it, it seems to be that part of it is the effect of COBRA, but a lot of it seems to be related to the strange dynamics of COVID itself that are hopefully unlikely to be replicated in the future. We saw older people were more likely to be hospitalized, but they were also more likely to social distance, which would drive up COVID-based hospital utilization from younger people.

Christopher Kerns:
So in the end it ended up being a little bit more of a wash, but here's what's really interesting, at least to me, as the economy improves and unemployment drops, mix still doesn't seem to be changing. And I think part of this is related to low labor participation rates from COVID-related policies. But part of it is also the fact that during the public health emergency, you can't be kicked off of Medicaid. So there are a lot of strange dynamics that could persist for some time. And it's quite possible that we could see a big change, not only in enrollment, but also in payer mix at hospitals, when we see what we're calling the payer mix cliff at the end of the year when the public health emergency ends.

Natalie Trebes:
Yeah, and I got to say, I think other things that could be happening is we see a pretty tight labor market now. So job seekers who are not yet employed, who lost their job previously, might be more selective in their job choices. It truly couldn't also be reporting data lags on different timelines, because we're looking at different metrics of employment. I think BLS statistics are pretty frequently aggressively updated and health plan coverage data is a long chain of reporting and filing to go through to get to the point where we can actually analyze it. So this might just be something that we need to take a look out in three or six months time to see what actually happens when we look at it on that. But I agree, it is a weird thing that we are seeing between the payer mix and the coverage mix right now.

Rae Woods:
And what I'm getting from this conversation brings me back to where we started, which is that there is a lot of variability when it comes to the financial outlook, not just because of the very specific conditions of the crisis that we are living through, but also because one segment of the industry isn't going to look like another segment. And even if you look at the same segments during the same time period, we still see differences, like Natalie, your example of the national health plans. Christopher, you alluded to this earlier, but what was the spread of performance on the hospital side of the industry?

Christopher Kerns:
When we look at the numbers on revenue performance, margin performance, overall cashflow performance, what we saw is that by the end of 2020, even the 25th percentile of performers did a little bit better than they did the year before, which I think surprised a lot of people, but so did the 75th percentile of performers. So what we saw was a widening gap between the haves and have-nots when it comes to hospitals and health systems. So the bigger, more financially strong organizations did better and they widened their lead over smaller organizations. Now that's not true across the board, there were a number of large organizations that struggled, and there were a number of small organizations that thrived, but by and large, we saw a widening spread in performance across 2020 that we have not seen in several years.

Rae Woods:
And what is your prediction for how that gap will change over time? Do we expect it to continue to expand or maybe to narrow back to where things were in 2019?

Christopher Kerns:
I would expect at the very least some stability in that gap, if not some widening of it across the course of the year. And one of the main reasons for that is the huge spike in costs that we have seen across the board, labor, supplies, technology, as I mentioned, but those are going to disproportionately affect smaller organizations that don't have either the financial cushion or frankly, the flexibility to be able to absorb those costs or adopt different in kind staffing, supply or technology models. So I think that we're likely to see a bit more widening between the haves and the have-nots across 2021 and probably into '22 as well.

Rae Woods:
Natalie, is this haves and have-nots problem also the same in health plans?

Natalie Trebes:
Yeah, I don't think it's as extreme, or rather, I think there's the have-a-little and have-a-lots, rather than haves and have-nots, but the big variable for plans is their enrollment mix. And I think it's worth teasing that out by the health plan type. So the big national plans that you're seeing make headlines right now for their massive profits, there is a reason for that, they have an especially good position with their different businesses for these kinds of enrollment shifts. Most of them have really substantial Medicaid businesses. So they were ready to absorb some of that drop in employer coverage right back into their own business, rather than lose it to other plans. I think Cigna and Centene are both interesting outliers there, Cigna's pretty heavily focused in the commercial space, Centene's pretty heavy in the Medicaid space. But in general, the extremely high profit margins might turn heads right now, but they are blind enrollment shifts. And again, they will be paying rebates back later.

Rae Woods:
What about plans that are slightly smaller in size? I'm thinking like a regional Blues plan, what are we seeing there?

Natalie Trebes:
So the Blues plans I think are actually particularly special, they are mostly really heavy in the employer space, both self-funded and fully funded. And I make that distinction because it's worth noting that a fully-funded business is more profitable than a self-funded business. So any drops in employer coverage for them can be extra painful compared to the nationals who mostly have self-funded coverage. And then they also, again, because of that mix had less of an opportunity to capture that new Medicaid enrollment. And finally, they are deeply integrated in their local market. So any kind of regional variation of what was going on with the economy or COVID policies, it's going to hit them more dramatically. So when we look across the Blues, there is about a 12 percentage point spread in margins across the Blues from negative 5% to 7% positive. So the haves and have-nots is really playing out within the Blues space.

Rae Woods:
And what about the even smaller plans, I'm thinking the local ones?

Natalie Trebes:
So that's where the variation in portfolio and geography gets even more extreme, but on average, these plans have tended to pick up enrollment in the government space and Medicaid's and individual in particular. I do want to distinguish the provider-sponsored plans locally in particular because they have this entire arm, the hospital system, that was struggling at the beginning of the pandemic. And so I think many of them were put in a position of feeling like they really had to focus on sustaining that provider arm. So they might not be coming out of the end of the year, even if they had growth in Medicaid or individual in the same place as some of these national plans.

Rae Woods:
And all of this really comes back to support our point, that the headlines are going to go for the attention-grabbing story, but aren't going to capture all of the variations between hospitals, between health systems or for the industry at large. I'm surprised that we haven't talked about Medicare Advantage yet. And I think that's because it's really removed from discussions that center on things like employment and insurance. What's going on in Medicare Advantage for plans?

Natalie Trebes:
So that I think is the really big story that's not getting talked about as much, is the shifts there. Growth in Medicare Advantage is really crucial for plans right now for a number of reasons. It's not tied to economic cycles, so it's a little bit insulated from all of the rest of the churn we're seeing everywhere else. The margins are extremely high, and it's really the only avenue that plans have for new growth. So they are getting enrollment in Medicare Advantage by shifting from traditional government Medicare to their own, versus in other business lines, they have to steal that market share from other plan competitors.

Rae Woods:
We've been talking about the fact that there are haves and have-nots, and that the spread in some instances have gotten worse, whether we're looking at the entire hospital industry or we're focused on the regional Blues plans, but what does that impact have for the industry as a whole?

Christopher Kerns:
I think there are a few things that you can expect. One is likely more consolidation, at least on the provider side, with some organizations having a whole lot of capital right now, and access to capital with interest rates being so low, and others struggling a bit, especially as we see costs rise. So I think that could lead to some consolidation in the future. And I also think that those orgs that have a great deal of cash in the bank, and we do know that because of CARES cashflow levels, or should say cash reserve levels are at their highest that they have been in a very long time. That's going to allow richer organizations to be more deliberative with their strategy, and they can look at their investments in things such as digital health and new types of care models for physicians in a way that will allow them to be much more strategic than those that have to be more reactive.

Rae Woods:
Well, hold on Christopher, if they got money from the federal government, don't some have to give that back? So is that really money that they can spend being more deliberative about their strategy?

Christopher Kerns:
That's true. And it's also true that a lot of orgs that were planning on having to repay those loans have set that money aside. So most organizations that we've spoken to have said that they feel pretty comfortable with the repayment terms, especially as those repayment terms eased across the course of 2020 with subsequent legislation. So by and large, we don't hear a lot of complaints about the ability to repay the advance payments. All that said, there is still quite a vocal constituency out there that would like the current Congress to turn a lot of those repayments into grants and forgive those loans. But I would say that even those orgs that would benefit from that, might want to think twice about what they're asking for, because that actually puts a lot more strain on the Hospital Trust Fund, which is slated to go into insolvency in just a few years. And that could be moved up to a lot sooner based on the upcoming CBO report.

Christopher Kerns:
And so, we should have that within a few weeks, but the reality is, turning those loans into loan forgiveness is going to have a much more serious effect on longterm Medicare financing that a lot of organizations appreciate today.

Rae Woods:
Natalie, I want to give you the chance to answer my earlier question to Christopher. We talked about the haves and have-nots in the health plan space, but from your perspective, what impact is that going to have on the industry?

Natalie Trebes:
Well, I think for the plans, especially the nationals that had time to pause and think about what they were doing with their resources, and not just money, but the actual attention span and FTEs, as they looked at the landscape of who they wanted to potentially acquire or partner with, or new stakes they wanted to take in different organizations. We saw a lot of movement in provider integration, home care investments, digital health space, Christopher mentioned that too. I think the nationals have had time to make strategic moves that they maybe already would have made, but they all did it this year, I think at a higher pace. And that's going to play out as we look at their big shifts towards becoming more health solutions companies, rather than just pure insurers, I think that accelerates further. Whereas on the local space, especially with provider-sponsored plans and Blues, I think being very tied to a specific market has kept them from being able to take that national perspective and look at what assets were potentially up for grabs and available to partner.

Rae Woods:
We've been talking about the variation that exists in the market, but it strikes me that even with variation being a certainty, the industry as a whole is actually in a pretty okay place financially, some might even say a good place. And I think that might surprise some of our listeners. Was that surprising to you?

Christopher Kerns:
I think the amount of cushion that the provider industry got was a bit of a surprise to the entire industry. And the degree of stability that it provided, I think was a bit of a surprise. But you look at the amount of dollars that came in, no, it's not all that surprising that we actually see most orgs in a better place, especially given that the nationwide search that we saw in the fall also, frankly, helped to stabilize finances, even if it was devastating for the country overall, and frankly for the emotional health and the workload for these provider organizations that we're talking about. But it's a bit of an awkward thing for a lot of hospital organizations to talk about how they ended 2020 and early 2021 in financially-strong places, because many of them had been talking about the financial devastation that they were experiencing at the beginning of the pandemic.

Christopher Kerns:
And that was real. And it's also true that because of the heroic efforts across the past year, hospitals have a lot of goodwill coming at them from the country as a whole, and they don't want to spoil that. But the truth is that it's time for a lot of hospitals and health systems to use whatever windfall they got, if they in fact got it, wisely because the expectations for patients, for physicians, for health plans, for all sorts of purchasers have changed. And the ways in which patients want to engage in the healthcare delivery system has also changed, and they better be willing, ready, and able to deliver on that.

Natalie Trebes:
So it didn't surprise me that plans made it through okay, because their entire business model is all about stability. And I think they would have only been in trouble if they really blew through the roof on utilization and spent a lot more than they had in premiums. But it did surprise me that things landed so stably for them, and that we're gearing up for some accelerated shifts across the field, and in some cases, trajectory changes like the MA growth we talked about, that are going to be harder for those left behind to recover from.

Rae Woods:
Well, Natalie, Christopher, I want to thank you so much for talking about a awkward and unclear topic, when it comes to the financial outlook for our industry. I usually reserve this time to let you give our listeners a takeaway, but I want to do something a little bit differently. As we think about the financial outlook for 2021 and beyond, what are the things that you're watching for next?

Christopher Kerns:
Personally, I think the answer is going to be the same for both Natalie and me, but we'll find out. One is significant increases in labor costs. So what will that do to bottom lines across the board? What's the trajectory of the pandemic going to look like, are we going to see things such as vaccine resistance? So far, we seem to be trending in positive directions there, but it's something to keep an eye on. And I think the impact of deferred care. We saw a year's worth of care, in many cases, just deferred. And that's going to necessarily lead to increased acuity of cases that are coming to providers. So the impact that that's going to have is a bit unclear at this point.

Natalie Trebes:
I think all of those things, as well as what's happening in the physician alignment space, what kinds of investments plans are making there, along with reimbursement changes they're making to further site-of-care shifts. And I think, especially with respect to virtual care, there's a lot of conversation happening right now about what should virtual care reimbursement look like. The reason that there is hesitation is because we saw last year that it did cost money and that's why plans largely came out with an intact MLR. So that's why they are scared to proceed, because they don't want to overspend in that space. And so partner choices, incentives are going to be huge here. And then lastly, I think I'm looking to see what plans do in the health equity space. There's a lot of attention going towards that, and there's a big question about how much they will collaborate with one another and others in the community versus going alone.

Rae Woods:
I could not agree more. Well, Christopher, Natalie, thanks for coming back on Radio Advisory.

Natalie Trebes:
Thank you.

Christopher Kerns:
It's always a good time. This was actually a lot of fun for us because Natalie and I and a few other colleagues got to spend two hours the other day looking over numbers that looked completely bonkers, and arguing with each other for the better part of those two hours. And it was probably the most fun that we've had at work in about a month or two.

Rae Woods:
You have been working at Advisory Board for too long. It is-

Christopher Kerns:
That is very extremely true.

Natalie Trebes:
Caveat, at work is the most important thing there.

Rae Woods:
Christopher is actually right, that at Advisory Board, we will completely nerd out over financial reports like these. And we dig into questions that seem like they don't make sense, or answers that feel like they're saying the opposite thing. What I want you to take away from this is that the financial impact doesn't look the same for any one part of the healthcare industry, or even segments within some of the segments that we've talked about. We're watching for how the dominoes are going to fall and how it's going to affect you. So remember, we're here to help.