Rae Woods (00:02): From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Private equity is disrupting the health care industry, and it's doing it in more ways than one. There is no doubt that PE is putting increased pressure on today's health leaders. But is private equity the villain? Are they the bad guy that we all love to hate? Or maybe, is PE just misunderstood? To talk us through our latest thinking, I've brought two Advisory Board experts, Sarah Hostetter and Vidal Seegobin. Hey Vidal. Hey Sarah. Welcome back to Radio Advisory. Vidal Seegobin (00:45): Hey Rae, how's it going? Sarah Hostetter (00:46): Hi Rae. Rae Woods (00:47): This is a milestone two plus years in the making because we are actually in person recording this episode. Sarah Hostetter (00:54): I mean technically, we are physically in the same building. Rae Woods (00:57): We are all physically in the Advisory Board office, although we are still recording in separate rooms, but that's okay. Vidal Seegobin (01:05): I'm just excited to watch the steady adjustment of dress code as we move back into the office. It feels like it's quite flexible. Sarah Hostetter (01:13): I know, I saw shorts today. Vidal Seegobin (01:14): There's critical mass of shorts, particularly with men. Rae Woods (01:17): Well, especially in the DC area, it is hot. It is a literal swamp. Not because of the people, it is a literal swamp. Before we get into the details of our discussion, I don't actually want to pretend that our audience fully understands private equity or what's at stake here. Frankly, I'm not even sure that I understand all of it. So Vidal, can you give us an overview of the key things that we should know about private equity and its influence in the health care space? Vidal Seegobin (01:57): Sure. I'm going to give it a shot, and then hopefully we won't get a lot of negative blow back afterwards. Rae Woods (02:03): All press is good press. Vidal Seegobin (02:04): Yeah, that's true. That's true. And I'll try to be as non-jargony as possible. I like to describe private equity to my parents as just another investor who raises money through limited partners who are committing sometimes very large dollar amounts to a fund manager. In this case, it's a private equity firm, who are going to use that money to invest in, in this case, established businesses. And to use that capital to grow the return on that capital. And they've looked for all sorts of different avenues to apply that capital and no surprise, health care has been one of the major winners for that money. And so we expect, and I think the reason why we're talking about this today, is because there's a lot of activity and interest from these investors to apply that capital with health care businesses, which can run the gamut of biomedical, pharmaceutical, outpatient settings, clinics, hospitals, all the like. Rae Woods (03:14): So there's a lot happening when it comes to private equity and health care, and you two are out there actually talking to health leaders about this topic every day. What are some of the things that come up when you have these conversations? What are some of the feelings? Maybe what are some of the fears that you hear when you talk to executives about private equity? Sarah Hostetter (03:34): I want to caveat Rae, your listeners probably know me by now. I've been on a handful of times. I'm like ride or die physician practice. That's where I spend my time. That's where I do my research. However, this research was really cool because we talked to physician practices. We talked to law firms that work on these private equity deals. We talked to PE firms themselves. We talked to other stakeholders about what they wanted to know. Our central question was around physician practices, so that's where I kind of caveat my take today and my standpoint. The research that my team has done has been focused on physician practices. Physician practices either hate or love private equity. Like you can't talk to a physician practice that doesn't have an impression or a opinion on private equity, however informed or not informed that opinion is. So it's a very polarizing topic for physician practices. Rae Woods (04:31): What about health systems? Vidal Seegobin (04:33): So health systems see a private equity largely as predators and disruptors to their current business model. I would argue that they are a little jealous that private equity is probably starting from scratch with a lot access to capital and building a network that was fit for purpose for the 21st century compared to what they're operating. And so I think it does skew a little bit more towards the negative side than the positive. Rae Woods (04:58): And these attitudes are changing or maybe just getting a little bit louder because there are changes in the way and the amount that private equity is investing in health care. Let's first talk about what we've seen historically. What has been private equity's role in health care and how is it changing today? Sarah Hostetter (05:17): At least in the physician practice space, the legacy model was invested in roll up specialty practices. So I am going to buy a lot of ophthalmology practices, dermatology practices, roll those up into a bigger aggregated entity. We still see that investment in specialty care. Some changes in the specialties, so ortho and GI are hotter more recently. Rae Woods (05:42): But the business model for any of those specialties is kind of the same. Let's be as efficient as possible, get as many volumes as possible because the business model is fee for service. Sarah Hostetter (05:51): Yes. You want to do fee for service kind of core revenue and then ancillaries, lab, what can we shift outpatient? How many component parts can we add on within these type of specialties or can we... Different business lines these specialties have? Rae Woods (06:08): And how is that different from what we're seeing today? Sarah Hostetter (06:11): Private equity, like the rest of the health care ecosystem, is interested in value-based care. Private equity follows what the health care ecosystem trends are doing. So we are seeing movement into value-based care, and so as a result, we are seeing private equity firms invest in primary care practices. So I think what is really interesting about these investments is from the outside, the model is still the same. You want to aggregate, you want to cut costs, but the way that they go about doing those things is different or the purpose behind it is different. Rae Woods (06:47): Because the purpose is value-based care. Sarah Hostetter (06:49): Exactly. So you want to aggregate to have more covered lives in a single region, right? You want to cut costs, but not at the expense of quality. But then you also need to invest in things that produce higher quality care. So data and analytics, care team redesign, virtual care. So that investment looks a lot different when we're talking about value-based care. Rae Woods (07:16): And this is exactly why the physician space is so interesting when it comes to private equity, because I'm just going to say it, the way that you just talked about primary care, Sarah, is not the way that most people talk about primary care, right? Especially when I think about incumbent health systems, no one is talking about primary care as a money maker. But you are telling me that the partnership between independent or hospital less physician practices and PE actually sees value-based care as a money maker. Sarah Hostetter (07:48): Yes. Vidal Seegobin (07:50): If you were going to ask the question about what's different or the same about private equity, private equity is in some cases, a pure economic actor, right? So they are trying to find the most effective return on investment with the minimum amount of risk and the fastest turnaround time. And I think historically they have looked at established businesses that can grow at a certain multiple. And I think it's very curious that some of them are making the bet that they can make those levels of returns in a value-based care world by partnering with or owning these physician practices, these primary care practices that will steer and direct patient traffic. Sarah Hostetter (08:30): And I will add two caveats to that. One is a lot of the movement is in Medicare advantage. In general in the industry for value-based care, that's where a lot of the movement is. Rae Woods (08:41): Yes. Sarah Hostetter (08:41): Right? And so a similar approach for physician practices, we are targeting primary care groups that do value-based or Medicare advantage. The other one I would add is that the difference between a independent primary care practice and a health system in terms of how they intersect with value-based care is there is a lot of places where the incentives are aligned for fee for service and value-based care. So if I am keeping you out of the hospital or keeping you in primary care, and I am the group that delivers the primary care to you, that benefits whether I am in value-based care or whether I am in fee for service. So either I can bill for the encounter from a fee for service perspective, or I am keeping your total cost down by keeping you in primary care. So there is this sweet inflection point of the incentives in the independent space that is the math is different for a health system. Rae Woods (09:45): What both of you are describing is effectively a partnership. And Sarah, like you said, you have been on this podcast many, many times before talking about how the partnership landscape is changing for physicians and that there is no shortage of partners available for physicians today. So I guess my question is what's the specific value that private equity would bring to physicians that other partners don't? Sarah Hostetter (10:10): The number one thing for me and for the groups that I talk to is fast growth. There is a difference between a large bureaucratic entity and a business ROI minded entity in terms of who's investing in you. And so the driving force behind a private equity investment is grow the business fast. That is return for shareholders if you grow a business fast of which physicians are often still shareholders. So that is the big value prop or the overarching thing. But then we see a couple other things on the ground that I think are part of the value prop as well. One that stands out for me is the promise of clinical autonomy. And I say... I'm air quoting right now, I realize people can't see that. But PE comes in and says, we will preserve your clinical autonomy. Practices say this, PE firms say this. I think the jury's still out on how much that is true or how long that will last, if our bet is on value-based care. Vidal Seegobin (11:12): I agree exactly with what Sarah said. I think about it just agnostic of any type of business unit in health care, where private equity's coming to the table with two key differentiators. Actually which are not in fact differentiators, they are providing you with expertise and access to capital, and everyone's going to pitch a different way that they think they can make through business grow. And the one underlying point I'd say that came out from some of the conversations we had is that private equity in many cases doesn't have the baggage as a capital partner or as a funding partner that some other potential incumbents have, like health plans or other health systems. So I think that's all part of the politics of the equation here. Rae Woods (11:57): Clearly there's a lot of feelings about private equity. I'm frankly not that surprised, because the more we see PE get involved in the health care space, we hear more, to Vidal's point, negative feelings about what that means for health care. Frankly, this bad guy persona is even seen in mainstream media. I can think of several cable medical dramas that have made private equity, or maybe it's specific investors, as the literal enemy, right? The enemy of the docs that are the saviors of their hospital or ER or medical practice. Is that the right way we should be thinking about private equity? Are they the bad guy? Sarah Hostetter (12:37): I mean the short answer, Rae, is no. I think private equity is a scapegoat for a lot of the other problems we're seeing in the industry. So the influx of money and where it's going and the influence that that has on health care. I think private equity is a prime example of that. I also think the horror stories all get lumped together. So we don't think about who the PE firm is or what is being invested in. We put together physician practices and health systems and SNPs, and we lump every story all together, as opposed to considering those on their individual merits. Rae Woods (13:16): And feeds to this bad guy kind of persona that's out there. Sarah Hostetter (13:20): Yeah. And like you said, the media doesn't help, right? If the average consumer is watching and seeing different portrayals or lumped portrayals, it's not helping. Vidal Seegobin (13:31): Private equity, as all actors in our complex ecosystem, is not a monolith. Rae Woods (13:36): Yeah. Vidal Seegobin (13:37): And no one has the monopoly on great decisions in health care, nor do they have a monopoly on the bad decisions in health care. And so if you attribute a bad case to private equity, then you also have to attribute the positive returns done from a private equity investment as well. Sarah Hostetter (13:54): Agree with what Vidal's saying, but bottom line is that every stakeholder is not going to have the same outcomes or ripple effects from a private equity deal. It really depends on the deal itself, the market, and the vantage points that you take. Rae Woods (14:09): I want to actually play out a scenario with the two of you and I want you to talk about the positive and the potentially negative consequences for different sectors or different stakeholders. So let's take the newest manifestation that Sarah, you talked to us through. Let's say that there is a PE packed multi-specialty practice heavily in value-based care. That practice starts to get bigger. They acquire other practices, including maybe even some big practices in a market and they start employing all of the unaffiliated or loosely affiliated practices in the market. I am guessing that every health system leader listening to this episode is already starting to sweat. What does this mean for the incumbent health system? Vidal Seegobin (14:53): So I think one thing that's going to be pretty clear is that size does confer clear advantages and health care is part and parcel that kind of benefit. What I think is challenging is when we're entering into a moment where access to capital is challenging for health systems in particular and we're going to need to scale up investments, health systems could see themselves falling further and further behind as private equity makes smart investments into these practices to both capture and retain volume. And as a consequence of that, reduces the amount of inpatient demand or the demand to their bread and butter services. Sarah Hostetter (15:33): And I think it's really important that you phrase the question, Rae, as health system. Because we so often equate health system and hospital. Rae Woods (15:43): Yeah. Sarah Hostetter (15:43): But a health system includes lots of hospitals, it includes ambulatory facilities, a range of services. And so I think for systems to equate health system and hospital, it's really hard when any type of super practice or large backed practice comes into the market. Whether we are talking about a plan backed practice, a PE backed practice, or just a really large independent group. There are pressures on health systems who think of their job or their primary service as the hospital. And there is a moment where the power dynamics can shift in markets away from the health system. Rae Woods (16:22): Oh yeah. Sarah Hostetter (16:23): If they aren't able to pivot their strategy beyond just the hospital. Rae Woods (16:29): Which is exactly why health systems see this scenario as, let's just say it, threatening. Sarah, then how do the physicians feel? Do they have the opposite feelings as the incumbent health systems? Sarah Hostetter (16:43): There's a huge range. Private equity is incredibly polarizing in the physician practice world, the same way that it is in other parts of the industry. So I think there is a hope from some practices that private equity is a type of investor that is aligned with them. Physicians who go into private practice historically tend to be more entrepreneurial. They are shareholders in their own practice, so there are some natural synergies between private equity, business minded folks, and these physicians. There's also welcome, even though I go into a small business, it takes a lot to run a small business. So there are potentially welcome synergies and help that you can get from a PE firm. On the flip side of that, there are groups who would never in a million years consider taking a private equity investment and are unwilling to have these conversations. Rae Woods (18:46): There is a tendency, especially in the conversation that we're having, for folks to think about private equity as being something that primarily impacts the provider space, at least when it comes to health care. But I'm not sure that that's actually true. So what consequences, good or bad, might the payers feel? Might the life sciences companies feel? Vidal Seegobin (19:07): So one common refrain when talking about private equity and their acquisition or partnering with traditional health care businesses like physician practices is that they are immediately focused on cutting costs. So they are going to consolidate all of the purchasing contracts, they are going to make pretty aggressive decisions about real estate, all the types of cost components that run the business. Now, if you are a kind of life sciences or a diagnostic business for whom you would depend on being an incumbent in those contracting decisions, you're worried that the private equity is either going to direct you to a lower cost provider, or in many cases, another business that the private equity firm owns as well, right? They would love to keep synergies within the portfolio of businesses that they've acquired and they partner. So if you were relying on incumbent or historical purchasing practices with these physician practices, it can be disrupted. Rae Woods (20:10): Yeah. Vidal Seegobin (20:11): Depending on the arrangement. Sarah Hostetter (20:12): And then I think there's a range of potential implications for payers. So you have some payers who themselves are aggregating independent practices, and they're targeting the same type of practices that the PE firms that are betting on value-based care are targeting. Rae Woods (20:28): That's right. Sarah Hostetter (20:29): They are targeting primary care groups who are big in Medicare advantage. So there's some inherent competition potentially for the physician practice landscape there. Rae Woods (20:38): Well, and I think they're trying to offer the same thing, right? They're trying to offer capital. They're trying to do that with the promise of autonomy. And they're coming up against a competitive partner that is saying, "I can do both of those things and I can do it better and faster." Sarah Hostetter (20:53): Yeah. And both of them are saying we can do it better and faster than hospitals. Rae Woods (20:57): Yes. Sarah Hostetter (20:57): That's the other thing, right? Rae Woods (20:58): Which that part's probably true. Sarah Hostetter (21:01): Yeah. Their goals are aligned and they believe they can get there different ways. And I think autonomy is a big sticking point here for me or a big bellwether for me, because I think whoever can get to value-based care while preserving autonomy is going to win. You have to have some level of standardization to do value-based care well. You can't just let everyone do whatever they want. You need high quality results for lower cost. That inherently requires standardization. So who can thread the needle of getting that standardization while preserving a degree of autonomy? Sarah Hostetter (21:37): It's fascinating, as we've had this calls, it was suggested multiple times that payers actually might be the end of the line for some of these PE deals. That there's a lot of alignment between what payers are trying to do with their aggregation and what PE firms who are investing in primary care do, and hey, payers have a lot of money too. So could we actually see some of these PE deals end with a payer acquisition? Because they're trying to achieve similar things, just differently. Rae Woods (22:05): What about larger market dynamics that we haven't talked about yet? I understand that the individual stakeholders that we just talked about might feel positively or negatively. Frankly, some might feel both at the same time. But what might this scenario mean for the market writ large? Vidal Seegobin (22:24): I say one natural conclusion I often come to is that private equity is one other player that is making health care entities larger and more connected. And Sarah and I and multiple other people have this conversation when we fast forward the tape is, does the future of health care involve mega systems with a lot of umbrella organizations under a bigger banner? And everyone's doing this somewhat independently, but we're all approaching it with the same levels of strategies in which, and converge on this bigger, this world of mega systems or mega entities. Sarah Hostetter (23:04): Well, and Vidal, as you talk about integration and particularly vertical integration, I have some outstanding questions on whether vertical integration is the way that private equity will go. Because so much of what we have seen is aggregation of like things and vertical integration requires just a level of... I don't want to say sophistication because that sounds wrong, but a level of a different value prop. Like you're just not trying to turn around ROI when you're getting to the level of vertical integration, you're trying to create an integrated health system with multiple business lines. That's hard and may not produce ROI as easily. Vidal Seegobin (23:43): I'm inclined to agree with you. And I come at it from a slightly different angle but come to the same conclusion, which is the time horizon that would be ideal for a private equity firm would be to identify a target and then to generate the return necessary within three years, if they could. And historically, when we're thinking about the sophistication, the complexity of vertical integration and making it run and making it work, I would be skeptical that you can do that in that short time horizon. What could potentially change is that the time horizon for private equity changes, right? Some of our conversations have indicated that the three to five year heuristic is being disabused for a longer time horizon. But I think we're converging on the same answer from different perspectives. Sarah Hostetter (24:29): Well, and I think you are also touching on an important distinction. We talked about the value prop before and how PE may be different. We say PE is another type of partnership, and it is a distinction that we should acknowledge, that the PE partnership is as it's defined now, shorter in duration. So therefore the goals are going to look different and the impact on a market is going to look different. Because you might have one investor that is coming in for even on a long end, five to seven years. You don't know who the next buyer is going to be. And it's likely what we're seeing right now is a lot of either trading between PE firms so that we have similar minded investors pick up that investment. But I think that's part of the concern is it feels volatile to a market, even if the what is happening is very similar across these different players. Vidal Seegobin (25:21): I went to a private equity happy hour last week. Rae Woods (25:24): What? Vidal Seegobin (25:25): Yeah. Rae Woods (25:25): Nerd. Vidal Seegobin (25:27): I know. Interestingly to Sarah, to your point, what's happening right now is private equity is asking about a potential acquisition for their 10 year plan. And if they are selling it off, they're asking for the 10 year plan. So I think that there's end of one, but an indication that the time horizon is going have to change, and maybe that makes value-based care more possible than before. But I think it's definitely something that's happening right now. Rae Woods (25:57): I want to come back to the context of this scenario, the context being that virtually every player in the health care market is seeing private equity as potentially a bad guy, right? Even those that have positive feelings maybe have some fears and may be willing to call PE the scapegoat. This is my question for the two of you. Is that even the right way to be thinking about private equity? Is the right question to be asking, is private equity good or bad? Or is there a better question we should be asking? Vidal Seegobin (26:30): I tend to take a somewhat philosophical point of view, and this is reflected in some of the comments that I made a moment ago that I think are important to underline. Private equity is an actor, a capitalist actor and it operates in a capitalist model. So they're trying to maximize returns, minimize risk, and do that as fast as possible. In the long scape of looking at all of these private equity firms, you can point to actors that did a good job, and you can point to actors that did a bad job. And so I think what the scapegoating ends up happening is we attribute the vagaries, the positives and the negatives of a market exposed health care system and we say, private equity is the one that's doing bad here. But in truth, they are simply acting within the rules that we've dictated or set for the way that we want to manage our systems. Rae Woods (27:20): So is a better question, is this a good partner or not? And private equity could be a partner or it could be any of the other people that we've talked about in previous conversations. Sarah? Sarah Hostetter (27:33): That's exactly the question that we decided to answer in our research instead. So we set out with this, is PE good or bad? That was the question that everyone wanted us to answer. And we instead started to discover some hallmarks that make for a good PE partnership with a physician practice or a more successful. One we've talked about at length so I won't belabor it, but what type of care is being delivered and how aligned are we on are both partners on that type of care? So are we betting on specialty care, fee for service? Are we aligned on value-based care in a primary care perspective? That's going to have impacts on how good quote unquote the deal is. Sarah Hostetter (28:12): Another big one when it comes to private equity is practice sophistication. So we have this idea with a private equity investment in a physician practice that you're either the platform, so you are the practice with the sophistication and the infrastructure that we're going to bring to scale, or you're an add-on. So you are coming in later, you're not going to get as sweet of a deal, so it may not be as successful for you or feel as successful to you even when it could for practice number one, the platform practice. We touched on this idea of quick growth. That's the third one. Are we really bought into this idea? Because people can think it's a good idea and then when it comes to doing the hard work of growing, things fall apart. Sarah Hostetter (28:50): And the two others that we discovered in our research are, Vidal actually allude to this, but no two PE firms are the same either. So PE firms can have a range of knowledge of health care and experience in health care. And just because a PE firm has been investing in physician practices doesn't mean they're a good fit to jump into value-based care. They need to understand the industry and the partners that they're working with. And the last one alludes to this idea that we were talking about before around what's happening in the market. The regional market dynamics actually play a big role. So what does the competition look like? How well can, especially in primary care, can you develop a regional strategy? We're still, we haven't really gotten to a ton of hugely successful national players in systems. The regional strategy is still really important. Rae Woods (29:40): As researchers, what are you looking at next? What are the unanswered questions that you have when it comes to private equity in health care? Sarah Hostetter (29:47): What it's going to do to value-based care. So we're throwing this money at value-based care. That's not to say that PE is like the savior that's going to bring us all to value-based care. That's not what I'm implying. But we have a large investor who is willing, or lots of money with many investors that are willing to take a bet on this in such a way that it may shift the dynamics to make it a more lucrative, or it might throw enough money at it to get us there. Vidal Seegobin (30:15): So as a fan of Marvel movies, I'm kind of having thinking about it from a multiverse perspective. So in the one hand, I think we can pretty confidently say that there's rough waters ahead economically. And historically, health care has been an industry that has weathered those waves pretty well. And does that result in more interest and more investment from private equity or other investors in health care? Or does other factors kind of slow down the aggressive acquisition and activity in health care? Because interest rates increasing means that valuations, future valuations have to decline or be adjusted. So I'm very curious about how macroeconomic forces will impact or influence private equity's participation in health care. My guess is that they'll probably still be at the same level, if not continue to increase. Rae Woods (31:04): Well Sarah, Vidal, I want to end our conversation as I always do, which is to give each of you the opportunity to give our listeners a takeaway. However, this time I'm going to tell you upfront that I want to hear multiple answers from you. Sarah Hostetter (31:17): Are you just doing this because I always give you two? Rae Woods (31:19): I'm just getting ahead of the fact that I know you're going to give me two anyways. And in this case, you probably should. What message do each of you have for private equity as they think about the future? Sarah Hostetter (31:31): For me, it is to not hide the ball. So when I talk to physician practices, they regularly tell me how they're surprised when they start to compare potential partners, how similar a private equity partner is to the other partners they're considering. So they may go in with a certain expectation and then PE comes in and they're like, wow, this is more similar than we thought. Because we know that so much of what makes a good partnership is alignment on goals and alignment on needs and alignment on things that we will not compromise on, you're better off not hiding the ball. So give the actual pitch of what you think of how you're aligned on expectations. Talk about how you're going to achieve growth. Nothing is going to make a physician more mad than if you come in and say one thing, I'm not going to touch your autonomy, and then you do it. So tell them what you're going to do and why you are the better partner to get them where they want to go. Vidal Seegobin (32:30): Private equity probably could stand to be a little bit more humble in terms of why they think that they are finding partners that work. I think generally they're making solid pitches and they are bringing expertise to bear and are providing a pretty compelling investment thesis. But I think that there's also part of the reason why they're being successful is because the incumbent players have a bad reputation when it comes to practices. Right? And I don't think that that's going to continue to be the case forever. There is definitely a spotlight in terms of what private equity is doing, even if their footprint financially is not as well documented as a publicly traded firm. But more people are going to get wise to the bad stories because people have an agenda to make the bad stories more public. And so I would probably echo what Sarah said earlier, which is your pitch is probably going to have to get more refined because more people are becoming aware of you as an actor. And that may not be to your benefit, even if you think it is. Rae Woods (33:35): And what message do you have for the rest of the industry? Sarah Hostetter (33:39): I think it starts where we started this conversation, which is, is PE the good guy or the bad guy? And I think that it doesn't matter, honestly. PE is here, it is investing in health care, and it's not going anywhere. And I think we play this good guy, bad guy card because it's a lot easier to debate, well, should it be here? Rae Woods (34:00): Yeah. Sarah Hostetter (34:00): Right? It's easier to say, oh, but it's bad and blame private equity than to figure out what we do with the fact that private equity is a player in the health care space like full stop, not just with physician practices. So for everyone else, figure out how we adapt, because private equity isn't going anywhere anytime soon. Vidal Seegobin (34:22): To build on Sarah's point, I would advise incumbent health systems, players in the health care ecosystem, don't bet so heavily that non-incumbents like private equity are going to run up into the barriers and walls that we've traditionally known that hinder our progress here. I mean, we all kind of index on, well, you look at what happened with Haven, same thing's going to happen in private equity. These actors are very sophisticated. They are very targeted in their approach and they have a very clear end game that they're playing towards. And if you think that when they come to know health care, they'll realize how hard and difficult it is, is a bet I wouldn't be 100% confident making if I was them. Rae Woods (35:07): Well Sarah, Vidal, thanks for coming on Radio Advisory. Sarah Hostetter (35:11): Thanks for having us. Vidal Seegobin (35:12): Thank you. Rae Woods (35:13): Vidal and Sarah are right. Private equity is here in health care and they are here to stay. But there's one important caveat to that. You are not a passive actor here. It is not a matter of simply absorbing what private equity is going to do to your health system or to your physician practice or whatever part of the health care system you are in. There are always steps that you can take to engineer the right path forward, even as these disruptive forces come to your market. So remember, as always, we're here to help.