The future of virtual care

Stephanie Schomer, Editor-In-Chief, Employee Benefit News; Bill Goodwin, Senior Director II, Walmart Virtual Care Lead; Ted Dixon, Chief Executive Officer, Dixon Associates

Transcription:

Stephanie Schomer (00:08):

Hi everyone. Thanks for joining us today. Thanks to my lovely panelists for being here. We're going to discuss the future of virtual care. Obviously a big topic today and in the past few year some. I'm joined on my far right by Bill Goodwin who leads all virtual care for Walmart and Ted Dixon, CEO of Dixon Associates. Before we dive into the talk today, if you guys could both just share a little bit about your organization, your role within it, and how you guys are kind of working with virtual care.

Bill Goodwin (00:38):

Yeah, sure. I'll start. Happy to be here. So Bill Goodwin formerly the CEO of EMD. We're the telehealth company that Walmart acquired about a year ago. And within Walmart, I think everyone knows a little bit about Walmart's footprint but just to give an idea, we are in about 5,000 different locations. We are in 4,000 medically underserved areas. So a huge opportunity to impact that population. And the great stat that I heard coming in, which was phenomenal, was 150 million unique individuals walk through a Walmart each week. So pretty big scale and opportunity, and what we're trying to do is really impact healthcare on a scale that nobody's done before. So

Ted Dixon (01:22):

Good morning. My name is Ted Dixon and I'm the CEO of Dixon Associates. We're a classic benefits consultant broker in the Boston area. We serve about seven, 800 corporate clients doing all things benefits but have taken a real look over the last five, six years about how our clients' health plans work how we can make them work more efficiently. And obviously virtual care has become a huge part of that.

Stephanie Schomer (01:54):

Absolutely. I think if we were having this talk two and a half years ago, it would be very different. But to say that point, I wanted to talk to you both about adoption. How have the views around virtual care really shifted as a result of the pandemic, and what are the nuances that you guys are seeing in attitude among employers and employees and providers?

Bill Goodwin (02:13):

Yeah, so I'll, I mean, obviously when Covid hit, we saw a massive adoption, especially in the medical space of our business. And then about 12 months later, we saw the kind of lagging effect of behavioral health adoption around therapy and talk therapy. And what I think was most unique about it, while most people I think have now had a virtual visit or two, and that's across all demographics, whether it's the Medicare population or whether it's the uninsured or what we have started to see is provider adoption. And that was one of the big issues we had in the past was providers didn't wanna do it and partially because they didn't get reimbursed for it at the same rate, a lot of that has changed. And now not only do employees want it, providers are willing to do it, and increasingly insurance plans are willing to pay for it. So virtual care, in our opinion, is here to stay. And I think, we'll, we're going to continue to see it evolve at a pretty rapid rate now because of all the benefits of virtual care to meeting people where they are and trying to reduce cost.

Ted Dixon (03:12):

Yeah, I think certainly the pandemic changed the conversation. The conversations that I was having with HR directors, owners of businesses, we had virtual care embedded somewhere within the health plan but didn't really give it much thought, do we have it? Great, okay, check the box. And all of a sudden we started to realize, wow, this is something that we have to have now. But we realized our employees were probably begging for this before we just didn't pay attention because yes, everybody got so busy during the pandemic, but they were busy before the pandemic. People didn't have time even to get to urgent care on a Thursday afternoon. It's just hard to do. And now all of a sudden it's like, wow, if the employer groups that recognize this and put it in place in a creative manner that meets the employee's needs, Truly needs. And it's fun because mm-hmm seeing it, we're living it in our own lives. The president of the company hr, they're living it in their own life now. So it's a neat coming together of the need and the services that are there.

Stephanie Schomer (04:23):

What have you both seen in terms of the impact virtual care has on health outcomes?

Bill Goodwin (04:28):

Yeah. Well, so we're starting to see a lot more data around health outcomes. I mean, that was one of the, I don't wanna say knocks on virtual care, is that where is the proof in the data? You can walk, Ted and I were talking about this earlier, you can walk around this trade show and see a lot of the different firms that are trying to impact some of the very costly aspects around chronic care management and how we look at that. And data is now starting to come in to say it's improving health outcomes. And the big challenge with any virtual program is how do you drive engagement and adoption? Because if you can do that, then you actually can improve health outcomes. And payers are starting to see it too. So we're starting to see payers say, okay, we have to do this because ultimately it's going to lower our overall cost and it's getting there. I think if we look forward five years from now in terms of the impact of virtual on health outcomes, we'll start seeing some really compelling data. And again, that just targets into the shift of VIR where we're going with virtual. That's going to continue and I think pretty aggressively over the coming years.

Ted Dixon (05:26):

So we had a specific situation this spring and I was talking to another broker outside and we were talking about how, well, what does the future look like? It kind of looks like the past. We found a solution for client of ours, a medium sized manufacturer just outside of Boston. It's a hybrid virtual care with home visits. And it's all, it is a service that was provided to nursing homes before. If you have somebody that's relatively ill at a nursing home, the last thing you want to do is bring them to the emergency room. So this service comes to the nursing home and they say, well, we could do this to people's houses in certain demographic areas for employer sponsored plants. And as you can imagine, and I had the conversation with the owner of the company, do as much as an ultrasound or an EKG in your house. And I said, think of the savings to the health plan. If we get an EKG done on a Thursday night instead of a massive heart attack on Tuesday afternoon, think of the plan savings to the plan there. The other neat thing about that was, I mean I've been doing this for close to 20 years now. It was the first time we had an open enrollment meeting where the guys from the factory floor stood up and gave us a standing ovation when we introduced it to them. I haven't, that hasn't happened in an open enrollment meeting in my 20 years. So it was pretty cool.

Stephanie Schomer (06:51):

That's preety good. Well, I wanted to ask you both to expand a little bit on that idea of cost. How does this cut cost for employers and employees alike?

Bill Goodwin (07:02):

Go ahead. Mean While

Ted Dixon (07:03):

I Mean this service that we brought, it's on a per employee per month. And that cost fluctuates based on usage. It starts at $4 per employee per month, and it's a $0 copay for the employee. So again, I'll go back to that example, an EKG in your house at a $0 copay and imagine now imagine the savings to the plan when that the employee realizes that they can do that without leaving their house. And that situation is caught so early. I mean it's a no brainer.

Stephanie Schomer (07:37):

And surely the people who are actually having that EKG done in their home, that's not the normal. That's not happening every Tuesday

Ted Dixon (07:44):

As far as I know. It hadn't happened since the 1920s. And that's kind of how perverse our healthcare system has become is that's now a more affordable way to do healthcare, bring it to somebody's house than it is for them to actually do it the way we've been doing it the last 30 years.

Bill Goodwin (08:01):

And the only thing I would add is when we start looking at the where healthcare virtual care is evolving, especially we talk about urgent care that everybody thinks of and now behavioral health, and now we're moving into more virtual primary care and employers and especially your larger self-insured employers are starting to play with primary care, virtual primary care in particular because the goal is to, with what primary care's number one purpose is really to not only prevent but catch things early. And if you can do that, basically for every dollar you spend in primary care, you save 13. So if they're able to funnel people into a virtual wellness visit versus, for example if I'm an hourly employee and I have to take half the day off to go see a doctor, I'm not going to do that. I can't afford to do that for my family. And so therefore the more we can push on virtual, we're going to continue to see employers are getting there, but it's slow. It is a little bit slow. And then for employees, they're now in may circumstances getting more options to where virtual is $0. Because if I can catch it early in virtual primary care, fantastic. If I can keep a claim outta my self-insured plan even better. So employers are even more embracing virtual. Still the challenge of trying to drive adoption. But I think that's just online bank. Nobody did online banking 15 years ago. And now I think everyone, that's all we do is online banking adoption will continue to grow as long as employers continue to drive virtual. And if they don't, I don't know how they can chip away at some of these increasing costs that they continue to have. And same with employees in terms of increasing costs of healthcare.

Stephanie Schomer (09:40):

What are some of the best methods you've found in terms of communication and education to really push that adoption further? And like you said, that 150 million people walk through a Walmart store every day, that's such a crazy statistic. But from your perspective, how do you get those people who might be resistant or not comfortable to really understand the value and that it's available to them?

Bill Goodwin (10:02):

Yeah, so some of the data we saw in our data is basically the first time when somebody has a virtual visit, they then come back 2.2 times in the same year. So it's like once you try it, you're like, oh wow, that was great. I could do that from my home or not have to take time off. And so getting that initial engagement and adoption, it's a lot of messaging. Let's talk about it from an employer standpoint is continual messaging. It's support, it's reaffirming the benefits of it. It's a lot of follow up in terms of communication. Now when you start talking globally and looking at 150 million people and that we have through the stores, that's a different messaging that we're doing. But ultimately anything, you try it once and then you're like, wow, that wasn't so bad. I think we had to continue to push for that adoption.

Stephanie Schomer (10:48):

What does that look like from your end?

Ted Dixon (10:50):

And so there's a long adage in my family, you need to be pleasantly persistent. And again, I think the pandemic really changed things from our perspective. An open enrollment meeting used to be me on your loading dock on a Monday morning at 7:30. And that was that well, how did the spouses independent benefit from that? They don't, all of a sudden during the pandemic, we found video, right? Two minute video clip, Hey, this is a benefit that you have. And that gets emailed to the employees and their spouses and dependents. But even that, we still run into, I don't even know we have this. People are so busy. So that's where the pleasantly persistent comes in. You gotta keep sending those videos, keep sending the reminders throughout the year, not just at open enrollment.

Stephanie Schomer (11:46):

I know you both anticipate that this will only accelerate exponentially in terms of adoption, but what are some of the obstacles that still remain?

Bill Goodwin (11:56):

Yeah, I mean there's quite a few. I mean, I think everyone here, let's just talk about technology. One is broadband access. A lot of parts of the country still don't have good broadband access. That's why you see bills floating around pushing to try and expand that. You have also technology literacy in terms of even being able to work at the most simplified app on a phone. That's a challenge too. You continue to have payer reimbursement challenge. What will payers reimburse for? What will be at a reduced rate? What will Medicare eventually do is it looks at telehealth and different types of support there on that. And those are some of the biggest barriers. The other thing that you also have in a lot of applications is I want to call cultural bias, even in AI driven applications and things that don't meet a lot of the needs of the different populations that we have. And so there's quite a few things that are barriers for us to really, I'd say even more rapidly expand that we're than what we are doing today and we need to address those.

Stephanie Schomer (12:52):

Anything to add that?

Ted Dixon (12:53):

Yeah, I'd just add that it's kind of at the same point, it's mindset. And I give the people who are here a ton of credit because they're here opening their minds to all the vendors that are here in this hall. And I would say nine out of 10 HR people that I meet with, it's all about I have to have the brand name network for my employees and then that's it. I think those businesses are going to fall behind the businesses where you have all the stakeholders, HR, CFO, the CEO willing to find these solutions for their employees because from a mindset perspective, I still see the most of you just aren't there yet because it takes little creativity, it's hard. It takes the education to the employees. And I give you guys a ton of credit cuz you're here cuz you're willing to do that.

Stephanie Schomer (13:50):

I have two follow ups to those points. With respect to payer reimbursement, how are you seeing that shift? I know there's ways for it to go, but what's changed so far in the past couple of year?

Bill Goodwin (13:59):

A lot's changed. I mean really early in the pandemic, I shouldn't say early, but shortly after the start you might have seen there were some of these virtual first plans that we're payers were piloting. We're starting to see more of those. We're also starting to see more of those and where they're partnering with self-insured employers to do some of these virtual first programs. We're seeing that we're seeing a lot of different discussions that are happening in terms of from our group that works closely with Washington around Medicare reimbursement and what that looks like long term and changing some of the stipulations that they're there long term so people can get care. I think that will take a little time to evolve as well in terms of what will payers reimburse for and at what rate. And ultimately, again, it does get back down to the physician because a physician's going to practice medicine in a way that they get reimbursed as they should for their, so there's kind of this synergy between payer movement and provider adoption that we have to continue to press on.

Ted Dixon (15:00):

Yeah, I think that's huge in the marketplace right now. And again, I go back to mindset. A lot of the folks that are running businesses and certainly running providers and payers, we started working in the late eighties, early nineties. When you had Blue Cross Blue Shield, you didn't pay anything for it. And we're still stuck in that mindset. I think the employer sponsored plans that get no, our new employees, they don't attach that same importance to Blue Cross Blue Shield. They want care. So you really have to creatively find vendor partners that are willing to be nimble and flexible about bringing all those stakeholders together. And they exist. They're out there and you just have to partner with them. And when you have a payer that is working on your behalf, your money, your employer sponsored healthcare, your employee's money, and that administrator is willing to actively engage with the providers and say, Hey, this is the way Stephanie's plan works, would you be willing to work with us? We're not going to starve you. We're going to pay you a fair amount. Well that's awesome because now we have plans where we're getting mental health providers, for example, that have never accepted insurance before. Now all of a sudden we are able to say to Stephanie, Stephanie, that mental health provider that you were paying $300 a month to see because she wasn't taking our insurance, she's now in network. So you can bring your daughter there four times a month for a $25 copay. Those are the kind of, and it speaks to what you're talking about, bill, we've gotta get around, oh okay, this is the set reimbursement that you get from Blue Cross Blue Shield. There's gotta be engagement there. Nobody's trying to rip a provider off. They get paid highly because they're highly trained and they're valued. But it shouldn't just be locked in stone because that's the provider's payment. And to have mental health therapists say, well then I don't want that. There's a way in which you can bring those providers into your network for your employees. You just have to be creative with it.

Stephanie Schomer (17:15):

I'm glad you brought up mental health care. I wanted to ask you guys about that. Obviously the pandemic brought on a mental health crisis that we're still very much in. And virtual care really rose to the challenge. And I think a lot of people who were uncomfortable with mental health care at all and also virtual care, those things came together and provided a solution to them. As we move forward into this future where to your prediction virtual care will really be prevalent in the decade ahead, where does mental healthcare fit into that and how are you seeing that ship that's so encouraging to hear about? Cause you're right, it's still out of range in terms of cost for a lot of people. So I'm curious about what kind of shifts you're seeing in that landscape.

Bill Goodwin (17:54):

Yeah, so I mean if you had to think about if there was one silver lining of covid I know everyone talks about how Covid exacerbated and made mental health worse. It was pretty bad before covid and it wasn't safe to talk about at work. And employers would've provide an EAP plan and be like, okay, I got it. Well that that's not ongoing mental health treatment. That didn't really help people. And so the one bright spot was all of a sudden now it became a little bit more to talk about it and people started talking about it. And I think employers and some embraced it head on. And you probably saw early on companies like Starbucks and Apple started doing stuff early and then other employers maybe reluctantly started getting on board with it. But we're now getting to that point where mental health is really okay. And don't get me wrong, there's a lot of things employers need to do to actually drive adoption and make it safe for people. They need to do that. But when you think of virtual care, oh my goodness, how could there not be a better solution to help with mental health? People can do it from their home. They don't have that stigma of driving to a behavioral health office. They can do it when they have time, they can do it by video or by phone. And there's lots of applications out there now where you can do it by text or you can leverage AI chat bots or different things like that. So I'm most excited about mental health and the market's still really fragmented. And I'd be curious to get Ted when he starts talking about from the employer perspective, but if we really treat mental health, we all know how much mental health impacts physical health. There's a big correlation between the two. And we were studying mental health because a lot of employers will say, well, I don't see the ROI on this. I don't see the outcome. Well, Deloitte did a study and I think this was actually pre pandemic and they saw that they had a hundred percent ROI in their first year and 231% ROI on mental health programs. I don't know how you get a better ROI on a benefit program than that. So I think it's incumbent on all of us to really push and drive more towards mental health and leverage things like virtual care that really bring the care to the person in a place that's safe and accessible.

Ted Dixon (20:15):

It was funny, I was joking with another broker yesterday. We were talking about EAPs and right when the pandemic hit, I feel the dozens of calls, Hey, we need an EAP program. You have an EAP program. The HR directors didn't even know that the EAP was embedded with your long-term disability or something like that. But oh my gosh, now it's a need. And I mean to your point, bill, mental health is such a driver in costs. I mean, my wife tells me every week your alcohol intake is what's going to kill you. And my alcohol intake comes from somewhere within my mental health. So, it's so obvious and it's a silver lining. You're right that now we're paying attention to it where our eye is on that ball and we can start improving it in our employer sponsored plans.

Stephanie Schomer (21:19):

And for sure. And the impact on productivity and presenteeism and retention is significant. And I'm sure I don't have to tell you guys that the talent market is still strained. Are you hearing that a lot of employees want not just virtual care but really strong access and easily accessed mental health support?

Ted Dixon (21:40):

For sure. And again, it gets back to a generational thing. My 25 year old daughter, her thought of going on a train and going to see a mental health therapist, just not within her bailiwick, but my idea of getting on my phone to see a mental health therapist, the one that needs the help, but we need to get that 25 year old so it's easy for them to access at a $0 copay, by the way

Bill Goodwin (22:16):

And I have a service for you, if you need some mental health, get you for free.

Ted Dixon (22:21):

Download the app right away.

Bill Goodwin (22:23):

Here's the challenge though. Some companies really embrace mental health and then they're like, okay, I provided this great benefit but nobody's using it. Well the employer has to do more than just provide it. Like you point out, we had a paper, nobody knew about it. Employers really have to mental health make it safe. There's this fascinating six minute thing on like NPR from six years ago and it was one of those stories and they construction worker on a Friday hands his tools to everybody else and nobody really thought twice about it. And then on Monday they learned that he committed suicide and this construction firm really reacted and said, okay, we gotta do a lot more. Because a lot of people in construction, at least with this firm, previous vets or maybe had some challenges in life and all that, and they're like, we gotta do better. And they made it safe. They did trainings, they put together peer groups, they talked about it every week. And if an employer doesn't do that, it's going to be the same issue, Ted, that you mentioned. Five years from now I'll be, another crisis will happen. They'll be like, well, I need a mental health program. You're like, well, you already have it. We really need to really push employers and all of us as employers to make it safe. And again, the ROIs there, productivity increases, presenteeism decreases, we have to do that. Employees want it still gotta make it so they feel okay using the service

Stephanie Schomer (23:48):

Bill. You had mentioned to shift gears a little bit, the idea of cultural bias in virtual care and in some of these AI tools and very fairly, you said we need to start addressing those things. What are the first steps to making sure that care that's provided that embraces AI is fair and equitable?

Bill Goodwin (24:08):

And I know there's some AI companies here too, and it is really, well, what are you in terms of who are you engaging, what data are you leveraging and how are you using that in some of your modeling? And then what are some of your ongoing inputs into it? It's a bigger discussion. And again, the cultural bias can be extreme or it can be small and nobody designs it with that intent. But you know, think about a lot of things in terms of communication and language and how that may change by different groups or ethnicities. And we need to start addressing that especially when we think of trying to extend care to groups beyond the self-insured population where a lot of people are on PPOs. You had to think about how do I get this out to people who need it, who may not have the same access? And so a lot of it is just really redeveloping our models. And even beyond ai, Stephanie, there's a little bit of bias, cultural bias obviously in care delivery. And so that's something we had to continue to work on and how do we remove that bias in training and who our providers are and how we interface with them. That's a bigger challenge for the overall healthcare system, but a huge opportunity.

Stephanie Schomer (25:14):

Absolutely. I also wanted to ask about to the point of technology in the home and people being comfortable with it as virtual care becomes a more everyday part of our lives. Bill, when you and I spoke before, you were just talking about the equipment that you anticipate people will adopt into their homes to enable the kind of care that Ted had mentioned in terms of you're not going to have to go to your doctor and get the EKG. What are homes going to look like in 10 years and how is this going to require employers to offer additional education and additional support and make sure that their employees have access to those things in their homes to embrace that care?

Bill Goodwin (25:57):

Yeah, I mean I think we will see a fairly high degree of transformation over the next 10 years. And right now we're consuming care virtually from home or from other places. That's pretty straightforward. We're sick and we don't feel well at two in the morning we have a visit or we do therapy or we do a follow-up visit with one of our physicians. We're starting to see more and more where especially around chronic care management, where we're enabling patients with devices in the home that they're going to utilize that you see companies like Tito who have devices out there that are targeted more for the general population and urgent care type of conditions. That's changing. But I start thinking about everything from labs, having people come to your home for labs versus you having go into a lab. So just think while it's virtual, strongly believe in 10 years, especially for a lot of people in this room, how much of your care will you not have to leave the house for it? It's going to increase dramatically. I don't think we'll get to where online banking is today in 10 years, but there's so much pressure on so much cost in the system, cost to the employer, cost to the individual. It has to move that way. We just have to continue to try and push to accelerate it cuz it benefits both parties.

Ted Dixon (27:14):

And I'd like to speak to how that addresses your previous question as well. Reaching a larger population this is a great opportunity for you. I think of that medium size manufacturer that we have in Boston when we brought them this hybrid virtual care a large portion of their population isn't on the health plan because they're on Medicaid. Well, Medicaid is great, particularly in Massachusetts cuz we have such a high bar where you can access it, but you have a hard time accessing good doctors and facilities on Medicaid. So this employer was able to wow now because it's not part of their health plan and Bill's product will be the same is you now have a benefit that part of your population was not benefiting from on your Blue Cross plan. This is a great benefit to them.

Stephanie Schomer (28:10):

We've talked a lot about generational divides over the past couple of days and we touched on a little bit, even just you talking about your daughter and how you guys approach care differently in terms of virtual care, I think it's easy to assume that a younger population is quicker to embrace it, but Bill, you and I have both talked about our parents and how this is actually really improving their health once they figure out that it's easy. So I'm just curious about what you both have seen in terms of these five generations that are in the workplace. How are they responding to this differently? How are they embracing it differently?

Bill Goodwin (28:38):

Yeah, so we see a few things. We see people who are in, I don't want to tell people how old I am, but in my age group who are now starting to take care of their parents and they're trying to help their parents navigate some of this. There is an issue when you're 80 year old mom. I mean she's been going in person to a doctor and wants to see Dr. Smith in person. That's the way she wants to do it. If you can get her to the well and have the first visit, she's like, wow, that was great. But because Covid has gone on so long, the percentage of people, let's just say over 65, they've had a virtual visit, they still prefer her in person, but they're actually okay with virtual and they like it in some circumstances, especially when mobility becomes an issue. Then you have my generation, whether it's parents or kids that you're doing it and then you have obviously the people who are under 40, even under 30 and really everything is virtual. I mean, my God, why would I want to go into a doctor's office if I can avoid it? I think we'll continue to see adoption increase, but at the higher age levels it's going to be a little bit slower and then that will phase out a little bit obviously over time with people who are 15 younger and continue to be primary drivers of adoption.

Stephanie Schomer (29:52):

Are you hearing anything from your clients about how to juggle these kind of different responses?

Ted Dixon (29:57):

Yeah, I just go back to the classic 60 year old machine curmudgeon has been so tickled by the fact that now he can just tell his spouse go on and watch the video, don't stop harassing me about what my benefits are. So it really has been a great benefit there and I see that and it's obvious that the younger generations are going to adopt it, but the older folks are definitely seeing the value as well.

Stephanie Schomer (30:29):

Like the term machine curmudgeon. I think we have time for a question or two if anyone wants to add, otherwise we'll let these gentlemen go.

(Audience Member) (30:39):

Thank you for this presentation. Appreciate you guys putting this forward. One of the question that I have involves ancillary care your dental, your vision, and they during the pandemic really suffered a lot because they couldn't figure out virtual care. You still have to do just go and in the eyes. And so I don't know, there's a great answer, but just looking for the opportunities around, you can't do the body without the head. So how do you get into ancillary care in a virtual way? What are the opportunities that are there? Again, I don't that we have the best answer today, but it's something that is a challenge. Yeah, you can do the medical, I get it. There's a lot of opportunity there, but when we think about the ancillary, there's still that touchpoint that is necessary. So what are the largest opportunities in the ancillary?

Bill Goodwin (31:41):

Yeah, I'll take a stab at I there's, there's so many opportunities and you're seeing some adopt virtual more quickly and a lot of that has to do with the type of medicine or care that's being delivered. So for example, Bell optometry is actually growing pretty quickly and you'll see more and more Bell optometry. Wow. How do they do that? How's that technology work? Well, there are some technology barriers that are being addressed to help with that, but there's some things that you do for well eye checks and things like that that you can do virtually. And for dentistry, same thing. There's some things you can do, you can't do today as much as you can. If you think of a primary care visits and a lot of your well checks you can do 80% of, depending on the primary care physician you ask, you can do somewhere between 65 to 80% of the visits they do virtually. Well, that's not so true on dentistry. There's not as many you can do. What I think we're really moving to, and you bring a really good point, is some of the technology has to advance to be able to do this and most likely from a smartphone. I mean, here's a great example, right? Teledermatology, 90% of dermatology can be done and is starting to be done through a phone with its our phones have incredibly high resolution cameras on them. So it's amazing what you can do with that. You also have things like title or other devices where people can do a little bit more in internal inspection into the ears or into the areas that technology still has to continue to advance, but I think you'll see a slower adoption but continue to see increased adoption back to the primary drivers as to why people are starting to virtual care. My out-of-pocket is killing me and as an employer How do I keep passing through these benefit increased costs? And I'm sure you see this all the time, Ted, how do I keep passing this through? How much do I put on employers? How do I even afford it as an employer? So obviously I'm pretty passionate about virtual and I think we'll move that direction. But you're going to see, depending on the specialty or area of healthcare, some accelerate at faster rates with others coming a little bit more slowly. And with those others, a higher percentage that has to be in person.

Stephanie Schomer (33:54):

That's a great question. Thank you. I think with that we can wrap it up. Thank you both for being here. Really, really great chat. Thank you all. I think we're free to go to lunch now, so appreciate your time. Thank you.