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The Innovators Exchange with Kaiser Permanente

As a successfully tenured physician recruitment leader with The Kaiser Permanente Mid Atlantic Division, Mr. Robert Hickey delivers comprehensive sourcing and recruitment services to the Primary Care, Radiology and Hospital Based Medicine and Acute Care Departments of the medical group. With over 30 years of experience in the financial and healthcare industries, Mr. Hickey is a passionate communicator in articulating the advantages of the Kaiser Permanente model of integrated care delivery and is an award winning thought leader within the medical staff development industry.

 

 

 

TM: Mr. Hickey, when did you first realize that you wanted to pursue a career in healthcare?

 

RH: I knew way back when I was going to college, I liked healthcare and I really wanted to get into it. Healthcare was going through some major changes at the time. We were coming out of the recession of 1982, and it was not a good time in healthcare with the introduction of DRGs and utilization management. The only thing in business I did not want to do was banking, so of course I did 30 years in banking. So…

 

The head of HR at one of the banks that I worked at became the head of HR at The Mid-Atlantic Permanente Medical Group (MAPMG) and they had a new initiative where they had to hire a whole bunch of physicians. I was starting a company at the time, and I said, “I don’t really have time.” She said, “You can give me four hours a day.” I said, “Absolutely not.” So, then I gave her four hours a day and informed them “You need two recruiters full time.” And she asked, “Can you give me full time?” I said, “Absolutely not.” Two weeks later, of course I was giving her full time. I was in the mortgage industry running my own company, and the mortgage industry was not doing well. I was having a good time being a recruiter, they had hired one, I decided to throw my name in a hat and I have never looked back. It has been a lot of fun.

 

TM: Bob understanding it is your ten-year anniversary at MAPMG we wanted to say congratulations. Given all the success that you have had personally here for MAPMG, in leading and growing the department to where it is today, what have you seen to be most effective in recruiting a recent graduate?

 

RH: Number one is trying to meet them where they are, finding out what their expectations are, and what they want to do. The demographics have changed as far as attitudes and where people want to be in their lives. Recent grads and physicians out of residency within the last three years, want work/life balance. I constantly ask them, “Can you please define work/life balance,” because not everybody defines it the same. What I have found is that they are very honest about wanting a family and personal life. They are willing to commit to 0.8 FTE, which is 32 hours of working a week and they will give you a very, very hard 32 hours.

 

The specialties that medical students are choosing to pursue are always changing. In 2008, very few people were going into radiology and it was very difficult. Five years later, graduates in Radiology began to rise and it became significantly easier to recruit.

 

The other thing is the changing economic climate. In 2009, Medicare changed the reimbursement cutting the reimbursements as much as 50 to 60 percent for some of the procedures cardiologists were doing. Well, cardiologists were not retiring, because they were not in a position to retire. So most of them added five years to their career.

 

When I first started, I saw a trend where there was going to be a significant shortage of primary care. Primary care salaries tended to be lower and graduates were encouraged to pursue specialty care. The Primary Care field was predominantly male and internal medicine based. That trend has changed, and now primary care is predominantly female and its predominantly family medicine trained

 

Populations are aging; 10,000 people are turning 70 every day. There will be an increased need for geriatric medicine trained physicians. Family medicine graduates are trained in women’s health, dermatology, and pediatrics. I tell a lot of the younger people that are starting family medicine residency, “I think you made the right decision to go into this. You can see from newborn all the way through. As soon as you finish, take every CME you can in geriatrics, because you need to brush up on that, because that’s going to be the area that’s the biggest need.”

 

TM: What have you seen to be most effective in recruiting a physician who is currently in practice?

 

RH: Medical practices have changed and continue to change. What we have done effectively is sending out blast advertisements and emails, “If your practice has changed, maybe it’s time to change practices.”

 

Unfortunately, medicine is a business, RVUs become a big deal, and we do not look at RVUs. We do not think RVUs have anything to do with quality medicine. We do what is medically appropriate and not what is medically justified. We find the more people who understand our practice, the more they gravitate to it.

 

TM: The immense success that your organization has had regarding physician retention — is there one defining program or quality that you have been able to identify in being such a market-leading presence in terms of physician retention? What are you seeing to be most influential in that arena?

 

RH: Success begets success. The healthcare system we are today, is not the healthcare system we were in 2008. We were number 235 in the nation out of over 400 healthcare delivery systems, based on NCQA ratings. We affiliated with our Northern California group and we received a commitment of $1.5 billion from the Kaiser Health Foundation for our region.  We got the infusion, we had a lot of very talented physicians that did not have all the right tools and equipment to deliver what they wanted to deliver.

 

The three things we look for in a candidate is collegiality, passion for medicine, and patient-focus. All of our physicians have that. With the affiliation, we initiated the following: patient access, quality medical care, and member satisfaction.  MAPMG was becoming the true integrated healthcare model that Kaiser was meant to be. People can get all of their care in one location. Our medical centers have labs, pharmacy services, and radiology.

 

TM: So, a true ACO?

 

RH: Yes. We were a patient centered medical home long before they coined the term. We have utilized an Electronic Medical Record System since 2004. We are the largest user of Epic and we have done a billion dollars’ worth of renovations, so that we have proactive care.

 

Most importantly, all of our physicians are tied into that record, so they can see things real-time. For example, in 2008, we did not have PACS, which is the system for looking at imaging results. We integrated that into our electronic medical records. Now our physicians can see the picture and see the report at the same time. They can share that picture and share the report with their patients at that time.

 

And a large part of this is getting your patient to buy into their own healthcare. So that’s been exciting and fun. So, we went from number 235 to 85 to number 15 in the nation. Cinderella definitely arrived at the ball. Johns Hopkins was our top competitor in the area, and we blew past them. And why? We invested the time, the energy, and the talent to make it happen. I think when you are number 235 in the nation, you’re just trying to get through the day as best you can. When you get to be number 15 in the nation, you realize there is only 14 ahead of you and you can see that you could win.

 

We set a goal for ourselves in 2009. 80 percent of our patients to be seen in ten calendar days through every specialty including dermatology. By February the following year, we were hitting it in every category including dermatology. So, again, the success begetting success. Tell me all the tools and equipment you need to be successful, and we told them, and they delivered. A large part of that they threw back on recruitment. They said our success is going to be the result of your success.

 

If you cannot get us these people, we got a problem. So—

 

TM: It is a symbiotic relationship in terms of what you have to present to the marketplace has to be accurate, specific to the reality of practicing medicine for this health system.

 

RH: And the other thing, too, is having our physicians believe that this can happen, because, for years, they struggled, because they did not have the finances and the tools and equipment. Once we got the physicians to believe and we started delivering, it was time to get the community to believe. When you talk about Kaiser Permanente, most people will think West Coast. I did not even know it existed here.

 

But what I’m excited about is a lot of the same physicians were here prior to the affiliation and made this happen.  Then we started hiring up a storm. We hired super talented people, and they integrated very, very well.

 

The way we onboard physicians is key. We do not throw them in the deep end. For example, in primary care, they see two patients in the morning and two in the afternoon the first couple days and then one patient per hour for an extended period of time, then we start adding in two. They have to get used to our patients; our patients have to get used to them, so we bring them on appropriately.

 

In 2015, we had incredible growth. We brought on our physicians the exact same way, which was very hard on our veteran physicians – but they sucked it up and did it because they knew what was appropriate. I think that gave us a lot of credibility with our newer physicians.

 

We also really improved as far as interviewing, asking the appropriate questions, fully disclosing what the job entails, etc. Instead of assuming, we found that our number one reason why people leave us is a trailing spouse; the number two reason, retirement. A distant third was going back for fellowship. 63 percent of the people want to be where they have family, 30 percent where they trained, seven percent go, “Oh, this is a cool place.” That seven percent does not stay.

 

Targeted advertisement, targeted recruitment, and establishing great relationships with the residency and fellowship programs are a big deal. We are also tracking where we are getting our candidates from more closely. What’s really, exciting is, in the last year, 40 percent of our physicians came from referrals of current physicians. They believe in our system to the point where they want to recommend us to their friends, and people like to work with people they know, people they like and people they trust.

 

TM:  From a trend standpoint, it is very obvious that your organization was at the forefront of the ACO transition and population health management, continuity of and continuum of care – from a specialty standpoint, what trends are you seeing within the marketplace?

 

RH: Within the marketplace, we have physicians that are not going for cardiology, hematology and oncology because they cannot find a job. So, there are some market-driven factors like that as far as their ability to find jobs. What I tell internal medicine physicians that are considering a specialty, I say if you have a true passion – go for it. If it is not a true passion, you may want to consider either primary care or hospital-based medicine. Hospital-based medicine, I think, was very, very underrated as a specialty and in the last couple years, people are seeing, “Hey, this makes a big difference.”

 

TM: The number of board-certified hospitalists is smaller than the total number of individuals that are actually practicing hospital medicine.

 

RH: Correct, but internal medicine trained is very, very well trained in hospital-based medicine if they go directly into it. They lose that confidence if they do primary care and then switch. Also, medicine has become so comprehensive and so intense, I think having the two different career paths of hospital-based medicine and primary care has worked out very well as opposed to seeing your primary care doctor during the day and you ran to the hospital in the evening. Additionally, medical technology and medical knowledge has kicked up so high that it’s very, very difficult to maintain that informational knowledge in all areas.

 

TM: The changes that have been evolutionary and revolutionary that your health system has successfully employed and that health systems are still tasked with are cost reduction and cost containment at least – we are all being tasked and asked to do more with less. Bob, are there any trends that you’re seeing within your organization from the standpoint of cost containment and cost reduction measures impacting your ability to go to market and successfully recruit the providers that your patient communities need?

 

RH: The way we are set up saves a ton of money and it makes a lot of sense. Our use of an integrated EMR removes the duplication of tasks. We order about half the number of tests that the fee-for-service world does.

 

The reason being is because once it is done, it does not have to be redone. Patients will go to their primary care physician and cat scan order. They are referred to an orthopedist; the orthopedist already has that information – they do not have to redo it. If that is not the right physician to go to, they are referred to the appropriate clinician. That carries along, because it is all tied into that system. The bloodwork, all done one time. So, it’s noninvasive and it makes a big difference.

 

We are a captive audience where our members pay a certain amount of money for the best possible healthcare. In the fee-for-service world, the sicker you are, the more money you pay. We are big on preventative care. We are number one in the nation for screening mammo. If you have a screening mammo done in the morning, they find a problem, they can do a biopsy that afternoon. Two days later, they can provide results.

 

Why can we do that? Because our radiology and pathology groups worked on this initiative together. The other thing, too, all of our physicians, because we are not RVU driven, are financially incentivized to teach people what they know. Our cardiologist makes the same salary whether they get the telephone call or not. They do not have to do a full-blown consultation. They can do a chart review, which can be done same day. Your primary care physician takes good notes; they order an EKG and they have the cardiologist look at it and determine, you know, “You’re on the right path” or “I’d modify this or modify that.” Think of how much better that is for the member because a lot of people, as they get older, have mobility issues and have transportation issues.

 

TM: Then patient access becomes an issue.

 

RH: Exactly – it is cheaper, more efficient, and more time-sensitive. With dermatology, we can take a picture, send it to the dermatologist, within 15 minutes, they can tell you what the rash is and what prescription to give. The number of people that must go to the dermatologist reduces. Those that need to be seen, because they have a history of melanoma or whatever the case may be, access is there, because we’re not tying up the physician’s times. If you have strep throat – that is bacterial, if I prescribe an antibiotic, almost guaranteed, you are going to clear up in five days. In the fee-for-service world, they have you come back. Why? Because it is a moneymaker – they cannot bill you if you do not come back. Here you can email your doctor, or you can Skype with your doctor. It is much, much more efficient for the patient.

 

Our physicians get to know their patients significantly better. They are capped as far as the panel of patients that they see. Our specialists are incentivized to teach our primary care and our hospital-based medicine physicians everything they know. If a physician comes to work for us for five years as a hospitalist or a primary care physician, I would put them up against anybody in the community – the reason being is their medical knowledge skyrockets after they get here.

 

We also have a call center – based on certain protocols, they can direct them to either, schedule an appointment with your primary care physician, urgent matters to urgent care, or this is serious enough you have to go to the emergency department of a hospital. Triage is available 24 hours a day through our call center.

 

We have what we call clinical decision units. The clinical decision units are freestanding. They look like an emergency room. It is staffed with a family medicine physician that does urgent care, an emergency medicine physician and a hospitalist that works as an observationist. If a person goes in with chest pain, they rule out an MI. They can keep him for 23 hours and 59 minutes. It is cleaner, safer, and nicer than a hospital. It does not bog down our hospitalist with seeing a patient for 24 hours when, basically, they are all being managed in the clinical decision unit. It really works out to be super-efficient and it is a huge, huge cost savings.

 

TM: That is a very impressive model, how many of these freestanding facilities do you have?

 

RH: We currently have five. We are going to be adding two more clinical decision units. As far as for urgent care, roughly 12, but that number is expanding, too. A lot of that is after-hours care from five to one in the morning. And there, again, if you need to have a plain film, if you need lab work, things like that, that can be done at those centers. We are trying to bring it closer to our patients.

 

TM: Again, it all goes back to access.

 

RH: Yes, and what’s interesting is when the affiliation took place with Northern California, they said this is what we’re going to do this year; this is what we’re going to do next year; and this is what we’re going to do the year after that. I raise my hand, I said, “What are we going to do the year after that?” Dr. Robbie Pearl, head of the medical group at the time of the affiliation said, “Depends on where our members take us and what our needs are.” We’re constantly assessing where are members are taking us and where are needs are. Fredericksburg, for example, is one of our smallest centers but it is also one of our fastest growing centers. So, we saw the need: this is where our members were coming from, so let’s build a center there.

 

We are going to build other clinical decision units, which are huge hubs that will have a clinical decision unit with multiple specialists there. So, again, it’s access and the ability to get to the physician. Many of our patients, if they do not work, they do not get paid; they have to take time off without pay. How beneficial is it when you can email your doctor, you can call your doctor, you can Skype with your doctor literally from your office or your home, so you don’t have to go in.

 

TM: Bob are you able to expound upon the Kaiser App and email capabilities.

 

RH: Of course – lab results can be obtained through a secure email where you can see your lab results. The dynamics of medicine are changing, and a lot of our physicians were getting a ton of emails. They do not really need to get an email, “I want to change my appointment from today to tomorrow.” Those are being picked off by the nurses and now— how late is the lab open, etc. So, they’re able to do that. But, again, this is able to cut down on the number of visits.

 

TM: With all of your success within the physician recruitment marketplace, are there concerns that are being expressed by your contemporaries across the country?

 

RH: There is one that is a very alarming trend, the current number of physicians is not going to be enough to cover the population. The number of people going for primary care internal medicine from the time that they start their training, they’re pushing them very, very hard to go into specialty care. There are just not enough physicians. You have to be in the top ten percent of your class to get into dermatology – as people get older, they’re going to have more dermatology issues, so that’s a huge, huge problem.

 

Also, there are not enough medical schools; there’s not enough residency programs throughout the United States. In certain areas, it is even a bigger challenge. I live in an area that is a very nice suburb of Baltimore and I found out that we are very, very underserved medically, we have about 60 percent of the physicians that we should have for that population – and I thought we were doing pretty well. The other thing, too, is that we are fighting for primary care physicians, family medicine. In Hartford County, the average age is 58 – that is another five, seven, eight years and they are going to be done.

 

TM: Exactly, a massive percentage of that market is going into retirement.

 

RH: That is right and another issue is the cost of education, the cost of med school is keeping people out. When you can come out with a degree in engineering or business and do amazingly well.

 

TM: We are losing our legacy physicians. These individuals grew up in a household where they had a view of what it would be like to practice medicine and the financial means potentially existed where they could conceptually see themselves as a physician – and their parents are telling them not to go into medicine. They are being encouraged to get their Masters or their JD – anything but medicine.

 

RH: That is an excellent point, and that is exactly what I am finding out. When I talk to candidates, I say, “If you had to do it over again, would you do it?” And these are candidates that are right out of residency or all the way up to age 62, and most of them said, “Oh, absolutely.” Would you recommend it to your children? “Absolutely not,” with rare exception. It’s the same approach when they want to consider specialty care. If you really have the passion for it, do it – and that’s what most of them are saying to their son or daughter.  “If you really, really have the passion for it, do it, but if not, please consider something else.” Again, $350,000 in debt coming out. Everybody thinks doctors make a ton of money. Well, a large part of it, they are graduating in the hole. The average student is not graduating with that kind of debt – the average medical student is.

 

TM: In addition to the load debt, many of them are starting a family, purchasing their first home and going into their first job.

 

Given the shortage that we are experiencing across the country and considering the average retirement age for physicians being in the mid-sixties – we are very rapidly approaching a period where we could lose a sizable percent of the physician marketplace to retirement. What programs does your health system utilize to circumvent the shortage that is impacting our healthcare delivery system to such a disastrous degree?

 

RH: If we get the recipe for the special sauce, I am not giving it away. But the reality is what we’re trying to do is meet physicians where their needs are better than our competition. A lot of physicians want to work less than full-time. Full-time with us is 40 hours of face-to-face with the patients. A lot of the physicians end up doing work outside of that. Many are beginning to consider .8 or .9 of an FTE. In some environments, they do not allow that. We do, so that’s been a huge plus as they receive full benefits.

 

One of the other things that is really alarming, as a whole culture, is that most people are not prepared for retirement. Our company has amazing retirement benefits. This is not as important to the new resident or fellow coming out, because they are just broke and looking at the salary. A physician that’s worked for themselves for ten, 15, 20 years and is saying “Okay, I didn’t have the money to put into a 401K. I would have liked to. I did not have a defined benefit plan. I will be retiring, but at the same time, I’m not going to be able to retire in the position I’d like to be in”. Psychologically, they are prepared to retire. You can tell their heart is not in it. It is just purely financial for why they continue to practice.

 

TM: Congratulations again Bob on ten fantastic years with Kaiser – all of the success that you have had here is truly exemplary. For someone who is just coming into a physician recruitment or a medical staff development role, as you look back on the last decade and what’s made you and your organization so successful, what advice would you give to someone considering this field as a career. 

 

RH: Probably the biggest thing in any new position is to establish very good listening skills and ask—

 

TM: I am sorry, what did you say?

 

RH: There you go – establish very good listening skills and find out what the market is for the specialty that you are hiring and find out what is the motivation for those candidates. It sounds very simple, but it is not. I constantly keep my finger on the pulse of and I try and stay ahead of the trends.

 

When I first got here, everyone kept saying don’t contact the residency directors, they don’t want to hear from you. I will tell you who does want to hear from us is the coordinators. The coordinators are the mother hens of the residency programs. They take care of their doctors and they get to know them very intimately and their family situation. So, we started having these residency dinners right off. We would contact the program directors, no response – contact the program coordinators, and we got an amazing response. I provide a list of questions for the candidates to ask in an interview. The reason being is we are looking for that good match. High turnover is very, very expensive for everybody and it has a lose/lose proposition. You are much better off getting someone stay for a career than have a revolving door.

 

TM: Especially if the physician leaves in less than 12 months, you are possibly taking a financially lose for having hired that provider.  

 

RH: Absolutely, absolutely – and the part that’s mind-blowing is the average resident only lasts two years on their first job. The reason being is they don’t know the right questions to ask and the people interviewing them don’t know the right questions to ask. One of the questions I tell every candidate to ask is it a new position or if you are replacing someone – and why.

 

Who else has left in the last two years and why? Moreover, look at their body language. That is a question you ask face-to-face, and most people do not do well with the body language.

 

TM: Also, the transition that we have experienced from solo or group practice to employment has mitigated a practice’s ability to misrepresent themselves. Now it is the hospital or health system that is being held accountable for the information they are providing to the marketplace. 

 

RH: Absolutely and even with the hospitalist groups, early on, they would ask the patient census and receive a response of 15, when in reality, they were seeing 18 and 25. They would like you to see 15 – so asking what the census is is a snapshot in time. What is it today, what is the worst it’s ever been, what’s the best it’s ever been. You almost have to be like an attorney to drill down to ask the right questions.

 

Same thing with the turnover. Why did they leave? Well, the census was too high. Well, why would it be if you are only seeing 15? Well, we are seeing 25. One of the other changes early on is several of the smaller practices were not on an EMR system, the cost was just through the roof.

 

TM: It is not a financially attainable resource for that practice.

 

RH: No, it is not – the smaller practices could not continue to survive, so many of them got bought out by the hospitals.

 

The whole market changed. People could afford to be generous when they were making a ton of money, but now we are much more into accountability management with the Medicare cuts in reimbursement and things like that. Everyone is trying to do more with fewer resources. Our success here has been the efficiencies of an integrated model. And now you’re hearing more and more of integration. When they came up with the cost bundling, the question I had was, “Haven’t we always kind of done that?” So, some of the things that Kaiser’s been doing for years, now have become the norm in the marketplace.

 

TM: Models like ACO and IDN – your organizations has been at the forefront of for many years.  

 

RH: Exactly and quite honestly, people did not talk about it. One of the things that if you are successful on your side of the street and I am successful on my side of the street, we are fine. There is really no need to talk. It is when things start getting tight for everybody, “Hey, we’ve got to get more collaborative here.”

 

TM: Bob, what motivates you and what have you found to be most enjoyable about your decade of successful work for Kaiser?

 

RH: It is interesting, because it has changed over time and that is really pretty exciting. My background is business and the average physician coming out has zero business background. So, sharing my knowledge as far as retirement programs and things like that. Everyone I have ever interviewed – very, very smart people, very, very capable. The brain can only hold so much, so they’re coming out of residency and fellowship and they’re just trying to hang on to everything medical they can. So, the ability to help people make the right decisions. I was trying to be very helpful to them in the beginning, but then I also found it was helpful for me. If I help them make the right decision, then they are going to stick longer.

 

TM: That has a scalable impact on your retention. You can transfer that successful experience to the next physician you interview and to the next physician and his or her family that you relocate.

 

RH: Yes – helping them by the way we set them up with very good real estate agents and very good mortgage people. My background with the mortgage finance side, I refer them to one of the top ten individuals in the United States, so that has worked out very well.

 

Also giving the candidates the questions to ask and to compare apples to apples, be confident in the answers you have. I tell each candidate, there is no illegal questions on your part, only on mine, so ask absolutely everything you want to know. We define the job and explain the job extremely well to people, because we want there to be a good match. Having that good match has made a big, big difference in our turnover remaining low. I constantly talk to our current physicians, especially our newer ones: was it what I represented to you? Is there anything that surprised you either positively or negatively when you got here? In addition, I will ask them that with a candidate sitting there. If it is a younger physician, what surprised you either positively or negatively when you got here? I am almost to the point where I know what the answer is going to be every time, which is great.

 

Our physicians work very, very hard, but they work very smart. So, when we’re talking about the cost savings, a large part of that cost savings is working smart – the medical group is constantly looking to work smarter. We started an innovations committee, there is a little light bulb in the corner of their computer – so you click on that if you have a suggestion for the organization. It might be something you want to be involved in; it might be something you just think is a good idea. One of the things in the last few years that has become a big deal are therapy dogs. I recommended that we consider doing a therapy dog program and they are implementing that.

 

Again, meeting the patients where they need to be met – what is important to them. We have our own social workers; we have pharm D’s. We take a very holistic approach in handling the patient. I do not know anywhere in the community where you go to the dermatologist and they take your vital signs – we do. When I got here, there were roughly 465 physicians – now we are at about 1,600. A large part of those physicians came here with the expectation of staying for a career and they have, which is pretty fun.

 

TM: Incredible insights and perspectives Bob, thank you so much for your time today. One last question as we celebrate your 10 successful years here at MAPMG, where would you like to see your healthcare career in 5 years?

 

RH: I would like to continue to help the medical group expand, grow and help the physicians. I have figured out, by the time I retire, I will have hired half of the physicians in the medical group. That is exciting to me.

 

Honestly, I did not consider becoming a physician as a career. This is the closest I want to come to saving people’s lives. But what a huge impact when you figure the medical group is 4,000 physicians, and I hired 2,000 of them – how cool is that.

 

TM: Bob, that is an incredible achievement. Going back to the question of wisdom and feedback that you would impart on someone who is considering a role like yours, having the understanding that the end result deliverable of a quality patient outcome is achieved by matching a quality clinician with the patient. A patient who could potentially be at the darkest point in their life, and you have connected someone who is very adept clinically and also with their bedside manner, with someone who, again, is potentially at the darkest moment they could encounter.

 

RH: Quite honestly, I just feel like I am doing my little piece of the pie. We are delivering hugely – and we are the number one healthcare delivery system in the nation! This did not happen overnight.

 

I really enjoy meeting with our physicians a year or two later. The radiology group was 32 radiologists when I got here – we are at 75 now. I hired 60 of them, and they include me in their holiday parties and I thank them and that is very humbling to me.

 

The bottom line is that the enthusiasm has become amazing and healthcare delivery throughout the United States has skyrocketed. Where we were at number 235 out of 400 and now being number one of over 500, that is pretty cool.

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