Introducing Donald Berwick, MD
Dr. Eli Y. Adashi: Hello. I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape One on One. Joining me today is Dr. Donald Berwick, the Administrator of the Centers for Medicare and Medicaid Services. A longstanding advocate for better and safer healthcare, Dr. Berwick is at the helm at the time of great change. Never in recent memory have we engaged the twin challenges of quality and cost with such intensity. At times like this it is hard to think of a better person to lead the charge. Welcome.
Dr. Donald Berwick: Thanks Eli.
Dr. Eli Y. Adashi: Absolutely wonderful to have you.
Dr. Donald Berwick: It's nice to be here.
The Center for Innovation -- A Release Mechanism for Ideas
Dr. Eli Y. Adashi: As we reflect on the last 6 months at least, and I know it has been longer, it is breathtaking. And I know we can't cover it all, but perhaps we can hit some of the high points. One of the most striking developments that took place is really the establishment of the Center for Innovation for Medicare and Medicaid. Can you say a few words about how you think about it, what it has accomplished so far, and what do you see as its role going forward?
Dr. Donald Berwick: Well, as you said, in the Affordable Care Act, the new law that is guiding a lot of our work toward a better healthcare system, one of the real gems is the Center for Medicare and Medicaid Innovation, The Innovation Center. It was funded by congress at ten billion dollars over the next 10 years and it operates on a very unusual and very promising set of rules, which give it more latitude to actually find and sponsor and support changes in payment and in delivery of care -- innovations that can show us the future that can be lanterns for where we need to go. It has the very special authority -- the privilege -- of when it finds an innovation that works it can report that to the Secretary of Health and Human Services, and she can convert that into rule making without going back to congress. So it is an accelerator of the spread of good innovation.
Innovation, in this case, means either changes in payment -- the way we pay to support better care -- in delivery itself, or both, which have the simultaneous effect of reducing cost and improving the wellbeing of the patient. They have to do both, or, if they are going to save money, they at least have to hold the wellbeing of the patient the same. So, it is a way to find some answers, answers to this very difficult passage we are at in healthcare, to find a sustainable future for a really, really excellent healthcare system.
I think of it as actually a release mechanism. I just think the imagination around this country, the number of people with really good ideas, the number of places that are trying to find a way to more sustainable better healthcare -- it's enormous. And if we really have a way, and we do now in the Innovation Center, to find these gems, to support them, to prove further that they have found something great, and then to spread that news both through communication and when need be, regulation. [That] we have an answer to a lot of our problems. I really trust the American healthcare workforce out there to find great new ideas, and we need them.
Patient Safety -- The First Major Innovation
Dr. Eli Y. Adashi: Has it produced so far for you or for us as a nation in terms of ideas that are worth mentioning perhaps to our viewers?
Dr. Donald Berwick: It's still a fledgling, so all of its projects are in early days. It was set up in November. It announced immediately project areas: one on federally qualified health centers, one supporting better community transitions from hospital to home. And those projects are just getting up and running now. Probably the most exciting thing now that has been announced was about a month ago. Secretary Sebelius and I announced the largest investment in our nation's history in patient safety. That echoes in better care and lower costs, what we are after, and the Innovation Center is sponsoring that. The Innovation Center is putting in half a billion dollars into a support system to support work on hospital acquired conditions, complications. And there is an additional 500 million dollars. So, a total of a billion dollars [is] going into support of change in hospitals and in communities to get lower injury rates to patients in healthcare, and better transitions, and fewer readmissions. It is pretty exciting; we are going to see that start to get traction in the summer.
Dr. Eli Y. Adashi: Perhaps we can think of it as a translational research institute.
Dr. Donald Berwick: That's a good way to look at it. People talk of a think tank, this is a do tank. It is going to make things really move fast. Both by releasing energies around the country, but also by commissioning work. It works through contracts, not grants. It is not a granting agency like National Institutes of Health (NIH) or the Agency for Health Research and Quality (AHRQ). It will issue contracts for work that it needs done, work on community care transitions, or work on patient safety/ We have a very interesting project called Pioneer ACOs (Accountable Cure Organizations). We just announced that center, which will support a cutting edge group of perhaps 30 organizations around the country that want to really show expertise in helping care [to] be very coordinated and seamless for Medicare beneficiaries who are still in the fee for service Medicare program. That is a really interesting idea; I am very excited about it.
Dr. Eli Y. Adashi: So the Center is really at the core of literally any innovation, any new initiative that has transpired or that will likely transpire in the foreseeable future?
Dr. Donald Berwick: It can be a home for innovation, an encourager. But it is not alone/ We have great partners in AHRQ. and we have demonstration authorities that are not in the Center. There is a tremendous amount of innovation going on around the country. So it is a very important piece of a larger puzzle.
The Physician Compare Website
Dr. Eli Y. Adashi: Just around the turn of a year -- and I would say just in time -- the Physicians Compare website went up. Can you share with our viewers your vision for this new compare site in the near future, but even more interestingly what do you envision it becoming? When will it incorporate quality measures, for example? And perhaps even other ideas that you may have in mind.
Dr. Donald Berwick: Well there is sort of a regulatory or a legal side to that, what the law is requiring us to do, which I will explain. And then I think there is a cultural one also. The Affordable Care Act does require us to have public information available about physicians that is now set up as of December 2010 on the Physician Compare website. Right now that website contains information on where a physician was trained, it tells a bit about their qualifications. It is possible to find out if they are contributing information to the Physicians Quality Reporting System (PQRS). Not what they are reporting, but are they reporting anything at all. Over time the richness of that information will grow. We are required to have quality information about physicians on that website by 2013, and over time -- downstream -- the projection is that [this information] will actually be linked to physician payment. So, we are meeting requirements to have information more and more available about physicians. That is all done in the testing mode, so we are currently engaged in pilot projects with physicians in several states trying to figure out what quality information is useful to display. Does it help the physicians and is it useful to the community?
But, you know, the way I think about this is really beyond the regulation. It has to do with learning. I am a fan of learning. I think we all can learn to do better, and one of the central resources for learning is knowledge, its transparency. So it helps us all to get more and more knowledge about how we are doing. So whether you believe it is good on the market side to have the information out there so people can chose physicians according to their performance or pay for quality, which is a plausible theory, or you are just interested in learning. I want to know that Dr. Adashi knows how to do something better than I do and I can learn from you. You ought to be a fan of this kind of progress or transparency. And we are not just staying with physicians; there is hospital compare, and nursing home compare.
Dr. Eli Y. Adashi: Of course.
Dr. Donald Berwick: I think more and more daylight is being cast on the work we do, which should help us give care better, not just be paid differently.
National Health Quality Strategy -- A Blueprint for the Future
Dr. Eli Y. Adashi: You had the responsibility and I would say the privilege of crafting the very first national quality strategy.
Dr. Donald Berwick: Yes.
Dr. Eli Y. Adashi: Do you think of it as a blueprint or as a backdrop for everything we do from here forward?
Dr. Donald Berwick: It is a really valuable document. We are in, I think and hope, an era of tectonic shift. The plates are shifting. We are coming out of an era when payment went with volume and the more you did the more you got paid. We are moving into an era when quality is the watchword: the better you do, the more you get paid. We have support systems for quality now. We have metrics for quality. We know so much more than we ever did before about how to orient the system toward doing what we want, which is to restore and preserve health. And I think we are well underway toward that kind of progress. And I do think it will be better for us all. It's hard. All transitions are difficult, but what did we become doctors for, Eli? You know that it was to do well for our patients. So let's do better. Not that we are not trying now, but with new information, electronic health records, the value of learning systems, and incentive payments that really move us toward thinking about the patients' needs and support us to do so, I think it is going to get better.
The Accountable Care Organizations -- Where We Stand
Dr. Eli Y. Adashi: Going back for a moment to a concept you've already mentioned, the accountable care organizations (ACOs). This may be a good opportunity to share the latest with our viewers. It is a truism that this is a concept that is much talked about. It is probably a truism that some concerns are raised regarding the concept and its implantation. What are your thoughts about where we stand with the ACOs at this time and how do you look at it as it unfolds going forward?
Dr. Donald Berwick: Well, first the context. I thought more and more since I came into this role that we are on a great national expedition. We are searching together, we want better care, and we know what it looks like, and sometimes we are able to give it. We understand what great care is, but we just have trouble executing it, we have trouble doing that all the time. We are too busy; the payment systems aren't aligned; we don't have the information we need; we haven't been trained to work in teams; and the institutional structures are in our way. There are a lot of barriers. Now we've got to get through that into the care we all want: safe, effective, patient centered, timely, efficient, equitable care, care that is fabulous.
The Affordable Care Act and other policy in government gives us a suite of tools, a suite of possibilities for helping us all move in that direction. And government is not alone in this. This is a public/private partnership, and the private sector is moving the same way, as you see in both the professions and the payer community. We all want seamless, coordinated, safe, good care. To do that we will need different tools and instruments. The Accountable Care Organization, the ACO, is one instrument. It is a pretty exciting idea. It's to be able to forge coordinated care possibilities in a fee-for-service payment environment. Before that people would have said, "Oh no, no. The only way you get coordinated care is to have some kind of lock-in or managed care environment." But can we award and support coordinated care for chronically ill people, for prevention, for us through our journeys through life in a fee for service environment? The ACO is a bet that we can do that.
And so what it does, it proposes to align patients with organizations by watching the patient's behavior. If Mrs. Jones sees Dr. Adashi regularly for Mrs. Jones' primary care and you want to be part of an ACO, [then] she is in the ACO panel. So it is done by watching what the patients do. Patients don't lose any choice. Mrs. Jones can go tomorrow and see a different doctor if she wants. She is just a normal Medicare A and B beneficiary. But if she sticks with you and you are in ACO, then she is in your panel. Now you get to help her. You get to figure out how can I anticipate her needs, how can I coordinate her care better, how can I make our care really attractive so she stays with me. If she goes in the hospital, l how can I make sure she has a good experience going home? If you do that, and her care improves, and you save money, [then] you get to share in the savings. So, it is shared savings in a fee-for-service payment environment, with very strong monitoring of quality, because we don't want to encourage you to withhold care from Mrs. Jones or save money that way. We want to encourage you to do better for her, so we watch her care, assess the quality, and, if costs fall, you share in the gains.
That should produce more cooperation between you and others who are caring for her. It should give you a real opportunity to think differently about the way you give care. It is putting resources where the patient needs it, not where a fee-for-service system [that] is [now] just organized around volume would normally take us. So it is paying for what we want -- quality.
The Small Practices in the New Environment
Dr. Eli Y. Adashi: One question we hear in that context has to do with the future role of the time-honored small medical practice that we all knew and still do. Does it have a role? Can it meet the expectations of some of these massive changes? Can it deal with the meaningful change requirement of electronic health records and the like? What can you say to those of our viewers who are still maintaining what has been a longstanding American tradition?
Dr. Donald Berwick: When you are talking to me, Eli, you are not just talking to a pediatrician. You are talking to the son of a solo practitioner, general practitioner for 45 years in a small rural Connecticut town.
Dr. Eli Y. Adashi: In other words you know the issues at hand.
Dr. Donald Berwick: Yeah. I respect it, I love it. What I say my father do in the classical rural solo practice to me still is the heart of medical care. And if we lose that we lose something really important. I think there will be communities where large medical groups or integrated organizations will form and thrive, and they should. But there will be plenty of parts in our country that are going to have the demographics of small practices. What I think will happen is that physicians in those contexts [will find] in this new modern age better ways to connect together with each other. [They will] have the support that comes with being connected and sharing knowledge, sharing ideas, sharing plans. [They will] have the infrastructure that allows you to take a patient with a serious form of cancer or advanced heart disease and guide them through what is going to be a complex system -- even if you are a rural solo practitioner. And then get them back into your hands. All that coordinated, integrated, modern view of care, we ought to find a way to make that compatible with this small practice environment, which so many of our physician colleagues still practice in. I am confident we can do that.
Is it the same as ever? No, there is change. My father would be scratching his head right now. He would say "How do I do that? What does an electronic record mean to me? Do I really want to be on a team? Accountability, what is that?" And we would have to help him get through that journey into the better world, the one where he is supported, and he is connected, and he can be sure that his patients will get the best possible shake and the health they want. I think we can get there. In guiding CMS I am thinking all the time about pluralism, you know, making an environment in which many, many different kinds of contexts can thrive, and people can find their way to their answers.
The Partnership for Patients: Cutting Hospital Readmission Rates
Dr. Eli Y. Adashi: You mentioned partnership for patients earlier -- the important initiative launched not all that long ago -- especially the community-based care transitions and the all-important issue of hospital readmissions. What is happening at this point with respect to this initiative? Are you looking for applications for demonstration projects? What would you like to tell our viewers in terms of being responsive to this initiative?
Dr. Donald Berwick: Well the partnership for patients is probably the most exciting thing I have been involved with since I came here. We have, as I said, a billion dollars of support to go out through states and healthcare systems to provide technical assistance so that physicians, and nurses, and hospitals can understand best practice with respect to patient injuries and community care transitions.
We will be putting out requests for proposals for community care transitions. In the safety part of it, we are going to put out contracts, in which we are looking for entities all over the country that will take responsibility for clusters of hospitals to help them become safer and reduce readmissions. Readmissions are a very big deal. We can certainly use tremendous physician energy on this problem.
You know 1 out of 5 Medicare patients who are discharged from the hospital are back in the hospital within 30 days. And, according to the science and the analysts, 3 out of 4 of those readmissions are unnecessary. If we are able to smooth the transitions, those people would stay home where they want to be and costs would fall because [the patients] are not deteriorating. We have a tremendous possibility there. That is on the pull side.
On the push side there is contingency here. Starting in 2013, hospitals will have payment reductions who are in the poorest end of readmission rates -- the highest readmission rates. And we need to help them really learn how to be players in continuity of care. Physicians will be pivotal here, there will be roles for them to participate in improving safety and working on continuity and that is crucial.
Dr. Eli Y. Adashi: You are making reference I believe to the hospital readmission reduction program for which the proposed rules are now on the federal register, which complements the partnership initiative. Does this say to all that hospital readmissions are a huge priority for CMS?
Dr. Donald Berwick: Very big priority. The 20% admission rate translates into unnecessary readmissions for 2.6 million beneficiaries a year, a 26 billion dollar a year cost to the Medicare Trust Fund, and we are not talking about out of pocket costs. And all of this is happening on the private side as well, so this is [also] affecting private pay costs. I think readmissions are a bellwether of whether we are really doing the kind of support, education, outreach, and coordination that really can keep people as healthy as they possibly can [be]. Some readmissions are needed, some are planned. But a lot of them can be avoided if we really support the system to do for the patient what it wants to do. The Partnership for Patients is not about the downside, it's not about penalties or cost, it's about help. We are reaching out. Let's figure out how to do this right.
Dr. Eli Y. Adashi: Would it be fair to say that you are in the midst of devising a multipronged attack on the issue of hospital readmissions?
Dr. Donald Berwick: Yes and we are not alone. So much that is going on now that is interesting and, I think productive, in Medicare and Medicaid in CMS is mirrored in the private sector. So private payers, employers, physicians, and systems are all focusing on the symptoms of a fragment system in order to foster coordination which is what we want. If money were no object we would want coordination. That keeps us healthy; it keeps us with our loved ones. So, as I said earlier, it's a suite of public and private sector activities and not just in CMS. And I think readmissions are a great bellwether, so is patient safety, so is patient centered care. Making sure that care plans and patients [are] in control of their own care characterize the system we are in, where patients are kind of the boss. And I think that is what we really want to get to.
The SGR Threat -- Any New Thinking?
Dr. Eli Y. Adashi: It is difficult to speak with the administrator of CMS and not raise the perennial issue of threatened reductions in provider reimbursement as dictated by the SGR formula? Recognizing that this is a congressional responsibility and therefore not necessarily your domain still what might you be comfortable saying to our viewers who are providers in this connection?
Dr. Donald Berwick: Well we are all in this together. I mean I don't think any one party can solve the problems of physician reimbursement. In the long run the solution to the problem of physicians being secure about their incomes is the same as the solution to American healthcare overall. A sustainable, high quality system focused on doing the right thing for every patient every time and reducing costs by improvement. That gets everybody out of the dilemma.
So partly we need to keep our eyes on the long run here, which is better care, better health, and lower cost through improvement. That is the three part aim we talk about all the time in CMS: better care, better health, lower cost through improvement. Every physician would be well advised and, I suspect, willing to become part of generating that solution.
In the meantime we have legacy anomalies, the Sword f Damocles of the sustainable growth rate, the SGR, which is a rather complex situation over time because of a law that required physician payment not to rise faster than the cost of living, but it did. We kept avoiding that problem and we are now stuck with about a 30% gap between what physicians are paid and what the law actually says they should get paid. Each year congress has maintained that difference and the bill has grown. That's a Sword of Damocles, as I said. It hangs over the head of the physicians who shouldn't be facing a 30% cut and it hangs over the heads of patients. I mean who wants their doctor to be worried about whether can they get through. The President is committed to fixing the SGR, working with Congress to do that. And, the President's budget submitted this year has a 2 year fix, which just gets us enough time to do some thinking. It won't be easy. We are going to have to find some really interesting new ideas in order to get through that, but the President is committed to working with Congress. It is Congress' lean on this, but we are in this together and we are going to work on finding our way through that, even while we are doing the very important longer term job, the investment in better care, better health, and lower cost through improvement. If we do that, SGR finally will be a distant memory only.
Supporting Primary Care and the GME Mission
Dr. Eli Y. Adashi: Earlier in your career you practiced as a primary care provider.
Dr. Donald Berwick: Yes.
Dr. Eli Y. Adashi: We have learned today that your father was a primary care provider. Obviously you and most reasonable individuals see great value and importance in primary care medicine. The Affordable Care Act has gone out of its way to support and encourage primary care. Do you feel we are doing all we can? Do you feel we are addressing the issues optimally or would you like to see other initiatives undertaken? And if so, what would you like to see done?
Dr. Donald Berwick: First I should confess that it is a three generation of bias, because my daughter Jessica, my third child, is now in primary care residency and will be a primary care practitioner, and she loves it as much as my father did and as much as I did. I am committed.
We are doing a lot. The news is pretty good. In the Affordable Care Act there are some neat changes that will help increase the robustness of primary care. There is a 2 year increase in payment for certain primary care practitioners. There is coverage of preventative services, which is important for primary care, because now Medicare beneficiaries have an annual wellness physical and they have first dollar coverage for certain preventative practices. All of that should be good for the patients and good for primary care. There are investments in teaching health centers, which is a very exciting idea -- to train young people in the setting in which they will learn about the beauty of primary care -- in the community health centers.
Dr. Eli Y. Adashi: In community health centers.
Dr. Donald Berwick: Yeah, I am very excited about that. So, there is a whole range of investment plus working parties. I am part of a working party co-chaired with two of my colleagues in HHS on how to improve the wellbeing and the robustness of primary care workforce in our country. And I am delighted to be doing that. it will have to be multipronged. There is no one solution here, but we will need to work hard on payment rates so that it is financially attractive to be in primary care. On support systems, I think actually there is a relationship between progress toward electronic health records and healthcare and a more vibrant, satisfying, and doable primary care job. I think as we modernize information, primary care will get more and more attractive. So we are forging ahead on all fronts here. It is something we really do have to solve.
I am very excited about some of the technological innovations I have seen around support systems that allow information, I mean expertise to be distributed more widely, telemedicine, remote care options for specialty distributed in rural settings. I know we can get this one right and that's why I chose it. It is the best place to be.
Dr. Eli Y. Adashi: Speaking of education, you mentioned the teaching centers. But perhaps we can take it or expand it beyond that. What do you see evolving for graduate medical education (GME) if you will, in the next year or two, partly dictated, partly not, by the Affordable Care Act in terms of resident caps and the like? None of us could ignore the recent budgetary cuts that were applied to pediatric residents in training programs. We realize it's a complex fabric. What light can you shed on the near and perhaps not so near future of GME across the board, not just pediatrics of course?
Dr. Donald Berwick: Well Medicare and Medicaid as you know are significant funders of graduate medical education in our country. So it is an issue we are taking very seriously. We know that we have to be very supportive to the educational mission; we need to invest in the future of the workforce. And so making graduate education support more and more in line, more strategic is an important idea. Exactly how to do that I don't know for sure yet. We are looking at it and talking with our colleagues in the academic world and academic community. I think a thematic notion would be that just as everyone in healthcare, every other stakeholder in healthcare. needs to be thinking about better care, better health, and lower cost through improvement, that is also a message and a need with respect to the training of young physicians, nurses, pharmacists, and all practitioners.
What do we need to do in the preparation of the young so then can be even more effective stewards, even more effective champions of better care, better health, and lower cost through improvement? That involves new skills, attitudes involving knowledge of systems, teamwork, patient centeredness, all of which I think are making their way into medical education, but we need to accelerate that. And, the distribution of the kinds of training they are going on should reflect the needs of the future. The Affordable Care Act does give us some latitude. It allows us to take residency slots that become available by closure of a hospital or downsizing of a program, and we allocate those slots where they are needed socially. That is an important step forward. But, I agree with your premise entirely. We need to be more and more thoughtful and strategic about nurturing the robustness of primary care. And that isn't just about doctors; that is about nurses and others who can participate in the primary care system.
Funding Medicare Long Term with Payment Reforms
Dr. Eli Y. Adashi: The trustees of the Medicate Trust Fund have recently released their latest report indicating that perhaps the longevity of the fund is now somewhat foreshortened because of the recent economic downturn. I surmised, however, from some of your comments a degree of confidence in the ability of the various payment reforms and perhaps the various quality initiatives that are currently underway to really have a salutary effect ultimately on the longevity of the trust fund. Perhaps you can expand on that sense of yours that much is happening that may in fact offset some of the concerns and perhaps make those concerns at least less ominous as they might sometimes seem?
Dr. Donald Berwick: Well I am an optimist. You're right. And, I think for good reason. First, we would be in a heck of a lot more trouble without the Affordable Care Act. You know the actuary said in this latest report that the trust fund would have gone insolvent in 2016, instead it is now out to 2024. It was 2029 until the recession, and then due to the recession and a few other factors has modeled it, it came back to 2024. But that is breathing room, that's some time. We have some time, not much, but we have enough. What I know is that better care can mean lower cost. That is the core lesson I have drawn from my career. It is what I understand both as a theoretician and a practitioner, and I have seen it. I have seen hospitals and clinical settings around our country, and not necessarily just famous ones, that have taken seriously the idea that better care, more coordinated, more seamless, safer care, care with more dialogue in it, more attention to the real needs of the patient reduces cost. It is more sustainable for communities.
There are communities in our country, Eli, that are operating at healthcare costs that are a significant fraction below median in our country. I mean, we are talking [that] 25 or 30% [lower costs] for some of the best care in our country exists. We can find our way to it. With the innovation center in our hands, with ACOs, and bundled payment, and medical homes, and health homes, and value based purchasing, and all these tools that the Affordable Care Act brings to us, we have a shot as a nation in finding our way to that better care. In many places it exists, and the problems want to spread in learning and getting things lined up properly. So I know it's there. When people say it can't be done, I feel like they are saying that you can't have a flying machine and there is an airplane going right overhead. And I say, "Well, look at that, there is one." And that's how it is. The answers are in our hands.
Physicians are key. Every physician faces a choice today, if you ask me. One is a choice of gripping the present and saying that we have to just do what we have always done and get through this storm and it too will pass. And then there will be the physicians who are going to help create the future, better care, better health, lower cost. And I think there are growing numbers of them and they are all over the country. And they are the people that are going to show us how to get through this -- doing what we stared out to do when we became physicians in the first place.
Celebrating Being a Physician
Dr. Eli Y. Adashi: Finally and on a personal note, you have dedicated your life to the betterment of healthcare. When did you know that this is what you wanted to do and why?
Dr. Donald Berwick: I'm no different from any doctor I have ever known, or certainly most. I wanted to be a doctor; I wanted to take care of people. And then as you are a physician, you and I both, we take care of people and sometimes it goes right and we celebrate and it gives us the joy of effectiveness in helping, which is what we chose to do. And then sometimes it goes wrong, and you say why. Why can't this be the way it should be, why did this person get hurt, why did this complication occur, why is the patient back in the hospital when they should be home? And then the question is what are we going to do about it? Can't we stop it? At that point if the optimism takes hold then you decide to get involved and that's all I did. And I've found thousands of colleagues all over the country who really want to do this. A really important point is, I think, that sometimes government can be perceived to want to do things to people and that is not going to work here. This is about [doing things] with people, and the people that really count the most are the people getting care because they want to do the same thing we want to do in government now, which is bring great care to our country.
Dr. Eli Y. Adashi: Thank you.
Dr. Donald Berwick: Thank you.
Dr. Eli Y. Adashi: On that note, sincere thanks to Dr. Berwick and to you our viewers for joining MedScape One on One. Until next time I am Eli Adashi.