SOMETHING YOU MAY NOT ALREADY KNOW
Mark Braunstein, an acknowledged authority on the health care industry, says that those who have objectively studied the issue, eventually realize that the economics of the healthcare industry are not the same as for other industries and that healthcare operations in which the doctors are paid a salary generally provide better medical care for the money than health insurers that pay doctors based on such factors as the number of procedures.
Q: This is Rob Hassett with btobmagazine.com. Today, I’m going to be interviewing Mark Braunstein who is a Professor of the Practice in the College of Computing at Georgia Tech, and who is also the associate director of the Health Systems Institute at Georgia Tech. Mark has an undergraduate degree from MIT, and was always interested in technology and computers, and is also a medical doctor. He attended medical school in Charleston, South Carolina near his home. Today, we’re going to be talking about the current healthcare crisis and what can be done about it. Mark, it’s a pleasure having you on today, and I understand that after you obtained your medical degree, you actually became a professor in that same medical school.
A: Yeah, I was on the faculty there for three or four years. I had actually gotten a grant while I was still a medical student, to develop an early electronic medical records system. The idea was really to have a model of healthcare in the community. So we had pharmacists and dentists and social workers, and all sorts of people that you would run into in the healthcare system community. The electronic medical record that we developed actually served all of those disciplines, so the idea being a unified record that everybody could use and see. The pharmacy part of that attracted a lot of attention. Most listeners to this probably recognize it when they take a prescription to the drugstore and they use a computer system to fill that prescription. What they probably don’t realize is that a computer keeps a record of all the medications they’re on and checks them to make sure that they’re safe when taken together and that the dose is appropriate, and so forth and so on. We were actually the first people to do that. And there was so much interest in that that, I approached the medical school with the idea of starting a company to commercialize the technology, which we did. It attracted the attention of Kaiser Permanente and the U.S. military, both of which ran huge pharmacies back then. And I actually thought I would remain an academic, so I went out looking for a company that would handle this thing commercially, and ended up finding National Data Corporation over here in Atlanta. And we did an arrangement with them and, in retrospect, that was really the beginning of NDC Health, which many people will recognize as a company that got to be pretty large. And two or three years later, they actually made me the proverbial offer you can’t refuse, to come over here and run that business for them, which I did. And I ran it for eight years. It grew to be a very successful business in the pharmacy automation field before I left and came over to Georgia Tech and started another company, this time developing handheld computer-based electronic medical records for the home healthcare industry. And I got involved with Georgia Tech as a result of that and remain involved, and that company was acquired almost 3 years ago. Several people over here wanted me to come and help them develop programs in the whole area of health information technology which, as again many listeners will probably know, is a major thrust now. President Bush made a big commitment to health information technology back in 2004 in the State of the Union Address because he and his Administration saw it as part of the solution to improving the quality and reducing the cost of healthcare. President Obama continued that. Not a lot of people seem to realize this. He actually pretty much continued President Bush’s programs, both in terms of the approach, and the dates. But the Bush Administration never actually funded the program, and Obama saw the Stimulus as a way to do that. And there’s $20 Billion in the Stimulus that is going to incent physicians and hospitals around the country, particularly those in rural areas, to adopt electronic technology and a more modern approach to practicing medicine, which those of us in the field believe, and hope, will lead to a more efficient and effective and safer healthcare system. That’s kind of my career in a nutshell.
Q: That’s quite a career, Mark. Mark, we know that most medical providers have computerized their financial information, but that most health information has not been computerized. I know you are a big proponent of that. What have the obstacles been to having that done? In other words, why has the health data not been saved on computer and available in databases as has the financial information?
A: What we’ve never been able to do before is overcome the disincentives that exist within the healthcare system that have actually kept physicians and hospitals from fully embracing electronic medical record technology. In the case of physicians, for example, studies would tend to indicate that most of the financial benefit, probably somewhere around 80% of it, accrues to payers because electronic medical records among other things can help eliminate duplicates of tests and procedures and they can also be used to alert physicians when the particular test or procedure they want to do might not be the best choice. Well, that doesn’t financially benefit the physician. In fact, it may reduce his or her revenue in that particular instance. So it’s hard to get physicians excited about spending $50-100,000 of their own money to install something that won’t really have all that much direct benefit to them. Now when you make healthcare more efficient, that saves money for whoever it is that’s paying for the healthcare, and in large part in our country, that is employers and the government. So that’s really the rationale for the government for providing these financial incentives if it feels that it will benefit. The cost of doing it is probably going to be about $50 Billion when all is said and done, which is a lot of money. But I was at the conference in 2004 when the Bush Administration kicked this off, and Tommy Thompson, I think he’s the former Governor of Wisconsin, who was, at that time, the Secretary of Health and Human Services, gave a speech to our group. It was all live in a big room. And I’ll never forget that he said he felt that this investment, once made, would save the Medicare program as much as $130 Billion a year. Now I’ve seen numbers as low as $70 Billion a year, and as high as $200 Billion a year, but it doesn’t matter whether you’re the low number of the high number, that’s not a bad return on a $50 Billion investment.
Q: Mark, how is the Bush Obama program going to work to incentivize healthcare providers to computerize their health information records?
A: The program that the Obama Administration developed and funded under the stimulus has four elements. First, that financial incentives will be provided so that doctors and hospitals implement electronic medical records that are capable of what the Administration is calling “meaningful use.” Now “meaningful use” is not yet finally defined in detail, but in general, it’s going to be about what I mentioned earlier to you, systems that can look at the clinical situation of each patient and compare the proposed treatment against what is generally regarded as the best available treatment for that situation. The second component is that these electronic medical records systems will be connected to a Health Information Exchange. Now there won’t be a national Health Information Exchange. There will be local exchanges that are connected to a national network, so it will really be a network of networks. There might, for example, be one in the metro Atlanta area. And the reason that’s important is that no matter where a patient goes … Let’s say you’re a patient of a doctor in Dunwoody, and you’re involved in an auto accident downtown, and they take you to the Grady Hospital Trauma Center, which is the best trauma center in this area, they would have instant electronic access to your information, and that could easily prevent a real mistake. Let’s say you’re allergic to some medication, or have had some prior history that’s relevant to how you would best be treated for whatever your problems were. Now there are obvious privacy issues in that. I mean if you are conscious and you can give consent, then there’s no problem. But even if you do that, there is the issue of who are you, exactly. If you have a common name, in a city as big as Atlanta, there will likely be many people with that name. So there are technologic solutions to all of this, but it isn’t simple. But HIPAA requires that all of these problems be solved. So that’s the second element, that the doctors have electronic medical records that can help them practice a more effective medicine, and that they be connected to an information exchange so that no matter where you go, your information is available. That works in reverse too. Let’s say that a doctor feels that you need an x-ray or a laboratory test, and you’ve actually already had it done recently, say when you were in the hospital. These days because it can be very difficult for the doctor to get those results, even if his office is across the street from the hospital, they often just repeat the test. If that information were available electronically, then presumably they wouldn’t do that. They would just look at the tests. I mean this stuff is already being done. There are places around the country where this capability already exists. The State of Indiana, for example, is quite advanced in this area. So I mean it’s not speculative that this could be done. The third requirement is that doctors will have to report on how well (really their systems will do it for them), they are delivering care according to the guideline that have been established. So what am I talking about there? Well, let’s take diabetes for example. There is a blood test called Hemoglobin A1C that’s accepted I think pretty much everywhere as the best way to determine how well diabetes is being managed in a patient. So it’s pretty likely that several guidelines are going to say that any diabetics should have that test done according to some regular period, annually or whatever they end up recommending. So doctors are going to be judged on whether they do that for their diabetic patients. The data today shows that it’s often not done, even though everybody agrees it should be done, and a big part of the reason is because physicians who are practicing in a manual paper environment, really don’t have an effective way to manage it. And then the fourth element of the plan is that de-identified patient data, in other words patient data that can not be attributed to anyone in particular, will be aggregated into databases, and there will be research centers established, maybe one at Georgia Tech who knows, where we are going to look for patterns that represent clinical effectiveness, and those patterns will become tomorrow’s standards. So what do I mean by that? Well, there was an article in USA Today just earlier this week. Kaiser Permanente already pretty much has a structure in place, so they can do it now. They’ve been studying knee replacements. It turns out (and I’m not a surgeon, so this is news to me too) that there are three approaches to gluing an artificial knee in place. One involves no glue; one involves something they called regular glue in this article, and the third involves a hybrid glue that I assume is more expensive. And what Kaiser was interested in is which approach actually works the best, because in Kaiser, if there is a need for the second knee, Kaiser’s going to have to pay for it. Their contracts with employers don’t allow them to bill the employers. They get paid a flat amount of money to provide care. And it turned out by collecting this data and analyzing it over a period of time, that the regular glue was actually the most effective. So you can be sure in Kaiser, there’s now a rule programmed into there computer system, or there will be one soon, that says you should use regular glue, and if a physician tries to do a knee replacement using another approach, he’s going to be alerted and they may report on it. I don’t know exactly how Kaiser handles that. But that’s an example of clinical effectiveness, or clinical effectiveness research. It’s looking at data about a large number of patients to see what actually works best in the real world. These are projects which might be extremely expensive or difficult to do, but if you have computerized data being collected about patients routinely, these research projects may become actually quite easy to do, or certainly much less expensive to do. So that’s the plan, and it isn’t really very different from the plan that the Bush Administration put forth. The major difference is the Bush Administration felt that by removing market obstacles, and I can’t really comment on exactly what those might be, that the industry would adopt this technology without federal incentives. I personally never thought that would work because of all the reasons we already discussed, and in any event, it’s sort of a moot argument since the Obama Administration, under the Stimulus, is providing the incentives that they hope will incent doctors to do this.
Q: Mark, how does the U.S. health system overall compare to the health systems of other countries around the world? Is it the best? Is it the most expensive?
A: How much time do we have? Well, it is and it isn’t, I guess is the best answer. When it comes to high technology care, for example, a heart attack or, to use the example I used earlier, major trauma in an auto accident on the downtown connector, the data would seem to indicate that we are the best in the world. The survival rates for those sorts of things in the United States are better than they are anywhere else. Now once you get beyond that, most of the rest of healthcare, and this tends to surprise people who are not close to healthcare, is the management of chronic diseases, things like diabetes, and hypertension, and chronic obstructive pulmonary disease, arthritis, and so on. The conditions that once you have them, you’re going to have them for the rest of your life because there is no cure. Now they can be managed, but they can’t be cured. The management is actually quite complex because people are quite mobile in our society, so they move around. Medicine is highly specialized. We have far too few primary care physicians. So, for example, I saw a study just the other day that said a patient with five or more chronic diseases, and that may sound like a lot to our listeners, but people actually rarely have just one chronic disease; they tend to have several of them. So a patient with five or more chronic diseases, over the course of a year, is going to have care provided by somewhere between fourteen and fifteen different organizations. Many of those are going to be different physicians offices, but some of them might be a lab or something like that. This data comes from analyzing claims, so any entity that can submit a claim gets counted. That’s over a year! Now you can imagine, if there is no organized system to assure the data is shared and exchanged among these fourteen or fifteen different entities, that there’s lots of room for mistakes and for duplicative care. I mean I don’t know what was done before or I can’t get to it, I’ll just do it again. This same group of patients, these patients with five or more chronic diseases, represent about 20% of the patients in the Medicare system, but they represent half of all the cost in Medicare, so it’s a group of people that people are quite interested in. There is good evidence out of some other countries, Denmark being the example that most people point to, that if you had electronic medical records everywhere and you had free exchange of this data, you can actually substantially reduce the cost of caring for people with these sorts of chronic diseases. I mean in the last study I saw, which is a period of I forget how many years, the cost of managing chronic disease in the United States rose by 54%. In that same period of time, the cost of managing chronic disease in Denmark hardly changed, and actually the populational statistics in Denmark are quite similar to ours. People are roughly the same age profiles and so on and so forth. So they’re we’re clearly not the best in the world. Now exactly how bad we are is a matter of debate. There is data that is widely quoted, and I must confess I use it a lot too, that would say we’re at or near the bottom among the 36 or 37 industrialized countries that contribute data to a database that everybody looks at.
Q: Mark, you’re saying that we’re near the bottom according to that data?
A: Yeah, in the management of these chronic diseases and in general public health statistics, things like vaccination rates and maternal and child health, so on and so forth. There was just an interesting study this week out of the University of Pennsylvania, however, which suggested that we’re not quite that bad; we may be more like in the middle. And the difference is because of lifestyles in this country. Another issue with chronic disease is that maybe half of it is due to lifestyles, due to poor diet, nutrition, lack of exercise, so on and so forth. And the obesity rates in the U.S. are the highest in the world. And this study suggested that the healthcare system is being unfairly credited or discredited by these lifestyle differences, and if you factor them out, then maybe we’re in the middle. But whether we’re in the middle or near the bottom, the reality is we spend nearly twice as much per capita or based on our gross domestic product on healthcare, as anybody else. So at least with respect to these chronic diseases, which are the things that are driving healthcare costs in the country, you can argue we’re not getting our money’s worth or we’re just spending too much money, because the results don’t align with the level of expenditure. And that’s really what all of this is about. I mean that’s what President Bush, and now President Obama, are so concerned with. Can we use the combination of electronic records and health information exchange, and quality reporting, and clinical effectiveness research, to allow us to more effectively manage in a coordinated and continuous way the chronic diseases that so substantially burden our healthcare costs. As a group, they represent 3/4 of all the spending in this country on healthcare. That’s 3/4 of $2.5 Trillion! From the federal government’s perspective, where they pay all the costs of Medicare, and where the trust fund is looking like it’s going to run out in a few years, we’re talking about 90% of the costs. So it’s the right problem to focus on, and there is data from other countries that it’s possible to do better, and that computer technology can be a key strategy in doing better, so you know, it all seems like a reasonable thing to do to me. But of course I’m prejudice. I’ve been interested in this for a long time.
Q: Now you mentioned that primary care physicians, that we have a lack of them in the U.S., and that effects our healthcare system in an adverse way. What is it that primary care practitioners do for us?
A: Well they’re the main line of treatment for these varied chronic diseases. I mean if you think about it, if you go to a cardiac surgeon, he or she is very focused on “I’m going to fix that valve problem you’ve got,” or “I’m going to bypass your Atherosclerosis,” or whatever it is. But who actually looks at you in total over time? Well, that’s the job of a primary care physician, a family practitioner, a general internist, a pediatrician, or an OBGYN. And the number of medical students that are going into primary care has dropped dramatically. I was at a meeting earlier this week and talked to someone who said that at Duke, for example, their graduating class in this past June, of 175 students, only three went into primary care. My own alma mater, I was there as well earlier this year, and only 8% of the class went into primary care.
Q: What’s causing that in your opinion?
A: Well, I think there’s general agreement on that. The average primary care physician makes about 1/3 of what a specialist makes in this country. So if you can imagine some young person who has gotten themselves into significant debt to go through college and medical school, and even though they might be motivated to go into primary care, they’re looking at a level of compensation that’s maybe 1/3 of what they can make by spending 3-4 years in training and becoming a specialist. Many of them, in fact it sounds like most of them, make the decision to become a specialist.
Q: Is that because insurance companies pay more to specialists or Medicare does, or both?
A: Well, I think the real answer is that specialists, in many instances, do procedures. And procedures are quite lucrative: surgical procedures, colonoscopies, and so on and so forth. I think we as a country are going to have to look at that issue. Or we’re going to have to do things that leverage the primary care physicians we do have, and there are interesting ideas along those lines, because there is a concept called the patient-centered medical home. I actually don’t like the term because it makes you think we’re talking about something that takes place in the home, and it really means a home for the patient with respect to medicine. The idea is for a primary care physician, instead of practicing medicine in the conventional way where they sort of do everything, for them to head up a team that would involve nurses and other practitioners to provide a level of access and continuous care, that would help achieve better results in the management of chronic disease. And there are physicians around the country doing this, and there is pretty convincing data that it actually works. That you can manage chronic disease more effectively and more efficiently using this approach. And, of course, the doctor leverages their time and effort. The interesting problem here, and this is particularly relevant to a state like Georgia, which is so large and has such a large rural area, over 1/2 of the physicians in our country are in practices of four or fewer doctors. And the kind of investment in people and technology, because everyone agrees the patient-center medical home requires electronic medical records to do the coordination and the record keeping and keep track of which patients need what done and so on and so forth, that level of investment is really beyond small medical practices. There was a recent study that rather dramatically showed that the larger a medical practice is, the more likely it is to be successful in practicing this way. So the government, as part of the Stimulus Program, has put a special emphasis on helping these small practices that tend to be in rural and underserved areas, adopt this technology. So in addition to paying for the technology, the Stimulus Program is also going to pay organizations to work with those doctors and help them successfully implement the technology. That’s actually something that Georgia Tech is going to be involved in, I think. We have a proposal in, and actually we heard earlier today that our preliminary proposal, which we’re doing with others, it isn’t just us, was accepted and we’ve been invited to submit a final proposal. So helping these small practices that are out there in rural and underserved areas adapt to modern technology is important. And another idea that’s starting to gain some attention is that if doctors have electronic records and were connected to a health information exchange so the health data was much more accessible, that maybe they wouldn’t need to employ a nurse to help them manage chronic disease patients because maybe they’re too small to afford that. But one nurse could actually work with several practices, from home or wherever, because the clinical data that’s needed suddenly becomes accessible. So this idea of doing a patient-centered medical home more virtually is something that people are interested in. One way or another, we’re going to have to get our arms around this. We can’t afford as a country to have chronic disease continue to grow like it is, fueled in large part by growing rates of obesity, and lack of exercise, and poor diet and nutrition, and continue to manage it so inefficiently. Because that really is the thing that’s driving the inexorable growth in healthcare costs to a great degree. Most people think it’s because the population is getting older and that’s a factor. But the lack of efficiency and effectiveness in managing chronic disease is a bigger factor, I think.
Q: Mark, you had mentioned to me those being some of the reasons the U.S. has such a high cost in the medical field. Also, you had mentioned that paying doctors by the procedure you thought was not the best way to efficiently provide medical care.
A: Well, that’s yet another issue. How should doctors be paid? Now this is probably a more controversial issue than anything we’ve talked about. But when people point to the real success stories in U.S. healthcare, they tend to point to organizations like the Mayo Clinic and the Geisinger Clinic. And the Mayo Clinic, of course, is in Minnesota, although they have a clinic as well in Jacksonville, and I believe they have one over in Phoenix, too. The Geisinger Clinic is in rural Pennsylvania, and there are others. Kaiser Permanente in California is held up as an example. These all actually have a very different economic system than we have in most of the country. Doctors are on salary. Often there are incentives based on the quality of care that’s delivered. In the rest of healthcare, the incentive system is really based on the quantity of care that’s delivered, not on the quality. People listening to this who feel like they wait a long time to see their doctors, and they only get a few minutes with him, should recognize that the doctor is incentived to see as many patients as possible during the day because they’re paid based on quantity, not on quality. And a lot of people, I’m certainly one of them, think we need to find a way to change that. Now doing that without these same information systems is virtually impossible. Because if you’re going to incent people, and reimburse people and pay people based on quality, you have to have a way of measuring quality, and to do that you have to have reliable data. So I think that is probably the ultimate objective here, that that’s probably where the federal government would like to take Medicare in time. But we’ve got a long way to go to get there. But there are examples in our country. If you look at the organizations I mentioned earlier, in general, they get better results for lower costs. And part of it has to do with their investment in information technology, but part of it has to do with the way the incentives are set up. And actually, I talk to more and more doctors, certainly I’m not saying this is a majority of doctors, but I talk to more and more doctors who say that they would actually be happy with such an approach. They’re really tired of trying to manage an office as a business. Dealing with all the various claims and insurance plans and everything is very tough. I think if a fair system that fairly values everyone could be devised, that it would probably be pretty well accepted. That’s not to say that there wouldn’t be physicians who would want to opt out of it, and I can’t imagine we’ll ever have a system where there isn’t private practice, and I can’t imagine we’ll ever have a system where people who want to have more care than whatever system we evolve to, feels is appropriate, won’t be able to buy it. That’s true in every country I know of, even though they all have some form of a single-payer system. I think virtually all of them also have some form of parallel private practice where people who want more and can afford to pay it can get it.
Q: That’s interesting that at the Mayo Clinic and Kaiser Permanente, the doctors are paid on a salary.
A: Right here in Atlanta, Piedmont Hospital has 400 physicians who are on salary.
Q: And I’ve heard that Johns Hopkins and the Cleveland Clinic are on the same program.
A: Right. I mean it’s a notion that surprises many people, but running a medical practice, given the complexity of our healthcare system … I mean, keep in mind that everyone listening to this who works for a company that provides health insurance, actually has a unique health plan. Every company that has health insurance sits down with whatever company it contracts with to administer that plan … and let me make sure that the people listening, understand that as well. Virtually every business in America that has, let’s say 100 or more employees, the number is not that precise, actually self insures. In other words, they’re not buying health insurance; they’re buying administration of a health plan that they’re funding. Typically what they do is they buy a catastrophic policy from let’s say Blue Cross which insures that their total annual expenditure won’t exceed a certain amount, but everything below that is actually their money. They are paying the insurance company to administer it. And they can sit down every year with the insurance company and decide what they want the rules to be. Do we want to pay for this drug? Do we want to pay for mental health? Do we want to pay for this, that and the other. So now imagine you’re running a physician practice in a big city like Atlanta where you’re seeing people from lots and lots of different companies and lots and lots of different insurance plans. Well, it’s pretty complicated to keep all of that straight. And there are costs associated with that. So it’s not totally clear that many physicians wouldn’t be just as well off on salary as they are trying to run a private practice in this complicated environment, particularly given that they were never trained to do that anyway and probably aren’t terribly interested in it.
Q: Now, of course there’s a lot of talk that the possibility of medical malpractice lawsuits causes doctors to provide more procedures than are necessary. What’s your feeling on that? What’s your observation?
A: Well, I don’t have a feeling, I’ve studied the matter. I can only tell you what I’ve read. And unfortunately, I’m not going to be able to give a terribly satisfactory answer here. First of all, a study that I always cite, done by Price Waterhouse Coopers, suggests that as much as 1/2 of all the money spent on healthcare in this country is actually a waste. Now they break it down into lots of different categories, but in a tie for first place among the largest categories, and I think its $120 Billion each but don’t quote me on that, is unnecessary tests and procedures. And then the question becomes, well how much of that is done for fear of medical malpractice? And I’ve done a good bit of research, looking at various studies, and they’re all over the place. The biggest number I’ve ever seen is, of course it depends to some degree on what test you’re looking at, but the biggest range I’ve seen is that it varies from 20-30% of all unnecessary tests and procedures. The problem was done by a medical group, so it was a survey. So it’s not really clear how unbiased that is. At the other extreme, there was a study done by the Harvard School of Public Health back in 1990, that concluded it really wasn’t a factor much at all. And there’s a third study that I show my students that concluded it was about 9-10%. So it’s kind of pick your money, and take your choice. I don’t know which is right. It’s clearly an issue that has a lot of attention, but it’s far from clear just how big a factor it really is.
Q: Mark, this has been very interesting. I understand your wife is co-author of a very popular book. I saw great reviews on it.
A: Well, my wife is a family physician and she’s a huge believer of patient empowerment. She believes that people need to understand more about their own healthcare and they need to be responsible for doing the things that will keep them healthy. So she co-authored a book called “Your Body, Your Health.” It’s kind of an interesting scenario. You have to know my wife to appreciate this, but she sort of goes chapter by chapter, and reviews the things that one of which is going to kill you, and one issue by another explains to you what you need to do to not get killed by that particular problem.
Q: When you’re in the hospital or being treated?
A: No, this is out in the world. Remember we said earlier that you know while everybody watches. … You know, I don’t watch a lot of television, but they watch shows like ER which, of course, focus on dramatic high technology medicine because it’s a great story, and we are the world’s best in that. But that isn’t really what kills most people. Most people are killed by chronic disease, and chronic disease in large part, and there are genetic causes, in large part is a result of human behavior. So there are things you can do to live a longer, healthier life, and that’s what her book is about.
Q: And Mark, if anybody wanted to reach you, what’s the best way for them to do that?
A: Well, the only way to reach me reliably is e-mail. I do have a public webpage, so anybody can type in “Mark Braunstein” and “Georgia Tech” and they’ll find my page. It’s the first thing that comes up on Google, and my e-mail address is on there.
Q: Excellent. And I do want to mention that Stephen Nagler is my good friend who was, at one time, the chief surgeon at Northside Hospital, and who did help on this. Mark, is there anything else you’d like to say about the medical industry or anything?
A: Well, you know, I hope people will not get focused on some of the stuff that gets tossed around in the media and the popular press. This is a very complicated industry. It doesn’t work the way the rest of our economy works. It’s very difficult actually to understand any of these issues without a good bit of study. But I hope people that are actually interested, will take the time to do that and to understand the dynamics as I indicated an issue like how significant is fear of medical malpractice, is not an easy issue. And I think if we have a more informed public, hopefully we as a society in a rational way, can come to some consensus and do the things we need to do to fix our system, because the system can’t continue the way it is. There just isn’t enough money to fund it.
Q: Thanks, Mark.
A: Thank you.