Episode 3: A healthcare crisis in the making: Medicare and Medicaid

Catherine: [00:00:05] Welcome to The Signal, a podcast presented to you by Third Bridge, the world’s leading independent research provider, exploring how some of the globe’s most investable industries are facing upheaval. My name is Catherine Ford, and I’m a journalist with a 20 year track record of reporting on a wide range of financial topics such as capital markets developments and M&A. In this episode of The Signal, we’ll explore the looming healthcare crisis in the US, the key players and possible ways out. Joining me today are Lee Brown, Third Bridge’s Global Team Leader for Healthcare and Safa Elshanshory, who focuses on strategy at a private healthcare services company. Both of you dialling in from the US. Hi, it’s lovely to have you on board. Safa, could I please ask you to introduce yourself to your listeners?

Safa: [00:00:49] Sure thing. Excited to be here, guys. Happy to have this conversation with smart people. As Catherine shared, I’m Safa Elshanshory, and I’m currently in a strategy role with a private health care services firm. And as some career background, I began in consulting and transitioned to a couple of different health care services organization over the past seven years, from kidney care to hospital and outpatient services, as well as PBM services and functions ranging from strategy to commercial strategy and new product and service development. And I’ll end it with I got into health care for very personal reasons, specifically the renal space. And unfortunately, the nature of our system is such that the longer you’re in it, the more sobering it is. But I’m confident we’re going to solve it all here, and it will be nothing short of uplifting.

Catherine: [00:01:35] Fantastic. Thank you so much. Lee, tell us about yourself, please.

Lee: [00:01:40] Well, first, I’ll echo Safa’s sentiments. Very excited to be here today and have the pleasure to talk with you, Catherine and you Safa. And as you mentioned, Catherine, I lead our global health care franchise at Third Bridge. I have a team that conducts roughly 1400 interviews annually covering all of health care, not only on the public equity space, but the private equity and credit markets as well. I have a fantastic team. I have six sector analysts who are supported by a dedicated team of research associates as well as operational and compliance support. We cover every sector within the health care industry, which is incredibly innovative and broad ranging and represents a significant portion of every country’s GDP. 

Catherine: [00:02:26] Thank you Safa and Lee for your introductions. Obviously, we’ve got two experts in the field to discuss the topic. Let’s start by setting the scene. Why are we talking about this now? Is there, in fact, already a US health care crisis underway? Is it looming and how will the recession play into it?

Lee: [00:02:42] I think the most important thing is to take a step back and realize the rather unique payer structure in the United States Health Care System, which is one comprised of CMS or the Centers for Medicare and Medicaid, as well as what’s known as commercial payers. These are the UnitedHealth and Cigna’s and Aetna’s of the world. There’s quite a few compounding issues that are driving the unfolding health care crisis. But the projected bankruptcy of Medicare as soon as 2026, as well as the current payment policies of CMS, are probably front and center.

Catherine: [00:03:13] Safa, from your corporate background, how do you view this space? Is it something where you look at it and go, goodness gracious me, how do we find ourselves in this situation and how can we prepare for it? Or what are your views on it?

Safa: [00:03:24] No, it’s not surprising. It’s unsurprising. You have a system where value sucks, outcomes suck, patient satisfaction isn’t there. And so, if you look at the trifecta of three, nothing’s working well. But if you look at how the incentives are structured, it’s operating as designed in many ways. And so, there’s nothing surprising about it. And I’m eager to get into the part of the conversation where we figure out how to solve it because I look at it from the 50,000 foot view and it’s so entangled and to disentangle it, where you solve for outcomes or you solve for patient satisfaction or you solve for value, where you’re not incentivizing for folks to get sick. It’s very hard to do that, especially in a political environment where there isn’t appetite for wholesale reform and the piecemeal stuff, with how convoluted our system is right now, piecemeal solutions will only tinker at the edges.

Catherine: [00:04:21] How predictable are the challenges that the system is going to face if the recession, that is sort of looming on the horizon, does fully kick in? Safa, if you want to take that first.

Safa: [00:04:32] I think the Great Recession was 13, 14 years ago. So, I think there was a lot of literature from the interplay between the macroeconomy and health. So, I think there is an expectation it will happen. You will see a rise in uninsured and underinsured folks and a reduction in employer sponsored insurance, and that’s in conjunction with the increase of the gig economy and folks maybe moving away from employer sponsored insurance altogether. And as we see in most issues, folks that are already marginalized will be disproportionately impacted. And if you look at the interplay and how a lot of health systems are able to be financially stable, you have a disproportionate reliance on commercial payers. And if a recession is to happen or if there continues to be the boogieman, that may be the recession, as we saw in the pandemic for different reasons, folks may delay elective procedures, and that could cause a domino effect for already precarious health care system.

Catherine: [00:05:31] Now, Lee, do you want to talk to us about how health will be impacted, what kind of consequences that we can see, and how outcomes can change as we possibly spiral into a recession?

Lee: [00:05:42] Absolutely. I think Safa hit on that quite nicely, especially as it relates to those who are most vulnerable in our society, which is a real concern. First, I would just go back to was this predictable? When you think about the large impact that CMS has on the system, they have a cumulative cash shortfall since inception that’s just shy of 6 trillion. Medicare’s contribution to the national debt is roughly 29%. So that’s not a small issue. And, of course, Medicare is predicted to go bankrupt and be completely insolvent in just four years. You add that onto the backdrop of a looming recession, which I fervently believe will happen. I don’t think it is a possibility. I think it’s a high probability. And the result of that is, one, rising unemployment. People lose their employer funded insurance, so they become either uninsured or underinsured. I think along with recessions and a retrenchment of economic activity with rising unemployment, you have stress that leads to mental health issues, as well as substance abuse issues and really sadly, depression, suicide and spousal and child abuse. So you have this…all these issues. And then on top of that, losing the ability to pay for your home or apartment and becoming homeless. You can imagine all of those factors create a health care crisis.

Catherine: [00:07:13] So all those points that you raised there paint a very, very gloomy picture and a very sad picture as well, I think, which we shouldn’t forget. Where does that leave the people who are most in need of care? Where would they turn? Who would provide support to them?

Lee: [00:07:28] Well, I mean, I think one of the issues, clearly, is they show up in the emergency room and are taken care of in a situation that doesn’t include proper preventative health care, which really goes a long way to saving enormous drains on funding within our health care system. But they show up and then they have what’s called charity care. And what this is, is booked, gross revenue is written off at the top line becomes net revenue. And of course, the expenses don’t go away. And so, what you have is a compressed top line with the same or elevated expenses and it results in compressed margins. You tie in that into this drive to migrate inpatient procedure to the outpatient, and you paint a very challenging picture for the providers in our US Health Care System.

Catherine: [00:08:19] Safa, if I can come to you just around the topic of the projected insolvency of Medicare and Medicaid, what potential solutions do you see for that challenge?

Safa: [00:08:28] Easy one. I mean look, like any good insolvency problem, you either need to increase revenue or you need to reduce unnecessary spending. And I think the answer is both. There’s a lot of unnecessary spending in Medicare that can be tightened and it can be tightened, most importantly, without reducing benefits or without reducing eligibility, there’s a lot of waste in the system. So that’s one. And then increasing revenue can look, you know, there’s the unpopular raise the payroll tax rate, the standard payroll tax rate, that employers and employees spend, or there is closing the loophole on folks that are finding ways to skirt that tax altogether.

Catherine: [00:09:07] So those sound like relatively straightforward and easy solutions. Lee, how easy are those solutions really to implement?

Lee: [00:09:14] In simple terms, the government can’t just keep printing money to bail out CMS. If you look at the M1 and M2 money supply, especially M1, we’ve increased that from 4 trillion at the beginning of 2020 to 20.7 trillion. I think this is a topic that doesn’t get enough airtime. You’re talking about 5x in the M1 money supply. So can we bail out CMS? It depends. If you print more money to bail out CMS, what are you do doing? You’re driving the persistent inflationary pressures and only therefore catalyzing the Fed hiking cycle to be even more aggressive. So it’s counterproductive. And it leads us to a very challenging set of choices, which is, to Safa’s point, to raise premiums. And I’d like to get into that in a moment or later in the discussion, but they’re just not feasible solutions.

Catherine: [00:10:04] Let’s talk about some of the realistic policy options to help cure the health care crisis.

Lee: [00:10:09] There’s two or three facets here. I mean, one is talking at the provider level, which gets into sort of capitated risk sharing in this, hopefully an accelerated move from fee for service or volume based care to a value based care system and just executing health care more smartly. But what I would say in terms of the funding situation, I mean, this is an issue that’s not going to be resolved by greater health care efficiency within the system. This has to do with the fact that Medicare has an annual cash shortfall that’s quite large and is projected to be insolvent in the very near future. And what I was referring to were the solutions for that are untenable. Let me just quickly get into this. Looking at the latest data, the Medicare annual shortfall in 2020 was $496 billion, and it was 16% of the federal deficit this year. So just to put that in context, that’s a very big figure. Now, in order to have paid for just Medicare Part A in 2020, payroll taxes, those are the taxes that everyone pays would have had to have increased by more than 32%. So that’s not possible. The annual premium increases to balance Medicare Part B would have to go up 267%, meaning the annual premium cost to our seniors. So this is not payroll taxes, this is premiums for the folks involved in Medicare would have to go from roughly $1782 a year to $6532 a year. So that’s an increase of $4750. Can you imagine if you’re an elderly person on a fixed income in retirement, having to come up with another nearly $5,000 to pay for your Medicare Part B?

Catherine: [00:11:53] But that’s unthinkable, isn’t it?

Lee: [00:11:55] It is unthinkable.

Catherine: [00:11:56] Thank you very much for that, Lee. Safa, with your corporate hat on, could you talk to us a little about the dynamic between the commercial payers and the providers and what we’re seeing there?

Safa: [00:12:07] Yeah, I mean, not to be true dramatic here, but the relationship between payers and providers in our current system is inherently antagonistic. One wants to control costs to the extent possible, and the other wants to get paid as much as possible for the care delivered. And in a world where you really can’t dictate what Medicare and Medicaid pays you, you’re increasingly reliant on your commercial payers, for better or worse. And so ultimately, the financial viability, as we talked about a little bit ago, of many organizations rely in these blunt, maybe not PR correct terms, but these more lucrative commercial paying patients are increasingly important for these health care organizations to offset the patients that, in some cases may be either neutral or costing systems more than they’re getting reimbursed for. And commercial payers obviously understand this. In an effort to control costs, you’re increasingly seeing commercial payers usurping clinical decision making to control costs in ways that are not entirely smart. And so I think we will continue to see that clash until we transition into a world where there is more value based care. And while I think there are some models that have worked well, I don’t think we’ve quite figured out what the scalable value based model is, especially leveraging the plethora of data we have now, which unfortunately is so siloed that you can’t really harness all of that data in a world where a lot of the data sources are so disparate.

Catherine: [00:13:42] So Lee, Safa described the relationship between commercial payers and providers as antagonistic. Is that something that’s always been the case or has that actually just developed over the last few years?

Lee: [00:13:52] I think the reason why this might be challenging to answer is it wasn’t always as bad as it currently is. This is obviously a very interesting topic as payment rates for Medicare and Medicaid, with the exception of Medicare Advantage under Part C, are set by law rather than through a negotiation process with the providers. You can imagine that sort of unilateral decision making on reimbursement creates some serious challenges. I think it’s important to step back and kind of put this into context because one might not understand what a large percentage Medicare and Medicaid play in the health care system. So I have some figures here, and it has to deal with the disproportionate amount of health care needed by the elderly and those that are marginalized in our society from different socioeconomic backgrounds. But Medicare and Medicaid provide health care to roughly 60 million and 74 million people in the US respectively. That’s a large number of people alone. But what’s interesting is CMS currently accounts for more than 60% of all care provided by hospitals. So that is certainly a large number of people representing the volume, which is so important to hospitals in terms of occupancy. And so this gets into our how bad are the underpayments, right? And so looking at the latest data from 2020, 67% of hospitals have received Medicare payments less than cost, while 62% of hospitals receive Medicare payments less than cost. And on average, Medicare paid about $0.84 on the dollar, with Medicaid paying $0.88. So if you’re getting that kind of volume that’s underpaid to the tune of 10 to 15%, it’s a real problem. They’re depending solely upon the very few lucrative surgical procedures that run through the in-patient setting. And those are being pushed by CMS policy out of the hospital. So this is going to create a real potential crisis in terms of access to health care and is another great issue other than the insolvency that needs to be addressed.

Catherine: [00:16:31] Thank you very much to both of you. You’ve painted a very challenging and quite distressing at times picture of the state of the industry at the moment. But obviously it is still an attractive industry for investors to put their money into. Lee, talk to us. What exactly will investors have to look at when it comes to that space?

Lee: [00:16:50] Well, there’s a few things I’ll briefly touch on them, but I think, one, this migration from the inpatient to the outpatient ambulatory surgical center is a huge one. To put that in context, our experts have indicated that this is roughly a $60 billion annual market opportunity. How do we think about that? Well, the inpatient setting does about $230 billion of surgical revenue a year. So, this is roughly a quarter, a little bit more than a quarter of potentially the most lucrative procedures leaving the hospital. So, you’re going to have a policy where you need to have a very strong ASC strategy. There are folks like HCA and Tenet in the general acute care space that have done an excellent job on that. We’ll talk more about that, I’m sure. And there are folks who have been in a constant battle of retrenchment like Community that that are really flat footed with their ASC strategy. I’d say investors are also focused, according to our experts, and quite evidently on the tight labor market, the ongoing nursing shortage and the upward pressure to SG&A, that’s going to potentially compress margins on top of a really difficult economic environment.

Catherine: [00:18:03] Thank you so much, Lee. Safa, does that sort of tally with what you’re seeing and what you’re hearing in the investment community?

Safa: [00:18:08] It does, and I just want to put it in simple terms, maybe for the folks listening that aren’t necessarily investors. I mean, what Lee basically said, the major portion that he just shared, is site of care. Instead of going and doing something in a hospital that you can go and do in an outpatient, and instead of it being a several hour procedure, not to say that the actual length of the procedure will change, but just the process in a hospital is different than a process in an outpatient surgery center for any of us that have had an experience with either. And so, it’s just getting the site of care, right. If you can provide care in a different setting that’s cheaper, that’s frankly more user friendly. We’re seeing, luckily, things transitioning in that direction, which I think is just a more common-sense system for all. The only two things that I will add to what Lee shared about where there’s a lot of dollars and excitement, it’s two things. One, patient and physician experience. I said it earlier, patient and physician experience sucks. And I think with all the pressures in the system and frankly, a lot of these technology players and some that we say, hmm, I wonder what they’re doing in the space. There is a lot of whether they’re in a self-insured situation where they say, well, I have a I’m a 200,000 person company and I want them to have a superior health care experience. We’re going to create it. And then that becomes something that can be commercialized. We’re going to see an improvement in patient and physician experience and then mental health services for many reasons, including the pandemic, including social unrest, the recession that’s looming in the background, there’s an increasing demand for mental health services and there is an increasing strap on the supply of mental health care providers. And so, there’s a lot of excitement and clashing trends. So, I think we’ll continue to see fun stuff in that space.

Catherine: [00:19:54] Lee, you already namechecked two businesses that are doing exciting things in this space. Can you elaborate a little and talk to us about some of the companies that are acting particularly innovatively, that are worth keeping an eye on?

Lee: [00:20:06] I think as we look at the provider space singularly, I like to focus on the general acute care hospitals. I mean, I think before I talk about why our experts like Tenet, I just want to lay out the rather dreary prospects, which I know we’ve kind of gone over ad nauseam, but…

Catherine: [00:20:24] Do you want to depress us all?

Lee: [00:20:27] But it’s not all depressing, to Safa’s point, but it is incredibly important. So, I think one very quickly, looming recession, which I think is going to happen and I think a lot of experts also fall into that camp south indicated rising uninsured because they’ve lost their health care policy through their employer. At the same time, rising demand because of the repercussions a recession has: homelessness, drug abuse, mental health. What that means is more and more people showing up for care. The care doesn’t go away; it actually increases. And then you have charity increasing, uninsured charity care. So, you have this increase in expenses with downward topline pressure, which compresses margins. You also have this nursing shortage which isn’t going away and you’re seeing this increasing use of contract labor, which is driving up SG&A, which also puts pressure on profitability, therefore drains ultimately free cash flow and can be precarious for those with higher leverage in the capital structure. You add on to that, that CMS is going to be insolvent and is currently creating this antagonism where providers have to be cross subsidized by payers, commercial payers, that is, and that they’re growing increasingly frustrated with that dynamic and pushing back because their clients are pushing back on premium increases, especially as high rate deductible plans become more prevalent. And so, you have all these swirling factors. And then on the top of it, we’ve talked about the amount of volume going through CMS and yet most of that volume is being underpaid. And then on top of that, the few surgeries that general acute care hospitals are doing well with those procedures are going to the SC. So, what’s the punch line? I want to talk about Tenet’s transformation over the last few years. It’s done a remarkable job, first with the acquisition of USPI that brought in interest in 399 ASCs and 24 surgical hospitals in 34 states. There’s obviously room to expand their geographic footprint in that area. They also just recently acquired SurgCenter Development, or what’s known as SCD. With that SCD transaction, Tenet picked up an additional 86 ASCs for 1.1 billion. They’ve also earmarked an additional 250 million to buy additional ownership interest. So, I think they’ve done a great job in getting into this ASC space, which is going to really position them for the most success in a challenging market. HCA has also done a great job there and, as I mentioned, Community, according to our experts, is really in a bit of a difficult position.

Catherine: [00:23:10] Safa, from your perspective, do you agree with that?

Safa: [00:23:12] I do agree with that. They I don’t know if you asked if they were the most exciting businesses. I do agree that they’re definitely following the changes in the industry and they’ve done a really nice job of positioning themselves. I think there are exciting businesses that are maybe in different spaces within health care that I’m very curious to keep my eye on. I think Hims & Hers and the concept of the direct to consumer, I think targeting younger patients who either don’t have an experience altogether with the health care system or don’t have a positive experience and want things quickly. They’re used to thinking of gummy bears showing up on their doorstep. And so just making it a much more seamless experience, similar to the other retail experiences they have and personalizing health care, I’m curious to see what other verticals specifically Hims & Hers gets into because I think they definitely tap into something interesting. And the other one that I think is really cool, on a mission, is very inspirational is Tempest, you know, they’re trying to cure cancer. So they’re using data, they’re using technology to personalize cancer treatment, using genomic sequencing and clinical data structuring and technology and figuring out how do we harness all of that information to actually benefit the next patient, which I think in theory a lot of health care systems and organizations try to do, but they’re putting their money where their mouth is and the way they’re financially backed helps with having a bit of a bottomless paycheck. But they’re a very mission-oriented organization and I’m excited to see what they do as well.

Lee: [00:24:35] I think in terms of online pharmacies and the availability of direct to consumer models, it’s fascinating. And one of the things that I’ve always found troubling is that you can go into a pharmacy like a CVS or a Walgreens and choose not to use your insurance card with your pharmacy benefit and pay as if you’re uninsured with a coupon that you can print online and pay less for a specific drug than you would if you actually use your insurance card. So, I think that’s probably an experience many people have had. If you haven’t, I would look into seeing what you can pay for prescription without using your health insurance card. And it’s troubling. Certainly, across all of health care, you’re just seeing amazing exponential advances in innovation in cell and gene therapy, synthetic biology. The more and more strengthening integration of biotech with life science tools, of course, structural heart and medtech and on and on in health care I.T. So it’s a, it’s a wonderful space that’s exciting. And of course, we cover it all at Third Bridge. So I think, again, looking at cell and gene therapy, especially not just with the big competitive players that everyone would know with sizable market caps, but just all the innovation that’s going on even in the private equity world as it relates to biotech, folks are putting together these amazing platforms that serve as incubators that are really looking to get more and more people into the field. Recently we had a call where the focus was on providing access to the foundational technologies and tools needed to advance innovation in medicine with the concept that competition should happen across intellectual firepower, not who has the best access to funding. So, you’re seeing these really interesting communal approaches and ecosystem approaches to getting us to the future of health care, which is really now.

Catherine: [00:26:41] It’s arrived. Now you’ve future. And I do want to spend the rest of this podcast taking a little bit of a look into where things are going, how more market efficient approaches to ensuring that society, particularly those that are the most vulnerable, can receive better, more consistent and more accessible standards of health care. Lee, from your perspective, what needs to change?

Lee: [00:27:04] Well, this is all about taking care of people. I think really interesting and a highlight of a private company that I did a recent call on Unite Us, which I was really blown away by because I was scratching my head of how they’re able to do the right thing and still make a nice profit. Unfortunately, don’t go hand in hand too much in our global society.

Catherine: [00:27:26] But what a lovely way to run your business. Doing the right thing and still making money out of it. Surely that should be an aspiration for all of us.

Lee: [00:27:35] It’s early stage, but they’ve reached unicorn status and more. And so, you know, there’s a lot of smart investors in the company who are probably a lot smarter than I am. And so, I know they’ve kicked the tires and are pretty confident, but I think there’s still proof required as they grow. But what I really want to focus on is not Unite Us, but the concept of looking at those who are most vulnerable and trying to actually solve their health care problems versus profit off their sad circumstances. And I think the more we can embrace preventative care, especially as it relates to obesity, proper health choices, nutrition, exercise, just the simple things that everyone understands but for some reason we don’t address, and it’s really leading to a huge drain on our health care system.

Catherine: [00:28:29] Now, Safa, you come to this space from a very personal experience, as you mentioned in your introductory remark, looking at sort of the development of the space. What more market efficient approaches would you like to see to take care of people who’ve been in a similar situation to you, but obviously everyone else as well?

Safa: [00:28:43] Yeah, I think two things and one of them, Lee, hit on, I mean, I think ultimately like follow the dollar like the payment systems need to change. Lee talked about preventive care versus reactive care. We are so, you know, we’re fighting over if and how we compensate once folks are sick when really we would be saving a lot of money if we went upstream and we figured out how we can control the obesity problem, how you can curb societal issues like smoking and excessive alcohol and etc. But we just need a fundamental rethink of like, what is the thing that we’re trying to solve for and what are all the different ways that we can solve for it? And we can’t be stuck in this bind of like fighting over how much we pay for this thing that happens 404 decisions later. The second thing is we have to make going back to…I think utopia is value based care. Utopia is saying when this person is healthier, everyone wins, incentives are aligned. But in order to get to utopia, measuring outcomes has to be easier in today’s environment. With the disparate data sources, it is very difficult to actually measure the health of someone in a holistic way.

Catherine: [00:29:55] Can I still come back to you on something that you mentioned in your earlier comments. You spoke about that we should take a preventative rather than a reactive approach to people’s health. Where do you feel the responsibility for that needs to be? Is that something where we need stronger directives, policies from the government? Is that something that we need to see at a community level? Is that something where people need to take greater personal responsibility?

Safa: [00:30:19] I think the subtext to all of this is an expectation and an aspiration that everyone takes a more active role. However, I think systems and institutions are in place to help direct things. Ultimately the government is a huge player in all of this. Like we’ve talked about the numbers the government pays for a lot of folks in the American health care system. And so, they have the power of the purse and they have the ability to dictate both what happens in the private and in the public markets. And I do think that government needs to set the tone around value based care versus fee for service. It’s in employer’s interest, it’s in commercial payers interest for people to utilize the health care system less. It’s just we haven’t quite figured out how to get there.

Catherine: [00:31:04] Now paint me a picture, to wrap up the podcast, of what you think the space will look like in the next 5 to 10 years. Safa, from your perspective.

Safa: [00:31:14] Ok, I’m going to put my optimist hat on because I am a thank you. I mean, I think people will continue to become more knowledgeable and active in their care. And I think there could be a watershed moment in the next, we’ll say, ten years to be more realistic, that makes care more personalized, more transparent, more patient centered. I think wearable technologies will become, rather than kind of this thing on the fringes, something that’s actually capturing important, not to say it’s not capturing important data today, but capturing important data that will actually inform clinical decision making, that will actually inform if and when and where you procure care. And the last thing is, I think site of care will be a foregone conclusion. I think telehealth, we’ll never hear that word again, because telehealth is health care and it’s just a matter of the modality by which you receive care. And so the notion of, oh, I have to get an ACL repair, do I go to the hospital or do I go to the AFC down the street? Foregone conclusion that would be silly. Why would I ever go to the hospital? And so, I think in ten years you’ll start to see more common sense and you’ll see the health care industry hopefully catapult in the 21st century, harnessed by some geniuses out there, actually allowing us to fix the infrastructural challenges that exist in health care, where we have so much data, but some of it stuck in the EHR and the EHR doesn’t talk to these other things. And so, using APIs and technology and all the smart people in the space, hopefully what we experience in health care will feel a lot more similar to the seamless, personalized experiences we have in retail and other sectors.

Catherine: [00:32:52] That is a very nice outlook on the future. Lee, do you share Safa’s optimism for where things are going?

Lee: [00:32:59] Not sure I share her optimism, but I do agree with many of the points she made. I think hospital expense transparency at the consumer level is absolutely required. And I think the need is for transparency of hospital care data at the consumer level. I think the wearable technologies where we can get more into preventative care is absolute. She’s spot on with regards to telemedicine and telehealth. I think, just to add to her points, this pending crisis, that I firmly believe we’ll experience, sometimes creates the necessary action. 

Catherine: [00:33:40] Unfortunately, that’s all that we have time for today. But thank you so much to Lee and Safa for sharing your experiences and your insights. It’s been wonderful talking to you. Thank you also to all of you listening to this week’s episode of The Signal, presented to you by Third Bridge, the world’s leading independent research provider. Join us again for the next episode when we will be discussing more upheaval in another key investment industry. Please rate, review and follow our podcasts. Indeed, if you like it, tell a friend. Find us on Spotify, Apple Podcasts or wherever you get your podcast from. And of course, thirdbridge.com/signal. From me, Catherine Ford, that’s it. Thank you very much and goodbye.