Episode 6
Understanding the Mental Health Parity Act: A Guide for Providers (From Payer Executives)
This podcast episode dives deep into the complexities of mental health parity and the implications of the Mental Health Parity Act. The conversation emphasizes the necessity for behavioral health services to be treated with the same level of care and coverage as physical health services, addressing the ongoing disparities in treatment and reimbursement practices.
Alex Yarijanian and Dr. Chris Esguerra discuss the challenges providers face when navigating insurance plans and the barriers to accessing equitable care for patients.
Dr. Esguerra is board certified in both Psychiatry and Health Care and Quality Management and is a Fellow of the American Psychiatric Association and the American Board of Quality Assurance and Utilization Review Physicians.
Dr. Esguerra’s extensive payer-side executive experience includes:
- Senior Medical Director, Blue Shield of California
- Senior Medical Director, Magellan Health
- Deputy Chief Medical Officer, Health Plan Of San Mateo
They highlight the critical role employers play in advocating for better mental health coverage and how they can leverage their purchasing power to ensure compliance with parity laws. Ultimately, the episode aims to empower providers with the knowledge and tools necessary to advocate effectively for their patients and promote a more integrated and equitable healthcare system.
A significant focus of the episode is on the role of providers in identifying and addressing parity violations. The speakers guide listeners through the necessary steps for raising concerns regarding unequal treatment, emphasizing the importance of gathering evidence and understanding insurance policies.
This segment is particularly valuable for behavioral health providers who may face obstacles in securing appropriate coverage for their patients. The discussion also touches upon the regulatory landscape, explaining how self-insured plans differ from traditional insurance plans and the implications this has for parity enforcement.
Additionally, the episode discusses the importance of employers in advocating for better mental health coverage, encouraging providers to leverage their relationships with these entities to push for systemic changes that prioritize mental health equity.
Takeaways:
- The Mental Health Parity Act requires equal coverage for both physical and behavioral health services, ensuring that patients receive the same level of care.
- Providers should gather evidence of parity violations and present it to state regulators to advocate for fair treatment.
- Behavioral health is lagging behind primary care in integration and reimbursement models, highlighting the need for systemic reform.
- Employers play a crucial role in advocating for mental health parity by demanding better coverage from their insurance plans.
- Effective communication and partnerships between providers and health plans can lead to better patient outcomes and innovative care models.
- Tracking outcomes and demonstrating quality of care is essential for providers to negotiate better contracts with health plans.
Companies mentioned in this episode:
- Blue Shield of California
- Magellan
- Kaiser Permanente
- Apple
- Anthem
- Centene
- United
- Cigna
- Aetna
- Humana
- CalPERS
- Pacific Business Group on Health
- National Business Group on Health
Chris Esguerra MD MBA
Transcript
Thank you for tuning into the VBCA podcast.
Host:The following is a conversation between myself and Dr.
Host:Chris Esquera.
Host:Dr.
Host:Chris Esquera is board certified in Psychiatry and healthcare and Quality Management.
Host:He has served on many boards and panels across the country.
Host:His academic pedigree is a bachelor's in science in Chemistry and a medical directory, both from University of Southern California.
Host:He completed his residency training in psychiatry at San Mateo County Fiero Health.
Host:He also received his MBA from University of Massachusetts at Amherst.
Host:Dr.
Host:Chris Esquera's extensive payer side executive experience includes being Senior Medical Director at Blue Shield of California, Senior Medical Director at Magellan Health, Deputy Chief Medical Officer of Health Plan of San Mateo.
Host:I hope you enjoy this conversation as much as I did.
Host:Truly eye opening to hear from a health plan executive as to what their thoughts are in terms of mental health parity.
Dr. Chris Esquera:Thanks, Alex, and thanks for having me.
Dr. Chris Esquera:And hi everybody.
Dr. Chris Esquera:So yeah, let's take what is this complicated thing or may seem that way with a lot of acronyms to let's just have it really Sabbath foundation and really the core of mental health parity through the Mental Health Parity Act.
Dr. Chris Esquera:It's a long acronym of actually a lot of letters, but everybody calls it MAPEA because we like to spell out or try to say out Our acronyms really just means that if you under the jurisdiction of this law are going to be providing coverage over a certain set of services in physical health and you're going to do provide coverage in behavioral health, how you treat both have to be the same.
Dr. Chris Esquera:The overarching way of thinking about it now when it gets into the details is where it's going to be a little bit more complicated.
Dr. Chris Esquera:So without getting too wonky, we'll talk a little bit about that then because the next question is great.
Dr. Chris Esquera:All right, so what do I equate certain how do I equate certain services on the physical health side to certain services on the behavioral health side?
Dr. Chris Esquera:Oh, things that are relatively straightforward hospital care and hospital care on both sides.
Dr. Chris Esquera:Sure.
Dr. Chris Esquera:Details is where it's going to be a little bit more complicated.
Dr. Chris Esquera:I'm hearing something there.
Dr. Chris Esquera:We'll talk a little bit about that because the next question is great.
Dr. Chris Esquera:All right, so what do I equate, Alex?
Dr. Chris Esquera:I'm hearing some echoing services.
Alex:Me too.
Alex:Okay, there.
Dr. Chris Esquera:There we go.
Dr. Chris Esquera:Sorry about that, folks.
Dr. Chris Esquera:But then the other and outpatient treatment is going to be equivalent to outpatient treatment.
Dr. Chris Esquera:But what is intensive outpatient?
Dr. Chris Esquera:How do we equate that into what on the physical health side, what does residential Treatment equate to on the physical health side.
Dr. Chris Esquera:So a lot of the work when MPA first came out was just to start building out those equivalents.
Dr. Chris Esquera:Now there's also the concept of things where we can put a number versus practices that aren't so, you know, can't be encoded in just a number.
Dr. Chris Esquera:So in technical terms, these are the quantified treatment limitations versus the non quantified treatment limitations.
Dr. Chris Esquera:And of course, since we love acronyms in healthcare, in particular, in parity, the quantified treatment limitations are QTLs and non quantified treatment limitations are NQTLs.
Dr. Chris Esquera:I'm not going to repeat that going forward.
Dr. Chris Esquera:We're just going to talk about why they matter in the first place.
Dr. Chris Esquera:From a parody perspective, the quantified stuff, we'll just say where we're going to compare either the physical health side as well as with the behavioral health side.
Dr. Chris Esquera:That's actually easy.
Dr. Chris Esquera:That's in the world of how much does the person, the member, the plans call their covered folks, who they cover, members, general, generally we call them patients, providers.
Dr. Chris Esquera:But essentially how much is that patient going to pay out of pocket?
Dr. Chris Esquera:How much from a CO pay perspective, a CO insurance, that sort of thing.
Dr. Chris Esquera:If there's going to be any kind of session limitation, for example, is that going to be the same on either side?
Dr. Chris Esquera:So if I'm going to limit the number of physical therapy sessions someone has on the physical health side, am I doing that similarly?
Dr. Chris Esquera:The principle being that not one side is more restrictive than the other.
Dr. Chris Esquera:Right.
Dr. Chris Esquera:They're all going to be the same in terms of how you have leveled them.
Dr. Chris Esquera:That's the quantifiable stuff because there's a number and it's frankly a lot easier, a lot easier to show.
Dr. Chris Esquera:Just imagine too that pricing in terms of the rate in which someone is paid, a provider's paid, usually based on a code, is also part of that.
Dr. Chris Esquera:We'll talk about that a little later because that gets interesting in terms of how those rates get buried and all that fun stuff.
Dr. Chris Esquera:And so Alex and I will delve definitely deeper into that.
Dr. Chris Esquera:But there's this other area and frankly, that's the harder area.
Dr. Chris Esquera:That's the one, that's the area where it's not about the numbers, but it's about the practice, the setup, the framework.
Dr. Chris Esquera:What does that mean in more concrete terms?
Dr. Chris Esquera:Well, it's how say the health plan, the health insurance company does utilization reviews, so.
Dr. Chris Esquera:Or whether they do them.
Dr. Chris Esquera:So for example, let's do the residential treatment level of care on behavioral health Side, the equivalent in the physical health side is skilled nursing facility treatment or that kind of level of care.
Dr. Chris Esquera:Both are 247 housing.
Dr. Chris Esquera:They're not hospital, but you know, they're definitely a higher intensity level of care.
Dr. Chris Esquera:Someone has to live somewhere in a confined setting.
Alex:So residential substance abuse treatment, for example, would apply.
Dr. Chris Esquera:Yeah, exactly.
Dr. Chris Esquera:Or skilled nursing.
Dr. Chris Esquera:Yes.
Dr. Chris Esquera:A residential eating disorder.
Alex:Interesting.
Dr. Chris Esquera:Yes.
Dr. Chris Esquera:So those would all essentially be equal.
Dr. Chris Esquera:There's a whole set of charts the health insurance plans have to give to their regulators to figure out what is equal, what isn't equal.
Dr. Chris Esquera:And so let's say that, you know, that we'll take that and let's say a health insurance plan is doing your typical utilization management.
Dr. Chris Esquera:They're applying criteria for residential treatment, for substance use disorder.
Dr. Chris Esquera:You know, they're definitely calling you as a provider every 2, 3 days to get the clinical information to tell you, yes, no.
Dr. Chris Esquera:How much more time do we have left for that individual?
Dr. Chris Esquera:I'm sure many of you can, can relate to that experience or your teens can.
Dr. Chris Esquera:Now, on the physical health side, that health insurance plan has to be doing the same thing for their skilled nursing facility level of care.
Dr. Chris Esquera:Now, there is a practice that sometimes for skilled nursing, there really isn't utilization management.
Dr. Chris Esquera:It's sort of the monitoring for what is known as the exhaustion of benefits.
Dr. Chris Esquera:Because for certain things like Medicare, you have a limit of about 100 days of skilled nursing facility treatment, for example.
Dr. Chris Esquera:And so, you know, there, it might just be that they're ticking off the number of days.
Dr. Chris Esquera:So you can imagine there's a disparity there because there is no utilization management if you're just ticking off the number of days.
Dr. Chris Esquera:And so that's lack of parity and plans could get into trouble because of that.
Dr. Chris Esquera:From a practice of how is it that you're providing oversight perspective.
Alex:So that dovetails nicely into the next question.
Alex:But since we have folks joining recently just to reintroduce.
Alex:Dr.
Alex:Chris Escura is a psychiatrist and he is also former director of almost all health plans, former senior medical director of Blue Shield of California, former senior medical director at Magellan, leadership roles at Kaiser.
Alex:He is also a Care Nodes expert network participant.
Alex:He has his undergraduate training at USC and his medical school training at USC and a master's in business administration at University of Massachusetts at Amherst.
Alex:Dr.
Alex:Esquera is actively involved in social determinants of health, behavioral health, and essentially spearheading market initiatives.
Alex:And we're having this session to educate providers, especially behavioral health providers during this national pandemic how best to continue to be in business using existing kind of regulations or statute such as parity.
Alex:And so doctor, I'd like to kind of go into, as a provider, how would I begin to think about parity issues?
Alex:How would I raise a concern, a parity violation concern?
Alex:How can I hold the health plan accountable?
Dr. Chris Esquera:Right.
Dr. Chris Esquera:I'll say that as a provider, I mean, talking about sort of the big picture about parity and how the health insurance plans are regulated, they're regulated by their state, usually Department of Insurance or Department of Managed Care, things like that.
Dr. Chris Esquera:And just to note that self insured plans, such as, you know, for large companies that do this aren't regulated under this, they're regulated under the Department of Labor.
Alex:Would you, would you, I'm sorry to cut you off, but self insured plans, so what type of plans are those?
Alex:Would you?
Dr. Chris Esquera:Yeah, so self insured plans plans are usually those that are set up by large employer groups.
Dr. Chris Esquera:So think like a Google or an Apple and instead of them partnering with an insurance company to provide coverage for their employees, they set up and fund themselves and purchase a variety of services, whether directly with providers or just for a variety of other tasks.
Dr. Chris Esquera:That's not regulated in the same way as a health insurance plan like a Blue Cross Blue Shield or an Anthem or a Centene or things like that.
Dr. Chris Esquera:So those are, they're different.
Alex:How would a provider know which is which?
Alex:So how would a provider identify what plan is self insured versus individual or group market or any other type of line of business that would be applicable?
Dr. Chris Esquera:Right.
Dr. Chris Esquera:So the challenge there really is.
Dr. Chris Esquera:Well, I mean, a way to think about it would be your traditional sort of insurance plan names that you know out there think like United or Cigna or Aetna or things like that, those are going to be selling traditional insurance products.
Dr. Chris Esquera:However, when you are applying to be in their network, that's going, you have to then in the contracting process understand which networks are you going to be a part of because they may actually be doing business providing services for self insured employer organizations.
Dr. Chris Esquera:Sometimes these self insured employer organizations may actually either do their own contracting with providers directly or hire out a third party that would actually be doing that for you.
Dr. Chris Esquera:And so it's really in the contracting process to ask the question and to understand who is it that you would potentially be serving.
Dr. Chris Esquera:And by being in the network.
Alex:Okay, great.
Alex:And so that's part one, right?
Alex:Identifying which plan, demystifying what plan applies to these regs.
Alex:And so let's say we identify a plan that is subject to these to the parity movement.
Alex:So how would then a provider go about navigating that situation?
Dr. Chris Esquera:Right.
Dr. Chris Esquera:So I'll say this, for a provider, it's generally really challenging to raise parity concerns.
Dr. Chris Esquera:And the reason why is that you're going to have to find some sort of evidence, or at least enough evidence to cause suspicion that your area in behavioral health is being treated differently than say, the similar area in physical health.
Dr. Chris Esquera:Now, that's not to say this is impossible because there have been recent lawsuits on this and there's actually a recent article talking about one, but there was one against United Behavioral Health in Northern California, and this was last year.
Dr. Chris Esquera:And this was all around how the organization covered mental health and substance use disorder treatment.
Dr. Chris Esquera:And that was actually found to be more restrictive than the physical health side.
Dr. Chris Esquera:And so that's a way of actually looking at how they health insurance plans have to publish something called an evidence of coverage.
Dr. Chris Esquera:And in that it's typically a long document, multiple pages, but it pretty much says, hey, we are going to cover these things.
Dr. Chris Esquera:We are not going to cover these things and give you the conditions under where things are covered or where not.
Dr. Chris Esquera:Generally it's very much reviewed by a lot of people in the health plans to make sure that it's meeting parity criteria.
Dr. Chris Esquera:But sometimes it doesn't work very well.
Dr. Chris Esquera:And that's where in that document for say you're treating a patient and you're experiencing something that seems to be deviating from your experience with other health insurance plans, it's worth looking at that evidence of coverage to see is the treatment for your type of care different.
Dr. Chris Esquera:An example, and I'll say most, I would love to say that most plans have done away with doing prior authorization for outpatient psychiatric services or outpatient therapy services.
Dr. Chris Esquera:I still hear from time to time of that occurring.
Dr. Chris Esquera:Because here's the reality.
Dr. Chris Esquera:There is no prior authorization requirement to go see a primary care physician.
Dr. Chris Esquera:The equivalents are there for a primary care physician visit is essentially equated to like a psychiatry visit or an outpatient therapy visit, because that's the outpatient sort of equivalence area.
Dr. Chris Esquera:So if it was the case that you're encountering, say as a psychiatrist, a requirement for prior authorization for routine follow up outpatient care, that's a problem because you're probably not encountering that with many other plans.
Dr. Chris Esquera:So that's something.
Dr. Chris Esquera:When you're noticing that there's a difference in that treatment, gathering that information as well and understanding those equivalents is going to be really important.
Dr. Chris Esquera:And so usually the complaints you would file it with the state regulator for insurance in the various states, whether it's Department of Insurance or Department of Managed Care, some equivalent of that.
Alex:And we'll post some resources, everyone.
Alex:So we have a series of links.
Alex:There's a lot of information out there, a lot of resources there.
Alex:And we'll post so that you can access.
Alex:Now a question that we're getting here.
Alex:We're getting a lot of engagement.
Alex:So one of these questions that I'm seeing, and this is pertinent, is around physician assistance.
Alex:So essentially, and you nod your head, this is a huge pain point where on the medical side PAs are paid for.
Alex:It's a natural thing.
Alex:Okay, here's a pa.
Alex:On the behavioral health side, they're not.
Alex:It's like the huge glaring.
Alex:I don't want to get started.
Alex:Please calm me down.
Dr. Chris Esquera:Yes, let's talk you down.
Dr. Chris Esquera:Well, no, there's actually there isn't a talking you down because that is an unfortunate one of the unfortunate realities.
Dr. Chris Esquera:So think of it this way.
Dr. Chris Esquera:I recall even, and this isn't that long ago, working to convince internally that nurse practitioners should be brought into and therefore paid on the behavioral health side from a network perspective, lo and behold, we've still kind of forgotten about physician assistance as well.
Dr. Chris Esquera:On the primary care side, it is very well normal for say a physician assistant to be a rendering provider and then of course billing under that primary care physician.
Dr. Chris Esquera:Right.
Dr. Chris Esquera:Ostensibly.
Dr. Chris Esquera:And this falls under that whole.
Dr. Chris Esquera:It's not a number, but it's a practice that's allowed that non quantifiable treatment limitation piece that from a network perspective on the behavioral health side that yeah, physician assistants should equally be able to do that given qualifications and under the appropriate supervision and all of those things.
Dr. Chris Esquera:And so, yeah, that's one of the clear glaring parody pieces right now.
Dr. Chris Esquera:And I think there is some work to be tackling that one.
Dr. Chris Esquera:But I'm surprised actually that it's only relatively recently I've heard rumblings about it.
Alex:Yeah, I was rumbling right before this meeting as the person responsible for operations over thousands of patients won't name names right now, but there are issues around physician assistants and their reimbursement in the behavioral health side.
Alex:And I feel like that's underappreciated given the shortage that we have in behavioral health.
Alex:I see a spike in individuals joining events.
Alex:So I'd like to introduce for those who just join, Dr.
Alex:Chris Esquera.
Alex:Dr.
Alex:Chris Esquera is an expert in this industry.
Alex:He is a psychiatrist with training, both undergrad and grad at usc.
Alex:He has his medical training at usc.
Alex:Beyond academia, he was a former senior director, medical director at Blue Shield, former senior medical director at Magellan Health, has held many leadership roles from Health Plan of San Mateo to Kaiser Permanente and really has a national reach and coverage in many markets.
Alex:And so Dr.
Alex:Escuera has been very active in his role, prior role at Care First Blue Shield, where I had an opportunity to meet with you.
Alex:He was really educating the community on social determinants of health.
Alex:So he really takes a holistic view.
Alex:But the issue that we're having right now, and the issue that kind of sparked this conversation is that now we're in a national pandemic, right?
Alex:And their mental health, we're just ravaged.
Alex:We're not sure whether the systems that we put in place are any way, shape or form conducive to some relief and health and well being, mental health and well being.
Alex:So we're talking about parity, Parity act, which essentially requires that, and Chris gives great explanation earlier on, requires that whatever is covered on the medical surgical side that you can measure, put in a beaker, poke, pinch, it needs to be equally covered and equally treated on the behavioral side where you can't put in a beaker or you can't draw blood and say, oh, you're this extent.
Alex:So these are chronic conditions.
Alex:And it's almost amusing that just because we can't see them, we feel like they're not as important as diabetes.
Alex:And so we're talking about just beyond the conceptual and like the dense regulatory verbiage, we're talking about practical actions that providers could take today.
Alex:Maybe they could multitask, share the link of this video and multitask looking at what it is that we're sharing and start looking in the areas that you can leverage so that you can advocate for your patients and so that you can actually practice to the extent that you're entitled by law.
Alex:So we were just talking about, and this is one of my favorite segments in terms of this discussion, is physician assistants and their reimbursement, which we know is not in any way, shape or form equal.
Alex:So on the physical, if I go to my primary care physician, a physician assistant, great, you know, well trained person comes out, sees me and that's it.
Alex:Now on the, and that that provider gets reimbursed accordingly.
Alex:However, on the behavioral health side, a physician assistant can even not be contracted or credentialed with a given network, just blanket.
Alex:We don't credential physician assistants, let alone want to pay for them.
Alex:So Going to the next kind of related topic is about reimbursement.
Alex:So, doctor, we've seen a lot of moves, you know, towards value based reimbursement and all of these, you know, kind of hashtags and ideation that we have.
Alex:And I'm still holding on to hope.
Alex:However, behavioral health is lagged way behind.
Alex:We're still fee for service, we still cross our fingers to get paid.
Alex:We cannot manage the populations on a level where, you know, we could take risk.
Alex:And so first there's a parody issue.
Alex:So I'm going to point out two areas and I'll let you take it from there.
Alex:One, there's parity issue, right?
Alex:Reimbursement is supposed to be in par with the parity issue.
Alex:Around reimbursement.
Alex:There also comes.
Alex:We have to have some hope.
Alex:What's the light at the end of the tunnel?
Alex:Where are you seeing some movement?
Alex:In conversation with plan executives.
Alex:They all have plans, but then we still have those plans and they have not been implemented.
Alex:What are the challenges?
Alex:I don't believe that these folks don't want to get it done.
Alex:When I was at Humana, you know, we wanted to do things, but there are systemic barriers that we cannot seem to be able to overcome.
Alex:So if you would please speak to that, I think that would be absolutely valuable to the many people who just joined.
Dr. Chris Esquera:Great, great.
Dr. Chris Esquera:And thank you.
Dr. Chris Esquera:And thanks everyone.
Dr. Chris Esquera:I think a good place to start.
Dr. Chris Esquera:And Alex, to your point, unfortunately for behavioral health, as much as I say it with some regularity, I really dislike saying it, but it's unfortunately still true.
Dr. Chris Esquera:And that behavioral health, from how it participates in the entirety of healthcare as well, and therefore in the economics of healthcare, is still unfortunately 10, 15 years behind where it's where primary care was 10, 15 years ago.
Dr. Chris Esquera:What does that mean?
Dr. Chris Esquera:It means that it still amazes me that as a.
Dr. Chris Esquera: I was a resident, finished in: Dr. Chris Esquera:We're still talking about integrating behavioral health with primary care, with the rest of healthcare.
Dr. Chris Esquera:Is that solely a very American thing?
Dr. Chris Esquera:I don't know.
Dr. Chris Esquera:But there are things that are starting to gain more salience.
Dr. Chris Esquera:Collaborative care, model integration, all of those things.
Dr. Chris Esquera:Yeah.
Dr. Chris Esquera:And we keep moving incrementally, yet we haven't necessarily made it as a default.
Dr. Chris Esquera:So that's one.
Dr. Chris Esquera:So what does that mean?
Dr. Chris Esquera:And why is it that I sound annoyed by that it's so slow, is that it's unfortunate that we have to keep first making the argument of why addressing behavioral health needs are Important.
Dr. Chris Esquera:And it's this interesting relitigation of talking about the data, talking about the benefits, talking about all these things now as a little bit complaining as I'm sounding, there's a lot of great activity out there now, especially in a lot of newer organizations, newer companies really trying to address this and being creative.
Dr. Chris Esquera:I don't think I've ever seen this much level of creativity and engagement nationally, frankly.
Dr. Chris Esquera:And so that allows me to say, great, you all are doing awesome, keep doing it.
Dr. Chris Esquera:Let's also think about social determinants as well and bringing that in.
Dr. Chris Esquera:So can I keep pushing things along?
Dr. Chris Esquera:All right, so that's sort of big picture, but let's bring it back in.
Dr. Chris Esquera:What about value based care?
Dr. Chris Esquera:So the unfortunate.
Dr. Chris Esquera:My bias is out there in that I'm not a fan of fee for service.
Dr. Chris Esquera:Fee for service unfortunately has the motivate.
Dr. Chris Esquera:It puts down the motivation of.
Dr. Chris Esquera:In order for me to actually derive value, that is monetary benefit, it tends to outweigh other types of outcomes because really I'm going to provide as much as I can.
Dr. Chris Esquera:And it ends up being quite an unfortunate back and forth between the health insurance and the providers in that it's going to be the fight for what is the appropriate amount.
Dr. Chris Esquera:Because really the incentive based on contracts is you're going to get paid more if you do more and yet then comes into health insurance to say, well no, we don't want you to do too much.
Dr. Chris Esquera:So it's inherently set up for conflict.
Dr. Chris Esquera:Not so good.
Dr. Chris Esquera:Right.
Dr. Chris Esquera:And so in the world of, in the physical health world, that's definitely the realization, let's try and do something else.
Dr. Chris Esquera:What if we all align on outcomes.
Dr. Chris Esquera:So a precondition to actually being able to develop something from a value based perspective is to then have an agreement of what are outcomes that matter that we can measure.
Dr. Chris Esquera:What about the patient experience that we can measure, that we can also make sure matters as part of this, of course, upholding quality.
Alex:Chris, I'm sorry to cut you off, but I have a good question here.
Alex:The question is how do we work incentives into our behavioral health contracts?
Alex:And I think the question is coming from for example, primary care will get an incentive for managing all these conditions.
Alex:We're doing an initial, initial annual.
Alex:But on behavioral health side, I have not seen such a thing in a contract.
Alex:On a behavioral health side.
Alex:Not.
Alex:I don't know everything by any means, and that's why you're here.
Alex:But how do we respond to this person's question?
Dr. Chris Esquera:It's a wonderful question and I think this is where providers we need to be stronger in knowing what are already the established outcomes that are there that we don't have to have to reinvent because they exist.
Dr. Chris Esquera:So if we look at.
Dr. Chris Esquera:So it means something and I'm going to make sure I look it up and don't mess it up.
Alex:Quality assurance.
Dr. Chris Esquera:Thank you.
Dr. Chris Esquera:So because we're going to, I'm going to, I apologize already from the beginning, but I'm going to just state a lot of, a couple of acronyms.
Dr. Chris Esquera:So National Committee for Quality Assurance has HEDIS measures H E D I S.
Dr. Chris Esquera:Right.
Dr. Chris Esquera:And the nice thing is there are TINHIDA stands for Healthcare Effectiveness Data and Information Set.
Dr. Chris Esquera:Does that mean anything?
Dr. Chris Esquera:Not really.
Dr. Chris Esquera:Just know that for most of healthcare, health plans are measured against this.
Dr. Chris Esquera:And then similarly the health plans work through their networks to make sure that these are outcomes that their network is performing.
Dr. Chris Esquera:So what does that mean?
Dr. Chris Esquera:There are measures from preventive care, you know, are kids going in for their, well, child visits, are kids getting their immunizations, our seniors getting their flu shot, for example.
Dr. Chris Esquera:Then there are treatment type measures.
Dr. Chris Esquera:So if you have diabetes, are you getting your blood test?
Dr. Chris Esquera:If you have diabetes and you got your blood test and it's high, is there work to bring it down and get it better?
Dr. Chris Esquera:Because ostensibly you're going to be healthier.
Dr. Chris Esquera:Now I'd say this really more so in the last four or five, six years there are behavioral health measures in there.
Dr. Chris Esquera:There's initiation and treatment engagement, as in when someone is wanting treatment, can they get in to that appointment, can they then get subsequent appointments thereafter?
Dr. Chris Esquera:There are specific ones for alcohol and other drugs.
Dr. Chris Esquera:There are specific measures around treatment for schizophrenia, for adhd, for depression.
Dr. Chris Esquera:The thing is, I would love to have providers be very well versed in that, using that, measuring themselves and being able then to present that as part of a contract negotiation engagement and saying, hey, we can help you with this because here's how we perform and here's our quality of care and that's the value that we bring and be able to have a much better position to have those discussions.
Dr. Chris Esquera:And the other piece, frankly, and I recall this, and this is still very important in working in the plans that we really cared about, hospital readmission rates as well as follow up after hospitalization.
Dr. Chris Esquera:And so when someone gets hospitalized for a behavioral health condition, we want to make sure that they're going to get to see a provider within seven days because we know the evidence is just by doing that and essentially catching them at the back end and getting them connected back to outpatient care is a really good thing because they're not going to go back to the hospital.
Dr. Chris Esquera:That means they're going to continue in their recovery.
Alex:So this is again an area that I've personally encountered challenges.
Alex:We at Inside Choices, it's a larger group, behavioral health group and we do track our outcomes.
Alex:And a very nice, you know, document with many metrics have been presented to many plans and essentially the challenges have been twofold.
Alex:One, the plan isn't tracking the information somehow.
Alex:And so, you know, we could show up with whatever chart and you know, cute infograph.
Alex:But if the plan isn't tracking that, then what is?
Alex:You know, how are they going to incentivize?
Alex:How are they going to pay out?
Alex:Is it that they're going to take Chris and Alex's word and say, yes, you know, we reduce your cost and pay us a shared savings?
Alex:It seems like another administrative burden for which we're not being reimbursed.
Alex:And two, cost share.
Alex:So for example, commercial patients have cost share.
Alex:So if patient comes out of the psych hospital and then you're wanting to follow up within seven days, let's say, and then you're sending the patient a bill for the cost share, it kind of.
Alex:How are you going to collect from that patient?
Alex:Hey, I know you just came out of a psych hospital, I want to get you in seven days before and you have to pay $100 or wait, wait, you haven't met your deductible.
Alex:Actually it's like $200.
Dr. Chris Esquera:Right.
Alex:It just seems almost abusive.
Dr. Chris Esquera:Yes.
Dr. Chris Esquera:So I'll say the challenge there is, and this is not to like go on one side or the other.
Dr. Chris Esquera:Frankly, it's both sides have really not paid attention to this.
Dr. Chris Esquera:And, but I'll say the elements of the recipe is there is that.
Dr. Chris Esquera:And I'll say even on the physical health side, it's still challenging to set up these value based payment models because frankly, everybody argues over the quality metrics and the outcome metrics.
Dr. Chris Esquera:Often it's a matter of getting the stakeholders together to do that.
Dr. Chris Esquera:And there is a way to do it.
Dr. Chris Esquera:And so I'd say it is a rare provider and I would love to see this just be the norm that actually comes in and presents here, here's how we're tracking our outcomes.
Dr. Chris Esquera:And I'll say, and I say rare because you know, I mean, Alex, you gave your example and I've heard of several others relatively recently.
Dr. Chris Esquera:But oftentimes when I'm talking to provider groups, I'm usually providing the Recommendation of hey, let's start tracking these things.
Dr. Chris Esquera:Let's start understanding these measures that nationally that's how plans are rated.
Dr. Chris Esquera:And nationally we should be at least tracking to that.
Dr. Chris Esquera:And nationally we should be also advocating for other metrics that map because imagine these are metrics that are focused more from the perspective of a system processing things.
Dr. Chris Esquera:It's not really from the perspective of the patient.
Dr. Chris Esquera:And so there's actually another movement there of patient reported outcome measures, for example, and different ways of doing that.
Dr. Chris Esquera:So going back to your question, yeah, in a way there is work for us for providers to take on this to show that things are actually improving.
Dr. Chris Esquera:And here are the things that we're doing to report on that.
Dr. Chris Esquera:It's one thing to tell a story of, hey, here's a great, wonderful thing we did for this one patient.
Dr. Chris Esquera:It's another show.
Dr. Chris Esquera:Here's how we consistently do it for all of the patients we care for.
Dr. Chris Esquera:That's important.
Alex:We're getting feedback that we should do a segment on what kind of data points does a payer want to do?
Alex:Payers want to see, especially from the payer side.
Alex:Chris?
Dr. Chris Esquera:Absolutely.
Alex:Just wanted to put that out there.
Alex:I think that's absolutely valuable.
Dr. Chris Esquera:Yeah, now we can definitely, I can geek out on that all day, but yes, we can definitely do that.
Dr. Chris Esquera:And I'm also of the mindset that we should be thinking about what else do we want to advocate for?
Dr. Chris Esquera:You know, because I'll say that you all probably have a good sense of what some other measures are out there that might be very, very useful and that it just may not have gained salience yet.
Dr. Chris Esquera:Now I'll say that there is a bit of interesting sausage making, so to speak, in just the development of measures from a national perspective.
Dr. Chris Esquera:Because the principle really is we don't want to make it so overly burdensome that you providers are having to check like little boxes on spreadsheets to be able to turn it in somewhere.
Dr. Chris Esquera:That's horrible.
Dr. Chris Esquera:We want to make it easy to pull from a data perspective.
Dr. Chris Esquera:We want it easy for you to collect it from a data perspective.
Dr. Chris Esquera:Those are things.
Dr. Chris Esquera:But I want to get to Alex, your other point on the cost sharing.
Dr. Chris Esquera:So I'll say that's actually not necessary.
Dr. Chris Esquera:So it can be an issue on parity, but oftentimes it's not because again, so cost sharing, co pays, things like that, those are that whole.
Dr. Chris Esquera:It's a number and the plans can then figure out are my numbers different between the physical side versus behavioral side?
Dr. Chris Esquera:I mean it's really straightforward and Very few issues have come up in relatively recently around things like lifetime dollar limits, annual dollar limits or things like that.
Dr. Chris Esquera:Those are tiny compared to that whole.
Dr. Chris Esquera:When things aren't a number, that whole non quantitative area, that's the majority of where the issues are.
Dr. Chris Esquera:So it's not the issue of parity per se.
Dr. Chris Esquera:It's actually more the issue of how these plans have been set up.
Dr. Chris Esquera:So it's really based on what they're purchasing, whether it is, has a higher cost share or deductibles as you talked about.
Dr. Chris Esquera:And that's really more the state of how benefits and insurance products are designed, unfortunately here in the US and there's generally that movement to try to move towards decreasing that cost share burden on individuals.
Dr. Chris Esquera:And that's more of our national discussion about healthcare and healthcare.
Alex:So Chris, that's interesting because the what do we need to do as again practical means?
Alex:For instance, let's say these are the employer.
Alex:So okay, let me, let me ask you this.
Alex:What is the role of an employer in parity assurance?
Alex:Making sure that the plans that they're, you know, purchasing for their employees and the plans that the employees are paying premiums for are actually, actually providing the benefits that they need to provide.
Alex:How do we do, how do we.
Alex:Oh yeah, you already got.
Dr. Chris Esquera:Yeah, no, it's a great question.
Dr. Chris Esquera:And I'll say the employers, let's remember the employers are the majority of the purchasers of these insurance products.
Dr. Chris Esquera:They have huge influence in that.
Dr. Chris Esquera:And in fact there are organizations that are geared towards banding together common goals amongst employers to really push for ongoing innovation and more of that centeredness around just the patient, the member.
Dr. Chris Esquera:So groups like Pacific Business Group on Health, for example, based in San Francisco, there's the National Business Group on Health and they bring together employers to really advocate for certain things.
Dr. Chris Esquera:Now you as providers may actually have direct relationships with employers as well and again to really educate them on what does this mean, what does this mean for access?
Dr. Chris Esquera:I'll say that it's only been relatively recently that I've started to see more education geared towards employers about the costs of untreated behavioral health conditions for their industry.
Dr. Chris Esquera:I'd say three, four years ago it would be really hard for, it would have been hard for me to quote what is the cost to an employer about untreated substance use disorders in their particular industry.
Dr. Chris Esquera:Now we have resources say in construction, if you employer do not have coverage or are not addressing proactively substance use disorders in your employee population in construction, not only will you have, I believe it's about $20,000 in healthcare per person for the, you know, based on prevalence, but you'll have an additional 20,000 plus based on missed workdays, absenteeism, turnover, all of those things.
Dr. Chris Esquera:We can now quote that.
Dr. Chris Esquera:That wasn't the case relative, you know, even two, three years ago.
Dr. Chris Esquera:So now we have that.
Dr. Chris Esquera:Yet I think it's, that's the work for us to begin to educate employers on that too, so that they see the importance not just from a healthcare cost perspective, because the reality is, from a healthcare cost perspective, yes, behavioral health costs are important in how they affect the cost of other things, but they really pale in comparison to the cost of a hospitalization, say with someone with chronic conditions or even just needing a surgery that's way more expensive than an outpatient behavioral health cost.
Dr. Chris Esquera:You want to frame it differently.
Dr. Chris Esquera:Part of that means that untreated behavioral health conditions also affect the workplace.
Dr. Chris Esquera:Worker productivity, turnover, all of those things.
Dr. Chris Esquera:And so I think that's the other area to be thinking about that gets you then into the discussion of, well, we need to be thinking about a more holistic approach to employee wellness as well as benefits and treatments from a parity perspective.
Alex:So we're getting a question.
Alex:Let's say I'm Google and I'm kind of interpreting the question, or any of these other purchasers, right?
Alex:So an employer of that size, how is it possible for that employer to request data?
Alex:Is there a way to hold that TPA or the claims processor accountable to, you know, what benefits they're providing to their employees, especially because it's not regulated as it should be?
Dr. Chris Esquera:Absolutely.
Dr. Chris Esquera:And so there is a bit of a firewall, right, because you don't want employers to know your individual healthcare information necessarily, but they can understand it from an aggregate perspective.
Dr. Chris Esquera:So that way they have a sense of knowing, you know, who's using what for what reasons, what's the prevalence of certain conditions and all that stuff.
Dr. Chris Esquera:And so, absolutely, these large employers can actually really advocate and say, hey, I'm seeing from my employee workforce, from wellness perspective, or my employees are saying this, that we need to have more of X or more access to the following.
Dr. Chris Esquera:Those are negotiations that tend to happen.
Dr. Chris Esquera:I recall this would have been a couple years ago, CalPERS major retirement system in California.
Dr. Chris Esquera:This is, of course, during the time when the opioid epidemic was really getting more and more salient nationally.
Dr. Chris Esquera:They realized, wait, our population is dealing with this.
Dr. Chris Esquera:And on aggregate, there's a certain percentage of individuals with what appears to be problematic opioid prescribing we need to do something about it.
Dr. Chris Esquera:And they actually pulled together their payer partners and said, convened and said, hey, what are we going to do?
Dr. Chris Esquera:You all need to now work together with us to do something.
Dr. Chris Esquera:So employers have that power to be able to do that.
Dr. Chris Esquera:Because let's remember, they're the ones at the end of the day thinking about every year, am I going to keep this payer?
Dr. Chris Esquera:Am I not?
Dr. Chris Esquera:Is it really working for my employees?
Alex:So that's very valuable.
Alex:So what I'm hearing is as a provider, let's say you have a relationship with some academic institution and you get referrals from those institutions, can we let, well, we can leverage that referral relationship to essentially say, hey, the patients that, or your employees that are covered and that we're seeing, we're not seeing parity.
Alex:Or here are the number of issues that you know, we're encountering in terms of barriers to providing the type of care and access that you know, they want.
Alex:Can they do a data pool or hold a TPA somehow accountable.
Alex:So that makes the life of the provider easier.
Alex:So it looks like there's opportunity for the employer to assert their purchasing power to make our behavioral health care system a more viable, accessible, affordable and feasible system.
Dr. Chris Esquera:Exactly, yeah.
Dr. Chris Esquera:And again, from an advocacy perspective, you can think about it in several buckets.
Dr. Chris Esquera:So there's informing and making sure you're sending over to the authority figures, whether that's the employers who can then, you know, advocate on your behalf because it's for their employees or if then that's on the self insured employer side or if it's, if it's your standard health insurance, then it's usually the state's department of insurance or managed care.
Dr. Chris Esquera:When you are noticing or experiencing some sort it's just unequal treatment, whether it's in rates or utilization management or any of those topics that we talked about vis a vis parity.
Dr. Chris Esquera:That's one area.
Dr. Chris Esquera:The other area actually is this other kind of advocacy where one really increasing the importance and prominence of quality behavioral health, demonstrating that and then saying, you know, this is why we need this as part of a system that is focused not on sick care because the hospital piece is super flashy still, despite the fact we really need to be looking way more upstream.
Dr. Chris Esquera:And the upstream part is how do we prevent that in the first place?
Dr. Chris Esquera:We get people in sooner, we have better access, we treat them well and we get them to feel better.
Dr. Chris Esquera:Right.
Dr. Chris Esquera:And actually alleviate their conditions, get them onto recovery.
Dr. Chris Esquera:That means earlier access, you know, networks that actually are able to accommodate.
Dr. Chris Esquera:So in thinking about it from that preventive perspective, it's a different kind of value proposition discussion overall.
Dr. Chris Esquera:And how is it that we do that?
Dr. Chris Esquera:I think we need to, again, in behavior health, really begin to articulate that in a much more cohesive, impactful way.
Dr. Chris Esquera:We're really good at storytelling.
Dr. Chris Esquera:What I would love to see is that we start bringing in all the quality pieces as well.
Alex:Yes, I'd love to see all the marketing dollars that are spent on these nice banners and hashtag quality or now we're fully integrated, actually spent on the resources that it takes to implement.
Alex:And that's something that will continue to bother me until it changes because we have a lot of stories, we have a lot of posts and blogs and ads, but when rubber hits the road and when the provider is trying to stay in business, get reimbursed, it's hard.
Alex:It's hard.
Alex:It's non existent.
Alex:So what are the escalation pathways within a plan that a provider can exercise?
Alex:Let's say the dispute resolution process is either unclear or there is some barrier to getting past that, you know, person on the phone, that rep or that specialist who sent you a letter and they're not connecting you with their supervisor.
Alex:Yet you are literally every single day you are hurting because you have to comply with some strange utilization management or, you know, prospective review at 100% of all patients.
Alex:So these bizarre measures and mechanisms, how do you, at what point do you go to the regulator?
Alex:So how many levels are you supposed to escalate?
Alex:How many names are you to Google?
Alex:Are you supposed to contact the executive via LinkedIn?
Alex:How do you escalate before you go to regulator?
Dr. Chris Esquera:Right.
Dr. Chris Esquera:So what I would say is, you know, again, having been both on the provider and the plan side, it starts with making sure that you have at least an existing relationship with your network contact.
Dr. Chris Esquera:Oftentimes what I've noticed with providers is that they sort of kind of know who they talk to to get a contract and that's it.
Dr. Chris Esquera:So really think of it as a partnership and start to treat it as such.
Dr. Chris Esquera:Because I'll say where I've had really successful relationships and I'll talk about a little bit, you know, recalling my experiences at Magellan where the providers came in and wanted to have a discussion both at a clinical quality level as well as how do we partner with you to cover what you need covered.
Dr. Chris Esquera:They were willing to hear and listen to our pain points as a plan.
Dr. Chris Esquera:And we were willing therefore to listen to how is it that we could work better with them and address their pain points.
Dr. Chris Esquera:So that to me made for more interesting partnerships and actually allowed us to pilot, I'd say, one of the very few value based payment models that we had really around preventing recidivism and relapse in substance use disorder treatment.
Dr. Chris Esquera:And so I haven't seen that since, unfortunately.
Dr. Chris Esquera:But it started with those types of discussions.
Dr. Chris Esquera:And I'll tell you what impressed me as a medical director at a health plan was really more about, hey, we've been tracking our outcomes, we have this database and I knew it really didn't take that much more work for them.
Dr. Chris Esquera:I'll say this is great opportunities for interns to actually really do some of this.
Dr. Chris Esquera:I've helped some organizations that actually use interns, summer interns, things like that.
Dr. Chris Esquera:It's a great project to just really start bringing this in and say, hey, here's what we're doing, here are some of the outcomes, here's why you really should like us.
Dr. Chris Esquera:And of course, especially if you're going to be talking to the medical directors, we're by definition going to be data geeks about this stuff because it's speaking both to the analytic portion, but also just the patient outcomes portion and that matters.
Dr. Chris Esquera:And so to hear those and have those types of discussions are very powerful.
Dr. Chris Esquera:Another equally powerful discussion is, hey, we're able to cover this area for you.
Dr. Chris Esquera:Do you have any other areas where you have challenges with coverage?
Dr. Chris Esquera:We might want to partner with you to see if that's something that we can help you with.
Dr. Chris Esquera:And those were also very important, especially when, you know, when we're talking about network coverage.
Dr. Chris Esquera:I mean, health plans know generally on paper they're okay, but they really know internally where they might be hurting.
Dr. Chris Esquera:Usually more rural areas, for example.
Dr. Chris Esquera:And so being able to be creative and providing access in different ways.
Dr. Chris Esquera:Of course, now with the pandemic, telehealth is the big thing.
Dr. Chris Esquera:Understanding though that even with rural areas, not everybody has wifi, not everybody has access to being able to get onto a video.
Dr. Chris Esquera:So and I think having those kinds of discussions really call the attention of the plan to then want to have more partnership type, co development type discussion.
Alex:That's very insightful.
Alex:I think some of our next sessions will be what impresses the medical director to plan and like a 15 minute or 30 minute tip to help bend the learning curve on the provider side.
Alex:We have a number of new entrants into the market, especially from the technology realm and we want to make sure we're good stewards of the healthcare system.
Alex:And at the end of the day, we leave this world better than we found it.
Alex:And so we're in better hands with our coalition, with our network.
Alex:And so this is very refreshing.
Alex:We're getting a lot of positive feedback and folks are indicating what areas are interesting and what areas they want to probe further and what impresses a medical director at a plan.
Alex:The folks were excited about that.
Dr. Chris Esquera:Okay, well, I mean, I'll say real quick, yes, because it was in this discussion where I actually blurted out and even to my team at the time, why aren't we doing value based contracting with this person, with this group?
Dr. Chris Esquera:And the group was in front of us in the meeting because again, back, you know how I talked about quality as a precursor to talking about value based frameworks.
Dr. Chris Esquera:And because this group actually did the homework and impressed me enough and said, hey, here's our model.
Dr. Chris Esquera:Yeah, it's a cobbling together of all the best practices that you would do for outpatient behavioral health.
Dr. Chris Esquera:But because we've actually tracked it and here's how we do it with regularity, here are our outcomes.
Dr. Chris Esquera:And because of that, we're able to accommodate follow up after hospitalization.
Dr. Chris Esquera:We're even working to make sure we prevent future hospitalizations.
Dr. Chris Esquera:We're doing all this stuff that was impressive enough for me to be able to think, wow, I can package this into a payment model.
Dr. Chris Esquera:And so it gave me enough of the elements to do that.
Dr. Chris Esquera:So it's kind of, you're kind of having to do some of the thinking work for them.
Dr. Chris Esquera:Because I'll tell you, creating some of these models is really hard.
Dr. Chris Esquera:And you know, conceptually you have to have at least that agreement together because when it gets to that actuarial level is where it gets extra tough.
Dr. Chris Esquera:But I'll say it's very doable.
Dr. Chris Esquera:And there are many models out there.
Dr. Chris Esquera:I would love to see more of that in behavioral health.
Alex:And it's up to us to make it happen.
Alex:So do you see a future for population based payments, whether it's a capitation or, you know, some type of lump sum payment, so that the provider could manage the care of the signed patients, like we have on the primary care side in the HMO model?
Dr. Chris Esquera:I think there's a way to do it.
Dr. Chris Esquera:I'll say right now that there are certain.
Dr. Chris Esquera:The easier way, frankly, is when we're talking about care episodes.
Dr. Chris Esquera:All right, so we're talking about say, bundling things like intensive outpatient or things where we know there's generally a beginning or an end of which of there are Things we could measure.
Dr. Chris Esquera:So that's a probably easier thing to conceptualize and chunk.
Dr. Chris Esquera:Now let's talk about more of a population capitated based type payment.
Dr. Chris Esquera:Normally from a conceptual perspective we're thinking with primary care and saying hey, primary care provider or a group, I'm assigning you this many lives and paying you this much a month.
Dr. Chris Esquera:Get them healthy.
Dr. Chris Esquera:However in the get them healthy part, it's usually behavioral health is not part of that.
Dr. Chris Esquera:Okay.
Dr. Chris Esquera:And so we might need to then be thinking how are we part of that piece that already exists within the primary care?
Dr. Chris Esquera:Because understanding the value of what we do really helps the pcp.
Dr. Chris Esquera:Having done work in my earlier career of really integrating that we definitely are very valuable.
Dr. Chris Esquera:And then thinking about well what is it?
Dr. Chris Esquera:What would it be like if we depending on certain populations think those with chronic serious mental illness, that's a different model where it's really more behavioral health forward that we really need to then bring in our primary care and specialty partners to address.
Dr. Chris Esquera:But the relationship really sits with us in behavioral health.
Dr. Chris Esquera:Right.
Dr. Chris Esquera:So that's a different orientation.
Dr. Chris Esquera:So there's a potential there.
Dr. Chris Esquera:We just haven't really looked at it.
Dr. Chris Esquera:What does that really mean and look like?
Alex:And if it's not paid for, then it's really not going to happen.
Alex:So it needs to be reimbursed all of these activities.
Alex:I'm sending an email to the pcp.
Alex:I need to be reimbursed.
Alex:Otherwise capitate me and I'll send all the emails I need.
Alex:So we're coming to the end of this.
Alex:I can't believe it flew by so quickly.
Alex:But again, so we've had a.
Alex:Today we had a conversation, we really just broached the topic.
Alex:The idea here was to give providers the tools they need to feel empowered and advocate on behalf of their patients and know that they have an important role to play in the system.
Alex:And I know they know this, but it's not always, you know, readily salient in the midst of day to day operations and fires.
Alex:We also talked about employer responsibility and employers prerogative and really entitlement to making sure that the plans that they're purchasing and that they're paying for and the employees paying for actually are to par and are as intended because the employer wants the employee to be well and productive.
Alex:But if you just leave it at that and hope and pray for that to happen, it might happen.
Alex:But there are ways that you can actually get data and validate and that could be another episode.
Alex:I have tools that I want to share with the world.
Alex:And these are templates.
Alex:You guys submit the template to your purchaser, to your payer, to your plan, and then they should be able to generate some responses.
Alex:So with that, would like to bring the discussion to a close.
Alex:And thank you so much for engagement.
Alex:Chris, any last words you'd like to share?
Dr. Chris Esquera:No, definitely.
Dr. Chris Esquera:I just want to thank everybody for joining.
Dr. Chris Esquera:Thank you, Alex, for this engaging conversation.
Dr. Chris Esquera:As you all could probably tell, he and I can geek out on this any day and we're happy to cover more topics.
