Health Care & Benefits Power Breakfast transcript

Indianapolis Business Journal gathered leaders in the state's health care and benefits sector for a Power Breakfast panel discussion Sept. 21.

Panel members included Ryan Kitchell, Indiana University Health chief financial officer; Dan Krajnovich, UnitedHealthcare of Indiana and Kentucky president and CEO; Sally Baker McCarty, Georgetown University Center on Health Insurance Reforms senior research fellow; Nathan Mowery, Activate Healthcare of Indiana president; and Ben H. Park, American Health Network president and CEO.

The discussion was led by IBJ reporter J.K. Wall.

The following is an unedited transcript of the discussion.

                       WALL:  As Greg Morris has said, to kick things

                off, he mentioned that a year ago we were just out from

                the launch of the health insurance exchanges.  One of

                our panelists last year, Rob Hillman from Anthem,

                memorably said he expected crickets to be chirping on

                October 1st and the meltdown of didn't

                prove that true, but we sort of caught our feet and the

                exchanges worked out okay, but we're headed into another

                enrollment, so we're just still in this kind of

                tumultuous mix of changes from the Affordable Care Act

                and some other trends, but I'd like to start with the

                Affordable Care Act and, Sally McCarty, can you talk to

                us about what impact you think the law's had so far,

                what do you expect for the future, what's your


                      MCCARTY:  Well, first of all, thanks for having

                 me here and including me in this august panel.  I'm

                 not sure I'm the right one to ask.  If you would've

                 asked me a year ago, I probably would've told you I

                 think the two most successful exchanges would be

                 Oregon and Maryland.  That didn't happen, they

                 probably were the two most disastrous ones, and, of

                 course, we all know, as you mentioned,,

                 all of those problems centered around IT and they're

                 all in the process or have been fixed, so the open

                 enrollment, the first open enrollment, ended up being

                 a huge success, much to a lot of people's surprise, I

                 think mostly because of the surge that occurred in the

                 last month, in March, and they ended up exceeding the

                 goal of seven million enrollees, so that alone says

                 that there's some value to this, to all of this, I

                 think.  The number of people who will gain coverage

                 one way or another through the Affordable Care Act

                 provisions will probably be in the neighborhood of 25

                 million by the time the next open enrollment rolls

                 around in a couple of months, so that alone as to what

                 effect is going to be kind of hard to untangle all of

                 that, if anybody ever was inclined to do so, in the

                 future, and that's a huge deal.  I mean everybody

                 looks at this from their own perspective, we have

                 providers and issuers and employers here, but looking

                 from the perspective of a consumer advocate that I've

                 been for most of my career, the fact that people can

                 get coverage, that people can get coverage if they

                 have a pre-existing condition, is a gigantic impact.

                 It was so discouraging in the past to have to tell

                 people, and some of those people who needed help most,

                 "You know, there's nothing we can do, the system just

                 wasn't built to accommodate you," so, I mean, that's

                 my No. 1 if you want to talk about impact.  I think

                 some of the controls on pricing, the MLRs, statewide

                 risk pools for the individual and small group markets

                 that will help to keep premiums down, and the rating

                 limits, the rating factors, all of those provisions of

                 the Affordable Care Act will again have a very strong

                 impact, already have I think on both affordability and

                 accessibility.  The latest RAND survey or a recent

                 RAND survey has the uninsured rate going from 20.5 to

                 15.8 percent since the initiation of the Affordable

                 Care Act provisions, and that's big, I mean that's big

                 for all of us to have that, to get that uninsured rate

                 ratcheted down hopefully more with the upcoming open

                 enrollment, and then we all know, we were talking

                 about this earlier, that there are new insurers, I

                 think 77 new insurers are going to be offering on

                 exchanges in the upcoming open enrollment, so somebody

                 must be doing something right if they want to get in

                 the Act.  So all of that is a pretty sizable impact on

                 what's been going on.  As far as the future, I think,

                 obviously, this is going to stay around for a while,

                 too many people are now looking to the Affordable Care

                 Act provisions, to the exchanges, to the coverage to

                 age 26 and all of those provisions that have made

                 insurance coverage more accessible.  I don't think

                 it's going to be a smooth ride the rest of the way by

                 any stretch of the imagination and, you know, I think

                 that at the upcoming open enrollment there will be

                 some new problems that will be faced.

                      WALL:  Who else has thoughts on the impact of the

                 ACA, whether that's on insurance or other aspects of

                 it and your outlook for the future, Dr. Park?

                      PARK:  I think the most important thing about the

                 ACA has been the dialogue that it started over the

                 spotty quality, the amount of waste and the uninsured.

                 There's been a lot of discussion that came out of that

                 and I think that was probably the most important

                 thing, followed closely by the Accountable Care

                 Organizations and access to data.  We have 50,000

                 Medicare patients in Indiana now where we have claims

                 data on everything that they do and it really has

                 helped us get insight into how other people are doing

                 in terms of delivering care, how we're doing, how we

                 compare ourselves, I mean the data's been huge.  The

                 other thing I think is probably to me one of the most

                 interesting things, maybe not the most important

                 thing, is that high-deductible health plans have been

                 sort of a Republican thing for a long time and for the

                 most part the Democrats have opposed those and the

                 Democrats passed a law which caused a huge increase in

                 the number of high-deductible health plans and then

                 the Republicans complained about that, so I thought

                 that was just, you know, sort of quirky.  I think that

                 the law's far from perfect, but I agree with Sally

                 that it's here to stay, it's really set the rules for

                 how we're going to approach quality and efficiency,

                 and the commercial carriers for the most part are

                 following suit.  Medicare's been an innovator in this

                 and I think the next few years will be full of

                 surprises.  CMS is emboldened to issue new rules and

                 regulations, they're changing things all the time and

                 it keeps us on our toes.

                      WALL:  Who else wants to chime in here?

                      KRAJNOVICH:  Well, I'll just tag onto I agree

                 completely with both Sally and Ben, and Ben mentioned

                 about the higher deductible plans and that really

                 drives a level of consumerism out there that we've all

                 been trying to get to and struggled with over the

                 years, but it's so important to have high-deductible

                 plans because it's easy just to raise the deductible,

                 it really need to be supported by proper tools,

                 whether it's transparency tools or tools that provide

                 information to make the right selection about

                 provider, pharmacy, imaging and other services, so if

                 we can arm the consumer with the right tools,

                 technology in these high-deductible plans, it really

                 brings them into the game where we've always said if

                 they've got skin in the game then they're going to be

                 conscientious consumers and good consumers of health


                      WALL:  Anyone else?

                      MOWERY:  Dan and I were talking before we came up

                 here about how the health care industry is cyclical

                 and if you were in the health care industry in the

                 '90s, some of the aspects of the current discussion

                 are somewhat similar to us, but the difference in the

                 discussion today is that there is a regulatory

                 framework that's driving integration, that's driving

                 new payment models, that's driving the change which we

                 didn't really have in the '90s, '90s was pretty much

                 an economic market-driven model, but today with the

                 technology enhancements that we have, with the data-

                 sharing and portable data that we have available as it

                 relates to patients with the regulatory framework

                 encouraging it, this feels very different from where

                 we were in the '90s and I think that we are on the

                 trajectory, it's the river of no return, we are headed

                 down that river.

                      WALL:  You don't think this is going to be

                 unwound like HMOs in the '90s?

                      MOWERY:  Well, we all were preparing for

                 capitation and contact capitation and percentage of

                 premium deals, all purely market-driven economic

                 models.  The economics are a byproduct of essentially

                 catching up with where the ACA is taking us and where

                 the markets are having to evolve to catch up, so it

                 feels very different at this point.

                      KITTCHELL:  From a provider perspective and from

                 a patient perspective, we know when patients have

                 insurance, they seek care more often when they need it

                 and the fact that more people are going to be insured

                 is a really good thing from a provider perspective.

                 There's some other aspects of the law that maybe are

                 less helpful, but that one in particular we think is a

                 great thing.

                      WALL:  Sally, do you want to come back to what

                 you want to say about this upcoming open enrollment

                 and the issues as you see them?

                      MCCARTY:  I think the river, and I'll use a good

                 one, but I think it's going to be some waterfalls and

                 things coming up with this open enrollment, and, J.K.,

                 you did a very good job just recently in kind of

                 laying out some of the issues that are going to happen

                 when people go to renew their policies.  The second

                 lowest Silver plan, as everybody probably knows, is

                 what determines how much of a subsidy people are going

                 to get, there's a formula that it all ties to that

                 premium for the second lowest Silver plan.  It's very

                 unlikely that that premium in any exchange is going to

                 be the same as it was last year, so subsidy levels are

                 going to change and also some of the policies will

                 change, there's some wiggle room where policies can

                 change without being called a new policy, so I think

                 the people who go to renew, whether they auto-renew,

                 whether they're auto-renewed by CMS or whether they're

                 wanting to go in, they have changes in their status,

                 income, something like that, some family makeup

                 change, they would need to go in and make changes, I

                 think they all are going to face some kind of

                 challenge about what their new subsidies, what their

                 new premium is and what their new policy is, so the

                 word I think that people need to hear who are covered

                 through an exchange is go in and shop even if you

                 don't think that there's going to be a change because

                 there probably will be, so that's going to be rocky,

                 and then right in the middle of open enrollment people

                 are going to be getting their 1095 forms that show

                 what they need to claim as an advanced tax credit,

                 what they received, the odds of all of those being

                 correct as we all know are probably pretty slim, so

                 that's going to be another issue that people are going

                 to face, so I think we thought last year was

                 problematic, I think this year's going to be even more

                 complicated for a lot of folks, so it's going to be a

                 very difficult open enrollment season.  I think the

                 people who will have it the easiest are the new

                 enrollees who are just coming in shopping and finding

                 a plan.

                      WALL:  Yeah, but for the repeat enrollees, you've

                 got some lower-priced offerings which is attractive

                 but that reduces their subsidy level and that can be a


                      MCCARTY:  Exactly.

                      WALL:  Anyone else have thoughts on just the

                 exchange enrollment that we're going to start in

                 November?  If not, the other thing I was curious about

                 and another kind of big trend that is affecting all

                 kinds of players in health care is this kind of slower

                 growth that we've seen in the last few years in health

                 care spending.  Certainly compared to the late '90s

                 and the first half or two-thirds of the early 2000s

                 the rate of growth here these most recent years has

                 been a lot smaller and I'm curious why people think

                 that's happening.  There's a bit of a debate whether

                 that's just the economy, whether it's a new-normal in

                 health care, whether it reflects the impact of these

                 high-deductible health plans and consumerism that

                 Dr. Park and Dan Krajnovich were talking about.  Ryan

                 Kitchell, can you take the first crack at this and let

                 us know what do you think is driving it and what it

                 means for the future?

                      KITTCHELL:  So one thing it's not, we're not

                 getting healthier and younger, I wish that were the

                 case.  Maybe if we go to Mickey's Camp and he gets the

                 fountain of youth in there next year, possible, but

                 otherwise it's not that, unfortunately.  That would be

                 great if it was.  You know, it's probably a

                 combination, as you said, of a lot of things.  I do

                 think the Affordable Care Act is putting reimbursement

                 pressure on health care spending.  I think most viewed

                 the past trend of health care spending and the growth

                 rate as something that was unsustainable and so

                 employers and individuals, as well as health insurers,

                 I think are putting pressure on that cost growth.  I

                 think providers are responding.  I think maybe in the

                 past providers maybe were more focused just on curing

                 whatever that ailment was and I think there's been a

                 growing appreciation that affordability and kind of

                 that full patient impact and the fiscal piece is just

                 as important as the clinical piece, and so in general

                 I think it's a good thing from a society standpoint.

                 It will be a little bit of a painful adjustment period

                 as we go through this given the size of the industry

                 and the cost structure, but I think when we get

                 through that phase it will be better for Hoosiers.

                      WALL:  Dan Krajnovich, do you have thoughts on


                      KRAJNOVICH:  Sure, I mean I'll just tag along on

                 what Ryan mentioned.  We're shifting in terms of the

                 way we reimburse from traditional fee-for-service to

                 more outcome-based and, you know, as Ryan alludes to,

                 we're kind of in a rocky phase of really implementing

                 that but know that's going to continue to expand over

                 the coming years.  Today we spend 34 billion dollars

                 on reimbursement that's tied to accountable care

                 initiatives at UnitedHealthcare, so a pretty

                 substantial number, and we expect that to grow to 65

                 billion by 2018, so clearly a shift in the way we

                 reimburse, but it's all based on, again, getting to

                 better quality, better quality outcomes that we

                 believe will help keep health care affordable in the

                 long term.

                      WALL:  Dr. Park, I'll bet you have thoughts on


                      PARK:  We knew that healthcare was eating a

                 bigger and bigger part of the economy and the

                 projections were in some period of time it would be a

                 hundred percent of GDP and if something can't go on

                 forever then it's going to stop and it's stopping and

                 we still spend twice what the rest of the world does

                 on health care and so we've got a long way to go.  The

                 Medicare trend is negative, negative 2 percent, so on

                 that population we're spending less money than we did

                 last year.  I think we're going to see that across the


                      WALL:  And you're a provider organization, too,

                 does that worry you at all or not?

                      PARK:  No, I'm pleased about it — Yeah, yeah, it

                 does.  We've got a few adjustments to make, I mean

                 everybody does, but for us it's a little bit less of a

                 problem because we don't have a lot of fixed costs

                 that we have to deal with and so we're able to get

                 skinnier and do things perhaps more easily than some

                 of the other folks, but it's still, yeah, it's


                      WALL:  Nathan, Sally, want to jump in on this?

                      MOWERY:  I would say that I think that,

                 obviously, is going to be a continuing trend and it

                 kind of touches on one of the other questions that you

                 teed up for me and I think Ryan, that is are we going

                 to continue to see consolidation in the health care

                 industry, what sorts of new models may emerge, and the

                 answer to that is yes, I do think we will continue to

                 see consolidation, either real legal consolidation

                 with new partnerships and trusted adviser type

                 relationships and there will be new emerging models

                 that come from this I think as we all are wrestling

                 with the reality of that kind of financial impact of

                 where we're heading.  I agree with Ben, we are on an

                 unsustainable path for any number of reasons, we're

                 all getting older every year and there are certain

                 health conditions that come with that as we age.  We

                 do live in Indiana, we have one of the top five health

                 conditions from South Bend to Jeffersonville, from

                 Terre Haute to Richmond, pre-diabetes, high blood

                 pressure, high cholesterol, et cetera, so those things

                 are driving some of the costs, so from my perspective

                 any model that evolves which gets on the front end of

                 being able to identify health care conditions early so

                 that you can intervene earlier and begin to change

                 behaviors earlier will also have a human impact on the

                 cost trend in the long-run, which is essentially what

                 an employer-sponsored health and wellness clinic is

                 all about, it's what Activate Healthcare is involved

                 with, it's understanding the individual employees and

                 their family members that we serve and getting to know

                 them closely and through data understanding where they

                 are from a health perspective and jumping in as early

                 as we can to begin to change behaviors to begin to

                 hopefully back off from the long-run some of these

                 worrisome trends that we see.

                      WALL:  Well, that's helpful.  I'm going to

                 actually take both of those topics one at a time,

                 consolidation and some earlier interventions.  As

                 we've talked about that spending question, certainly

                 hospitals, which have a lot of fixed costs with

                 infrastructure, have been hit in visible ways by the

                 slowdown in spending as in fewer patient visits,

                 several of the largest systems here had some prominent

                 layoffs last fall and have just been working for a

                 couple of years to try to cut costs.  Consolidation is

                 kind of part of that mix and, Ryan, can you tell us

                 why does consolidation make sense, why now?  Maybe

                 while you're at it can you give us a status update on

                 where you guys stand with your Methodist-University

                 consolidation plans?

                      KITTCHELL:  Sure.  So on the last question, big

                 announcement today on where our new hospital's going

                 to be.  I'm just kidding.  J.K. wrote first where it

                 was.  You know, on that piece, because, you know,

                 we're trying to figure out what should be our new

                 adult downtown hospital, what kinds of care should be

                 delivered and how, and really focus on the what and

                 the how.  There's a lot of interest in trying to race

                 right to the "where" question, I know there are a lot

                 of folks that are interested in that.  We're not there

                 yet and we're trying to do it in a very deliberate way

                 and we've got some great clinicians focused on, you

                 know, the world's changed, this hospital's been around

                 a hundred years, and so we're really trying to think

                 about what the next hundred years should look like and

                 it probably looks different and so once we figure that

                 out then we'll figure out the "where" question.  I

                 guess on your first piece from a consolidation

                 perspective, I think it goes to a lot of things we're

                 talking about, those were built where our length of

                 stay was two or three times what it is today and so as

                 volume moves from an inpatient to an outpatient

                 facility we have more facility and more cost than

                 would be necessary and it allows us to lower health

                 care costs.  The other great patient benefit is we've

                 got, you know, world-class doctors downtown about two

                 miles apart and getting them in one facility, a lot of

                 the complex patients that we get have multiple issues

                 and if you can get all of that care under one roof it

                 can really be very beneficial to the patient, and so

                 it's a big deal, it's not going to happen overnight,

                 but we think it's the right thing to do for patients

                 both on the clinical and on the cost side.

                      WALL:  Does anyone else have thoughts on provider

                 consolidation?  If not, let's talk about ways to

                 intervene earlier and, Nathan, you mentioned that and

                 you're involved in one possible way to do that with

                 the employer clinic.  I'm interested in where you see

                 that going, I mean they have proliferated in Indiana

                 perhaps more than anywhere else in the country,

                 employer clinics have and now have a lot of lives

                 under their care.  Hospitals have also been in the

                 clinic game and continue to be so.  Perhaps we're

                 reaching a critical mass, perhaps not, but if we are

                 with the number of people involved in some sort of

                 clinic, what difference could that make in just how

                 the broader health care marketplace works?

                      MOWERY:  Thank you, J.K., for giving us all the

                 questions that we needed to prime ourselves on in

                 advance of this morning's meeting, I thought that was

                 very, very helpful so we could organize our thoughts.

                 The question that you asked me which I think goes to

                 this point is are employer clinics disrupting the

                 Indianapolis area health care market, that was your

                 question, which was actually a great question and it

                 made me think about the word "disruption."  When I

                 think of "disruption" sometimes I think of it in a

                 negative sense, my wife and I are on the patio, we're

                 having a nice quiet dinner and our neighbor gets his

                 lawnmower out and decides to mow the yard and it's

                 very disruptive, that's a very negative definition of

                 "disruptive."  I think we're all going to need to get

                 comfortable with grappling with the positive

                 implication of a disruption because disruptions

                 oftentimes are those things that drive evolution, they

                 drive change, they drive improvement, they drive

                 access, they drive those things which we in the health

                 care industry all say that we care about.  So I think

                 grappling and grasping and embracing the disruption

                 that's come with the Affordable Care Act, that's

                 coming with a number of the other market drivers,

                 which we could discuss if we had time, grappling with

                 that and embracing that and making it change the way

                 we think about health care I think is going to be

                 fundamental to our success in the future as a company.

                 It reminds me of an article by Clay Christensen

                 several years ago that was in the "Harvard Business

                 Review" called "Can the health care industry reform

                 through disruptive innovation?" and I think that's a

                 really good question for all of us.  The employer-

                 based health and wellness clinic was born out of a

                 frustration of the employers that each year they were

                 getting double-digit premium increases year on year

                 and there were not many tools left in the tool kit for

                 them to consider, so I think Indiana's very

                 enlightened benefit consulting and broker community,

                 they are the ones who I think initially began working

                 with their employer clients to figure out what could

                 be done differently in terms of how primary care was

                 being delivered in the state, and there is a

                 proliferation of wellness clinics as a result of that.

                 The Activate model is to engage the patient one-on-

                 one.  We talk about population management, really we

                 should be talking about patient engagement because if

                 we don't engage the individual in caring about their

                 health and in wanting to be around to walk their

                 daughter down the aisle and wanting to be able to

                 retire to Florida, if we can't connect with them in a

                 meaningful way so that they take ownership of their

                 own health care condition, then I think we're all

                 going to be having some very serious discussions 10,

                 15, 20 years down the road, that's what has to happen

                 and I think that's what Activate Healthcare and other

                 health and wellness clinics employer-based are focused

                 on, providing acute care services so it's immediate,

                 valuable, it's less disruptive to the work day, is a

                 great satisfier for the employees.  In fact, we have a

                 clinic at Monarch Beverage, and Phil Terry, the CEO,

                 is here today, for years the No. 1 benefit when they

                 surveyed their employees that they liked the most they

                 got from Monarch was free beer and wine.  Hey, what's

                 not to like about that?  Since the clinic has been

                 there the clinic has taken over the No. 1 slot, it's

                 such a satisfier to employees to be able to have

                 quick, unlimited, free access to primary care.  It may

                 be disruptive.  It certainly goes a long way to

                 engaging patients early, understanding what's going

                 on, and then if they do need to be referred outside of

                 the clinic, making sure that referral is to a good,

                 trusted advisor and the patient comes back for overall


                      WALL:  Dr. Park, what do you think about employer


                      PARK:  I like them.  30 some years ago when I was

                 a medical student I worked at an on-site clinic at

                 Ford Motor Company and we did histories and physicals,

                 preventative care, we provided acute care, we provided

                 chronic disease management, we did physical therapy

                 and x-rays and dispensed medications.  That is what

                 essentially the clinics today for the most part are

                 doing.  If that trend were really disruptive, I think

                 it would've been disruptive 30 some years ago.  It

                 wasn't.  We have 5000 patients, roughly, in our

                 employer program now with 14 companies.  We provide

                 those services, plus the additional things which I

                 think are critical and that's health coaching.  We

                 also do direct contracting for high-end imaging to

                 reduce those costs, for laboratory services to reduce

                 those costs.  A mid-size employer will see $150,000 a

                 year in savings from those things alone, so I think

                 there's savings to be had.  The most important thing,

                 it goes back to the big data.  You know, I can look at

                 the variation and the cost of care provided by various

                 hospital systems and specialists and I can tell you

                 that in Indiana the cost of a joint replacement, a

                 knee joint replacement under Medicare where everybody

                 gets paid the same varies from as low as $18,000 to as

                 high as $36,000 and that's not driven by price, that's

                 driven by the results and by having access to this

                 50,000 lives, it really allows us to look at those

                 things and say "Okay, where do we want to send our

                 patients where they won't be readmitted to the

                 hospital with an infection, where they won't have to

                 spend three weeks in a skilled nursing facility

                 because of the way the surgery was done."  So we think

                 that that's really going to be the big value.  Some

                 concerns I have about them is some of them do, and

                 we're trying to work in our clinics to not do this,

                 but it interferes with the continuity of care with the

                 primary care physician and, you know, we provide

                 after-hours coverage through our offices which we

                 think helps that somewhat, but, still, you know, we

                 try to get people back to their primary care physician

                 as an important thing.  The other concern I have is a

                 lot of these clinics are being sold by brokers based

                 on a significant commission and we don't pay

                 commissions to brokerage firms for our clinics and I

                 worry that the wrong motivation might be there in some


                      WALL:  So you like them, you have some concerns

                 about them, you don't see them as disruptive to the

                 other players.  Ryan Kitchell, do you have any

                 thoughts, do you see clinics, are they a big dot on

                 your radar screen or not at all?

                      KITCHELL:  Yes, so I agree with what's been

                 shared.  We're big supporters of them, they hit on

                 access and affordability, two things that we think are

                 great for health care.  After a lot of requests we

                 have been offering these as well, so we have 35 on-

                 site clinics across the state, and one of the added

                 benefits that really hits to the concern Ben made is

                 on our on-site clinics all of that patient information

                 is flowing back to the physician and into that

                 electronic health record and so that primary care

                 physician or when you're in the hospital knows all of

                 those episodes of care and what's happened to that

                 patient so we can give the best care for that patient,

                 so we think it's a good thing and look forward to

                 doing more of that.

                      WALL:  One other question about employers.  I

                 actually visited one of Nathan Mowery's clinics, I

                 won't name them, earlier this year who ended up

                 putting in a large employer clinic but got to that

                 point after first saying "Why don't I just get out of

                 the business of offering health benefits?" and that's

                 a topic that's been coming up a lot, particularly for

                 smaller employers, fewer than 50 workers.  I'm curious

                 to whether the panelists see that as likely or will

                 see lots of employers do that because now there is

                 subsidized insurance available individually through

                 the public exchanges or will do an individual strategy

                 with a combination of the public Obamacare exchanges

                 and perhaps some private exchanges, those are options

                 that are changing the game a little bit.  I'm just

                 curious whether people think that a lot of small

                 employers will stop offering a group plan or whether

                 they'll stick with it and why.  Sally McCarty, why

                 don't you start on that.

                      MCCARTY:  I think that if there are employers who

                 would go that route who would just decide to forgo

                 offering it would be the smaller ones, the ones that

                 pay lower wages, minimum wage or maybe slightly above,

                 because for them it probably, first of all, is the

                 employers who aren't inclined to be generous anyway

                 with their employees, so to add health cost coverage

                 or increased coverage so that their employees are

                 getting the minimum essential coverage that's required

                 would mean that it would have to go up from the bare

                 minimum and I think the employers who aren't inclined

                 to do that are the ones that would probably forgo

                 offering and let people take their chances on the

                 exchanges to see what they can get.  I think large

                 employers, it just doesn't seem that it would pay for

                 them, they get, you know, good rates and just the law

                 of large numbers allows them to have that offering and

                 not give that up as an employee benefit, it would not

                 behoove either them or their employees to do that, and

                 then you've got that middle range where I think there

                 will be a lot of calculated cost-benefit analysis by

                 those middle-range employers, you know, which is going

                 to work out best for them, but I'd say in the long-run

                 I'd be real surprised if there were many employers who

                 went the route of just giving up other than the very

                 small ones that I described.

                      WALL:  Dan Krajnovich, what are you expecting?

                      KRAJNOVICH:  And I agree with everything Sally

                 just said there where, clearly, the mid-size/large

                 group employers tend to be a bit more paternalistic

                 with respect to offering health care coverage to their

                 employees and dependents still view that as an

                 important benefit offering, it's still second to pay

                 as far as what they offer in a package to somebody

                 coming in as a new hire, and also as I remind people,

                 too, you know, if unemployment ever dips to a point

                 where they're really out recruiting for top talent,

                 offering health care coverage becomes a critical item

                 in their recruiting talent.  So I think for the

                 foreseeable future mid to large size employer groups

                 are likely not going to explore the exchanges.  We

                 haven't seen a shift in the small business employers

                 as of yet, but we are seeing more interest and

                 activity in looking at those options, you know,

                 "Should I keep my plan or should I dump in, have my

                 employees go to the exchange?" especially about 15

                 employee lives and under, I think those in particular.

                 What we've been focused on at UnitedHealthcare is

                 trying to come up with solutions for those small

                 business owners, for example we've got defined

                 contribution strategy called Multi-Choice where it

                 allows the employer to budget year over year so they

                 know what their costs are, it allows the employee to

                 pick from a portfolio of plans so they're not just

                 having one or two choices, they can find the benefit

                 plan that best fits their needs.  We've introduced an

                 ASO product down to ten lives, so if you have in

                 particular a good risk profile, that plan is likely

                 going to be cheaper than an adjustable community rate

                 if you go explore that avenue, and we have an exchange

                 platform that's kind of been embedded with the

                 Multi-Choice as well, so when you talk about a small

                 business owner, that's their job, so they don't have

                 the luxury of an HR person or a benefit director, so

                 if we can offer an exchange platform which really

                 minimizes the amount of work they have on their end

                 with respect to offering a benefit plan, that that

                 always is a plus from their standpoint.

                      WALL:  You mentioned the ASO plans.  If the

                 employer doesn't actually buy insurance, they hire

                 UnitedHealthcare or Anthem to be their administrator,

                 and also community rating, which that's really the

                 thing that small employers are looking at that

                 Obamacare's rules would say you can only charge the

                 oldest person covered in your plan three times more

                 than the youngest person and in the past it was more

                 like five or six times more, so for any employer that

                 has younger-than-average workers that rule when it

                 kicks in could really cause their premiums to go up,

                 that's the scenario.  Now, that probably doesn't hit

                 as I understand it until 2015, 2016.

                      KRAJNOVICH:  Correct.

                      WALL:  So given that cloud on the horizon, how

                 dark is the cloud, are people making it seem worse

                 than it is, and when do you expect the rain to come?

                      KRAJNOVICH:  Well, before you had best risk down

                 here in terms of price and up to your poorest risk and

                 so that's going to flatten out as we move forward

                 here.  I have my PR person looking at me, so I won't

                 make any predictions on the "dark cloud" issue there,

                 but, again, I think it comes back to I think we'll

                 continue to see a shift there as far as when the

                 employers, small business employers, are looking at

                 those rates and looking at their options in the

                 marketplace and I think those are going to drive, you

                 know, are they going to dump into the exchanges or

                 not, so are there solutions out there that are going

                 to offer them the opportunity to continue to offer

                 coverage.  In the end I think they'd like to offer the

                 coverage if they could do it in an affordable

                 standpoint, but if it becomes just too onerous from

                 cost and administering it, then they're likely to look

                 to those exchanges.  So from our standpoint, again,

                 we're looking at small business solutions from a

                 product standpoint but also we look to help those

                 small business employers that decide "You know what,

                 we're going to shift and offer our employees 'X'

                 amount of money to go into the exchange," how can we

                 work with them in terms of helping that transition

                 from a group plan to the exchanges.

                      WALL:  Okay.  Anyone else have thoughts on this?

                 Well, I wanted to go back to something you said,

                 Dr. Park, you were talking about the data that you're

                 starting to see as well as the high-deductible health

                 plans and the consumerism that that has helped

                 encourage.  So more customers that have more skin in

                 the game have more reason to be sensitive to price and

                 quality, but can they get the information they need

                 yet and, if not, what still remains to be given to

                 them to help them make decisions, I guess is the

                 question I'm asking?

                      PARK:  I think we need to start looking beyond

                 pricing and look at actual cost.  We have a

                 partnership with Milliman, the actuarial firm, and

                 they're helping us to sort through this data both on

                 where's the best place to go for a particular problem

                 and also on what's our performance look like.  We're

                 having Milliman run the numbers on our employer

                 clinics, as an example, to see if there's savings, I

                 mean have an actuarial firm put a stamp on it.  So I

                 think that the data is going to drive everything.  My

                 background is in information technology.  I was a

                 computer programmer.  I love this stuff and I really

                 enjoy getting into it and finding out things like the

                 variation in the cost of a joint replacement.  It

                 helps us tremendously because no integrated system is

                 going to be best at everything.  They're going to be

                 good at some things, great at some things and terrible

                 at a few, and so we try to pick the places for our

                 patients that are at the "great" category.

                      WALL:  Who else has thoughts, I guess to sum up,

                 what do consumers need in the way of transparency to

                 really be able to make better decisions?  Sally?

                      MCCARTY:  I was going to mention something but

                 actually it ties into what you're saying.  The

                 Affordable Care Act, there was 250 million dollars

                 appropriated to give grants to states for more

                 transparency in rate review and a lot of the states

                 took advantage of those grants and actually Indiana

                 has a really nice rate review website now, thanks to

                 those grants, so they did those the first couple of

                 years, and as I said, many of the states now have much

                 more transparent rate review processes, but also in

                 the third cycle of those grants they offered money to

                 any state agency who wanted to do an All Payer Claims

                 Database and again many states took advantage of those

                 grants and I think you're going to see a lot more of

                 these decisions based on some of the big data that's

                 now being collected and aggregated, and I've worked

                 with a few states, Minnesota and Oregon, who are

                 looking for ways to use that in all segments of the

                 health care delivery system, including regulatory

                 functions and any way they can crunch that information

                 to be useful in cost controls and just analysis of all

                 types, so I think you're going to see, we're already

                 seeing, a lot more movement to the use of data to make

                 these sorts of decisions and that's data that wasn't

                 there before or wasn't collected, and I'm not sure how

                 happy the provider or the issuers are about it, but I

                 think it will end up being useful for everybody in the


                      KRAJNOVICH:  Just to add, and I certainly don't

                 want to speak for Ryan, but I think providers

                 certainly are not opposed to it when the data's

                 accurate and is reflecting truly their position and

                 procedures that a consumer can go out and look at and

                 consider, and Ryan and I have had this discussion, I

                 think we're more at the kind of still infancy stage of

                 the transparency tools that are coming out there, and

                 one of the things that I believe is very critical is

                 the accuracy of those tools.  For instance, if a

                 consumer goes in and gets a cost for a particular

                 procedure and then goes out for that procedure and

                 gets a whole different price or cost for that when

                 they arrive, they're going to become very disgruntled

                 at the whole transparency model and likely not want to

                 use it again, so what we really want to aim for is

                 that that consumer, when they go out and get that

                 information and use it and it's not just the cost,

                 it's the quality and everything around the whole

                 episode of care that's being provided it's accurate,

                 so United's transparency tool is contract based, so

                 it's real-time, it's based on the actual rates that we

                 have and it's episode-based, so it's on the whole

                 treatment, so if you're going in for a colonoscopy, it

                 gives you entire cost for that, but, again, it doesn't

                 have the variations that a claim-based transparency

                 tool would have, so in a claim-based, that tool is

                 going to be dated in terms of the information,

                 especially if there's been a new contract that's gone

                 into place, it's not going to reflect that for another

                 year or so, and it also will have variability if

                 there's not a sizable or credible amount of activity

                 with a particular physician or facility, and so again

                 I think accuracy of these tools are going to be very

                 critical as we move forward.

                      WALL:  Ryan, do you have some thoughts?

                      KITCHELL:  Yes.  I appreciate Dan's comments, the

                 accuracy piece is important.  The last thing is folks

                 coming in and having a different expectation about

                 what something would cost and for our own employees

                 we've hired Castlight that a number of other big

                 employers, Lilly, the State of Indiana, et cetera,

                 have hired to do this and it has been a little bit of

                 a struggle to get accurate data.  Being on both sides

                 of that transaction we know what that number should be

                 and it's really complicated and not always accurate,

                 so we've not seen the level of uptake I had expected

                 with our own employees using that tool.  United has a

                 tool that we think is more accurate, actually.  I

                 think it is a nice tool, but to go back to what Ben

                 said, I think for radiology and lab and maybe some of

                 the more commoditized services, that unit price is

                 probably relevant, but for a lot of other things that

                 total cost for that episode of care I think is more

                 relevant than some unit price for one step of the

                 process and so it's one of the reasons that we've

                 started a health plan so that we've got different

                 incentives to manage that whole cost along that

                 episode of care rather than have a unit price piece,

                 and we're seeing good results there.

                      WALL:  The question on transparency actually came

                 from the audience and thank you for that.  Another one

                 from the audience mentions that his wife has been

                 battling cancer since 2001 and had access to MD

                 Anderson, a cancer facility in Houston, but since

                 joining a marketplace plan last year they're now

                 limited to midwest health care providers.  Can you

                 speak to the impact of the coverage in these

                 marketplace policies, how much has that changed things

                 and do we expect that situation to remain the same or

                 some of those plans will broaden out in the future?

                 Sally McCarty, I know you've thought a lot about this,

                 so why don't you take it first.

                      MCCARTY:  Well, I think this ties in very closely

                 with the transparency discussion and that is because

                 of all of these things we've talked about, cost

                 controls, issuers have to find other ways to keep

                 their 20 percent share of that premium dollar and one

                 of those tools they've used is narrowing down the

                 networks in their offering and this seems to have been

                 accelerated, this trend in the exchange policies,

                 there are a lot more plans being offered with narrower

                 networks, and, granted, these have been around for a

                 while.  Whenever an employer offers an HMO and then a

                 PPO, an array of types of policies, there's going to

                 be a narrow network selection in there in terms of the

                 HMO, but in that case people were pretty clear on what

                 they were buying, I think, or are pretty clear.  Even

                 though they're not big here, they are in other places,

                 but these narrow networks, I don't think people were

                 expecting them and I don't think the communications

                 have been very good, apparently not in this situation

                 as to which providers were covered by that particular

                 plan, so I think a lot of work needs to be done.

                 Narrow networks are not necessarily bad in themselves,

                 especially as those plans are offered in an array of

                 choices.  However, I think clearly from what we're

                 hearing from consumer advocates across the country,

                 more transparency needs to occur as to exactly what's

                 being bought, what's the network, what are your

                 options going to be when you buy this plan, and I

                 think a whole lot of work needs to be done around

                 those types of plans.

                      MOWERY:  Can I ask a question of Sally?  Do you

                 think that there will be a regulatory intervention to

                 address that issue?

                      MCCARTY:  (Nods head affirmatively.)

                      MOWERY:  So to kind of keep the access more open

                 as opposed — So will it have a limitation on the

                 narrow network strategy?

                      MCCARTY:  Not necessarily, I don't think, to keep

                 the networks open, I think to make sure there's

                 adequate choice, so I think in a place like New

                 Hampshire last year when there was one plan, that was

                 a problem because everybody wasn't in that plan,

                 consider that a narrow network, but I think there will

                 be interventions as far as the way issuers make sure

                 they're contracting with an adequate selection of

                 providers, and as I said, I think the messaging about

                 "Here's what you're buying, here are your options

                 you're going to have if you buy this plan," I think

                 there will be a lot of regulatory intervention around


                      WALL:  And do you see that coming from federal

                 regulators or state by state?

                      MCCARTY:  I know a lot of states are looking at

                 enhancing their network adequacy standards, but also

                 the federal regulators will be involved as well.

                      WALL:  Okay.

                      KRAJNOVICH:  The narrow networks have been

                 interesting.  We started exploring this several years

                 ago and Chicago was one of our first markets where we

                 launched a narrow network and they've had some

                 success.  We've had struggles elsewhere, but, again,

                 as Sally alluded to, as these exchanges opened up a

                 lot of the strategies have been designed around a

                 narrow network offering on these exchanges.  It has

                 created a network access issue.  We have filed with

                 the intent to participate in Indiana for 2015 on an

                 all access basis across the state, so we'll let you

                 know how that works out in terms of the attractiveness

                 of that versus the narrow offerings, but we do see

                 regulators are clearly looking at that.  I think there

                 was a lot of rumblings this past year with limited

                 access from folks that had enrolled in the exchange

                 and didn't necessarily know her doctor wasn't in the

                 network or the length they may have to drive to get to

                 a particular facility.

                      WALL:  Ryan, do you have any thoughts?

                      KITCHELL:  Yes.  So our health plan's going to

                 have a narrow network offering on the exchange next

                 year, so it will be an interesting contrast to Dan's

                 offering that's open access versus some narrow network

                 offerings.  I think in Indiana that has been an open

                 access employer-based market in general, part of that

                 adjustment phase that we were talking about from a

                 sector perspective is going to need to play out on the

                 consumer side as well where I think last year there

                 wasn't enough maybe awareness and attention on what

                 network you were buying when you were buying an

                 exchange product and I think as folks have understood

                 what the consequences of that are you'll see more of a

                 focus on the consumer sector of what the network is

                 that you're getting.

                      WALL:  While we're talking about benefits I did

                 want to ask about the potential Medicaid Healthy

                 Indiana Plan Expansion.  I'd just be curious to hear

                 to what extent you think Indiana's health care

                 providers were impacted by the State's decision not to

                 expand this year and how they might be impacted if

                 indeed this Healthy Indiana Plan 2.0 goes forward.

                 Ryan, do you want to answer that one?

                      KITCHELL:  Sure.  So let me start by commending

                 the Governor and his team on taking a bold step and

                 proposing something that had some political risk and a

                 tremendous amount of work.  You know, most importantly

                 it gets about 350,000 Hoosiers that have never had

                 health insurance and as a provider that's a good thing

                 because we know they'll seek care when they need it

                 more often than without.  From our perspective it's a

                 really big deal.  The grand bargain on the Affordable

                 Care Act from a health system perspective was

                 significant Medicare cuts but getting paid a modest

                 amount for folks that previously didn't have insurance

                 both from the exchange and Medicaid and so in Indiana

                 it's about a five billion reimbursement reduction as

                 part of the Affordable Care Act over the next 10 years

                 and so this is a key piece of making up some of that

                 ground so that we can continue to deliver on our

                 mission of providing care for folks, so it's a big

                 deal and I'm thankful that they've stepped forward and

                 hopeful that CMS quickly approves it.

                      WALL:  Dr. Park, go ahead.

                      PARK:  I think not expanding Medicaid under the

                 current system was a good move.  What they did was to

                 try to enhance the network of physicians available to

                 serve the Medicaid population, they offered us

                 Medicare reimbursement but only for a limited period

                 of time and not very many physicians opted into that,

                 and so had they expanded Medicaid with an inadequate

                 base of physicians it would've been a disaster.  HIP

                 offers Medicare reimbursement long-term and so most

                 physicians are going to sign up for it, and so even

                 thought we'll be bringing all of these new people in,

                 we'll also have a markedly expanded network of

                 providers to serve them and I think it makes sense.  I

                 agree with Ryan, the Governor's to be congratulated on

                 this one.

                      WALL:  And I know it's way more complicated than

                 my question will make it, but tell us roughly how much

                 higher is Medicare reimbursement for the Medicaid


                      PARK:  It's about 20 percent higher in primary

                 care services.

                      WALL:  While you have the floor, Dr. Park,

                 another audience question is how will you address the

                 primary care crisis?  You were talking about it

                 getting worse, you thought, if the State had expanded

                 Medicaid without enough primary care providers in that

                 program.  Kind of more broadly there's that issue just

                 across the whole health care market, perhaps more

                 demand than there is primary care providers to meet

                 it.  How will that problem get solved in the future?

                      PARK:  The concern I have is that people are

                 buying primary care services privately, concierge

                 practices are bringing up.  Employer clinics are

                 really an example of concierge care provided through

                 your employer and people who have enhanced primary

                 care access, by and large, do better than those who

                 don't.  What we're doing about that, because we still

                 want to be a broadly-based organization, is we teach

                 in the PA program at Butler, the nurse practitioner

                 program at IU and University of Indianapolis, Ball

                 State, and we get nurse practitioners and physician

                 assistants from all of those programs and we're

                 growing that part of our provider base much more

                 quickly than we are our primary care base because

                 physicians still aren't really choosing primary care

                 in the numbers that they need to.  If you take

                 internal medicine docs who go through an internal

                 medicine residency, only 8 percent of them will end up

                 practicing general internal medicine and seeing

                 patients, the rest of them will go into some

                 subspecialty, cardiology, GI, they'll become a

                 hospitalist, they'll do something other than practice

                 in primary care, so for at least the intermediate time

                 we're going to have a lot more physician assistants

                 and nurse practitioners in our practices, and over

                 time, like all economic problems, it will correct and

                 the reimbursement will change and the primary care

                 physicians will be paid more, and more people will

                 choose it.

                      MOWERY:  I would add to that that need, and if

                 you look at the long-term trends in terms of the need

                 for primary care providers, it's very startling, that

                 will drive innovation and that will drive change to

                 address that need, and I think one of the ways that we

                 will do that is through technology, particularly

                 through telemedicine, and we have around 20 clinics in

                 the state of Indiana and then a number of outside.

                 All the clinics are on the same medical record, and if

                 an employer has employees located around multiple

                 places of the state, they can access any one of our

                 clinics and they can do that through a telemedicine

                 visit, and so I think we're on the front end of the

                 change that's going to be unleashed in terms of what a

                 provider-patient relationship looks like when it's

                 impacted by kind of the unfettered use of tele-

                 medicine.  I think we're on the front end, I think it

                 holds great promise for us.  We're using it today, but

                 it will continue to be something that I think perhaps

                 addresses the primary care shortage because you can be

                 there virtually.

                      WALL:  We have a question from the audience about

                 telehealth services, what you think about them,

                 whether they should or shouldn't be reimbursed, and I

                 think I would add to it whether the state legislature

                 should or should not allow telehealth to happen

                 without a prior in-person visit.  What are your

                 thoughts on that?

                      MOWERY:  Yeah, I think that's a great question

                 that I'm sure legislators are getting multiple

                 perspectives on, and every state is looking at that

                 differently.  Today I think where we are here is you

                 need to have an initial face-to-face contact with the

                 provider and then telemedicine can be done after that,

                 so there needs to be that sort of face-to-face touch

                 point.  Will that be the status permanently in

                 Indiana?  I think there will continue to be pressure

                 on what that looks like and I think every state is

                 probably going to look at it somewhat differently and

                 you are going to have some potential conflicts among

                 states in terms of their respective views of

                 telemedicine.  Sally has an opinion on this, too,

                 because we talked about this at breakfast.

                      WALL:  All right, tell us your opinion, Sally.

                      MCCARTY:  Somebody once said "Change is good, you

                 go first."  I think that's sort of the telemedicine

                 mantra.  I think there's a lot of other systems that

                 are going to have to adjust in order for that to be a

                 viable alternative, but I do think that it is a viable

                 future alternative, but we're talking about the

                 medical licensing system and all of that.  If you're

                 going to talk to a specialist in Seattle, does that

                 specialist have to have a license in Indiana and how

                 that works.  But my provider network, which is IU, I

                 just received a survey by e-mail about what kinds of

                 things I would be willing to do through telemedicine

                 and I thought that was pretty interesting, so it's

                 definitely the trend of the future and definitely I

                 think will be a good way to address some of the

                 concerns about primary care shortages.

                      WALL:  Dr. Park, you're in the thick of this,

                 what do you think about telemedicine?

                      PARK:  Well, IU and AHN are piloting a telehealth

                 program, we're waiting on the final rule.  The

                 legislation is actually done, there's enabling

                 legislation that's been done, and we're waiting on the

                 final rule from the Medical Licensing Board to go

                 ahead and pilot this, and we think it's a great thing,

                 and we've done online visits using a product for 20

                 years now and I think you'll continue to see that part

                 grow.  I'm not completely convinced that's going to do

                 away with the primary care shortage, though, I mean,

                 because a doctor is sitting here and doing it on

                 telehealth, I mean that doesn't really enhance the

                 number of hours a day that you'll get primary care

                 from that person.  So it's an interesting thing, I

                 think it's going to get traction slowly, but I think

                 it's the right direction.

                      WALL:  Dan Krajnovich, the original question was

                 about reimbursement of telemedicine.  You're running a

                 health plan.  Why do you want to or not want to

                 reimburse your telemedicine?

                      KRAJNOVICH:  Didn't think of that one.  Again

                 just listening to all of my colleagues here talk about

                 it, I mean clearly it's something that I think is

                 going to pick up traction.  UnitedHealthcare has been

                 involved with some telehealth in the past and

                 currently, so obviously we do support it to some

                 degree.  I think, again, there's a question mark in

                 terms of where this is going, how much impact is it

                 really having with respect to the PCP shortage there

                 and the amount of time they're spending relative to

                 telehealth services, is there a real differential

                 there between delivering via telehealth versus not, so

                 I still say it's somewhat of an uncertainty.

                      WALL:  I'll ask one last question, this will be a

                 lightning round thing, from the audience about

                 Accountable Care Organizations, they get talked about

                 a lot, a big part of the Affordable Care Act.  The

                 question is do you think they'll be able to save

                 health care?  Dr. Park, you're in the midst of ACOs,

                 what do you think about them?

                      PARK:  We have three of them, one is a

                 partnership with Franciscan, one is a partnership with

                 Premier in Bloomington and the other one is our own in

                 Columbus, Ohio, and we only have one of those that's

                 beating the benchmark.  It's a difficult road.  You're

                 trying to practice population-based health care but

                 your population keeps moving.  25 percent of the ACO

                 lives turn over every year.

                      WALL:  Meaning they stop seeing the doctors that

                 are in your organization and go somewhere else?

                      PARK:  Well, you know, they get well, I mean they

                 don't need us for a year, and so we don't get those

                 well people attributed to us and then they come back

                 the next year.

                      WALL:  When they're sick.

                      PARK:  And another 25 percent are well.  We can't

                 get them all well at once.  So there are problems with

                 it.  I think it's a step in the right direction.  I

                 think you're going to need, instead of attribution,

                 you're going to need up-front assignment so you know

                 your population that you're serving, you know those

                 people, who they are, and I think that that would be

                 an important change.  I think it needs to be more

                 community-based.  Our problem is that we had the

                 lowest cost of any ACO that I've seen for our

                 benchmark.  We looked at other people's and their

                 benchmarks were like $12,000 a year and ours was like


                      WALL:  That's per patient?

                      PARK:  Yeah, $8400, because we've been doing all

                 of this stuff and we don't have as much room to

                 improve, so it would be great if it were community-

                 based and assignment was done in advance, I think if

                 that happened they'll work.

                      WALL:  Who else has thoughts about ACOs?

                      KITCHELL:  So you can chalk me up in the "no"

                 category, too, on this.  So we have the largest ACO in

                 the state, about 50,000 lives in the Medicare Shared

                 Savings Plan, and maybe to add to what Ben said, we

                 see a couple just fundamental problems with the

                 program.  So, one, you don't know what lives you're

                 accountable for until after the fact based on this

                 attribution model.  The network is broad, and so we

                 talked about kind of the advantages and disadvantages

                 of the broad and narrow network, 50 percent of the

                 50,000 lives that we have are outside the IU Health

                 system in other systems around the city and so it is

                 hard to be accountable for their care when they're

                 outside your system and you don't know what you're

                 doing.  And then finally, the data is really slow to

                 actually kind of be actionable, and so we have a

                 Medicare Advantage Plan and stack that up side by side

                 and you know who your members are, you're getting

                 real-time data, and it's a narrower network and so

                 we're having much better success on the health plan

                 side than an ACO structure.

                      WALL:  Does anyone want to make the last word,

                 give the last word?  All right, well, we'll wrap it up


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