It doesn’t take a lot of mental gymnastics for someone to realize that the healthcare system in America isn’t ideal as far as patients are concerned. The system is broken to the point where access to primary care isn’t that easy for most people. Direct primary care aims to change that and more. For the patients, it means increased access to competent doctors without having to deal with the headaches that come with institutional medicine and medical insurance. For the doctors, it means they get to practice medicine the way they envisioned it would be like instead of just being a cog in lumbering institutions. Wes Clements III and Jen Clements join us on the show to tell us what it’s like to work in this field. Wes and Jen are the founders of Tailored MD, a DPC provider operating in the San Antonio metropolitan area. Tune in and learn how they take part in this incredible movement that raises the bar in healthcare access and doctor satisfaction in one blow!
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Raising The Bar In Direct Primary Care With Wes Clements III And Jen Clements
In this episode, we are going to talk about direct primary care with my friends Dr. Wes Clements and Jen Clements, who own SADPC and an individual practice under that called Tailored MD so you’re going to know both. Many of you know that I am a huge fan of direct primary care as a patient myself. I can see what it does for both employers and employees and how it can benefit each party. I thought it was important for us to talk about that.
One of the things that I hear quite a lot is, “Why would a doctor want to do that?” In this episode, you’re going to know why. You’ll get a better sense of how much of medicine is the business of medicine and how there is a large and very rapidly growing number of physicians that want to be doctors. How DPC is a way that they can practice in their ways because not all DPC practices are the same? How are you?
We’re doing well.
How are you?
I am all right. I want to go back to why you started DPC. You are one of the few physicians, Wes, whom I don’t believe ever practiced in a system. You have always been out on your own. Is that right?
There’s a short stint of doing traditional primary care working for the man for insurance. I did that for two years before I opened my practice in 2020. I’ve been out of residency for a few years, two of which are in an insurance-based practice.
You came here and started a practice that is growing like wildfire. You have moved from Tailored MD into SADPC. This is a business model and a viable business model for you.
It’s more than viable. It’s been fantastic. There’s a lot of career satisfaction and practicing medicine the way I love again. You’re right. It started as a small practice and we’re growing a network in San Antonio called SADPC, a group of different direct primary care practices so we can work with employers and cover a larger area for individuals as well. Satisfaction is much higher. You could say maybe it isn’t saying much compared to the doctor satisfaction in the traditional model. I’d say that’s not too high but it’s in a different world of career satisfaction for sure.
I know several DPC doctors but your office has to be the most interesting one I have ever been in. It does not look like a medical practice at all. You’re sitting in your office with those beautiful bookcases behind you and your beautiful wife. You typically sit on the other side of the desk and talk with your patients and then you have an exam table. I believe you told me that it gets used not very much.
It’s a very casual environment. You’re right, this is my office. I’m sitting at my desk. You’re virtually sitting right where my patient would be sitting across from the desk and we chat. We come in. They don’t go straight to the exam table and sit there like some specimen to be examined later on. They come in and we chat. It’s very relaxed. We have 1 hour to 1.5 hours to visit with the patient in person. If an exam is needed, we sometimes go to the table. You can listen to heart and lungs in a chair, though. You don’t have to put them up on an uncomfortable table. It’s got the rug. It feels like a living room almost.
When you walk into the office, the first room you see does look like a living room. We’ve got a couch and two chairs. We have one desk set up where MA sits. We like to call it lovingly the no waiting room because our patients don’t have to wait. When they come in for their appointment, we’re ready to see them. It’s there just for looks. Sometimes it gets used but we like to make it a homey, welcoming environment where people can bring their whole family. Their kids are welcome here. Their spouses are welcome here to wait while they’re seen. It’s what we were going for.
Let’s talk about spouses and children for a minute. You treat employees. You treat regular patients, individual people that find you. You get a good flow of those people who find you and are looking for individual medical care because that’s what you deliver. You don’t deliver insurance. If somebody is having a heart attack, they’re not coming to you. They’re going to the emergency room. If they’re receiving chemotherapy, you might be supervising that but you’re not delivering that. You can take care of a lot of somebody’s day-to-day medical needs. I would imagine you can also help cut down on some of the extraneous things or the more expensive things that happen that may not be necessary.
I want to tie that into the satisfaction too, the doctor’s satisfaction of practicing. What increases doctor satisfaction in this model is we get to practice medicine the way we learned and imagined, which is to the fullest extent, we’re utilizing our knowledge instead of being just a cog in the wheel of the machine and primary care. That cog is a referral coordinator it feels like at times. When we can practice medicine to our fullest extent, we’re way more satisfied because we’re using our skills.
What you’re referring to is we get to do a lot in primary care, which is underutilized in the traditional insurance model. A lot of clinics don’t do this anymore but I can do in-office procedures a lot, stitches and toenails. I don’t do the toenail. Our other clinician, Nicole, will do toenails but we do those kinds of services like toenail removal, dermatology stuff, mole removal, biopsies and a lot of women’s health stuff. Pap smears, coordinate mammogram studies and things like that. We do weight loss, which is the bread-and-butter stuff that we see all the time in any primary care clinic. Also, cholesterol, hypertension and things like that.
I want to give you an example of something that happened to one of my clients and compare that to what would’ve happened to that person had they been in your office. I have a client that they do not have a direct primary care relationship. They have a spouse. The spouse is a husband. He is diabetic, overweight and not getting a lot of care. He went to a primary care physician who threw about five medicines at him, including some very expensive medicines that you have heard me go off on a tangent about.
The wife came into HR and they got me on the phone. We got him to an endocrinologist and the endocrinologist was like, “We’re going to take you off every single one of these.” Many of his problems have stopped. One of the things that happens in primary care when you have 7 to 16 minutes is you may get to the first issue, write a script for something and then you’re referring out because you don’t have time. Is that an accurate assessment?
That is accurate. You can’t practice to the full of your license and take care of an issue when you only have 7 to 16 minutes. You end up having to over-refer. People have 5 or 6 different clinicians who are all different specialists sometimes with contradicting recommendations. Maybe they needed one of those but primary care can treat most diseases up until the end stage so we can treat fatty liver disease until the end stage. We can treat heart disease until somebody needs a procedure or stent. You don’t need an endocrinologist for Type 2 diabetes in all cases. Sorry, we need you for insulin pump management. Sometimes, it’s tough to control diabetes but a primary care physician’s perfectly capable.
In your case, primary care should be able to manage Type 2 diabetes and not have to refer to endocrine, especially at the beginning when the first steps are obvious. I don’t want to say it like it’s just a beginning thing. You can manage a primary care clinician. You can manage diabetes throughout your life. That would save a lot of money. I don’t know the numbers. You probably know them better than me but it’s one of the highest revenue-producing diseases in the American health system. It’s probably after heart disease and cancer, I imagine.
I don’t want to sound like a conspiracy theorist or anything but let’s say the health system isn’t incentivized as a whole to be cost-effective. We know that. That’s not a conspiracy theory. We approach diabetes systematically as a management thing. We treat people long-term. That’s great. We manage it. We get their A1C down. That’s the goal. Get your A1C down below 7 or 6.5 if you’re not on insulin or something like that.
That’s a great revenue producer. Somebody’s got diabetes for their whole life. You’re managing it. They’re seeing a primary endocrine. They’re seeing ophthalmology to get their annual eye checks. Nephrology for kidney management. When in reality, we have tools that can reverse people’s diabetes. It’s such an exciting time. Especially if you have the tool as a primary care of time to talk about diet and exercise, more than just saying, “Do diet and do exercise.”
We have time to break it apart in their daily habits and create a good intervention that’s effective. I’ve seen it many times. Some great medicines in the last years can be used temporarily to reverse diabetes. We’re going to see the recommendations change on standard diabetes management. The nice thing is as primary care doctors, we have time to take advantage of those novel therapies and create the best outcomes.
One of the things that are very underestimated in all the metabolic syndromes, let’s call it that because there are so many people that are in that metabolic syndrome, pre-diabetic, diabetic kind of journey where we are in South Texas is who is cooking and what they are cooking. I don’t think if you have ten minutes to spend with somebody, you’re getting to cooking. That is one of the most challenging things. That’s not necessarily a high use of your skillset but it’s a very important use of your skillset.
People want that information. Trust in the medical system with doctors is at all time low because we’re not taking the time to offer those and other people are, who aren’t in the medical system. We need to take that control back in primary care and offer that kind of advice. Time is what’s needed for them.
What is the business case for an employer to offer direct primary care besides this is good for the humans? I’m a very big fan of this is good for humans. Sometimes we have to do something good for the humans.
Getting their employees access to care is the main selling point for employers. This reduces absenteeism. When patients have direct primary care, they’re taking care of their preventative health. They have access to a doctor that will overall make them healthier. Along with those things, doing good things for good humans is a cost-saving. I signed on with a hospice company with nine employees. We are saving them $1,400 a month and $16,000 a year, replacing their traditional insurance with direct primary care and an insurance alternative. That is a comprehensive plan for them, getting them more care than they were getting before and better access.
For an employer with 9 lives, $16,000 is a meaningful amount of money.
The keys are not sacrificing quality or level of service. As a matter of fact, they’re improving it. It truly is the best of both worlds. For a lot of employers, the biggest barrier we see to explaining the model is it sounds like it’s too good to be true. You can’t have better care for a lower price. That doesn’t make any economic sense. When you deconstruct the whole system and build it up to only service the provider and the patient, you get rid of all the extra crap. You have an efficient model that means that very thing.
If you have a health insurance arrangement, there are 3 to 5, sometimes more layers between the person that receives the care and the party that pays the bill. That never occurs to people. Why would it? How do you combat the, “I have great insurance. It just pays for everything,” conversation? “I have a doctor.” I have many things to say about that, most of which should remain in my hit.
Being a clinician, if somebody’s happy, I’m not here to combat somebody’s happy situation. I’m here like, “If you’re happy and you feel that you’re getting value, great.” We’re not here to disrupt that. We’re here to help people who aren’t happy with the health system and are paying too much.
Direct primary care exists to help people who aren't happy with the health system and are paying too much. Share on XThe first question I would ask that person is, “How much are you paying in premiums each month?” 8 times out of 10, they have no clue. It comes out of their check before taxes. It’s just a deduction. They don’t even look at that.
Not only that but their employers pay a hefty part of that. I don’t think you’ve ever had a conversation with somebody who gets their COBRA notice and they call you and say, “This cannot be right.”
I have teachers that are retiring. They’re like, “This is ridiculous. We can’t afford that.” I hear that all the time. Also, people that do know how much they’re paying in their premiums. We have plenty of people that have traditional insurance and come to us. They want the level of service that we can provide. Many times, we hear people say, “I have great insurance. Let’s run my labs and get this MRI through my insurance.” We know where the best cash prices are for these services and how to get them. We advise our patients on that but they think, “I have great insurance. I pay all this money every month.”
Unfortunately, we had a patient who wanted to use her insurance. She had great insurance for an MRI. We could have gotten the same MRI for $450. This was in November of the calendar year. She had paid $0 towards her deductible. She had a $3,000 deductible. The MRI ended up costing her $3,000, the entire deductible. If she would’ve gone through us, it would’ve been a fraction of $450 of the cost. You can have great insurance but still pay more for services. Wes likes to say a good quote. “Insurance, a lot of times, can be an exclusive club where you pay more for things.”
A lot of times, insurance can be an exclusive club where you pay more for things. Share on XA lot of the time, that’s the case. I see it almost every day. Patients tell me, “My Viagra costs $100 to fill.” I’m like, “Did you know you can get it in cash for $10 a month?” These are the ones I see a lot. A young male doctor said, “My testosterone costs so much money.” “Do you know that you can get that for $10 a month?”
I have a patient who has two insurances. They have United or Blue Cross Blue Shield, one of the big insurance companies and also Medicare. They got an annual panel of labs. I don’t know if you know this but a lot of insurance companies are denying annual as a code. They’re getting a bill for cholesterol, sugar, kidneys and basic annual labs for $450. They have two insurances. Those cost cash of $25 worth of labs that we got.
I have a big headache with the lab people. One of the things that I hear a lot is, “We get the best discounts.” Most often, those discounts are a made-up number from a made-up number that has no relation to reality. You and I have had some conversations about drugs like Ozempic, who needs to be on what, how you get it and where you source it. Prescriptions are incredibly overprescribed. When you have a relationship with a physician, your approach tends to be less is more because you have more conversation. How does that impact somebody’s health over the long-term?
The less is more. I’m trying to think of a good example of that because there are so many. The most probably costly example of the opposite of that, which we see in this model, is going back to the referral trigger happiness of the traditional model. The medication trigger happiness. We can extend it to that. When you have time to get to the root of a problem, you can adjust the lifestyle stuff we talked about. I encourage it. I love referring to physical therapy. We have great insurance and cash-based physical therapies throughout San Antonio. There’s a lot of information online.
I don’t want to undermine my physical therapist people but I usually recommend my patients do 1 week or 2 of home-directed therapy. I get out of my desk and do it with them. We’ll do a squatting pattern or a glute exercise of some kind for hip problems or something for different musculoskeletal issues. We’ll do that in person. I’ll sit right next to them and do the exercise with them. We have time. They don’t need, necessarily, an orthopedic surgeon referral or an X-ray yet because they have easy-to-access therapy, whether that’s a cash-pay therapist or those online resources.
Those medications they were taking every day, like NSAIDs, muscle relaxers or pain medication.
There are a lot of long-term consequences to that.
We don’t need to prescribe pain medicine as much, although I prescribe anti-inflammatories like it’s candy, to be honest. They’re great short-term but they’re very cheap too. That’s irrelevant to the cost conversation. On the other hand, I would like to put out that we’re mentioning pain medications like opioid pain medicines, which have gotten bad press in the last decades. That bad press has led people to be unable to access clinicians that can prescribe those things.
I get some patients. We’re not a pain clinic so we don’t usually start pain management or increase opioid pain management long-term in our patients but we will continue it. That’s because we have time to do all the necessary safety protocols and discussions with the patient to prescribe opioid pain management long-term safely. I get so many patients who have a severe inoperable condition that causes severe pain. They can’t find anybody who will prescribe pain management for them. Especially if somebody is not insurance based or doesn’t have insurance.
I have a client who was having an unnecessary MSK surgery because that’s its own discussion. Her surgeon would not give her pain medication prior to her surgery. I was a little surprised by that.
There are some studies that show that anti-inflammatories have a similar effect in certain cases but surgery often should require strong at least the option. Maybe it doesn’t need to be automatically scheduled but it can be an option if somebody has a pain level over rate or whatever number they decide on or agree on. In those cases, it’s extra important for the clinician to be accessible to the patient for those kinds of situations.
Let’s say a patient does have severe pain. One of the scares of just treating it with pain medicines, you could be covering up a postop infection or something. Maybe some of the fear is that if they have pain medicines, they’ll take them when they shouldn’t have that degree of pain. In direct primary care, our patients can call or text us anytime. We don’t do texts after hours but they can call us anytime. They can text us during the day with any questions and we get back to them within two hours.
Let’s talk about after-hours care because that’s a very strong value proposition. Most people are quite respectful of everybody’s time and every clinician’s time. If it’s 9:00 at night and I’m not quite sure if I need to go to the emergency room, it is much more beneficial for the patient to have access to somebody to say, “You’re okay. Do this or maybe you should go to the emergency room.” It’s better for the human but it’s better for the plan.
DPC is known to reduce urgent care and emergency room admissions. Many case studies show a decrease in claims with direct primary care as part of the healthcare solution.
Direct primary care is known to reduce urgent care and emergency room admissions. Share on XI have this theory that urgent cares are everywhere because people can’t get to the doctor.
Urgent cares have a place but honestly, the rapid growth of urgent care in the United States is a symptom of poor primary care. If primary care doctors had adequate, reasonable access, the need would drop significantly. It’s all about access. What’s funny is a lot of those after-hours needs could have been taken care of during the day but it’s not even that there’s no access in the evening. There’s not even access during the day for patients.
The rapid growth of urgent cares in the United States is a symptom of poor primary care. If primary care doctors had adequate, reasonable access, the need would drop significantly. Share on XThings get pushed until the evening and the doctor’s not available. Access day and night is what’s needed and has been the problem and what’s led to the overutilization of ERs and urgent cares and also the under-appreciation. Patients have lost interest in primary care because they don’t see the value in it anymore if they can’t access it.
We get calls every day with simple health issues like urinary tract infections. They are concerned they may have COVID and they call their doctor’s office. They’re already established at that clinic. They don’t have availability for three months to see them.
By then, you’re either better or dead.
They’re forced to go to urgent care. They have probably two $300 bills, which would buy them three months of care at our clinic.
I had that experience. I had a traditional fee-for-service primary care doctor who, when I thought I had COVID, wouldn’t even get on the phone with me. The woman answered the phone because of hospital-owned practice, that if I was concerned, I should go to the emergency room. Given what I do, do you think I’m going to the emergency room? If I were a regular person, I didn’t know better. I would be like, “I should go to the emergency room.”
I would have been admitted to the hospital and spent three weeks. I called a doctor friend of mine and said, “Help me. Please walk me through this.” If you don’t know, you don’t know. I had another client who had elevated high blood pressure. She went to the emergency room and her blood pressure was coming down and they insisted on doing a head CT. I believe that there is 1,000 times of radiation in a CT than there is in an X-ray. Do you want that in your head? How do you talk to people about that?
Let me say this. Do not go to the ER for high blood pressure. You got to get ahold of your primary care. An ER clinician will say the same thing, “Don’t come to us for just high blood pressure.” If you don’t have symptoms but your blood pressure’s 160 or 170, that seems like an emergency but you need to get ahold of your primary care first because ER is going to get it down with medicines. It only lasts for 12 or 24 hours. They’re going to get it down on paper so they can safely discharge you but the next day, it’s going to be high. Most likely, if you’re at a traditional practice, you can’t get in the next day. Blood pressure has to be managed by primary care. I got to say that for sure about blood pressure.
These doctors that work in the traditional setting are not bad. They do care. They’re working in a broken system in which they’re incentivized to see as many patients in a day as they can rather than keeping their patients healthy. In direct primary care, instead of focusing on quantity, we focus on the quality of patients. That’s the main difference in how we’re able to do that.
Doctors that work in the traditional setting are not bad doctors. They do care. They're simply working in a broken system in which they're incentivized to see as many patients in a day as they can rather than keeping their patients healthy. Share on XOne of the ways that you do that is by controlling your panel size. A panel is how many patients a doctor has charts for. Your panel size is considerably smaller than the panel size of a traditional fee-for-service doctor.
The average direct primary care panel size is 300 to 600 patients. Three hundred is on the low side. Many are over 400. It’s around there. I don’t know the numbers exactly but there have been ranges in a traditional clinician to see 2,000 to 5,000 panel size. We’re 10 to 20% of a regular panel size. That alone is a statistic people need to take away from the comparison between direct and traditional primary care panel size. That’s the only thing you need to know in terms of service. I can provide 4 to 5 times the medical service per patient.
Many people are concerned with this fact. “We already don’t have enough primary care doctors. How is this going to help our system? It’s going to cause access to be even lower.” Changing the way primary care works, it’s going to make it so much more attractive to people to go into primary care instead of going into specialties. That is a fundamental way that direct primary care can flourish.
By changing the way primary care works, DPC makes it so much more attractive to people to actually go into primary care instead of going into specialties. Share on XThere are a lot of primary care residencies, despite the fact that many residents didn’t match. I don’t know if our audience has heard of the match process, meaning medical students go into residencies for a specialty or primary care. Primary care, because of what it’s become, is a less desirable field. I’ll admit it. Despite the fact that some residents didn’t match at all into residency and they have to wait another year to start practicing medicine, some of the other end of the match and some of the residency positions in primary care didn’t fill immediately. That tells you people would rather just wait a year to become a specialist rather than primary care, even with all that debt and the fact that they wouldn’t be a doctor. It’s not a desirable field in terms of the traditional model.
That’s going to change as DPC grows, which is growing rapidly and the awareness is getting higher in the medical community. Let’s look at where people train in giant healthcare systems where the incentive is to keep people in that system in that less desirable position. They won’t be able to hide DPC for much longer from our residents in training. As Jen said, make primary care and direct primary care more desirable and you’ll have more clinicians.
That’s a slow process and it’s going to slow the access to DPC. The other thing I would point out about the fact that there may not be enough docs for our clinicians in general to see 400 or 500 patients is I’ve thought about this a lot. The truth is having 400 or 500 patients whom you’re providing great medical care for and saving them money is better than having 2,000 to 5,000 patients that I’m bankrupting every single day or that have lower life expectancies.
We have somebody who’s reading whose specialty is kidney disease. Talk about how you can help somebody navigate through kidney disease, keeping them out of a dialysis chair for quite some time, maybe forever. It is a horrible way to live. It is a tremendous financial burden for everybody involved.
There are different stages of kidney disease. All the way to what you described is end-stage kidney disease, where kidneys are no longer functioning and you need dialysis to live. The top causes of kidney disease in the US are high blood pressure and diabetes. Those are what caused the majority of kidney failure and kidney disease. Like diabetes, we don’t want to just treat the kidney disease. We want to treat the causes. Having adequate primary care to control or reverse diabetes, I want to make that the buzzword of management of diabetes is reverse diabetes, to be able to do that and control blood pressure adequately by having access.
My patients can call me if their blood pressure is high and we can make an adjustment, monitor them, have them check at home and communicate about reading. Controlling those conditions is the most important part. That’s what directs how somebody’s kidney disease evolves. The other thing is a good primary care clinician can manage early-stage kidney disease. There are different levels of comfort and maybe a nephrologist is needed to rule out some other possible causes of kidney disease, especially if trajectories look bad.
If they take a little bump and had a clear cause, clear uncontrolled hypertension for a while, high blood pressure and that’s controlled and it’s stable, primary care can manage that as long as they’re continuing to manage those conditions and as long as they understand the great tools to optimize the kidney conditions. There are some blood pressure medicines that are preferred in those cases. There are some diabetes medicines that are helpful in preventing the progression of kidney disease. To do that, you have to be up to date with the knowledge. You have to have time to spend with the patient, study read articles on how to manage these things. That’s what DPC clinicians have.
Do you ever get pushback about, “My employer is going to know what’s going on with my medical history or with me?”
I don’t think I’ve ever had that concern. We have about 25 businesses we work with. We have a privacy policy that each person signs in the beginning that there’s no reason why the employer should know anything about their employee’s healthcare information.
What about everybody going, “I have to go to this one place?” Do you ever get any pushback on that?
That was a big reason why we decided to create San Antonio Direct Primary Care, where we’ll have 3 clinics and 4 clinicians to choose from. We don’t want that to be an issue. If there is an employee that has a primary care doctor that they love and have a great relationship with, they can continue with them. We’ll be here for any urgent needs that come up when they can’t get in to see the primary care that they love.
That’s a very important thing. Somebody having a relationship with you doesn’t preclude them from keeping something that they already have.
If someone loves going to their endocrinologist and it’s something that Dr. Wes can manage, we do not want to get in the way of that relationship. We’ll support the patient in whatever they decide with their healthcare.
Before we wrap up, what would be your best advice for employers considering DPC either for everybody or as an option for their employees?
Reach out to a local DPC and see what they have to offer, see if they have discounted rates for employer groups and what all entails. More employers would be willing to make this change if the awareness was out there. That’s what you’re helping with, Allison so thank you for that. Most DPCs in San Antonio are more than willing to accommodate employer groups and would be willing to take them on.
We’re very fortunate in San Antonio. We have a robust cash-pay medical community. It is not difficult to find cash-pay pricing for imaging. Labs have cash-pay pricing. It’s probably not as good for me, the person, as it is for you, the clinician but it’s much better than insurance pricing. What do you see in your future? Will you continue to expand in San Antonio? Will you grow a little bit outside of San Antonio? Where do you see this going? What do you see happening with the insurance?
You talked a little bit about insurance alternatives. For those of you that are listening, that typically means a health-sharing arrangement. If we’re not going to talk about that now and you have any questions, let me know. Talk about where you see smaller employers going. If you have more than 50 employees, you can’t do a health-sharing arrangement but if you have under 50, you have quite a number of those clients.
We do. In the short future, talking about plans, we are opening up another clinic. We have one in the medical center. We have one downtown, King William and we’re opening up a third clinic in Alamo Heights. I see us growing to more clinics in San Antonio to span the entire city. A great solution for those smaller employer groups is a combination of direct primary care and health sharing. It saves on premiums each month. It saves about 50% and better access to care.
It significantly cuts down on the out-of-pocket cost for the employee. Let me throw that in there. It’s not for everybody but it can be incredibly effective.
The main way that we are getting more employer groups is by word of mouth. That’s how we get more patients too. Getting the word out there, our best advocates are our current patients and employer groups. The more awareness there is out there about us and how we can save people money and get them better healthcare, the further along DPC will be.
The more awareness there is out there about us and how we can save people money and get them better healthcare, the further along DPC will be. Share on XWe’ll wrap it up there. I would leave people to think about how you purchase everything else and healthcare is not everything else but some of those fundamentals can apply. As an employer, I hope you apply them to how you measure your plan performance. As an employee, I hope you measure them in terms of what you pay out of your pocket. Ask a couple of questions and see what remarkable things can happen. Thank you for joining us. We are going to leave it there. We will see you next time.
