 On Saturday, Republica published a story that struck a deep chord in readers across America. We spent months investigating SIGNA and found that the health insurance giant had built a system that allowed SIGNA doctors to almost instantly reject a claim without even opening the patient file. One SIGNA doctor single-handedly rejected 60,000 claims in a single month. Even though health insurers reject about one in seven claims to cover treatment, patients rarely fight back. Christopher McNaughton is one of those rare few who did fight back and he wrote a story about his battle with United Healthcare last month. The ensuing lawsuit uncovered a trove of internal documents that gave ProPublica a behind-the-scenes look at how United Healthcare relentlessly fought to reduce spending on his care, even as profits rose to record levels. We've split today's event into two parts. The first part will feature our reporters talking about these two investigations and what they uncovered. The second part will feature outside experts who will weigh in on our findings and discuss potential changes to the health insurance industry. And now, allow me to introduce you to today's speakers. Patrick Rucker is a senior correspondent for Capitol Forum, covering Wall Street, finance, and the housing industry. Maya Miller is an engagement reporter with ProPublica focused on community-sourced investigations. She's worked on stories about aggressive medical debt collection practices, toxic air pollution, and more. Ron Hauergon is a former SIGNA executive and current president of Fulcrum Strategies, a healthcare consulting firm specializing in payer contract negotiation. Mona Shaw is the senior director of policy and strategy at Community Catalyst, an organization dedicated to building a health system rooted in race, equity, and health justice. Dr. David Rubin is a professor of medicine and chief of gastroenterology, hepatology, and nutrition at the University of Chicago Medicine. And our moderator tonight is ProPublica senior editor, T. Christian Miller. Before I hand it off to T, I just want to note that we've received more than 300 audience questions ahead of time. We won't be able to hit them all, but we're going to try and cover as much ground as possible. And if you'd like to submit a question in today's session, you can do so by clicking the Q&A icon at the bottom of your screen and typing it there. Thanks again for joining us. I'll let T take it from here. Thanks, I want to repeat a conner by thanking you all for showing up in the middle of busy days. This is an important topic, and it's one that really has touched a lot of readers almost everyone has some kind of an experience with the insurance industry, and many of you have probably had denials before when you tried to get paid for medical care. I'll be monitoring today's session. We're going to start off with Patrick Rucker, who is one of the reporters on the story. Patrick, why don't you just give the audience a little bit of a summary of what you guys found in terms of what Cigna does with its denials. Thank you. Essentially, insurance companies private insurance companies that handle claims and decide what care will be paid for what care can go ahead are left in this trusted position, where they decide this care will be paid for we're going to do this surgery this operation or treatment to go ahead. And that process of deciding whether or not the care will be reviewed or will go ahead and how it's reviewed is unseen to the average person and the consumer. But it is a trusted relationship because under the law and certainly the expectation of consumers is that if they're going to look at my decision and whether or not I should get care, certainly they're going to do it, even handily and with like some detachment, and maybe they're even going to look out for my best health interest as my doctor does. The story raised a lot of questions about that process. The most recent story on Saturday, looked at how quickly medical directors that's the name for these doctors who work for the insurance company that are hired to do these reviews. How quickly they are handling the claims reviews so whether or not something will be paid. And we found that they were often handled in less than two seconds. When a doctor looked at this thing decided someone's health impacts whether or not this is a valid whether or not this could go ahead in less than two beats. Obviously just that fact alone just raised our eyebrows and raised a lot of questions for us and so we were asking how could that possibly be that anyone could make up any kind of meaningful determination about healthcare in that period of time. And again, more we found out that there were a handful of medical directors who were turning these things out in in mass in batches is one way to put it just signing off on them in blocks without looking at all at the at the care, or the condition of the patient, and at least one former insurance regulator who you said that doesn't look like what I thought was happening when I was regulating the healthcare industry in California. And, you know, that's where we are right now in terms of what this all means but we, we, you know, we're going to do more follow up reporting with other people believe as many readers do that that is not satisfactory two seconds to decide to claim. Okay, well, let's dig in this a little bit more. Maya, you have some specific examples of what happens and how it goes about putting one of these procedures onto its list of automatic denials. You want to tell folks about that. Yeah, so during the course of our reporting, we came across this presentation that a couple of sigma employees had put together back in 2014 about autonomic nervous system testing, which I'm not a doctor so forgive me for all the doctors on the call if my language is a little murky but the test is generally used to measure nerve damage for people with diabetes or other autoimmune diseases. And what we found is that sigma in this presentation was considering adding this an s testing autonomic nervous system testing to this system in which they would kind of expedite reviews so that they could go to these medical directors in batches for, or go to the medical directors who could then sign off on denials and batches and then according to the presentation kind of gave two reasons for doing this. One was that they thought that for some of the diagnoses that this type of testing is not, was not found to be clinically necessary. And, you know, we did some further reporting on this and we went to signals current coverage policies and we didn't include this level of detail in the story but there were, you know, in signals coverage policy today for this test you'll see that there's about five different diagnoses for which they say they will approve this kind of testing if you write a diagnosis to match it. But for the other ones they say it may be denied as experimental. And what we learned through our reporting is that if this and, you know, when this test was actually added to this list, it, and if it didn't match any of those different diagnoses, it would be slated for this essentially automatic denial. So we did ask a couple of folks who work on this testing doctors who, you know, order these tests and they said that the list of diagnoses and signals covered current coverage policy was missing some, you know, some important diagnoses like Parkinson's for example that this testing is important for. So that was one reason they gave was clinical reasons but again we dug into that a bit more and found some issues with that. And the second reason was savings, which I think Ron will talk about in a little bit more detailed but yeah in the presentation they estimated that if they added this test to the list they could save $2.4 million a year. And so that was, I think the reason that the two reasons sigma gave in this presentation for wanting to add this test to the list. Let me take it to Ron now Ron you've been in and around this business for a very long time. Could you tell us a little bit about how insurance companies view the process of denying a claim. Is it something that saves the money is it something that they're really wanting to do to kind of keep medicine costs down. Just tell us a little bit about how insurance companies look at the Niles. Absolutely. Well I think it's important to understand that sort of the core function of an insurance companies to process claims to process those bills from your doctor's hospitals etc. And their systems are designed to automatically auto adjudicate claims they don't want people involved. So they've got these very elaborate systems that first of all determine is it a claim that I should have as a member. Is it a covered service and they check all of these things. If the claim clears all those things it'll automatically pay. A denial is something that has to pull that claim if you will out of the process to stop an approval. So the point I want to make is it's not like they're approving care approval is the default. The denial is the exception. And what they do is build functionality into their systems to pull things out that they want either review, or in the case of the story and signals case auto deny. Okay. And so they do that because of two things one, as Maya just talked about it saves millions of dollars. Secondly, it's a way for them to keep their product if you will from being a commodity. If all the insurance companies ever did was just auto adjudicate claims that would be very similar they'd be a commodity. So this is one of the ways they differentiate themselves from their competitors. We do this better we save you more money. You know we we have a better process for looking at these things. And so it's a product differentiator that's one of the reasons why they pursue denials. That's interesting. And if it's a product differentiator. Why don't they focus more on sort of approving claims more often than they do. I think it's a couple of reasons. One is the denial is where they save money. Think of this as claims which are revenue for doctors or hospitals are expense for the insurance company or for their employers. The other is a concern about what's called adverse selection. Adversal selection is basically an insurance company getting too many people with certain disease states or chronic illnesses. I'll give you a perfect example. If you suddenly were known to be the easy insurance company to get drugs for an expensive condition like MS. And suddenly it came out on all the chat rooms the internet's a signal base for all the new MS drugs, you're going to attract more people with MS. You can't make money on so that's what they call adverse selection. The flip side of that is if the if the community of, and in this case, MS, people with MS say oh geez, don't join signals horrible to get your meds approved and you'll never get your MRI approved, they'll gravitate to someone else. And that's an extremely profitable situation for insurance companies, because they know that 5% of the population consumes 50% of all the cost. That's very, very interesting and a little bit disheartening to hear. We did a second story last month regarding the case of one particular individual young man named Chris McNaughton, who was denied care for his particular condition, and had to fight that all the way to the court so Patrick do you want to talk a little bit about that case. Christopher McNaughton is in another one light a different narrative but getting to the same issue and the same issue is who is going to decide my care are they thinking about my best interest or what's on their mind really when they're thinking about whether they're going to pay for my care. Christopher McNaughton, as you said was young man he suddenly developed ulcerative colitis, which is a type of an autoimmune disease which is a class of these diseases where the body just sort of turns on itself and attacks its different systems. In this case it was his, his intestines. And so he had chronic health problems that we can, you know, just debilitating put it mildly. And there was expensive to treat. And by the doctor it came up with a way to treat it which was a blend of drugs that worked in together to curtail his illness. And it was working. There wasn't any doubt that it was working this, you know, expert at the Mayo Clinic, one of the most esteemed doctors in his field said, this is demonstrably working for this patient. And in that case United Health Care said, it was run sort of got to this it just the insurance companies and the doctor and the patient are all asking different questions. The doctor and the patient are asking how do I make this person. Well, and the insurance company says is there any way I can not pay or find a pretext to not pay for this person's care. And so the Chris McDonald and his doctor goes to United and says, Hey, this is working surely that counts for something that's what, you know, we must be after, but for United Health Care, their question was, you know, is this under certain guidelines that would be denied. Can we push this through an appeal system that ended up leading to a denial. And so that was just an extraordinary journey of one family that was in the point zero one maybe percent of people that get denied care and fight back smaller and of course would take that all the way to a federal court. And so, but in the course of that work, and in that persistence on the part of the family. A lot of facts and documents popped out of that discovery, audio recordings video. So well yes video recordings deposition, plenty of documents and paper. And so it was in the interest of the family clearly to get all this on the record and goes without saying probably it certainly helped a reporter. To be able to build out a story based on all the facts around the record. And we also grant my I was just to say we also wanted we had a recording actually that Connor was going to play that we pulled from the lawsuit during the discovery. Connor if you want to do it it's a recording of a phone conversation between Chris McNaughton's a nurse at United who was reviewing Chris's case and Dave opperman who also works at United so you'll hear. Dave answering the phone and then a quick back and forth but we just wanted to kind of for those who haven't heard it yet give you an insight into kind of the conversations that can happen behind these cases. Hello, this is Dave. Hi Dave this is Victoria. Sorry to bother you I have some updated news for you though. Okay. So we did get the medical review back from the gastroenterologist and he states that it's not medically necessary treatment. I knew that was coming. I did I did too but I thought maybe they thought something I didn't do because I'm not a doctor. So, you know, I think what stood out to us when we heard that if I don't know if you could make that up but it was Dave was laughing when he heard that it was rejected and, or that they came back and said they weren't going to approve it and this had been medication that had really changed Chris's life and enabled him to, you know, be an active member of society and go to school again and, you know, get off his couch and be able to. And really interact with with people and be out and about and so yeah that kind of, I think that's the kind of thing we're interested in continuing and reporting on is really understanding what's behind the scenes of these denials as they take place. Great. And Ron, why would it. Why would an insurance company like United Healthcare suddenly change regime that had previously approved, and all of a sudden say no Chris this medications work for you. But now we're going to change the rules of the game we're going to give you a different medication try on a different treatment or deny your treatment. What's enough for insurance companies. First of all, this is one of the more frustrating things for physicians, especially with difficult patients like this to get a patient on something that's working, and then have an insurance company say oh we're not going to prove that we're going to do something else. The economic extent incentives are obvious I mean there's the first incentive that a lot of these especially with difficult patients, like the one in the story, they're very expensive treatments. This is not aspirin this is not a statin that they can get for a bucket bill. These are expensive treatments. And so the easiest or most obvious economic is you don't pay that claim, and you avoid an expense. There's also an incentive of part of what they're selling to their self funded employer groups is this concept of medical management we're looking out for your money we have this responsibility to look at your expense item. We're showing these employers that look what we're doing for you there was this expensive treatment that we denied. And then the last one is what I talked about earlier is the last thing that any insurance company wants to do is attract a whole lot more patients like Chris, who are very difficult we're going to have ongoing clinical needs etc and so if you're the sort of the pushover insurance company that always pays this stuff. You know, more people that have conditions like Chris's are going to then flock to that insurance company and that's, they call that the death spiral, and that's a quick way to have your stock price go down and your earnings drop. Wow, I know insurance companies worry about their own death spiral. That's a real insight. Maya, do you want to talk about the call house we've made because it's for those of you in the audience per public I really like to reach out to its community and its audience to help us tell these stories. And often the best information we get is from folks like you reaching out to us to tell give us the insider's view of what's happening. Yeah, for sure. And thank you all for coming in for all for all of you who have already written into us thank you so much we've been reading everything that you've been writing in and it's been really helpful in guiding our reporting. Chris is Chris McNaughton's case actually came in through a tip. We put out a call out that Connor just dropped in the chat if you haven't seen yet. I'd encourage you to open it. And his lawyer had actually saw that we had put that out there and encourage Chris to reach out to us and that's really what enabled us to get this information out there more publicly for people to understand. What's going on behind the scenes and so yeah if you have a minute now or later today or if you know somebody who has worked in insurance, or is currently working in insurance. Please feel free to send them the link and we read everything that comes in. And it helps guide our reporting and you might hear from me Patrick or our colleague David as well. You know, if you all write something in. A lot of our servers do come from just those kind of tips and write ins and one of the jobs reporter is to kind of try to find out what's happening and that's made much easier if we're talking to people who've actually lived and gone through that experience so I do encourage folks to fill out that form. Ron going back to you so I get my denial from the insurance company what is the best way to go about appealing that denial. Two things. First of all, read the denial very carefully. This is a communication that's going to be written by insurance company lawyers. For obvious reasons, and it's not going to be really easy to read but you need to read it thoroughly in that denial. We'll talk about your appeal rights, how to appeal in what timeframe you have to appeal, what information that needs to be provided you need to follow those steps and follow them very detailed. And then you want to do is miss one of those steps and give them another reason not to want to hear your appeal. So again, read the denial and then follow the steps and try to do it quickly and thoroughly, make sure all your T's across demise or dotted. And is there any kind of a time limit or statute of limitations on filing an appeal. There is, but it's very specific to what state you're in, who your employer is whether that's fully insured or self insured whether it's covered by federal. And that's why I say there isn't a universal where you must do this with an X, it will be in the denial they have to give you that information the denial they have to give you those time frame so follow that. So don't trust that you're, you know your neighbor said oh I had 90 days to appeal mine, you may only have 60, depending on either because of a different employer different state etc. So look at that to now and follow that statute of limitations if you will that's in that denial. Right. So, Maya, if you are a person who's been denied. So what you can do to find out more information about the reasoning behind it or what the insurance company is as saying and as their reason is for issuing your denial. Yeah, so there's a law that generally applies to all health insurance plans and we'll be sure to send this out in the follow up email to the event. But if you have been denied, you can actually request request your claim file from the insurance company. I'm trying to focus more about this in the next couple weeks as well as we keep reporting on it but you can see the documents that the notes other things that the insurance plan has written up about your, your claim and why it was denied and this can be, you know from lawyers that I've spoken to, they said this can be really helpful information as patients are trying to appeal the denial. It provides some good insight into what's actually happening behind the scenes and what people are saying about why your claim is denied and what process it went through. Yeah. And we really encourage folks to kind of share with us that information because again the only way we have to kind of get behind the scenes. Obviously, we're not going to put anything out on the internet or anything like that. But we those documents really help reporters, as well as other people in terms of finding out what is going on, like why this insurance company issuing these denials. So a report is always like documents. So those are the kind of documents that we would really help us along in our trying to uncover the inside story of the insurance industry. And that no Patrick like it is very difficult as a reporter to kind of penetrate this veil of secrecy and surrounds the functioning of insurance companies and what they do and don't do. Can you talk to us a little bit about that and how you as a reporter how did you guys report out the story. It's suffice to say there's, and it's hard this is, despite the corporate bottom line profit seeking element to this. This is at the end of the day people's health and well being that's on the line. And the idea that a company would be mucking around with the, the rules of the care in a way that could lead to harm did not sit well with with a lot of people that are in this in this business. And so we spent a lot of time trying to track them down and see if they were willing to talk to us share the insights they had. People move in and out of this space as well like physicians that had been in a clinical setting then maybe spend a little bit of time reviewing claims, find they don't like that they want to get out of that business and do something else. So there's enough people that have, you know, varying degrees of expertise or have some contact with the system. It's just too vast a system not to have people come in and out of it that we, that we track down. And Ron, we have a question from our audience here. If you wanted to make a complaint about the specific medical director who signed off on your denial that information provided. Can you make a complaint against that medical director who is a doctor, often in a state where they are licensed. Sort of. Most people when they think about a complaint against a doctor, you know, they think of either complaining to the medical board which you can, or complaint being a suit of malpractice. The medical directors for insurance companies are almost universally immune from this concept of malpractice. And their defense to that is, we're not saying what care you can have or should have we're just saying whether or not we're going to pay for it. That wonderful get out of jail free card on I see you can have that test I'm just saying we're not going to pay for it. But yeah, you can file a complaint to the medical boards. I'm not aware of any situation where an insurance company medical director had any sanctions or lost their license from the medical board because of their work involved with an insurance company. And just in general, who is responsible for regulating insurance companies can give us a little bit of an overview there of, if I'm somebody who's upset about the story or who's concerned about my own denial who do I go to to file a complaint normally who oversees the insurance Well the insurance companies are really oversaw in two different ways one they're they're over there's oversight by the State Department of Insurance, every state has that function whether it's State Department of Insurance Department of Corporation something that But what people need to understand is they really only have per view over what the insurance companies call fully insured which is usually small employer group. For most of the companies like Signet and United etc. That's about a third of all the people they cover the other two thirds are covered by a self insured or an ERISA plan. That doesn't fall largely under the state regulation that falls under federal ERISA legislation. So a lot of people get frustrated because they say why my state has a law that says you have to do X. Well that may not apply to you if you work for a large self funded employer. So that's one of the other difficulties is finding out who the regulator is new plane to And is there anywhere you can go to look up insurance companies denial rates. Not that I'm aware of a lot of the internal workings are considered by the insurance companies to be proprietary and confidential trade secrets etc so very little of that data of their internal workings ever gets reported either to State Department of Insurance or the federal government. So it really isn't an industry that has some regulation but it's limited in what they can actually do. So it has some regulation and very limited what they do and most people understand they're also exempted from almost every bit of antitrust law insurance companies a long time ago got exempted from Sherman antitrust act so they can't even really be brought up on collusion or or antitrust violations. And Patrick you've done some of this work in terms of are the insurance companies getting bigger and bigger. I mean, you can see I'm sure a lot of consumers have seen this themselves it's you know who is selling the drug who is controlling the, the insurance policy who's doing the review. So that's more and more becoming the same organization might be different names, but signal for instance owns prescription distribution distribution systems, as well as even medical review systems overview their their claims overview claims for other companies. The economies of scale applied to this as well as anything and unless something stands in the way they're going to meaning a lawmaker or law or court or something. There's always an impulse to try to get as much under the same umbrella as they can. So they can basically kind of just grow and grow and get bigger and bigger and they've got no worries. The commission, of course, has injustice department any trust runs remarks not understanding that's the course true but the mergers do still have to and some have been either the companies walk away due to exhaustion and courts telling they can't do it. So, there are some checks there, but just look in the last 10 years of concentration I don't think anyone would say there's very much standing in the way of these companies controlling more parts of the medical apparatus. And my another question for you before we move on to our other speakers, just give us a flavor of some of the things that we've heard from folks writing in like what is there. What are the concerns one of the most common things that we're hearing. So, we've been hearing, you know, for six, seven months now about a host of issues surrounding denials. We've heard some themes, for example, imaging and scan seems to be something that a lot of people experienced in Niles and so we've heard, you know, specific categories of types of claims that get denied often. We've seen kind of the fallout that it has had, both, you know, for people's physical health but also the mental health exhaustion of having to, you know, battle your insurer day in day out to get treatment for yourself that your healthcare provider is saying is necessary and that you feel is important. You know, a lot of people talk about just being on the phone for hours and hours and some people aren't even able to do that so they have to give up and just go without that treatment that they think will be helpful. And then, yeah, since we've published, you know, the signal story on Saturday we've heard a lot of people asking questions and I'm seeing them in the Q&A as well of, you know, is this legal like, you know, what's what's going on here, like how can this be allowed to happen and so, you know, those are questions that we're posing to regulators and lawmakers right now as well. But yeah I think this is, you know, we're eager to continue recording and really going behind the scenes of what's happening, what when these claims are denied so we can try to answer some of those questions and be responsive to what folks are telling us. If I can just say one thing, I mean, for those who are listening, we are still doing a lot of reporting and want to hear from insiders, people that have sat in front of stacks of paper that have these claims that I also said in on meetings where things were said that were disquieting because, you know, didn't sit well, frankly, we are all ears and we want to hear from people who have been inside where these decisions get made. Yeah, these stories have struck a chord, I think in part because so many people are just so frustrated with the industry and what they're seeing. I'm sure there's plenty of satisfied customers out there, obviously, but from the tweets and the messages and everything I've gotten that we've gotten this story has really had a lot of pickup and I think that's indication of how much people are always fighting and getting frustrated by what's happening in terms of their health care and the insurance company is paying for their health care. So I think now that we'll move on to our other guests. I believe Connor is going to give us some introductions and then we'll move on from them. Thank you very much, Patrick and Maya for the reporting you guys did and for talking to us about it. Yeah, we'd like to welcome back Mona Shaw and Dr. David Rubin and just to reintroduce them really quick, Mona Shaw is the senior director of policy and strategy, a community catalyst. It's an organization dedicated to building a health system rooted in race equity and health justice. And Dr. David Rubin is a professor of medicine and chief of gastroenterology, hepatology and nutrition at the University of Chicago medicine. Thanks guys for appearing here with us to discuss this issue. Ron, I'd like to ask you a kickoff question because we're going to be talking now about a little bit more about what you can do to to get an appeal and get your health care that you paid for approved by your health insurance company. So we're talking about medical necessity, Ron, who determines what is medically necessary and not medically not medically necessary, who actually makes that determination is that something the federal government sets out as a local state ordinance is something insurance companies determine like who makes the decision. There's really two parts to that so first of all, every state has a in their laws in their regulations a definition of medical necessity, and every state that I've ever seen that definition includes something to the effect of within generally accepted medical care in the community. That's a fairly common standard. There's been some federal lawsuits, etc, where the 1990 in Florida, where all the insurance companies at a federal level for the ERISA plans agreed to a common definition of medical necessity. The problem isn't with the definition of medical necessity. The problem with who decides what is within that common medical community practice and that's where we get to the insurance companies and their medical directors who have an incredible amount of gratitude to determine that this is not within community standards. And one of the real problems for that and problems for physicians and I know Dr Rubin probably sees this all the time is one carrier would say this is not within community standards and another carrier would say it is and Medicare might say something completely different. And so the physicians who are practicing and really have this horrible time of trying to guess when something is going to be covered, because they really don't know because someone somewhere else is going to decide for them. If I could add to that. Yeah, that's a perfect segue to Dr Rubin. Dr Rubin. So first of all, let me thank ProPublica and my colleagues who are appearing to discuss this today, but also all the listeners and viewers who are putting in the questions that I was scanning before I had the opportunity to speak. My specialty is actually inflammatory bowel disease. So the story that ProPublica broke on Chris and his experience with ulcerative colitis is relevant to something that my team and I and my colleagues around the world and specifically in the United States deal with all the time. But relevant to the question asked here. One of the challenges we face is that the liability for care of patients falls to the provider, the physician, or the expert nurse or whomever is delivering care. Insurance companies are indemnified from bad outcomes in many cases because they'll say, we didn't say you can't get the test or the treatment. We just said we're not going to pay for it. And that's a problem because we all know that most of the things we'd like to have our patients receive are unaffordable for any normal person. So for all intents and purposes, they are in fact denying access to things that people need to have an appropriate diagnosis or management of a complex condition. So my comment here about that goes to the issue of what standard of care. And one of the denial claims that often comes across our desks and I'm sure many people who are viewing this and others will relate to is when they call something experimental, or they say that you have to do something else before you can be considered for this particular test or treatment, the so-called step therapy or step approach to management. And these things lead to consequences. So I've been public in over the years about this. I think that insurance companies recognizing their conflicts of interest regarding fiduciary responsibility to their shareholders and their other challenges of literally delivering care to the greatest number in the way that they can can actually still be cost effective if they incorporate standard of practice. If they look for outcomes that are measurable that will save them money. And if they actually use some of the profits that they continue to make on a quarterly basis by dialing up the cost of premiums to invest in actually learning what the standard of practice should be in the ways to measure effective care and know how to do this properly. And I've said that many times and I believe that there is a way forward, even recognizing their conflicts. And the only other point I'll make without belaboring this is that we haven't talked yet about the pharmaceutical companies and the costs of therapies, which continue to go up dramatically even even old treatments that have been around for many, many years. And the costs go up because they can. And then what happens is people charge more because they only get a percentage of it. And it's a completely broken system that we all acknowledge. And so I'm hopeful that ProPublica will also turn their eye to some of the costs for these therapies as well. And some of the challenges that we've faced because they've been priced out of range for most of us, including insurance companies. We'll take that as a tip. Thank you. Mona. So you're in the policy realm. What kind of things can we do? First of all, maybe you could talk to us a little bit about the protections that consumers have now. And then maybe you can talk to us about what are some of the things that are on the table that can improve the regulation of insurance companies. Absolutely. And so, you know, just to put this a little bit in context, and I think some of the previous panelists mentioned this, you know, just earlier this year Kaiser Family Foundation actually looked at a lot of the healthcare.gov marketplace plans and looked at the number of denials and found that actually consumers appealed less than two tenths of 1% of denied in network claims. And so certainly one opportunity is just creating awareness for consumers that they have a right to actually file a complaint and also appeal their denial. The federal government also through the Affordable Care Act, you know, established a consumer assistance program. So a lot of states have their advocates and consumer assistance individuals who can, you know, we talk about how overwhelming it can be how a lot of people have time and resources to fight these things. So certainly tap into that. And then, you know, there's different avenues. So there's actually a bill that was introduced last Congress that hasn't been reintroduced this Congress yet, but mindful of certain practices like certain insurance plans that when you appeal, you have to go through an arbitration process and you're not allowed to file a class action lawsuit, depending on the type of plan you have or you're not allowed to file a lawsuit period. And so, you know, opening up some of those channels that individuals do have access to is really important. But also, you know, if you have a private or marketplace plan, you can file a complaint with your state insurance regulatory body. Usually that's the Department of Insurance or insurance commissioners, officers, states that have their own state based marketplaces, you can file a complaint directly with that state run marketplace. If you have Medicaid, you can file it with the state Medicaid plan. And then also you can also leverage your attorney general not to go too much into the weeds, but there are a lot of federal parody laws around mental health parody. And it's actually the state attorney general who's tasked with primarily enforcing that. And so, you know, I just want to basically create awareness there are a lot of different channels that individuals can use at the moment to file the complaints, the more complaints that are heard, the more likely there's going to be some action. And Mona, could you speak a little bit more about that? Like what can I expect if I file appeal? Can I suddenly expect somebody to magically waive a wand and they'll pay for my care? What do I look forward to when I file an appeal? So, I think maybe Ron can speak to this a little bit more than I can because I'm focused more on the higher level policy. But, you know, I will share that one of the findings that came out of this Kaiser report was that insurers do uphold the majority of these appeals. They found that about 59% of the appeals were upheld. So, you know, I think the next case, if you are allowed to file that lawsuit is to move forward and filing that lawsuit. So one lesson here might be that if you have an appeal, you should make it. Yes, absolutely. If I could just make a comment, Mona, those are extremely helpful points. In the practice of doing this, it's a war of attrition. In other words, they count on people not appealing and giving up. And I'll also say that while we're trying to appeal and while we're waiting for decisions, the patients continuing to suffer and getting sick or having complications that cost everyone more money. And it's a big challenge that we face. We did an analysis here of our patients with Crohn's disease and ulcerative colitis who are getting advanced therapies. And we found that the time to decision, first decision before appeal was longer when there was going to be a denial than when it was approved. In other words, the negative result of saying we're not going to cover this took longer to find out while the patient was suffering and then we had to start the appeal, which then took longer still. And so there also needs to be accountability and some policy as well as regulation regarding the amount of time necessary. And we found that even when there are policies that individual insurance companies have, they don't necessarily follow them. I have a patient who got a letter that said she had 14 days to make an appeal from the date of the letter, but the letter arrived after the 14 days had passed already. And it's those types of things, those little details that get everyone caught up and then patients don't get what they need and we're continuing to struggle and fight. I'm fortunate to have a great team working around me here, but my colleagues in other places don't have all those resources. And certainly the patients on the other end who are trying to make sense of these letters they get in the mail and trying to navigate are incredibly complicated and broken healthcare system. Don't even know where to turn. It's really a very difficult problem. And when you're taking care of an individual patient in an exam room and looking at that one person and trying to help them. You realize that that without the right resources, the right physician, the right team logging in to see this discussion. You don't even know where to turn for most people in our country and it's really a problem. Let me follow up with you for a little bit more, Dr. Ruben. What does it look like from a physician's eye view when you get a denial and especially I'm interested to hear about a term that some folks might know called peer to peer reviews. So if you could take a show like what does it look like to a physician what do you guys have to do if an insurer is turning down care that you believe is medically necessary. Let's start with the fact that not all denials are wrong. Okay, some denials are appropriate and they exist for a reason. So we shouldn't say that every time something's denied it was the wrong decision. I just want to acknowledge that that some of these are appropriate when there's something that's not necessarily indicated or there's another issue. When you get a denial and you appeal, it used to be that we could request so called peer to peer discussion. And the challenge to that was that we noticed over the years that the person we would have on the other end of the phone was not in our specialty, let alone an expert in this particular disease. I understand that that can happen. And most of those individuals when you got on the phone were reasonable, you could discuss what your what your expertise was and why this might be relevant. And you would finish the call and they would often say, I understand this is approved, and you'd be done, and you get a number and you'd be finished. What I just started seeing was that the individual who would take the call would say, yes, I'm a physician I'm not in your specialty. My job is to tell you how to appeal through the usual process of writing. And they have no authority to actually approve the request or the appeal. So they're just there to satisfy some policy or some status that they have that you're talking to another physician or appear, but they had no authority to make override decisions. And most of the insurance companies that we deal with, don't even allow that you don't even have the option of speaking to someone who's a peer, or who's a physician or who's even at the right level to make decisions and override it, because it's become so automated. It's showing your recent article that you have published. While you're reading the article it's showing you how many denials are occurring by the second, because of how fast some of these are being turned over by SIGNA, and I'm sure others that it just doesn't even give you the option anymore. So there's nowhere to turn except to fight back in paper, and to wait, and to try to figure out what else you can do for your patient who on the other end of this is suffering in some way. And picking up with what Dr. Rubin just said at the beginning, Ron, I can see an insurance company coming back to you and saying exactly that these denials are necessary. We can't approve experimental treatments, we can't approve treatments that are for unapproved things. How do you respond like an insurance company which would say denials are actually an ordinary part of this process that help everyone save money, to help keep health care costs in general down, they reduce administrative fees. What's the response to that? You know, I think much like Dr. Rubin said, every physician that I talked to understands that there are definitely in any profession, there are bad actors and there are definitely requests for things that truly aren't indicated. And whether those are because the physician doesn't understand what they're requesting or they're just trying to help their patient or whatever. So I would agree with Dr. Rubin, there are appropriate denials. There are things that insurance companies employers shouldn't pay for because they don't have clinical value. The challenge becomes the scenario, but what about all of those denials that aren't valid in all the cases we hear about, etc., and the fact that then there's a patient suffering because they're not getting what they need. That's where the real challenge is. And most of the physicians that I talked to aren't really, don't have a problem with the insurance company doing that review. They just want the review to be logical, fact-based, based on clinical data. And for those things that don't fit the obvious, this is the clinical approach. This is the right approach. Having that peer-to-peer discussion with somebody who can say, you know, that Dr. Rubin would say, this is what I'm seeing. This is why I do this. Now tell me why you think that isn't the right thing to do. Almost every physician that I work with or talk to almost yearns for that. They want to be better. If they're doing something that isn't the best approach clinically, they want to know about it. They want to get that next study. That's where it comes. They just don't have that opportunity. And they view it as, and I think rightfully so, is just a monetary denial, not a true what's best for the patient denial. But it's a fallacy that they're saving money. If they actually looked at the downstream costs of some of these denials where there's delay in care or there's an adverse outcome because of a treatment that's been withheld. Or you look at indirect costs which are never calculated by the insurance companies of absenteeism or inability to go to work and then dealing with the illness and time at the doctor, etc. And that can always add up in different ways, but for the most part in the US they've calculated that many people will move on to another insurance company or go on public aid before they'll actually need to file those complex downstream costs. I would add one more point to the list of what we want, which is a timely decision. We don't want to be waiting and waiting. And I would suggest that I've said this publicly that insurance companies can make money and deliver better care. If they translate some of their profits into better public and customer service. And if they actually worked with experts to make sure that they're up to date on how to do this better and to know if therapy is working or not in a timely manner so you can move on or keep it going. As well as have more transparency over why one treatment is preferred over another, because we also know that the pharmacy benefit managers behind the scenes and the rebates that are being offered by the pharmaceutical companies. End up with why certain things are considered first line or not and not necessarily what might be best for the individual patients or this particular disease state. And it's a big challenge that we face and we've offered many times to help with this across our specialty. And they've not taken us up on it so you're left with companies that copy and paste policies out of one disease state into another just because the drugs are similar. Or don't stay up to date at all. The term experimental is used, which is wrong. It gives the wrong message to the patient and a lot of times that's not even the right term is just the term they use as an excuse to deny something. And so there's all sorts of low hanging fruit here that could improve care and the delivery of care and still make insurance companies profitable if that's where they need to be, but deliver it in a much better way better stewardship of resources that are currently available could easily be done if they invested properly. Interesting. And Mona, can you sort of pick up from there and talk about in your view like what kind of reforms do we need to make if any to like the Affordable Care Act or any other areas of medical law that governs insurance health insurance. Yeah, there's, you know, there's three pieces that community houses focused on right now. So the first one is strengthening this essential health benefits. So those are 10 categories of care that were included in the Affordable Care Act of the buckets that ensures are required to cover through different types of health plans but it affects about 50 million individuals in the United States. And what we found is that every state has to choose a benchmark plan. So it's kind of the basic plan of everything that needs to be covered, but there are a lot of inconsistencies around this and the actual kind of regulations around essential health benefits hasn't been revisited in 13 years, you know, since the Affordable Care Act was actually passed. And you know, there's a lot of evidence that there are things that are supposed to be covered. A lot of attention was given recently to contraception coverage and a lot of insurance companies just denying methods of contraception that should have been covered under the preventive care bucket for example. So we're actually, you know, working with HHS at the moment to encourage them to reopen kind of their process for evaluating essential health benefits. And ideally we would like to both see what is considered essential health benefits right now dental care vision care that's not even considered an essential health benefit. And then also just having more consistency and you know, we were talking a lot today about transparency and data. But there's a lot of denied claims, especially in the mental health and behavioral health space, or they cap, you know, the amount of visits for example we all know that there's a mental health crisis going on. And so, you know, we just need better standardization in terms of the description of benefits for those plans. And also just, you know, again, more of that data. The other piece is that, you know, the Affordable Care Act did actually try to have more reporting so they did have some requirements around claims payment policies and practices. Plans were supposed to report on the data on the number of claims that are denied specifically, you know, CMS has a requirement to insurers to report the reasons for denying those claims at the plan level. And then they actually gave the Secretary of HHS broad authority kind of other information as determined appropriate, but you know today, this authority hasn't really been fully implemented. And a lot of the data to answer these questions isn't actually collected by the plans. It's not always audited and insurers aren't reporting the data consistently. So there is a lot of space and leverage really that the federal government has the authority to have right now that they're not necessarily doing. And then the third piece is something we're focused on, you know, Dr. Rubin had mentioned, well, you can still get the care. But now you're paying for it out of pocket. And what does that lead to that leads to medical debt. And so there is a huge medical debt crisis. A lot of that based on, you know, part of it is not having insurance or affordable insurance to begin with. And then even if you have insurance, what we're all finding out is that it can still be unaffordable. And so we're trying to work with the IRS and another agency, the CFBP to make some changes to bolster financial systems policies for patients so that when they walk into a nonprofit hospital, they're more aware of their rights as patients about different avenues that could be helpful. So even if they don't have coverage or they have coverage but that care has been denied, there are just other options available to them. So they're not going into medical debt, you know, trying to combat some of the collection practices, what can be reported on your credit score around medical debt. So there is a lot of policy opportunity there as well. And we just go back for a second to the issue of what insurance companies are required to disclose is the the agencies that are in charge of that, whether it's HHS or whoever. Why haven't they cracked down on insurance agencies to make them deliver more of this information that could allow more consumer awareness. That's a good question and we're trying to figure that out. You know, I think part of it is it's a resource issue, but also it's, it's again the inconsistency. So kind of how are you able to, you know, capture trends and themes, you know, when the data isn't all presented in the same way. So having kind of more standardized ways to collect that too. Dr. Rubin, what would you tell a colleague about how to prepare a request for payment from insurance company in a way that would would result in the patient not being denied payment for that claim. Well, this comes up often and we actually discuss this frequently with our colleagues. You don't want to make simple mistakes. So first of all, if you're ordering a diagnostic test or if you're ordering medical therapy, you should be sure to know what the appropriate indications are to document what that is in your request, rather than asking for the test and leaving things out. And in your notes to make sure you're adequately describing why it's indicated. That's all basic but a lot of times it gets lost in translation and then when you leave that off it's an easy denial right out of the gate. For example, if we're prescribing a therapy that's for moderate to severe ulcerative colitis like the story ran about poor Chris's situation. You want to make sure you say this patient has moderate to severe ulcerative colitis and this is a therapy that's required or needed and these are the therapies that didn't work and just documenting the basics. That actually deals with a lot of the easy things that insurance companies will deny out of the gate that are potentially legitimate for lack of documentation you just don't want to be dinged on those. Then when it gets to more complex issues you got to make sure that you go the extra step to say this is indicated because an x-ray wouldn't be as sensitive as an MRI and we need the MRI because an x-ray was done two years ago and didn't show what we need, or whatever it's going to be so you're anticipating some of those things. The extra seconds you take to document that properly will save you a lot of heartache and troubles down the road when you're trying to appeal and getting into that black hole of communication. Right, Ron turn it back to you so one of our audience members wrote in that their spouse who got a cancer diagnosis in February and was denied and denied and denied gone through a lengthy appeal process. Is there a point where you can see damages from an insurance company for delaying treatment and more broadly speaking kind of medical director at all be sort of directly sanctioned for decisions that are not to be wrong. So, first of all, I mean, these are the kind of stories that I think we all hate I mean, you're already dealing with a cancer diagnosis and the worst possible time to also be dealing with these financial denials, and all this care denial stuff I mean that's that's really, you know, something that we all hate to see happens way too often. There have been situations where patients have successfully gone after insurance companies for these kind of denial things I mean once I'm aware of there's one and you know it blew across a Delaware and and about denying cardiac scans there was a case famous case just happened much longer ago against admin California were actually, there was a medical director that was deposed and in the deposition center I don't ever look at medical records. And you know I just I just signed these things and they settled that case on a court. The problem for people, especially at the time when they're dealing with this when they're dealing with so many other things is it's it's sort of like that old adage of, you know, yes you can strangle a porcupine it just hurts like hell. It's so hard. You know these are large, massive corporations that have more lawyers than you have people. They're so good at defending what they do. So theoretically, can you yes and there are been a few successful cases. Is it really an option for sort of the average person, not really. It really isn't and that's one of the problems we have here. I completely agree. And I think that as I said earlier I want to say again that when they say that we're not telling you can't get the treatment, we're just telling you we're not going to pay for it. The cost of care in the US essentially means that when the insurance company says no, you can't get the care. That's just the reality of what exists now in our system. And so I think it's a matter of time for someone to sort that out and take that to a higher level court to actually help us understand who's responsible in these situations. But when you have insurance companies that are reporting, literally billion dollar profits, quarterly, despite the downturn in the economy or anything else, or the arrival of biosimilar therapies which are supposed to drive down costs of care. Yet we don't see changes in access or changes in premiums of the people who are getting the therapies. I understand the competitive marketplace of the US system, but I do think that there's a way forward that can help hold people accountable and provide more people with the care they need and try to address these issues. Yeah, and one one last quick point. When Dr Rubin signed something he takes responsibility, whether that's a prescription and order a chart note. You know he's signing his name, either, you know, electronically or pen and he's taking responsibility for it happens. When a medical director at an insurance company signs a denial there's no responsibility. They can't be held responsible for it they can't be held under malpractice, they're not going to be sued individually, etc. So that's one of the problems that I have significantly in this is, you know, one of the things I like about practice medicine one of the things I respect about physicians is they do take responsibility. They know that that signature means that they're going to be held responsible for it, except in this version of a medical director signing a denial, which has zero responsibility. And do you have any sense Ron about whether the practice that we outlined with SIGNA is more as more widespread in the industry do you have any sense of whether other insurers are kind of denying claims really quickly without ever doing any kind of in depth review of a patient's condition or file. Absolutely. I mean it just, the numbers don't work when you realize how many denials happen. There is absolutely no way that they employ enough or spend enough money on medical directors to actually do any sort of meaning for review on all of them. Now, and, and I will say, there are definitely medical directors doing review that actually dive deep into the end of the chart notes etc those tend to be very expensive, you know, complex cases transplants etc. I think they never review the chart, but you can't deny that many claims and insurance company and not do it sort of in an automated way with physicians just sort of signing at the bottom line. They all have nurses that oftentimes prep these cases before the doctor even sees it. And again that's again one of the problems I have is that doctor signing their name but with no responsibility and never having actually looked through it or even know what's done with that with that patient so yeah it happens throughout the industry signals and the only one that does that. And there's been no attempt so far to acknowledge expertise either. I certainly don't want to funnel everybody down to the level of needing experts for everything. There are certain practitioners who know standard of practice and who have not made errors in their prescribing. And for the most part when they ask for specific available FDA approved therapies that are on label are doing so properly and they could make this a more efficient process and eliminate some of this so that the time could be spent on the more complicated cases, or the requests that are not typical. There's been no effort to do that in any way that makes sense. It's there are, you know, just to jump in, you know again bringing it back to the policy level there's some states that are trying to do some interesting things so in California, for example, about two years ago, again, mental health services tends to be one of the most frequently denied types of health care. So they actually developed a law where insurance companies are no longer allowed to use their own internal guidelines, and they had a group of nonprofit organizations develop guidelines. There's still issues a lot of the plans aren't adhering to those guidelines, but that's one step of, you know, trying to bring some of these decisions around medical necessity and other things, and having plans adhered to those rather than make up their own so to speak. And what are you talking about that's kind of an accountability effort are there kind of wider efforts to bring more accountability to the whole system. I think it's, you know, primarily around the, you know, I think we think the authority exists right, but really pushing to make sure that all of this data is being reported. So, and then also we're keeping an eye on certain court cases. You know, there's one called the Tilevsky case right now in front of the Supreme Court. That really would affect individuals right to appeal decision under Medicaid, which is, you know, a federal and state funded program. So there's, there are a lot of different things happening, I would say in the courts as well. So I think we're keeping an eye on to make sure that people maintain that right to appeal and I mentioned this earlier but the more that people appeal and file complaints the more that this information can really come to late and then the more that the federal government really uses the authority that has to collect all of this denial information. That's proven right now, when you go, are there any kind of regulations that all the governor that govern peer to peer discussions, like is there any kind of standards that the insurers have to meet in providing a peer to peer conversation. There are any I don't know about them. I would say to you that I doubt there are I've never had any proactive communication from any insurance company. So we just all of a sudden one day they were, they weren't there anymore, you would ask for peer to peer and they say sorry we don't offer that. And that was it. So, I don't know if Mona knows more than I do Iran but I am not aware of any actual laws that govern them. Ron, let me ask you do you are you aware of any kind of laws that govern any kind of part of the procedural issues that insurance companies health insurance companies have with their patients. Because there anything that they have to do to deal with a patient denial. As we talked about before the appeal process you know you can send them this appeal, etc. But I'm not aware of any law that demands or or requires a peer to peer review let alone a peer to peer review that for the physician would consider to be a peer somebody who understands this specialty and the most current clinical thinking around it. Okay, let me let me bring you back to issue you raised earlier about the pharmacy costs going up. Can you talk to us a little bit about how that affects approval denial claims. Well, obviously, if the, I don't want to oversimplify but if therapies were less expensive or actually cheap. There could be these policies and these denials that exist to try to save money. They're not. Unfortunately, the primary motive of these denials and the decisions by the insurance company is to manage their finances and to balance their books, not to deliver the best care. I'm sure some in the insurance agency and industry would take issue with me saying that, but that's the way it appears to all who are dealing with this on a daily basis and we have to acknowledge that that is real. And I would just say to you that the cost of care as therapies have gone up in complexity, and in the R&D that leads to a new treatment being approved which we acknowledge is a big investment is what's driving some of these big problems. As I mentioned earlier, even older therapies like insulin or Epi pens, or even some of the old fashioned suppositories we sometimes need for our patients. None of these are new, but their costs have gone through the roof, and so have denials of basic things that we used to be able to get our patients all the time. And so there's a lot of challenges here and it's being driven by profit motives, unfortunately. I don't think it's a supply and demand issue as much as it's about we can charge more, therefore we will. So, so, so other than sort of like getting costs down. Is there nothing else we can do about insurance companies kind of acting in their economic interests before a patient's interest. I think this is part of that process I appreciate what you're doing to have this conversation I appreciate the work that Mona's doing I think there's a lot of people who are trying to address this and I honestly to be fair. I'm sure there are good people in the insurance and agencies and industry that are trying to do good things. There are meetings and discussions and round tables with insurance managers, their concepts and their mission and their ideas of how to manage are very much different than what a physician who's at the, who's on the front lines is dealing with. That doesn't mean they're all wrong, but it starts with this issue of even having a communication with them about how can we do things better or what would be easier for everyone involved. There's a disconnect because they think about it very differently. They're not interested in the latest guidelines, necessarily, they're interested in how do we take what is a limited resource in their mind, the amount of money they have, and the amount of requests they're getting for very, very expensive therapies and try to make it the end of the day to make the numbers add up. I get that. So there's a big divide between these goals. And that's a big problem that we have to continue to struggle and figure out. I saw multiple people in the comments during this program saying maybe we should be reevaluating a single payer system and a different way to manage all this. This comes up. It's the perennial question and it's worth having an ongoing conversation about it. Probably not something that's going to happen soon, but it's certainly one way to continue discussing this issue and Mona's nodding. So maybe she has more to say about that. Well, I just, you know, I want to add. Part of it, part of the challenge is the complexity of the health insurance system that we have. And so even when you talk about the different government agencies and who has the authority, you know, outside of HHS, you know, there's a lot of labor for the employer-sponsored plans. There's the Treasury Department. You know, there's HIPAA laws. There's a risk of laws. And so that almost makes it easier for, you know, some of these health insurance companies to do what they're doing. You know, last year there was a lot of attention that was placed on Medicare Advantage organizations and kind of their denial based on prior authorization. And there are a few bills that were introduced as a result of that. But again, you know, Medicare and Medicaid also to different health insurance plans. And so I think if there is a way to, you know, streamline things and have the requirements honestly be the same across the board. Because right now there are not, you know, even with the Affordable Care Act, you know, it applied to non-grant and frothered plans, marketplace plans, small group insurance, large group insurance, you know, a true policy one can really get into the weeds with you. And I think that's one of the biggest challenges is not, you know, really understanding your rights as a consumer because the type of insurance plan you have really matters in terms of what they have to do. A lot of private payers look to the to Medicare to guide their changes in policy and coverage. And so certainly that would be a helpful place to continue focusing efforts. So we're drawing close to the end here as a final question. A little bit of an artifice here. I like for each of you, could you name like one the one most important thing that we could do to improve health insurance companies approval rates to make sure that more people get more care paid for. What's the one what's one top thing we could do. Ron, I'll start with you. First of all, I think I think it'd be great if we had one set of coverage policies, a national set of coverage policies, not decided by insurance companies decided by, you know, an extra on T you could take a representative from every medical specialty, you know, the American College of cardiology, etc. That's the coverage policy people shouldn't get a test, because they have this insurance and somebody else with the same presentation not get it to have a different insurance. So once you've got that one set of coverage policies, much like if you will, how we've got, you know, OSHA looking at workplace safety to make sure people are safe. Have a government to overseas that if they violate if the insurance company violates that coverage policy, just like if an employer creates an unsafe work environment there's penalties for it. There's consequences to me that would be a wonderful first step in helping solve this problem. Yeah, so, you know, very similar. I had spoken earlier about the essential health benefits, but I really think when that's a first step when it comes to coverage policies and, you know, really working to make sure that those are consistent. And that those are enforced. I think it's really important. I will say also, making it easier for consumers to file those appeals and to make those complaints would be second on my list. Two is okay. We'll take that. And Dr. Rubin, one thing that we could do to really improve the delivery of insurance payments to patients who need them. Well, I think the insurance company should be required to convene experts periodically, I wouldn't say annually necessarily, but to make sure that they understand what the standard of practices in the space and can update their policies appropriately. I agree completely that streamlining the appeals process would be helpful. But I think that underscoring this is the recognition that medicine is advancing and that there are things that they need to stay up to date with so that they're not behind and they're just making decisions based on cost rather than understanding how we're actually improving the care of people. So that would be my first request and they can afford it. They can afford to do this. It's a matter of telling them that they need to and then holding them accountable. Well, that's our time for today. I want to thank all of our speakers, Ron, Dr. Rubin, Mona, Maya, Patrick and our moderator T for sharing their insights on this important issue. A big thank you to everyone who tuned in for today's discussion and all the excellent questions you submitted. I'm sorry we couldn't address all of them but I hope you consider subscribing to ProPublica to stay updated because we're going to keep reporting on this issue. And from all of us here. Thank you for joining and we'll see you next time. Have a good day.