Addressing Social Needs in Medicaid — The Evidence Is In. Now What?

[MUSIC] Welcome to the 80 million podcast. During this season of the 80 million, we've been talking about innovation in Medicaid, not only to tackle today's fiscal crisis in the program, but to make transformational change. Today's conversation continues that theme. A disproportionate share of Medicaid spending is driven by a relatively small group of people with complex medical and social needs. And our traditional healthcare system isn't designed to meet those needs. There are approaches that are starting to show impact. One is addressing social determinants of health, not as an add-on, but as part of how care is delivered in Medicaid and Medicare. We're here today to talk about the evidence on addressing social determinants of health or social needs. Does it work? And if it works, how do we scale it? I'm joined today by two leaders who've been at the center of this work. Dr. Mandy Cohen is a national advisor at Menad Health, and one of the nation's leading health policy and public health leaders. She most recently served as the director of the Centers for Disease Control and Prevention during the Biden administration. And previously, as Secretary of North Carolina's Department of Health and Human Services, where she led the creation of the Healthy Opportunities Pilots, one of the strongest real-world demonstrations that addressing social needs through Medicaid can improve outcomes and reduce costs. And Dr. Rajay Bhadneji is a physician entrepreneur and co-founder and CEO of Waymark, where he leads a technology enabled community-based care model focusing on improving outcomes for people with Medicaid coverage. Rajay was previously a co-founder and chief health officer at Collective Health and has trained and practiced as an interest. Mandy, Rajay, welcome. Great to be here, Patty, thanks. So for many years, the discussion related to addressing social needs in Medicaid has been theoretical. We've been testing and piloting. But we have evidence now that interventions to address social needs or social drivers work. So Mandy, I'd love you to just jump in and talk about healthy opportunities and what you learned. Well, great. So great to be here and certainly to be here with Rajay is doing some really innovative things because in North Carolina, we started this work now nine plus years ago when I started in North Carolina as Secretary of Health and Human Services. And we asked ourselves a fundamental question at the department, which was if we could think about our budget in totality, not in silos of Medicaid and social services and mental health and public health. But just to say, we have all these resources, how can we actually buy health for the people of North Carolina? And that took us on a journey to say, how do we use our levers in better coordination? And what would we actually spend our dollars on? And we looked around for the evidence to help guide us. One of the things that we saw in our own program, we knew that our Medicaid beneficiaries, we knew that more than 40% of those who are on Medicaid were eligible for SNAP, but not enrolled. We were like, oh my goodness, right? They're folks who have the ability to have more access to food and support to buy food, but aren't enrolled in the program and aren't using that. And the fact that we were seeing evidence in small pockets around the country. So North Carolina certainly wasn't the first to do this, but we said, hey, I'm seeing small pilots, 200 people, 500 people, where if you facilitate paying for food or housing or transportation, actually solving the problems that folks are facing, then we were able to actually seek cost reductions. You were able to keep them healthier and out of the hospital. It almost feels too good to be true, right? That we-- And also simple, right? Right. You're like, wait a second. Can we just give folks what they need to be healthy and actually save money? And the answer overwhelmingly now is yes. And look, we did this again. I said, starting nine years ago in North Carolina, it took a lot of work. I know we'll get into what work it takes to do this, but we now have the evidence we need to say, this isn't a pilot anymore. This isn't something where we are discovering will this or won't this work. It works. So let me go through the evidence in North Carolina. We publish it in JAMA, so you can see a peer-reviewed study of this. And I will say it was only for the first chunk of work. And actually, there's going to be another evaluation coming out that's going to even be show even more cost savings. But let me go through what we did first. So if first this program was launched in many of our rural counties in North Carolina, which folks don't often know. So North Carolina is pretty rural in a lot of our state. And we launched it in this program almost exclusively in rural counties. So every one of you who is out there right now thinking about the rural transformation fund and how can we do things in rural communities, look at North Carolina's healthy opportunities pilot, it was a rural intervention. So that's one. But we were able to reach 38,000 people. That is not a small number in Medicaid. And able to use the flexibilities that Medicaid gave us in our waiver. And just to point out that was a waiver that was approved during the first Trump administration, Seema Verma, who is the administrator there. And I worked together on that waiver. And we were able to pay for predominantly food was the major intervention. But we were able to pay for a range of services for folks including navigation to enroll in SNAP. As I was saying, we weren't getting folks enrolled in SNAP. We were able to pay for food delivery for folks who may not be able to leave their home and had some serious medical conditions. And then we were able to pay for transient housing, supports, transportation. So we were able to do a lot. And the number show that when you provide these supports, we were actually able to save $85 per person per month. And what that meant is that the program paid for itself in eight months, which was really exciting. And like I said, that was only the beginning, because look, you do have to make the upfront investment in paying for these services to then see the cost reduction. And the cost reduction comes from keeping people out of the emergency room and out of the hospital. It turns out it's pretty expensive for people in the emergency room in the hospital. So doing things like food delivery is pennies on the dollar compared to an emergency room visit compared to a hospitalization. And so you could see those results in JAMA right now. And so I'd look, I think we're at a place where we're not to see in North Carolina. We've also seen evidence at the national level. Yeah, talk about that because I know we're talking about Medicaid, but there was another Medicare pilot in the same area. Can you talk about those results? Yeah, so the CMS Innovation Center ran the accountable health communities model over a number of years. And so different than the North Carolina model. In North Carolina, we actually paid for the food delivery. We paid for those end services, not just navigation, but what the kind of health communities, they paid for time to screen someone and the navigation. And just those two pieces alone showed a result. So they were able to show a decrease in Medicaid spending by 3% and in Medicare spending by 4%. Right? So again, this isn't even paying for the end services, which is what we did in North Carolina. And now we were able to show bigger savings in North Carolina because if you actually pay for the end service, that's making it even easier to keep people healthy and out of the hospital. But just the navigation alone was so impactful. And that was a program that was running for a million people. So we had 40,000 folks in North Carolina, which I think is a quite scaled pilot. And again, in a rural place, so no one can tell me across the country that they can't figure this out. And then it was a million folks in the CMS and the kind of health communities model. So look, I feel pretty great about us having the data here. And I know everyone is looking at their budgets hard as they should be. Like affordability is a huge, huge issue. It's our huge issue for patients. It's a huge issue for employers. It's a huge issue for governments. We all need to be focused on it. And this is one of the few things that I see that where you can actually give more, do more, provide people the things that really keep them healthy and save money. And so, and we have the evidence now, you have to do it smart. And we're going to talk about what it means to implement this. But I think there's a real opportunity here to use this as an affordability, as an improvement of health play for states, for folks who are really looking for cost savings and the same time as improving health. So, Rajay, I'd love you to enter the conversation here and talk a little bit about way marks, technology solution, what it does, where it's deployed, how it supports the type of interventions we're talking about here. Yeah, thank you, Patty. And maybe just to back up a bit, because listening to Mandy describe her journey in creating the program in North Carolina, it's actually remarkably similar. to the journey that my co-founder Sanjay Basu and I went through five years ago, which is we did the same thing, right? We looked at the evidence of what appeared to work, what we observed at the time. There was really good signal that these programs that whether they were community health workers or navigators of some kind, basically programs that moved care outside of the clinical setting and into the community setting to directly meet social needs or social needs were best met to connect people to care where that was necessary. They looked incredibly compelling. I mean, the data that was coming out and these were mostly pre-post studies, so they weren't perfect trials, but it looked like, hey, there's a thesis here and if we could actually take this and replicate it, this could have a huge impact. I think the difference was that, you know, Mandy was running a state agency and we were two people that were trying to start and you company that would really be able to scale this nationally. And so we had very different kind of methods for how that's staged, but really that the thesis is the same, which is there was good signal and we could build on that evidence base. I think one of the challenges that we observed was that, you know, the reproducibility challenge, if you looked at all of those studies that were done early on, the challenge was that, you know, you asked like, well, how can I do this in my community? Mandy just said, like, there's no excuse because I did it in that rural setting in North Carolina. Well, most of these studies that were done, if you look at the key ingredient, it was like, you needed a local hero, right? There was no process for getting the data for identifying which members would benefit for hiring and training the teams for deploying them cost effectively. The kind of common ingredient was like, there was this local hero that really led this and you need to find that person. Well, that's not super scalable. And so we said that actually what we can do is is through technology, make something that was previously not reproducible, reproducible, so that it could be scaled everywhere. And we could actually improve on those outcomes by really iterating on and refining and honing in on what works the most and doing that really well. And so that's exactly what we've been doing for the past, you know, five years and Pat, you asked specifically about the technology that makes it possible. And so very similar set of community-based interventions. We've got CHWs, pharmacists, licensed clinical social workers providing direct therapy on our team. And what they're doing is they're identifying which members are going to be most likely to utilize the ER or end up hospitalized in the next 60 to 90 days, reaching out to those patients and then getting them engaged so that they meet their social needs. They get the housing, they get their food, they get transportation, they can make it to the doctor's appointment, they can fill their scripts. And then they don't end up utilizing the ER or being admitted during that time window. And so the first piece of technology that we built was let's get really good at that. And we call that WeMark signal, which is not one algorithm but a series of algorithms. And we've published about a dozen papers now on signal. The first one was in Nature or Scientific Reports where we showed that we had 90% accuracy and actually predicting future avoidable acute care in the near term. We published several more follow-up papers that further refine that for sub-populations like duels and expecting moms. But one thing that we've said is that's so much better than the baseline, right? If you're baseline, the best model prior to us was about 30%. And so seven out of 10 people will not benefit from your service. Then your program is a lot more expensive than if only 10 out of 100 people will not benefit from your service. And so we got really good at figuring out who are the future acute care utilizers and let's focus the program on them. The second piece of technology that we created to make these really effective interventions more reproducible, more scalable was really building kind of an AI chassis for everything that we do. We started out with what we called our AI Oracle and we published this in New England Journal of Medicine Catalyst, which makes it so that our care teams are told for any given patient that you're identifying. Here is the next best action for that patient. And one of the things that we saw was we think we train our teams really well. Obviously, humans are compassionate and generally make the right decision. But what we saw is that when a person followed the next best action recommendation for a patient versus did their own care plan, we had about a 12% absolute percentage decrease in acute care visits. And so comparing basically humans to what the AI recommends the next best action, you know, people guided by that did substantially better than the team not guided by that. And we published that in more recently. We built a broader set of AI Oracle tools that really do everything from quality control, identifying errors, identifying gaps for patients and really flagging all those things for the care teams. And then the continuation of that is a product that we've just launched called Walmart Compass, which is basically an always on 24/7 concierge for the Medicaid patient. And so what that is doing for our patients is we're able to say, you know, they can ask us a question over SMS, AI voice, and they can say, you know, I don't have enough food for this month. And then, you know, we can actually help them find food, call out to local facilities on their behalf, schedule transportation, close that process end to end, and similarly on, you know, for patients that want to understand the benefit, understand the benefits plan. And then on clinical triage, able to actually very safely handle clinical triage with escalation to our care team members, where that's necessary. And so keeping our care team members in the loop and really making it so that these interventions that used to generate, you know, break even or better ROI can now be massively ROI positive, but more importantly, can be massively scalable. Even before the full deployment of the AI solution two years ago, we published in New England Journal catalysts that we were able to generate about $250 per member per month in cost savings for those patients that we engage with, which is obviously way in excess of the cost of running these programs. And that cost savings continued on for basically a full 12 months post engagement, which is means that you've got that patient now on the right trajectory. And so I can elaborate more on what we mean by with patients we identify, but that to us is important. And for us, a foundational belief is we share everything that we do. We publish our data broadly, we publish our technology broadly. I think a lot of people are talking about how AI can shape Medicaid care delivery. And our view is we're actually publishing the data on how we are using AI to shape Medicaid care delivery. Yeah, and I want to just jump in and say that that's how I found Rige. I was reading one of their studies that was helping to identify high-risk pregnant moms even earlier. Right? So in the North Carolina work that we were doing, high-risk pregnant moms are definitely a huge important group that we were focused on. But what the work Waymark is doing is making that even more tailored and even earlier in the pregnancy, which again, all published, all public, I really appreciate Waymark's ethos of making this something that not just they can benefit from it Waymark, but that states can go and use that use those tools right now to identify high-risk pregnant moms. And I think that it's so important that as you're thinking about delivering these kinds of services looking at the upstream drivers of health, you're not going to be able to do that for everybody. Like our budgets are not going to be able to do it. And so actually identifying who are the folks who are most highest risk for being in the emergency room, being in the hospital and really focusing on those is really important. Mm-hmm. Well, I want to talk more about that. So we have evidence based on more than sort of small pilots, large-scale pilots. We have enabling technology and infrastructure for scaling. It all sounds so simple. Yeah, it's only. So I want to get into that a little bit. Especially you know, I'm thinking about a state audience or state policymakers that might be listening to this. They have a lot on their plates right now. And so I really want to dig in on what does it take to implement? And Mandy, if you could talk more about implementing hops and what you learned and you know, what are the essentials for successful implementation? Yeah. So the first it is very much that this cannot be done by any one sector of the health ecosystem. This is really an effort to break down silos. And so what I mean by that is, you know, the patients are often walking through a front door of a health care facility. But these services, food delivery, right, is a completely different sector. And often wasn't at the table speaking different languages. So thinking about the workflow of that is really important. So one, we needed to bring everyone who could think about these issues to the table, having one conversation. So that's the first. And then we needed to make someone the quarterback, like someone in charge of this. So that was a combination in North Carolina of our Medicaid managed care plans. Right. They were the ones that were helping to identify the patients. And then we created these new entities that were essentially in charge of helping that those folks get the right service. Right. And so that's all, you know, work. Like let's be honest, like that is work. And so to do this to get those cost savings, you do need to have a team that is thinking about this and focused on execution. You need to think about this in a multidisciplinary way and you need technology. Now we started this 10 years ago. This is before, before chat GPT and all of the new tools that we did not appreciate is talking about. Yeah, we did not have those kind of tools, but we did have underlying tools that embedded into the electronic health record to allow for closed loop tracking of folks to make sure that the services we were going to pay for actually got delivered. And so we developed the first statewide technology tool. We called it NCCare 360. It still exists and we use it actually through many many disasters, COVID hurricanes, the floods and the western part of our state. But it was the backbone that allowed us to right, we had to be good stewards of taxpayer dollars. So you got to track what's happening. And so we developed that platform with the company United us as well as the United Way and they put that together and what was important about that platform is there was one there was one platform for the state. And that really helped because right we're navigating folks to smaller entities like food banks and charities that are, you know, like they're already struck, you know, our strap for time and resources. If you thought about the idea of asking them to log into different portals, like for every single managed care company or every hospital, that wasn't going to work for them. So the fact that we did this together as one state to say North Carolina is going to do this together. And frankly, it was a wonderful collaborative effort with philanthropic support. We actually, when we first were launching NC Care 360, there wasn't a single state dollar that we put into it for years. As we built it, we used a lot of philanthropy is to support that together. And then as we were able to generate evidence and work with our legislature to say, hey, we're going to support this in different ways. They were able to, but, you know, just to put another thought out there for folks about, we're like, how do I start here? Well, sometimes starting is working collaboratively with the philanthropies in your state as the seed venture funds, if you will, of this effort to get it started, because there are upfront infrastructure costs that are associated with this, that are one time costs that I think are really well suited to philanthropy helping you get started on this journey. For a similar question for you, just in terms of what it takes, funding wise and infrastructure wise to really implement and scale your technology or the type of technology that Mante is talking about to support these efforts. Great question. I mean, I'll start with infrastructure. Infrastructure is actually quite simple. You know, all we need is the basic information on, you know, who's eligible for the program, the claims information, which we can get directly from a payer or from an HIE, and then we go on and gather the relevant social information to power the algorithms and then staff the teams and do the outreach. And so infrastructure is really simple. That part is incredibly solvable. I think your point, maybe this is this is similar with what Mante was saying, is actually the challenge is actually sometimes on the funding side, which is, you know, we're doing a lot of work here that is not reimbursable under most chief for service mechanisms, which is, you know, there isn't a billing code for like 90% of the work that our team does, right? Whether that's our care teams or the work identification or even even some of the automated work. But we also know that it's incredibly impactful. And so the way we tend to structure our arrangement is basically you can call it value-based or performance-based, which is, you know, there's, there's a small fee and then that fee is at risk for actually generating the desired outcomes, which in our case, you know, our quality improvements and total cost to care savings for the population. One of the things that we've done that has actually been very well received broadly is we actually structure our contracts as randomized control trials, which sounds, you know, crazy to some, but if you believe that what you do works, that is the best way to structure the contract where, you know, literally we will have our intervention group and then a control group. And then we will reconcile not based on last year's MLR, but based on the direct comparison of those two groups, which is objectively fair, it shows that this is reproducible and I think aligns the incentives really well to make sure that we maximize the impact of the program. I think where states get stuck and where health plans get stuck is sometimes in the realm of, you know, does this count toward medical cost? And so, you know, increasing clarity that these types of programs do count toward medical cost is helpful and we've managed to get there in every state that we're operating, but it does require some some conversation. The second is in this world of value-based care, double counting a member to more than one value-based care program is very complicated. And so, I'd say that sometimes one of our obstacles is, and I've written about this in health affairs, what we call value veneers, which is there's a lot of fake value-based care programs out there that are literally like a veneer, like somebody put in place a value-based arrangement just to say that it was in place because maybe the state regulator said you will have x percent of your your patients in a value-based arrangement, but they didn't change the care model at all. They didn't invest in new resources and the value-based program doesn't have enough bite to it that any way change like incentivizes that change to occur, but what that that program has done is it's kind of occupied that value-based care real estate and made it so that member then can't be assigned to another program like ours, even if that's totally additive to the care that they would have received. And so, we have sometimes had to kind of work with plans to unwind with, you know, especially big health systems that we work with, prior value-based arrangements and that obviously takes time. And so, I think one of the things that we have got to do is make sure that we put outcome improvement transformation of care delivery first and then, you know, requirements around, you know, x percent value-based care second because I've seen that incentive a line that go in the wrong way. And so, really, for us, that's what we need is this program, you know, to somehow be paid for. We can do it with fees at risk and we need to make sure that, you know, we're not stepping on too many toes when it comes to existing value-based care arrangements. Yeah, one of the things that I think in North Carolina, we were rolling out this program as we transitioned our Medicaid program to manage care and we did a couple of value-based payment underlying architecture with this program. So, I totally agree with Rige on needing to align incentives. And now, we have more tools. So, certainly, you can't be doing this program in isolation from thinking about those incentives in value on outcomes and now we have more tools to get there. So, totally agree. But maybe I'd also just bring up. I don't want anyone to leave here thinking that everything is okay in North Carolina. Like, we've solved it because- - I'm gonna ask you about that. - Yeah, yeah. So, I just, you know, because I want to talk about scaling, but recognize that these kinds of, this kind of work takes continual explanation, education, re-education, re-introduction. Right, so, we'd actually had this program running for a number of years. It was successful. We'd publish in JAMA, but look, budgets are tight everywhere. And legislatures are looking to give folks tax breaks understandably because, you know, folks are really feeling pocketbook issues every single day and Medicaid is a big part of the state budget and it trades off against other priorities on education and other things. And so, folks who don't, who might mean new to this base to say, go, why are we giving extra things, right, in this moment? We just should focus on the health services, right? The health care. I want to pay for lab tests and doctor visits because they haven't been introduced to this whole fact of actually when you do this, you could save money and here's how. And so in North Carolina, we saw this impasse year, unfortunately, not the funding that had been there for this program, unfortunately, is at risk. Now, I know they're still working to see if it can come back. And it's particularly unfortunate in North Carolina, great, because they made that initial upfront investment. Like I said, there is upfront investment. So, if you don't continue the program, you actually lose all that investment that you made on the front end, whether it was a sweat equity of just the stakeholder work that Rajay is talking about to get it implemented, or the true technology deployment, if you don't help continue to educate folks and show them the evidence. And I know this is a paradigm shift, so you can't take it for granted that everyone's on on board because legislators change the leadership of programs change. So, it really important just to say as we get into this conversation about how we do this everywhere, it's not a set it and forget it kind of kind of effort. And we're definitely seeing that in North Carolina. Right. So, just staying on that theme and thinking about how do you scale it? Mandy, can you talk about sort of at the federal level where you can mention that the Healthy Opportunities Pilots were approved in the first Trump administration. A lot of what you're talking about is very consistent with the make America healthy again, agenda that we're focusing on, you know, things lifestyle and food and nutrition and things outside of, you know, traditional medicine. So what's the federal policy perspective here and what changes or sort of championship would be we needed there to help to scale this? Yeah, look, I think as we were saying before is that I think the evidence here is pretty compelling. And if anything, we're getting smarter as we go, we're learning about the implementation challenges. We're learning how to use technology to scale this. And so we do need an enabling environment from a policy perspective in order to really scale this. And I think states need to hear from CMS that this is a direction that they should go in. And so I know that we're for state leaders, there in a place where some of the Medicaid policy that was governing this has been rescinded. And so they're like, oh, does that mean folks aren't supportive? And I actually don't believe that that's accurate. I think there is support for this kind of work. You know, look, Dan Brillman, who currently runs Medicaid, he and I worked together on launching this practice. Yes, with United us. And we worked on launching this in North Carolina. So I know he knows this work well. I know he was part of making that successful in North Carolina. So, you know, look, so what do I think Dan, the team at Medicaid needs to do is give guidance. Like what are the parameters here? I know that they've said, oh, come to us with an 1115, which is okay. But we all know that folks need the guardrails and guidance around like what is possible to both to speed up the negotiation process with CMS and actually get these waivers out. But to make sure that folks are embedding the lessons learned from a place like North Carolina, from the work that Waymark is doing from the published studies that are out there. So we're all actually doing this in a way that is being good stewards of the resources. So we need the guidance. I think there are opportunities to put quality measures around screening into the program. But look, I also think there needs to be congressional action. 1115 is good. Right. And basically you're saying, how can I expand the authority the state has? But I think we have enough volume of evidence screaming at us at this point for Congress to take action here. Look, like I said, there's so few places where we can give folks more meat their health needs and save money for Medicaid. It's time for congressional action. And what I mean by that is to say, particularly for the navigation, right? The accountable care at the health communities that the Innovation Center really showed that even just navigation is important. And going back to my first statistic where I said so many people in North Carolina Medicaid were not enrolled in SNAP. Right. So how do we make a permanent benefit in Medicaid that paying for that navigation to Regis point 90% of what they're doing is not paid for right now. It should be because it saves money. So let's pay for something that makes people healthier, make them healthy again. And actually reduce costs from from the program. That's going to need congressional action. And I think folks are looking for cost offsets. Look, look here. Right. Look here to this these efforts. So you'll see myself and a few others will write some papers about this to really convince people. But I think that this is really something we as a country need to be doing. Yeah. It's a really important point. And for people who don't know all the insider Medicaid lingo 1115 is a waiver. It's a demonstration. It's a pilot. Essentially, it's pilot authority from the federal government. And I think what you're saying is we're going to move out of the pilot and make this a permanent feature of the Medicaid program. Yeah. I would just add to that. I mean, one of the things that I know is under great scrutiny when it comes to future 1115 waivers is, you know, budget neutrality and that not just being kind of a projection, but being something that is truly sound and has a strong evidence base behind it. And now more than ever before that evidence base is very clear. I mean, just our own team has published 32 papers showing these interventions and what works and the cost savings to generate. You've got other programs to look to, including what what Mandy did in North Carolina and the CMS demonstration. And so the evidence here is so clear that it feels like there isn't even bigger opportunity for for scaling this, especially in comparison to everything else that people would have otherwise or states would have otherwise put forward for a waiver. So I think, you know, now more than ever is at the moment. And I did not have on my bingo card that Mandy would be saying, ma ha on today's podcast. There you go. We're all going to work together to make it happen. 100% I'd look, I think that the underlying tenors of what that is, which is we want to be healthy is right. It's what I've been working my whole career for. And I know both of you as well. And so look, these are the enabling pathways for that. But Patty, if I could, I don't want to make this all about what happens at the federal level, like states can do stuff now. Okay. Right. And can work with their managed care company. And most states have managed care in their Medicaid programs. They can work to embed social needs screening. Right. So Campbell Health communities showed us that screening and navigation alone save you money. You want a 3% reduction in your Medicaid spend. That's what the handle come to you showed, right? Just from the screening and navigation. And so how do you think about aligning what you're doing? Do you have a contract, you know, a renewal of your managed care contract coming up? Can you put out a contract amendment to think about who's doing the screening? How are you tracking it? How are you? How are you linking folks from navigation? I think those are all things that states can do right now. You can think about using your in lieu of services right now. So there are ways to do this even without an 1115 waiver. Look, rigid, you know, call, RJ, call us. We will help you. You don't have to wait. But I do want to seek the action at the federal level from a scalable perspective. But don't wait for that. Right. I would add, even the simplest thing a state can do is just tell your health plans that you want to see them take action, do sing that avoidable acute care utilization and tell them that they won't you want them to present you strategies for doing it. I think you'd think that that health plans would already be motivated to do that. But they're often, you know, concerned with whether this aligns the state priorities. And so I think even just that simple communication of this is important to us at a state level will go a long way with with health plans and having them do the right thing downstream. And look, we have new the only new dollars that are flowing right now are the rural transformation dollars. Look at North Carolina. That that was a rural intervention. But when right, I recognized there were real upfront costs here, but put those rural transformation dollars to work to think about the infrastructure that is needed to facilitate this kind of work. So you pair together your rural transformation dollars, your Medicaid authorities and dollars, the work you can do with your managed care companies. And you can really put something together here that is reducing your cost trend and keeping people healthy. It's a win-win. There's so few of those. I think every state should be looking very closely at how to do this again in pairing all of these together. But again, it's going to require Medicaid to work together with with social services and snap to work with your with your rural team to pull all of this together. But I know you can do it and we're here to help. Well, I love ending on that note. I think we all believe states really are catalysts and laboratories for innovation, including here. So I just thank you, Dr. Skohn and Batniji, for this conversation. It was really rich and I learned a lot from it. So thank you so much for joining. Thanks everyone. Thank you.