Designing for Health: Interview with Minal Shah, MD [Podcast]

Show Notes:

[00:00] Intros

[00:46] What is TEAM

[06:06] The importance of consistent care pathways

[08:41] Data, surgeons, and the patient voice

[22:26] Pre-surgical prep

[23:25] Tech tools for follow-up and recovery

[26:36] Rethinking clinical decision support with AI

[29:25] Turning data into actionable insights

[32:32] Karen’s favorite well-designed thing

[33:52] Outros

Transcript:

 

Dr. Craig Joseph: Welcome to the podcast, Karen Joswick from Benevolence Health Advisors. How are you today?

Karen Joswick: I'm good, Craig, how are you doing?

Dr. Craig Joseph: I am, as always, excited to talk to people like you. Where do we find you today?

Karen Joswick: East coast, Delaware, the first state.

Dr. Craig Joseph: You and I met when we were, you were trying to educate me on the TEAM program, and I had said to you, I use Teams every day. I can even chat on it. And I told you I didn't need to know anything. And you were. You were like, no, no, no TEAM was with no s.

Karen Joswick: Yeah. We use the word TEAM in all senses of the word. I can't tell you how many times we've approached organizations and said, so how's your team doing? And people go; they're great. What are you talking about?

Dr. Craig Joseph: Why don't you tell us a little bit about yourself? How did you get to become the person that you are now?

Karen Joswick: Let's answer what TEAM is. TEAM is the new mandatory bundle payment program from CMS. It impacts about 25% of the hospitals across the United States, and the hospitals were selected based on their geography. Or CMS has a term called CBSA or core based statistical units. And so, it's kind of a big deal because it's a mandatory model. And there was a little bit of betting going on about what was going to happen in Washington. Was the administration going to keep it, you know, move forward with it. And there were a lot of naysayers that said it's going to get wiped like everybody else, or it's not going to be mandatory. And actually, that's not true.

The administration kept the TEAM model. They came out with some new proposed regulations in the last couple of weeks on it, and it's mandatory. So that means these hospitals have to comply. I went into healthcare wanting to make a difference and a change. Same reason why you probably went into medicine. You want to help people and make a change. And I started my career in it and then was asked because I understood all of this data and analytics and informatics work. Could I help the operational teams implement these programs? And kind of just grew from there. And I think part of it, I had a good amount of my career in the state of Maryland, and Maryland's known for innovative models. And so, I think it kind of was a natural growth in that way.

Dr. Craig Joseph: Fee for service versus value-based care. Fee for service, as I understand it is, hey, you do this thing, you get paid. Whether it turns out well, whether the patient really needed it, none of that really matters. You're going to get paid this amount of money with value-based care. It's more like the payer. In this case, the federal government is interested in results and paying for results.

And so, we've had value-based care for decades. That concept kind of started with the HMOs a gazillion years ago, I believe, and it's kind of been some fits and starts, and it's kind of going back and forth. So, this is, yet another, another attempt from the biggest payer in the United States for health care, the federal government, to make sure they're getting their money's worth. And as you mentioned, TEAM is not optional for the 25% of hospitals that were selected by the government. And they, I presume, know who they are at this point.

Karen Joswick: Gosh, I hope you do know who you are. I mean, there's a list out there. I will say, as of a couple of weeks ago, we've done some outreach, and I think most hospitals know. But early on, when the list was out there, there were some that were a little surprised, like, oh, we're on the list.

Dr. Craig Joseph: So hopefully people know, you know, if they're on the list and what do they need to do? So how is this different from other kinds of, value-based care who's being evaluated and what kind of information do they need to present and that kind of stuff.

Karen Joswick: Well, so first, if you don't know, check the list. So happy to send the list and where you find it. But one check the list, and two, if you're on the list, make sure you identify who your point of contact is going to be with CMS. They want to know who they should send emails and data files. There's going to be a whole bunch of information that's going to come straight from CMS to your organization. More importantly, it's going to be a reflection point for an organization to understand the volume of these surgical procedures and understand the key service lines.

So, in prior bundle payment programs, they were predominately in orthopedic space. This program's a game changer and includes cardiac surgery. Not a surprise, right? Think about what the federal government pays for a lot of open-heart surgeries. Right. So, they put CABG in. There is one example. They also included some spine in some bowel surgeries.

And so, I think this is indicative of where the government's trying to go is to lean into the high-cost procedures or also procedures where there's we know care continuum across whether it's in skilled nursing or home health. And, where we think there's opportunities to bend the cost curve and improve quality. And boy, when you think about seniors and the cost that Medicare is underwriting, cardiac surgery seems like a great place. So, the hips and knees and spines.

Dr. Craig Joseph: And I assume the idea from the government is that if this goes well, it won't be 25% of hospitals. It will be.

Karen Joswick: More. Yeah, yeah. All right. It's going to be more. And if it goes well, by the way, they save money. So, if it goes well, it doesn't mean the hospitals will make more money. There are some hospitals that are in a favorable position based on what we've kind of modeled and projected that some, some hospitals, because they're already a low-cost, high-quality provider, may be positioned well. There are most hospitals who are not, and so this is a haircut. Right. And for some of these health systems, it's not a trim. It's a pretty big haircut a couple million dollars a year. Craig, you know, in this day and age, that's huge. That's not just a rounding error for some of our health system partners. These are big cuts.

Dr. Craig Joseph: Maybe let's just dig in on one example. And so, you had mentioned CABG. You were talking about, bypass graft. So, a heart bypass, which is a major, it's a big operation. So maybe talk us through how it is today and then how will it be tomorrow or early of next year for those quarter of hospitals that are on the list?

Karen Joswick: Sure. Well, CABG is a is a good example to talk about. You know, there are patients who get, emergent CABG and there's not really much you can do about that, right. There are patients who are in the CATH lab. They get balloon pumped and they sent to the O.R. and kind of like, that's just going to run its course. Those are patients that you need a clinical pathway for. You need to be able to make sure you have data and insights, and you've got good partners to manage them across the continuum.

But then there's a cohort of patients which is most patients, right, where it is considered, a scheduled routine procedure. And so those are patients that are known to you as a provider ahead of time. And so there's an expectation that, how are you engaging those patients ahead of time? Have you been educating them on what their plan is after discharge? Right. We know for patients who have had this surgery that they need to be up and moving around, and they need to be exercising. And the patients who are up walking around the nursing unit in the hospital are going to be better walking around at home and going to cardiac rehab.

And so there's kind of these basic tenants that good science, right, good care we know about. But frankly, sometimes we're inconsistent and how we do it. And part of it's the patients not being educated, not being aware, not having the right support system at home. And some of it's that we are inconsistent in our clinical practice at some of our facilities, right, for lots of reasons.

And so the model really is kind of pressure testing and saying you need to be consistent, right. Reduce care variation, but also engage the patient ahead of the surgery and also figure out what your plan is going to be after surgery so that those patients who have a CABG, then maybe go home with home health or with cardiac rehab services and not get transferred to a skilled nursing facility for 20-30 days. Right? So really try and manage the cost of that episode and also improve the care. And we know patients who have a good destination right at home and good support system. They're going to be less likely to end up as a readmission. And I think we all know, like the challenges with readmission, not only around cost but quality. And it becomes a downward spiral.

Dr. Craig Joseph: Is the government looking, how are they going to be evaluating how consistent the care is? How are they going to be evaluating what kind of rehabilitation? That's one of my favorite terms as opposed to rehabilitation, you know, how do they evaluate that? Or is it just no, it's the outcomes. Like we don't really care what you did. If you have, majority of your patients don't bounce back and they're meeting certain criteria afterwards, it doesn't really matter what you did before. It sounds like it's somewhere between those two extremes.

Karen Joswick: Yeah. No, you're exactly right. So I think there is an expectation on your benchmark cost. That's just it, it's a cost program. There's a cost savings program. So are you less expensive than your competitors in your market? And also how do your outcomes fall? So, there's a variety of quality measures that are included in this program. Right. Some of it around patient experience. Some of it's just around like all cause readmissions and all cause morbidity mortality rates. So, there's measures in place to look at, like you said, outcomes. But then there's the biggest stick, or carrot, really is the cost.

Dr. Craig Joseph: You're being evaluated about your cost compared to your competitors compared to like kind of peer institutions in your area. It sounds like.

Karen Joswick: Yeah, your market. And the challenge with these, you know, sassy CMS is word CBSA. So, score based statistical areas I'll use in the word market. In some organizations, their market is small. In other words, it's like California, Oregon, and Washington, right. And so like, they're massive geographies being compared to Sacramento when you're in Oregon may or may not be right. Really fair assessments based on Metropolitan. And we see this in New York, on the East Coast. There's a lot in the New York New Jersey area, etc.

Dr. Craig Joseph: Is this significantly different than two years ago with a different program for a different surgery? Like you'd said earlier, orthopedic surgery tends to be the one that payers in general and the governments specifically look at. But is this much different? It sounds like one of the things that sounds different to me is the fact that I'm going to be judged based on how much I bill versus my other people, either in my region or my state. Is it more of the same or is this a particularly different kind of approach?

Karen Joswick: Yeah. So, yes. So, it's a little bit of the same. It's a bundled program. So we've had bundles for decades and decades in health care. So that part's not new in the fact that we're including orthopedic procedures. There's been a huge shift right over the last 15, 20 years to move routine hips and knees out of the hospital into ambulatory care. Right. Bundle those, that parts not new. What is new is that some of those other specialized procedures, like we talked about cardiac surgery, is a perfect example. And the fact that you're going to be graded, if you will, and compared against your market. So you're not beating against yourself, right.

Comparing against yourself, but you're trying to beat the market, not just improve your own cost. And that's important. For lots of reasons. One, you may not know where you sit compared to your market. Right? So, a lot of health systems don't have good benchmarking information and data about where they sit relative to the hospital down the street. The other thing that I think is a game changer on this one is the service line engagement typically and a fee for service world cardiac surgeries. The last area you touch for lots of obvious reasons. And so, this is one that's going to really challenge health systems to have their foot kind of in both canoes. Right. How do you balance fee for service and value-based care and hope that you don't hurt either side?

Dr. Craig Joseph: One of the things that was initially confusing me, and some listeners might be confused about with respect to needing to know how much I charge for this, my hospital charges for this procedure versus others in general.

I've always taken this simplistic view because I'm a simplistic person, that, hey, I could charge $100,000 or I could charge $1 million for this procedure, for this admission, this hospitalization, I'm going to get paid X number of dollars based on the DRG. And so that was always my kind of assumption. It doesn't really matter what I charge because I can send a bill for anything. I'm just going to get what I'm going to get. But now that's actually or maybe never, but certainly not now that that's not the case. The more I charge, even though I can charge $1 million and I'm going to get $50,000, it's going to not work great if I'm charging $1 million. And if my, others in my area are charging, for the same procedure, DRG half of that, it looks bad and it's going to be calculated as such.

Karen Joswick: Right. And I think the best way to really kind of needle down more on that is the total cost of care. So, for these patients, yes, you can charge for your surgery, but are your patients going to home health, which is, you know, maybe $1,000 of expense versus skilled nursing, which is maybe $25,000 for that post 30-day window? Are your patients having a bunch of extra scanning and imaging and so forth pre procedure that maybe they don't necessarily need is a is it a necessary variation in care based on the standards. So those are kind of the puts and the takes.

And then to your point, yes, there's a whole internal exercise that health systems should be doing around their fixed costs. So what are you charging versus what does it cost you to actually provide those services. And that's really where I think there's a sweet spot. Organizations that are looking at their internal cost structure, how well they're managing their internal costs to provide the care. And then also looking at the care continuum, what are those patients experiencing? Are they going to skilled nursing? Are they going to home health? Are they getting extra physical therapy appointments, imaging etc.?

Dr. Craig Joseph: So now that we all understand what this is, sounds like, step number one is to know if your hospital is in the group or not, which most people probably know by now. But sounds like there's a link that you can go to and see that list.

And then step two, once you know that you're in this list and probably it's not a bad idea for folks who aren't on the list now, given the fact that they might everyone might be on the list soon, is to start collecting some data and some of the data they surely have. Surely there are other programs or other quality metrics that hospitals have to be collecting. One of the new ones is, hey, how much am I charging for this on average? And again, not just for the procedure, but for all the care that's involved versus my competitors. So, they need to get that information. How you get that information, Karen, do you just call up? Hey.

Karen Joswick: It's a yes or no, right. So, if you're on the list and CMS has your contact information, you will eventually get claims data from CMS. But that's not going to be until later this year. So, you're going to need to look at your internal assets and tools. So, you know, depending on whether you're currently in MSSP. So a Medicare shared savings ACO, maybe you already have claims data, maybe you already have a pop health platform or a tool that you're using to do that, that some of the hospitals, for sure, there's many hospitals that frankly, they don't have those tools in play, and they're on the list and they don't have access to the data. And so, then there are certainly partners that have access to benchmarking, where they can give you the analytics to help at least start planning to do that work. And that's some of the work that we're doing to help organizations right now is forecast where they have opportunities to focus on care redesign.

Dr. Craig Joseph: Are there other data points that folks should be collecting that you're seeing that they don't have, that are unique for this program?

Karen Joswick: I'm a firm believer they really should know by those service lines which of those stocks are employed versus a community-based or a partner. I think that there is an opportunity around provider engagement to really be intentional. Certainly with your employee docs, but also with your community docs that you know right now, if you've got, you know, maybe a spine surgeon that's in the community, but they have privileges and they operate, but there's an opportunity to lean in around quality and engagement in this. There should definitely be conversations, right. And an evaluation of who's employed, who's in your community. The same thing is true with your post-acute partners. Who are you sending these patients to? Do you have their data? Do you have a partnership? Do you have a preferred partnership? So there's definitely some internal operational areas that the organizations should be evaluating as they prepare.

Dr. Craig Joseph: Is there anything that differs based on the specialty? So ortho versus cardiac versus GI is pretty much all the same. Or are there any numbers? Oh my. For gastroenterology really need to know X.

Karen Joswick: Cardiac surgery is usually the most expensive, and spine, kind of you know, follows some of the bowel surgeries are pretty expensive because they're usually very medically complex. You know, if I were sitting right there in the hospital today, I would want to look at my outliers. So, any patients in the last 12 to 24 months in your med teams, right? You're made exactly like they'll know that they'll know your outliers for your CABG. They'll be monitoring that, especially if they're involved in other registries like STDs, registries. Any of the quality improvement work that you're doing? I pull all of that and really dig deep, on where you are performing right now.

Dr. Craig Joseph: Okay. And you mentioned engaging with your clinical team, especially the surgeons and procedural, as.

Karen Joswick: I enjoy working with surgeons. And maybe it's because throughout my career I've had the ability to do that. So, you just kind of learn what motivates and engages them. Right? So, these are typically very passionate, quality focused. They truly are outcomes focused. They don't want a bad outcome. Nobody wants a bad outcome. And so I think if you position this program as an opportunity to really evaluate how their patients outcomes are doing and get them the support needed, whether it's special care protocols or figuring out how your care management team can help support them for discharge planning or realization like you talked about.

I see this as a great way to engage those surgeons, maybe in ways that you haven't since maybe the service line launched, or a program opened, or a new surgeon came on. Right? Typically, those movements are when organizations will have a, oh, we should. We just hired a new cardiac surgery specialist. Let's look at our clinical protocols.

Well, you should be doing that more routinely. So, I think this is a great opportunity to have those conversations. And then I'm a big proponent of sharing the data with them, helping them understand where they're sitting and help them be competitive, because by the very nature they're competitive. They want to know; they want to be better than others. And so, I think supporting them in that way is the best way to do it.

Dr. Craig Joseph: Yeah, I love that. From an intentionality perspective, physicians are 100% and surgeons 1,000% are competitive. And, sharing those data points with them, whether they agree that they're important or not, they want to do better than that next person, and especially if they have a negative opinion of that, of someone, they're like, oh, they're beating me at this thing. I don't really, even if I don't see the value, I will not allow them to beat me at this thing. So, yeah. And so, engaging with the surgeons and procedurals makes a ton of sense. We haven't talked about another, important person in this endeavor, which is the patient. Are there things that we should be doing to engage the patient directly, or is this something that now the clinical team and the operations folks are the ones who are the only important keys in this puzzle?

Karen Joswick: I think you know the answer to that one. Right? Patients are at the center of all that we do. It's amazing how many patients don't have a good understanding of what their recovery process could look like for these procedures. It's I mean, even for things that are, that are routine, like, like a knee, some people feel really, you know, you have different experiences. You'll ask a patient or a friend, hey. And they'll say, I had no idea it was going to be so hard to get up the stairs and shower. I had no idea what it was going to be like. So, there's I think there's an obligation, right, to make sure that we are really arming patients and families and their support systems better when they have these procedures.

And I think that's ultimately going to get us into a better place long term around outcomes. But if you haven't invested time and energy resources into educating patients ahead of the surgery, right? Not immersion. Right. But for the routine and scheduled, I just you're just not in a good place long term. And if people have time to focus and plan and worry about the steps to get someone into the house or make sure they have time off those first couple days, you know, as a supporter for their family or their loved one. It makes a big difference. And there's a lot of digital tools too, right, to be checking on your incision site and send us a picture of that. Right. There are so many tools that are out there now that it's kind of like we have to be doing this, in my opinion, for sure.

Dr. Craig Joseph: We need to involve the patients. And I love the idea of kind of doing, again, that pre check of trying to get you in the best shape you can be before the surgery, assuming that it's not urgent. Of course. You know, can it wait a few months for you to quit smoking or for you to start exercising a little bit? Yeah. If so, we know you're going to do better afterwards. And the concept of oh, no one asked you where your bathroom was located because it is upstairs. So that's where the showers are, we're going to have a problem if there's no one there to help you. And that's going to lead potentially to you, not to you kind of failing at home.

And then having to go to a post-acute facility. And then that's going to cost a lot more money. And it's also not as much fun to be in a facility like that as it is to be at home. It's certainly better to be at home. So sometimes these little pieces of work which don't cost a lot can really bring some value. Let's talk about how you kind of teased us a little bit with some digital tools that might be helpful. One of them is using the patient portal or an app that can take a picture that you can use. Take a picture with your phone and send it to your surgeon or your surgical team. And hey, there's really no reason for me to come in the main question that you're going to that you need to see me for is just to look at my wound. If the rest of it is just me talking to you on the phone, or over a video, then that's easy. And then that saves everyone time and money. Are there other things that you've seen kind of be successful in general for patient engagement for some of these, these procedures?

Karen Joswick: I think there's some really interesting ones specifically around I've seen for cardiac surgery and or those reminding the patient of just some of the exercises that they need to be doing. So, you know, like, did you do these exercises kind of post-surgery, you know, for cardiac surgery, it's, you know, making sure that they're doing there is, you know, incentive spirometry and they're coughing. Right. Just some of these basic things like, have you done this? And those are in the early days. We know that makes a big difference for folks that have had, you know, orthopedic procedures. It's obviously watching the, watching all of these surgical sites, but exercising and moving and, you know, did you get up and move around.

And so, I think that there are gentle reminders and app tools, right, that are ingrained into folks' phones that they can either go to the patient or to their supporter. You know, did mom get up today? And I think that we've certainly grown and evolved so much. I mean, we have reminders to my Amazon is going to run out of paper towels, and I get a reminder, hey, Karen, do you want to order more paper towels? Right? As opposed, why can't we do this with some of our surgical is, and I think we're seeing it, but it's not embedded in just this is good care. Then it goes back to that clinical pathway. This is just good care.

Dr. Craig Joseph: Yeah. I, you know, and that good care concept I think really resonates with clinicians especially. We don't really need to talk about TEAM versus another program. It's just oh it doesn't really matter what your insurance is. It doesn't matter how you're paying for this. These are things that we do for all of our patients who are undergoing these procedures.

Karen Joswick: And oh, by the way, come with some of the other commercial insurance companies who are having conversations if they haven't already. They're looking at this to say, well, why would it matter if it's Medicare or a commercial plan? Why wouldn't we want you to save money for our patients, too? So, I think I've heard from some health systems that we're doing work with that their commercial plan has said we'd like to talk about doing bundles and for these patients too. So, I don't think it's that far for health systems to see a knock on the door about this one.

Dr. Craig Joseph: It makes complete sense. And again, that I typically say that, my job when I, when I've been the CMO before with one foot in the I.T world and one foot in the clinical world, is to make it easy to do the right thing, that the hard part is figuring out what the right thing is in this case where we're being told, and I think there's some consensus about what the right thing is, and then we just need to enable it, pivoting off of that, enabling, making it easy to do the right thing. How do we do that? And the tool that most clinicians use all day is the electronic health record.

So, we're kind of like, I know I've just opened up a whole can of worms. Are there clinical decision support tools, or do we really need to rethink how we use clinical decision support for some of this? Have you seen any organizations successfully figure this out?

Karen Joswick: It's interesting. You said clinical decision support and I think probably everyone listening just like, got a chill, right? I mean, think about how we spent the last 20 years implementing these rule-based algorithms. If this then this, right. And these alerts that we have out to folks. And now we're moving towards more AI tools where we're trying to really learn from prior decisions to make more informed and more enabled, you know, decision support. And so, when I think about how clinical decision support can evolve with value-based care, we really need clinical decision support tools that help us manage some of the outliers and the ones that are, if you will, where we have blind spots. And that's not always been the case for CCDs or, you know, the decision support tools at the 80% that fits in the square peg.

Right? We'll tell you to do this. And so, you think about the patients who we'll pick on the cardiac surgery patients, since that's our theme today that we've been talking about. What about the patients who maybe don't have a good support system, or they don't have transportation, or they are not going to be able to get food at home. And we need to worry about meals on the wheel, meals on wheels, or we need to worry about follow up, transportation to home, whatever it may be. I think that's where there is power in some of the new models and some of the new testing that's happening in their EMR around AI, clinical decision support. And I think this is whereas informatics leaders, we've got to lean in and kind of harness that because it's the 20% that we keep missing. That can be a challenge.

Dr. Craig Joseph: Do we definitely focus on the easy part? Why? Because we're humans and that's easier to do that. And so, but your points well taken in that I found if I really, really want to irritate a physician, I should remind them to do something that they were just about to do. Yeah, they really dislike that. That's a big bummer. And so, kind of making sure that clinical decision support helps, whether it's a physician who's seeing the patient, pre-op or in a, in a follow up, appointment or it's more of a kind of a population health perspective.

Are there any tips or obvious things that we should be doing from a population health, from dealing with multiple patients for team or for other programs like it that we don't that you typically see folks aren't doing.

Karen Joswick: You know, I think that there is a tremendous opportunity to kind of keep your head down and lean in on some of the projects that a lot of health systems are already doing. And, right, those are data standardization. Right now, so many health care organizations are receiving claims data, maybe from a payer or from the federal government, and they just don't know what to do with it. You've got to be able to integrate claims and clinical data together. And if you don't have a roadmap and a plan for that, you're going to be behind. You're just going to be behind. It doesn't matter what model it is. So that's something that's really important. If you don't have a way to give performance dashboards right back to your providers, sometimes we would lovingly call them provider scorecards, right? So, if you don't have those things in play, and that they're actually being used. Right. So, it's not enough to have a dashboard, but are they actually being used in a collaborative sense and driving outcomes? You need to look at that because that kind of data is what's ultimately, we, we see the people who are top tier, top performers in these value-based care programs.

It's because they have the data right in front of them. And they are, you know, just moving right along and using those data insights. And then Craig, the last one I would say is it goes back to the claims a little bit. If you don't have a collaborative relationship with your payer, CMS or your commercial payers. And what I mean by that is there's some sort of data sharing. Right? So, think most health systems work with ten or 15 different insurance companies rate payers. And guess how many file formats are sent to them? Exactly. The number of payers is. Like nobody's using a consistent file format. Nobody's using consistent tools or definitions. And so, the onus, unfortunately, is sitting on the health system, and there are some tools that have starting to improve that. But if you don't have a strategy to take all of this external data in, normalize it and then share it with your clinicians and your operators, you're going to be very hard to blindly perform well without those insights.

Dr. Craig Joseph: Let me just jump up. And in that last word you said insights. That's so it's not the data that I'm interested in. It's what I am doing. What am I doing wrong or what am I not doing right that these insights can bring to me so that I can say, you're right. I never asked about stairs, or no one on my team asked about stairs, or they did, and the patient said, yeah, I have stairs. And then that was recorded dutifully in an electronic health record. And then no one did anything with that information, and we were setting ourselves up for failure. So, yeah, that, that that plan to actually take data and move it into insights and then make actions out of those, that's where a lot of people don't design their processes. Well, this was great, Karen. Thank you so much. We always end with the same question, which is that we're talking about design and intentionality. Is there something that you use that's so well designed that you feel joy whenever you interact with it? Anything like that in your life?

Karen Joswick: I've got kids, probably like most folks, and I have to track them all down and they are everywhere. So, I really appreciate some of the calendaring options to just share with them. But also, there's an app called Life 360 where you can track your kids. And so, like the teenage driver that's driving fast and so forth, so I think me, on a personal level, the ability to monitor and know what's going on with my kids in this tech-enabled world and still be close to them is a good place.

Dr. Craig Joseph: It was much more complicated than now to know people they needed to be. And so, I accept your calendar option, and I think there is some joy in that. It's a lack of stress. Right. Where's my kid? He was supposed to have called me. He didn't call me. Let me track his location. He's still on the baseball field or at the high school where I know that he's okay because he's obviously been paying some more attention to sports than to answering my texts.

Karen Joswick: For me, the calendar growing up was the calendar on the wall of the kitchen, and my signal to come home was the streetlights turning on when it was dark. So, it's, it's a very different world to imagine all of parenting and so forth. So, yeah, that's my season of life right now.

Dr. Craig Joseph: I love it; I love it. Well, thank you again. It's been a pleasure. And look forward to seeing how, team works out for the 25%, lucky participants starting next year.

Karen Joswick: Thanks, Craig. A pleasure. It's always great talking to you.