Exploring chronic disease management trends, strategies

Transcript - Exploring chronic disease management trends, strategies

Anuja Vaidya: Within the virtual healthcare world, this is the perennial push and pull.

Sara Heath: They can't engage in all of these really cool solutions that we've talked about because they don't have a primary care provider.

Alivia Kaylor: I think clinical trials too is maybe an area that a lot of people forget is a solution.

Kelsey Waddill: Welcome to season six of Healthcare Strategies. Get excited because we have some great conversations coming for you this season, and we are going to start it off with a bang. Three of our Xtelligent senior editorial staff members sat down to discuss one of the most influential and prevalent topics in the healthcare system today, chronic disease prevention and management. Alivia Kaylor, Anuja Vaidya and Sara Heath covered a lot of ground in this episode, so buckle up. Also, listen all the way to the end to potentially hear yourself name-dropped if you left us a review on one of the major podcasting platforms. Okay, here we go.

Just a quick note before we get started. If you're listening to this episode a second time, first of all, wow, we're so excited that you liked it so much that you're listening to it a second time. But if you reach the 20-minute mark and you say to yourself, “This doesn't sound like I remember,” that's because we had to make a couple of changes. There were some data inconsistencies in the citations around that time frame in the episode, and we wanted to prioritize getting you accurate data, so we've made some changes to the audio file to make sure that that data is up-to-date. But thank you for being so astute to notice those changes, and we hope that you enjoy the episode.

Heath: Hi, I'm Sara Heath. I am an executive editor at Xtelligent Healthcare. I write for our Patient Engagement site.

Vaidya: Hello, I'm Anuja Vaidya. I'm a senior editor at Xtelligent Healthcare and I write about Virtual Healthcare.

Kaylor: Hi, my name's Alivia Kaylor and I'm a senior editor of Pharma Life Sciences. I obviously cover pharma and life sciences.

Heath: Cool, so I will jump in here to start because we're talking about chronic disease management today, and I feel like most of us can agree that the patient activation and engagement part of that is important to every aspect of how we treat chronic illnesses.

So I want to start by talking about patient education with their treatments because most of the time they're getting their treatments or taking their treatments at home on their own. So that is use of medications as well as why it's important to take your medications, what you can expect from taking your medications, ditto for any digital therapeutics that they might use and how that's super important.

I think it's really important for there to be some clinician-led patient education at the point of care. There's a lot of data showing that nurses can be super effective in this area. There's one report that I have read about nurses driving patient education, it helps cut medication nonadherence -- which isn't my favorite phrase, but -- it helps cut it down by up to a third. So those are really important.

I do think that things get a little bit sticky with different social determinants of health because those affect a patient's ability to engage with their care. Where I'm most passionate about social determinants that affect a patient's ability to engage with their care or be 'educated,' I'm using scare quotes with that, with their care, it's the idea of the digital divide because healthcare is so digitized now. If you don't have the smartphone that allows you to ask your doctor questions or if you don't have access to the digital therapeutic or if you don't have the digital health literacy to engage with either of those tools, I feel like those get really in the way.

Vaidya: I definitely think that within the virtual healthcare world, this is the perennial push and pull because, on the one hand, you have all these amazing new technologies and innovative remote patient monitoring devices and telehealth and digital therapeutics that can really improve specifically chronic disease management just because of the fact that it can deliver data in real time to clinicians who can use that to make treatment decisions on the fly without waiting for patients to come back in and give them that data a few weeks, a few months in, which is amazing. So, all great things for chronic disease management. But with the digital divide, like you said, it just becomes that much more important for clinicians to make sure patients are actually comfortable using those devices and know how to use them and are able to deliver accurate data. Because if patients are confused, then the quality of data they are sending over may not be great, which in turn obviously doesn't do anything good for chronic disease management. So I definitely think that, yeah, like you said, at the point of care, having the clinician or care team really go through and provide that education and support upfront.

Something else, I think especially when it comes to some of these take-home devices is having a specific team dedicated to managing technical issues and being on call for patients who might need help setting up their blood pressure cuff like at home even if they got a demonstration in the office. And then, we have a couple of companies entering the space to fill that niche. So, one I think is really interesting is that Best Buy Health, which is obviously a retailer-turned-health division situation, they are really positioning themselves as being that niche. So they have Current Health, which is a remote patient monitoring company, but one of the things they tout a lot is the fact that they have their Geek Squad, which is usually your team that helps you with your computers and your TVs, but essentially they're like, 'we are training that Geek Squad to also learn how to use medical devices so that if you partner with Current Health, then you get the advantage of having our Geek Squad that can go to patient's houses and help them with their medical devices,' which I think is very interesting and kind of a different way for a new healthcare entrant to position themselves.

Heath: I think a lot of organizations are also using community health workers for that, which is such a smart, low-cost way of helping to address this need. So that's really cool.

Kaylor: Yeah, I've noticed too, especially during the pandemic, they were really heavily relying on pharmacists to really inform individuals say about COVID vaccines, COVID-19 vaccines, and now I feel like they've really realized how many individuals actually do trust their pharmacists. So now it's another added source of information, which is great in my opinion.

Heath: Pharmacists are so cool. Even if you aren't visiting the pharmacy that day, if you're just picking up toilet paper at CVS or wherever you pick up your medications, you're going to see your pharmacist when you're walking by the aisle, which I feel like there's a lot of power in the pharmacist.

Kaylor: You don't have to schedule an appointment and no co-pay to go to talk to them. Yeah, exactly.

Vaidya: Yeah. Also, it's just easier to get in touch with them versus getting on your MyChart and messaging your doctor. But just call Walgreens when you really just want to be like, 'Can I take this medication and that medication?' Or, 'Is it okay if I missed a day?' That's a pretty low, quick question.

Heath: How many times during allergy season do I walk up and I'm like, 'Can I take this allergy pill and this allergy pill in the same day?' And my pharmacist is like, 'You ask this every year. The answer's no.' [laughs]

Kaylor: A great resource right there. [laughs] I wanted to bring up too, as we were talking about chronic conditions, the fact that our population is aging, so there are many individuals who now have multiple chronic conditions. So I think that especially what you said, Sara, with the digital divide, definitely hard when you're dealing with different doctors. Let's say you're going to an endocrinologist and a cardiologist and all these different specialists, and then there's data silos on different management systems. It's fragmented data across the board and then that just makes it hard to coordinate the care for that specific patient, in my opinion.

Heath: Oh, for sure. I think a lot of people would agree with that. It's a bummer because I feel like that leaves the patient in this position of being responsible for managing that data and having their personal health record, which is great. We love seeing an engaged patient coming in, being like, 'Here are all my notes from my other clinician.' But I also, sometimes -- this is some personal opinion being interjected here, but -- I get a little bit bummed out when I see how much responsibility we put on the patient for their healthcare management. I'm like, they have an entire life. They don't get paid to put together all of these puzzle pieces. It should be so much easier. So yeah, the lack of data interoperability, especially when you're seeing separate specialists, is super hard and just like the wherewithal, 'Oh, did I tell this doctor or that doctor about this thing?'

Kaylor: Yeah, the care coordination, the lack of communication between providers that could lead to duplicated therapies or conflicting treatment. That's horrible.

Heath: Yeah.

Vaidya: And also if you have a chronic condition, you are not in the best physical or mental space to manage all of that. So yeah, it is ... it's putting a lot of burden on patients.

Kaylor: Yeah, exactly. I guess we've talked a lot about the problems here. So we can move on. [laughs]

Heath: One solution, and I wanted to ask Anuja if you've heard this from any people that you've spoken to in the industry, I've heard it a little bit in terms of patient portal access, but -- some of these digital therapeutics aren't always super accessible in terms of cost. Have you heard about any sort of charity care from healthcare organizations or from therapeutic vendors themselves donating these for free to populations in need? I know a lot of health systems are doing that to enable patient portal access, but I don't know about other tools.

Vaidya: I don't know. So a lot of these digital therapeutic tools just usually require a smartphone and things like that. I think if they're working with a big health system or employer, then yeah, usually there is a way, especially with health systems, I've heard of them just giving devices for free and not charging. Usually, they don't charge for those kind of things.

It does create a bit of a barrier because I do know that, especially for like RPM programs, patient eligibility becomes really important and part of what they look for is, 'Do you have access to the internet? Do you have access to a smartphone?' And unfortunately, with some health systems, especially the ones that don't have the resources of a really big multistate one, it could just be that they just don't take those patients into the RPM programs, especially right now where they're just trying to prove efficacy and prove that it works and to get payers to just even pay them to offer it before they can begin. So definitely a big need that needs to be filled, but not seeing a lot of movement there right now.

Heath: I do think, if we want to add a silver lining to that, at least health systems through asking their patients about broadband, they can collect that information and go back to the state and be an advocate and be like, 'Hey, this region of the state, we have all this data that they don't have broadband. So what can you do about that?' But because health systems are so huge, job creators, we all know that, they do have a little bit of leveraging power there. So that could be a little silver lining even though there are definitely some access gaps.

Kaylor: I have a question actually I want to ask both of you. You guys are obviously aware of Alexa --mine's probably going to start talking now -- and these kinds of AI communication devices. I've heard that they are starting to put this in hospitals so that the patients can ask for certain things so that it lessens the burden on a nurse. Maybe it was a question that technology can answer and now the nurse no longer has to come into the room after the button's called and that can save so much time over the course of their day. Have you talked to anybody who has used anything like that?

Vaidya: I haven't talked to anybody, I remember it being flashy news of .. Amazon is adjusting their Alexa devices so that they can be used, making them HIPAA-compliant, things like that. But on an offshoot of that, what I have heard about more recently is ambient listening technology, so like an offshoot of remote patient monitoring where essentially it's technology that is put in patient rooms that just picks up sounds and gives care teams information. So for example, if a patient has a fall, things like that, or if their breathing is not sounding okay, things like that, it can pick up and give that information and then have nurses come in and check and things like that.

Kaylor: Right. Right. I think definitely more room for improvement for maybe upgrading some of those hospital systems, making it more user-friendly for the patient to get information. Instead of just, really, the only information you can get as a patient in the hospital, you have to push a button to talk to a healthcare provider. You shouldn't get up out of the bed and go try to find somebody. They recommend you not do that. So I think that having these other types of systems to provide help may actually reap pretty big rewards, in my opinion.

Heath: Even think of all the things that you might want to ask that don't have any -- I know we're talking about chronic disease management here, but -- don't have anything to do with your clinical care. 'Hey, I don't know how to order my lunch.' And that's kind of a stupid reason to click your nurse call button, but if you can't figure out how to use the system in your room, it might be helpful to have an Alexa companion and be like, 'Hey, can I just order whatever food is on the menu?' Or, 'Oh, I can't get the TV to turn on and I've been here for two days, so I want to watch it.' Right?

Kaylor: Yeah.

Heath: All those low-level things are probably the best application of those types of tools for right now. I don't know if we necessarily want, just in terms of proof of concept and sophistication, I don't know if we need patients to be asking the most sophisticated healthcare questions to these tools, but there are so many low-level, nonclinical needs that probably could be met, and that then frees up your care team to actually address the harder things, including patient education, which a lot of people say, 'I don't have time to do it.' Which is very fair. So it definitely all adds up to the same end goal, I would say.

Kaylor: Absolutely. Shall we move the discussion to prevention now?

Heath: Mm-hmm.

Kaylor: Okay.

Vaidya: Obviously, we talked about some of the more challenging aspects of remote patient monitoring and telehealth, but they are really, really incredibly useful tools to prevent and better manage, I think, chronic diseases. Obviously, the data aspect is huge. The ability of patients to just connect with their providers even in spaces that maybe wouldn't generally think that they could be useful.

One of the more interesting use cases that I've come across in the past few years is using remote patient monitoring and telehealth in cancer care, which is not really something I thought would be possible because when you think cancer care, you think chemotherapy and things that you actually have to physically be present for. But where a lot of hospitals and health systems are now using telehealth, even just simple audio-only telehealth, literally just a phone call to manage symptoms, and that is really helping in reducing patients coming into the ED once their symptoms have already worsened to the point that they need emergency intervention, especially because with cancer care, you just don't know how any patient is going to react to any different treatment, and once you get the treatment, you go home. So just having a nurse call in, or a way for the patient to reach out to be like, "I'm having this symptom. Is it okay? What should I do?" And they can manage it virtually versus getting to the point where this patient who's already managing a really horrifying disease also then has to have these unnecessary stressful ED visits.

Heath: Yeah, I feel like that's the beauty of RPM is that it's allowed all of us to really mitigate a lot of the concerning stuff at home. And I'd be curious to hear what you've heard, Anuja, how RPM can be used even just in patients who don't quite have a chronic diagnosis, but they're prediabetic, for example, how much are we using RPM tools to flag where they are and make sure that they aren't sliding right into full-blown diabetes because these resources are also scarce and reimbursement for them are also scarce. So in terms of risk stratification, are we really using them on prediabetic people? But is there also a ton of potential there? I don't know. I'd love to hear from you.

Vaidya: Yeah, no, absolutely, and I think that gets into the digital therapeutic space because essentially those are defined as software-based programs that are meant to treat conditions. So I do know that some digital therapeutics have a prediabetes program, like a 12-week program where in addition to things like looking at your blood sugars, they'll have nutrition specialists and information on lifestyle changes that patients can make to prevent diabetes or any condition, especially if they look like they're at risk for it.

But I think the big conversation around digital therapeutics has been around their efficacy, because we've had a lot of companies jumping into the space and saying that they have this amazing program that can do X, Y, Z, and thus far hasn't been too much on the investigative side of does this really work or it's just all exciting ideas.

But then, earlier this year there was a report by the Peterson Health Technology Institute, PHTI. They basically had a report that said that there are some very prominent diabetes programs that aren't showing clinically meaningful results. I think this goes to this idea, I know Alivia and I, we've, talked about this a little bit of having the devices, for example, taking diabetes, you have CGMs that are proven to be extremely effective and helpful that are a part of these programs, so what's the misstep? Why aren't they being used as effectively? So we have these programs, we have these devices, but I think making sure that they are actually effective and not just a great idea is going to be the next step in this arena.

Kaylor: Yeah, absolutely, Anuja. I want to flip the conversation on the more proactive side, leaning away from the devices just because I feel like we definitely need to highlight the importance of screening for prevention. I'm not sure we can prevent any type of disease if we're not being proactive and trying to treat it in early stages. Right? Obviously, screening's controversial. The same way, do these devices actually provide the benefits that these companies are touting? We are all pretty much aware that pap smears, right, cervical cancer screenings, they work really well. Depending on the study, they can cut cervical cancer cases and deaths by at least 80%, which, I think, that's great because they're not that expensive to do. However, on the flip side of that, like I said, they're not that expensive to do if you're insured.

Heath: Right.

Kaylor: The numbers sadly drop when you look at the uninsured individuals because they're not going in for those preventative screenings like an insured individual would. Even some workplaces will have, it's probably more common among like higher-earning individuals, but their companies will have health days where they bring in a health organization and they're checking blood pressures, they're doing small screenings, not in-depth invasive screenings, but still they're getting that through their employer for free during work. Uninsured individuals don't get that.

And something that I thought was actually pretty alarming was there was an article, I believe it was the Georgetown University Health Policy Institute, and they were talking about the importance of screening for chronic diseases like cancer, heart disease, diabetes, things that we've all been talking about here, and for instance, in 2015, only half of women aged 50 to 64 got a mammogram, and 63.4% of women aged 50 to 75 had a colorectal screening. Mammogram rates also dropped by 3% between 2000 and 2015. For men aged 50 to 75, 61.9% got screened for colorectal cancer. By 2018, 68.8% of U.S. adults aged 50 to 75 were up-to-date with their screenings, but the numbers dropped for those without health insurance, down to just 40.1%, and even lower for people without a regular healthcare provider at 36.1%.

Heath: That's crazy.

Kaylor: Obviously, we can't solve the insurance problem today. We're not going to try to do that on this podcast, I wish we could. But people with insurance are obviously more likely to get screened. That's the moral of the story here. But significant gaps still exist, though, even in rural and low-income areas. So I think that that's where maybe some of these telehealth devices, these remote patient monitoring, improving the access may help in these areas, but again, I don't know if it's going to help if people aren't being insured.

Heath: Even beyond not having insurance. Insurance obviously has to cover the initial screening. Your mammogram is free, but if you get -- first off, how many patients know that? But if you have an irregular result, the follow-up tests aren't always covered by insurance or entirely covered by insurance. So a lot of people aren't taking the first test, like, 'What if it's irregular and then I have to take the second test and I don't have the money for it,' or they don't go in for the second test. There's also a lot of data about people who just don't really want to engage with the emotional toll that a cancer screening could have. I know I've read a bunch of op-eds about people are still scared out of their minds about cancer and they're not screening themselves for it. So definitely a hard thing.

And then, the last little thing that I'll throw out there is people might even know that the screening is good for them. They might know that it's covered, but they're like, 'I just don't trust healthcare, haven't had good experiences. My family member didn't have a good experience. I just don't want to go in.' And so, I think we need to also be working on ways to show the public that healthcare is here to make you healthy and feel good. Definitely an uphill battle, but I think we'd be remiss to say that there are some people who just for very justified reasons are just very iffy on healthcare as an institution.

Kaylor: Right. It's alarming from my standpoint, just especially because I'm sure you guys have heard about the rising cancer rates around younger adults, those aged between 18 and 49. That's terrifying because those individuals would be the key demographic to go in for those precancer screenings, and if they don't trust a doctor, they're not going to go in and get those screenings and they're not going to catch their chronic illness in their early stages like they should, and that's going to cost them financially, physically, emotionally, which is, I think, really sad.

Heath: I think this dovetails really well into a conversation about care access because what was also ringing around my head throughout all of that is the idea of having a usual source of care, which is so critically important in terms of even just getting your physical, but also those preventive screenings or having a doctor to turn to help you manage your chronic illness. There's 100 million people who don't have a usual source of care in the country, which … that number is wild.

Here's the lead from something that I wrote in February 2023: 'A third of healthcare consumers are being left susceptible to public health threats and complications from untreated chronic illnesses as the U.S. stares down primary care access problems.' And the headline was '100 million people lack primary care access or usual source of care....' These people 'face some kind of primary care access barrier and that includes rural hospital closures and a primary care provider shortage.'

So they can't engage in all of these really cool solutions that we've talked about because they don't have a primary care provider or usual source of care to help coordinate all of that for them.

Vaidya: Yeah, I think that kind of gets to the heart, I think, of everything we've been talking about is that there are solutions, there are great intelligent people working on solutions, but there's just such a chasm between the solution and the person that it could most help. There's so much between those two entities, but until we figure out a way to bring them closer and get those solutions in the hands of the right people, yeah, I don't know. It's sort of a little bit, what is the point of this innovation if it's not actually doing anything?

Kaylor: I think that's where maybe we were talking about digital devices and not having internet.

I think clinical trials too is maybe an area that a lot of people forget is a solution. For example, if you have an illness and you want to join a clinical trial, the clinical trial involves a tablet or some type of internet capable device, they will provide that for you. They also have to provide you with internet. They have to be able to get good data. So with that, they're going to provide all their patients with all of their resources that they need for free, and then you're obviously participating in a study. The catch-22 is if you're in the placebo group, I am so sorry, you probably won't be receiving treatment. However, you are, like I said, it is progressing science and then at least, if the treatment plan does work, those results will come out of that study that you participated in and then you can reap the benefits on that.

Back when they did the Aducanumab, (I butchered that), dementia, Alzheimer's disease trial. I remember some people were just going to the trials just hoping that they would not be in the placebo group and would receive treatment because it was so expensive. They would never, ever obtain that drug unless they were in a clinical trial. And then in that case, if you do get the placebo group that might be sad. But it's science, man.

Heath: That's showbiz, baby.

Kaylor: Yep.

Heath: You mentioned Alzheimer's. I need to give my flowers to caregivers of people with chronic illnesses. Going all the way back to our patient education conversation, if you can get an at-home caregiver or a family caregiver, whoever in the clinic office during any education conversations, that is so important. I just think of the dynamic between my mom and dad, and if my mom was educated on anything that my dad had to do at home, my mom would be on top of him, 'Did you do this? Did you do it? The doctor said you should do it.' So it's so important to make sure that you also have the caregiver. There's so much data at this point. It is a little old, which is why I didn't pull it up, but there is a lot of great data that indicates that people who have a family member in an office visit with them have such better outcomes with their chronic illness.

So just something to think about, making sure that we're also paying attention to the caregivers, making sure that they're supported and have the information that they need to see their loved ones thrive. And also care for the caregivers. I don't know if you guys saw the study this morning, trigger warning of suicide and mental health, but there's higher trends [among] caregivers or spouses of people who are newly diagnosed with cancer, which is very sad, and one of the quotes that I read accompanying the story was essentially, I'm paraphrasing here, we have the mental health resources that we provide to the patient, the cancer patient, and this is just showing a glaring lapse in how we care for caregivers. Again, I just have to mention them because I feel like that is definitely an unsung part of this entire equation.

Vaidya: I'll quickly add to that, especially with virtual care devices and tools, having that younger family caregiver is huge. I think a lot of clinicians depend on, especially if the patient is older and not comfortable with technology, one of the questions they ask is: 'Do you have someone at home that can help you with this?' So even in terms of increasing access to those tools, having a caregiver that maybe is better versed in technology can really move the needle there.

Kaylor: Yeah, Anuja, that's a good point. Bringing it full circle, as I said, the population is aging. We are getting multiple illnesses, so I think that as the populations do age, obviously the younger generation as they age, they're going to be more and more comfortable with technology just because technology is rapidly evolving. However, these older patients that may not be as familiar with smartphones, these smart devices, smart watches, all of these devices that could help...I think that it's definitely, like you said, definitely important to have a younger individual to teach them. Definitely more meaningful coming from a younger loved one than just a healthcare professional who--and that's not their job, the healthcare professional, they're not a tech expert. They're a healthcare expert. Right? Taking another burden off the healthcare professional by asking your caregiver a question that they can easily answer and show you in person anytime that you need. Right? So yes, an extra clap and cheer for them.

Heath: Cool. So I guess maybe to wrap up some final thoughts. We didn't talk about this a lot -- which is why it's my final thought -- is the idea or the role that social determinants of health play in this whole conversation, they're really important. I will say, though imperfect and there are a lot of barriers, it's an area that I'm very hopeful for. I feel like I've made social determinants my entire online identity in the past decade that I've been at Xtelligent. And I've definitely seen the conversation progress from 'this is a term that we're starting to widely use, some people don't like it,' and now it's just given that these are a thing that needs to be fixed. So, it's nice to know that, again, while the work isn't perfect, it's really nice at least seeing the progression into something that everybody is super jazzed about solving for. Want to end on a high notice that I'm hopeful about us moving the needle on social determinants and how they affect chronically ill populations.

Vaidya: Jumping off of that, I do think that that conversation is really, really helping device developers, people within health systems that want to implement some of these really new technologies, new digital therapeutics, new telehealth programs. Just having that conversation I think immediately puts hopefully some of that burden that we currently put on patients back onto health systems, onto device developers to really think through how their solutions are going to get into the hands of people, what that patient journey looks like. I know in the virtual care world, there's a lot of talk about the patient digital journey, which I think is super important because you really have to think through every step of what the patient goes through to really even make any of these programs and tools and devices, to make them effective, you really got to start with the patient. And I think that is happening the more kind of social determinants, health equity come into the conversation.

Kaylor: Yeah, Anuja, I think that's definitely a good point. One resource I'd like to point out for our audience to be aware of is a website called findhelp.org. What you do is you type in your zip code and it will pull up many different resources, food, housing, financial assistance, healthcare, dental even, stuff like that. But I wanted to definitely let our audience know that this is here for literally everyone. I was made aware of this site by a social-worker-turned-doctor. And that person said that this website is something that every single healthcare professional should be made aware of.

For example, you can just go in, type in your zip code, and it will pull up a whole list of different ways to find help. For example, obviously we're talking for health, so you go into health, they have lots of links just in my area code for 'health education.' There's 360 links alone for 'health education' in my zip code that I just pulled up here. 'Help pay for healthcare,' 356 links. Medical care, mental health care, sexual reproductive health, vision care, end-of-life care, addiction recovery. I think that this is definitely a great resource, especially for those that we talked about who may not be insured and are looking for ways to find cheaper healthcare or maybe subsidize their healthcare. Anybody who is in that position, I think that this resource would definitely help.

Waddill: Thank you to Sara, Anuja, and Alivia for starting off our season right. And thank you, listener, for tuning in. If you liked what you heard, head over to Spotify or Apple and drop us a review. We'll be choosing some of our reviews to be read on the show in appreciation, so keep listening through to the end because you might get name-dropped.

Speaking of getting name-dropped, today's review by Obacker19 on Apple podcasts name-drops, our own executive editor, Sara Heath. They wrote, 'Whether you're well established as a healthcare innovator or just getting started as a catalyst for change, this is a must-listen podcast for you. Sara and the entire Xtelligent team do an incredible job leading conversations that cover a huge breadth of topics related to the ins and outs of building a thriving healthcare ecosystem with leaders who actually experienced success themselves. Highly recommend listening and subscribing.' Thanks so much Obacker19, and thank you all for listening. See you next time.

Music by vice president of editorial, Kyle Murphy. And production by me, Kelsey Waddill.