A Hypothesis
• Part 1: The Ineluctable Smell of Beer
• Part 2: Two Things Happened
• Massless Ropes, Frictionless Pulleys: Coordinative Communication
• Part 3: Money Flows Through It
• Part 4: The Proliferation of Organizations (Or, Crabs in a Nash Equilibrium and Other Observations)
• Part 5: The Proliferation of Industries (Or, Your Premium Dollars Pay for These)
While I may not be in a position to compare the quantities of coordinative communication required by different nations’ health care system, I have all these observations about the US health care system, which are notable because they’re things that are, apparently, pretty invisible to people who don’t work in it. At least, I never see them discussed in the public discourse.
They fall into two categories: the proliferation of organizations and the proliferation of industries. In this post, I’m going to talk about the proliferation of organizations.
I’ve already touched on the topic of how organizations have been proliferating in the healthcare system, back in Part 2:
This is a pattern of introducing middle-men that has proliferated throughout the finance side of health care: “Hmm, this part of our enterprise sure is expensive! Why don’t we spin it off as an independent business or outsource it? Surely some enterprising entrepreneur can figure out a way to do it more cheaply than we can, so we’ll just black box the problem and pick the lowest bidder to solve it for us.”I gave two examples of that pattern: (1) HMOs shifting from hiring doctors to hiring organizations that hire doctors, and (2) How in Medicaid money becomes MassHealth money becomes industrial insurance company plan money becomes subcontracted insurance company plan money.
There’s problems with the proliferation of organizations. One of them is that all these proliferating organizations’ employees need to be paid. Every organization that participates in ultimately paying for healthcare sips up some of the money that’s flowing from premiums into healthcare, as explained in Part 3.
Now, that’s not obviously a problem; if it were, nobody’d do it. The whole idea behind organ-ization is to reduce cost. The HMO hires a firm that hires doctors because it believes (correctly, we must assume) that those firms can hire and manage doctors more cheaply than it can itself. Which is not at all impossible. The HMO may decide, “You know what? Managing a medical practice is hard and outside our expertise; somebody who actually knows what they are doing could save a lot of wasted wage time and money. We should totally hire somebody to do this for us.” A service organization can specialize in one part of the process, and thereby get really efficient at it and comparatively cheap, at which point it makes sense for a health care provider organization to hire them to do that for them. IT services, for example: a small clinic can’t afford their own full-time IT staff, but they can maybe hire an IT management/support service part time.
What’s not to love?
Well, for one thing, most of those organs are for-profit. That, itself, is not bad or wrong, but it is expensive. When you outsource a business function to another organization to reduce your cost, not only must the outsourcer’s employees need to be able to do your business function cheaper than you can, they have to be able to do it enough cheaper that the difference can also pay whoever owns the organization being outsourced to.
I’m not saying there’s something wrong with some enterprising entrepreneur founding and running a business which provides health care providers with some coordinative communication service that would otherwise cost them more, and to make a handsome profit in doing so. That’s capitalism, and that’s what the rules of our society say you get to do. More power to you.
What I’m saying is that maybe it should take us aback that our health care system incurs such extreme coordinative communications costs, that paying all those people to handle it is actually more cost effective than not. We could look it as a sign of just how out of control our coordinative communications costs have gotten that paying all those additional CEOs’ salaries is something the system can afford.
When we compare a less organ-ized health care industry with a more highly organ-ized health care industry, we’re not comparing a bad thing with a good thing. A highly organ-ized health care industry, that saves money by having lots of specialist layers, all of which must be paid for, may be better than a less organ-ized health care industry, in terms of controlling the costs of coordinative communications. But it’s not actually good. It’s merely less bad.
I propose that we should look at all those proliferating organizations, all those layers of middle-men, as kludges. As epicycles rationalizing errors. As the duct tape holding together a system that is losing its structural integrity. They make the system more bearable than it would be without them, but that doesn’t mean they fix anything.
Or put another way, when Neighborhood Health Plan (which, as I mentioned previously, is not a plan but a company) outsources the mental health component of its insurance product to Beacon Health Strategies (which it does), the premiums of NHP customer-patients have to cover both NHP’s expenses and BHS’s too. Wouldn’t it be nice if NHP could manage to offer behavioral health care insurance services, without having to outsource to BHS, so we didn’t have to pay for BHS’s CEO and BHS’s profits out of our premiums? But they can’t. Apparently. At least: they don't.
Wait, it’s more horrible than that: NHP is a non-profit organization. NHP, a non-profit organization for providing insurance to the indigent, is outsourcing to a for-profit company to... provide some of the insurance to the indigent they’re supposed to be providing. So it’s not like NHP is sharing some of their profits with BHS. NHP doesn’t have any profits to share. By outsourcing to BHS, it’s as if they’ve introduced a whole new line item expense, “corporate profits”, that has to come out of the premiums stream.
As I said, I’m not opposed to clever businesses making a profit by doing something well, or even just cheaply. And I’m not complaining that BHS charges for saving NHP, and ultimately us, money – as well they might, and it’s money well earned if they succeed. I’m not complaining about NHP hiring BHS and paying their profits from our premiums to save us money. I’m complaining we have a situation in which that trick can even work.
Assuming, of course, that it does work. Which brings us to the next problem.
While organizations do outsource in an attempt to reduce costs, I have a deep suspicion that it usually doesn’t work, and that it isn’t really working in health care now.
I come from high-tech. In that world, outsourcing is enormously controversial, and subject to extensive thoughtful criticism and analysis. High-tech is a community of practice with a very... opinionated... attitude about outsourcing, treating it as a powerful tool – one amply powerful enough to destroy your business, if you’re not really careful with it. It is a community of practice with ideas about when it is and is not likely to be feasible to outsource.
I see none of that wisdom and contention in the health care sector. Instead, I see a lot of wishful thinking, coming with a whiff of desperation. “We’ll just offer to pay somebody to do it for us, and despite the fact we’ll have to pay their profit margin, they’ll somehow still save us money!”
And I say that because I see no thoughtful critique of the effects of outsourcing on the delivery of services, to say nothing of the bottom lines. Since my experience with outsourcing in IT leads me to believe it’s highly prone to slashing quality while enriching nobody but the contractor if not really carefully done, and I see no discussion of that, I find myself dubious that there’s much honesty in the discourse.
I suppose it is possible that outsourcing just works better in health care where actual human lives are at stake than in building websites, and that’s why outsourcing is not controversial in health care. I suppose.
Or, it’s possible that BHS isn’t actually managing to save NHP any money, but NHP is stuck with them now, and doesn’t particularly want to admit that it turned out not to work. That is, I don’t know that it’s not working, I haven’t heard anything to that effect – but I wouldn’t expect to.
One of those bits of IT wisdom is the aphorism, “Never outsource your core competency”. Your (if you are a business) “core competency” is the thing you are good at that people pay you for. NHP’s core competency might be reasonably assumed to be providing health insurance. Which is what makes their decision to outsource part of providing health insurance to BHS look very dubious, very unlikely to work out well, and suggests to me a move of economic desperation.
There are other things not to love about the proliferation of organizations in the health care system, like the fact that it’s an utter patient privacy fiasco. (HIPAA was not created to protect you from this. HIPAA was created to protect this from you. This is what HIPAA was created to enable.) But that’s a different class of problems; we’re talking solely about financial costs.
What else isn’t there to love about the proliferation of organizations? Nash Equilibria.
So far, I’ve been hand-waving through the difference between organ-izing within an organization, and organ-izing of an industry, the later of which comes about not from organ-izing of organizations, but by organizations outsourcing. Outsourcing is delegating a business function to an external organization.
Here we come to the place where the distinction matters a lot. There is a huge difference between having, e.g., a billing department and hiring a billing company. And that difference is in the differing power structures those two organs function in.
A billing department exists under the same hierarchy of decision-making authority as the rest of the company. While whoever heads that department gets (or should get) a certain degree of authority to make decisions on how that department will function, that department will not (or should not) be permitted to make decisions that advantage the billing department at the expense of the company as a whole. There is someone, presumably, in authority over the whole company who arbitrates conflicts between perspectives within the company, to maximize business success for the whole of the enterprise – someone to keep their eye on the big picture, and make sure the localized decisions made by organs within the organization don’t sabotage it.
But a billing company has no such common manager over both it and the organizations it works for. There is no party with authority over both, who can mediate relationships for the best of both. A billing company makes decisions based, first and foremost, if not solely, on what is best for it as a company. It does not have to take the well-being of its customers into account, and should its own interests be in conflict with those of its customers, it will chose its own interests over those of its customers.
Consider the most extreme scenario: a billing company can decide not to do business with a customer organization any more. They can decide “we don’t do small accounts” or “we don’t do labs” or “we don’t do medical billing” or “we don’t like your tie”, and, sucks to be you, you’re out a billing company and need to find some other billing company to take your money. I think it’s fair to say that it generally doesn’t happen that a billing department tells the rest of its organization that it wants nothing more to do with them and won’t be doing their billing any more. A billing department doesn’t get to decide to do that. A billing department doesn’t get to reserve the right to refuse service to the Radiology Lab, or to the CEO.
This is not a trivial difference. Because there is no shared decision-making hierarchy over the various independent business and governmental organizations, there is nothing – nothing – stopping them from acting in their own best interest at the expense of the other organizations in the health care system.
And I mean “expense” entirely literally.
The proliferation of organizations sets up an inadvertently antagonistic system, where each entity in it attempts to optimize for its own function, and there are no incentives for minimizing the expenses to others. Organizational boundaries become enormously enticing rugs under which to sweep costs – or perhaps it would be a better metaphor to say they’re walls over which to pitch hot economic potatoes.
Given a choice of absorbing a moderate cost in one’s own organization or reducing it by increasing another organization’s costs a lot, of course an organization is going to decide to reduce their own costs.
Psychiatrist Dinah Miller provides us with a great example:
Preauthorizing medications. This was by far the biggest complaint by psychiatrists. One noted that it had taken her 2 hours the night before to get a medication authorized; another had spent an hour that day on it. Another rough figure I got was 20-60 minutes a week, and it was noted that preauthorization often is required for very inexpensive medications. Another psychiatrist said her office manager spends a couple of hours a week on preauthorizations and that she had to give her a raise to get her to agree to do it. Personally, I feel insurance companies should not be permitted to divert physician time away from care for inexpensive medications. Does it really make sense to have a physician spend 20 minutes of uncompensated time getting authorization for a medication that costs $10 a month?Well, it certainly makes sense to the insurance company. For the insurance company to make the doctor spend that time incurs no direct cost for the insurance company, and possibly saves them money by discouraging the provision of that medical care (the medication). So the insurance company saves themselves the $10 by costing the physician many times that.
As I explained in Part 2, the insurance company wants a veto on certain expenditures. Requiring prior authorizations is their way of requiring doctors to ask in advance for permission to prescribe certain medications, if the insurer is going to be paying for it. The insurer does not offer to pay for the doctor’s time in calling up (or faxing) the insurer to say, “Hey, I want to prescribe this med, are you cool with that?” The insurer just requires that the doctor do it. This, theoretically, allows the insurance company to oversee the doctor’s prescribing choices to control costs, so, insofar as it works to that end, it reduces the insurers’ costs – at the expense of doctors’ time.
Thing is, doctors’ time isn’t free, even if nobody’s directly being charged for it. Here’s the gruesome punchline: this quote of Dr. Miller’s is from her recent post on why there aren’t enough psychiatrists to go around, leaving very, very mentally ill people without care:
Recently I was contacted by a reporter who wanted to speak to me about why it’s so difficult for patients to find a psychiatrist. […] She then told me about an insured man who had been diagnosed with schizophrenia and substance abuse who was unable to get an appointment with a psychiatrist. She asked me an interesting question: “Don’t psychiatrists want the challenge of treating the difficult cases?” The patient in question never did find a psychiatrist in time and he ended up committing a murder then dying by suicide – an awful tragedy that highlights access to care problems.And that is precisely the problem with the proliferation of organizations: because nobody oversees the big picture, nobody is in a position to tell any one organization in the health care system, “No, you aren’t allowed to reduce your own costs in this way which multiplies the costs of another organization so extremely.”
[…]
The problem is that demand for treatment at outpatient clinics is high, and sometimes the waits for an initial appointment are long, or clinics even may stop accepting new patients at times when they get overloaded. […] And then the reporter asked me another interesting question – with such long waits, why don’t the clinics hire more doctors? I explained that there was a shortage of psychiatrists and began to talk with her about demands on physician time that take time away from patient care. […] she heard a lot about the factors that drain physician time and money, both limiting how many patients a psychiatrist can see and driving up the cost of care.
By the time I got off the phone, I decided to tally all of the things that we are required to do to see patients. I was able to get some quick help on the listserv, from friends, and on Twitter.
Every time an agency or insurance company sets up a requirement for a physician, there is a small diversion of time. There is no limit on how many different requirements can be set or whether they need to be relevant to the physician’s work. While I realize there is little sympathy for physicians who, for the most part, are still blessed to earn a good living while doing meaningful work, these diversions add hours to a doctor’s day and cause them to burn out more quickly. So the insurance company that demands that a physician devote 20 minutes to get authorization to prescribe a medication that costs pennies a pill is actually harming society. And no one oversees the big picture.
It’s crabs in a bucket: all of these organizations in straitened economic circumstances, trying to minimize their expenses in ways which advance their own ledgers one cent by shoving others’ back two cents – or ten cents.
But here’s the awful thing: it all has to come out of premiums. Since ultimately there’s only one revenue stream, all this cost-shifting causes the overall costs in the system go up.
In game theory, this is what is known as a Nash equilibrium: a situation among vying, non-cooperating parties, where if each pursues its own best strategy for maximizing their own position, everybody winds up worse off than if they’d been able to cooperate.
You know, like in the Prisoner’s Dilemma.
Nash equilibria are states that systems get stuck in, states that are suboptimal for all the parties in them, because the only way out is for at least one party to unilaterally do something disadvantageous to themselves. Some can only be resolved by all parties unilaterally acting to their own disadvantage.
It is really, really hard for a for-profit entity to do that. Like, something close to impossible. It pretty much requires visionary leadership that is willing to put some principle higher than their loyalty and duty to their own enterprise, and has the authority – typically meaning a private owner – to do so.
Returning to Dr. Miller’s blog post, most people who can’t get psychiatric care don’t kill others or themselves – well, not directly. But here is another example of cost shifting by incurring expenses in other organizations. People in crisis who can’t get psychiatric care any other way do wind up presenting before the treaters of last resort: emergency rooms. Which was precisely what Obamacare – and before it, here in Massachusetts, Romneycare, and before either of them the HMOs – were trying to prevent: using very expensive emergency room care instead of lower cost clinic care. As Dr. Miller alludes to, when providers have to limit their case loads of clients simply to have enough time to do all this additional coordinative communication, society winds up with less total care available to the population, and thus we can wind up with a situation where (even more) people who need care go without. Because clinicians are spending time on hold with insurance companies getting pre-auths for $10/mo medications, instead of seeing patients who need help. So those patients wind up in emergency rooms.
It is beyond frustrating to me that insurers economically put their boots to the throats of mental health care providers, while smiling for the cameras and shrugging innocently and saying, “Hey, we totally were willing to pay for care; the patient had psychiatric coverage and everything. What does the shrink shortage have to do with us?”
You’d think they’d notice about the emergency room utilization, but I don’t get the impression that they do. Look: Jan 1 2013 CPT introduced a new billing code for emergency psychotherapy: 90839. That would be when the patient in crisis shows up in my office instead of presenting at the local hospital’s emergency department and I either stabilize them and save their insurer thousands on an unnecessary inpatient admission, or do the coordinative communication work necessary to make hospitalization go smoothly, like procuring the patient’s med list and apprising the EMS team about how to keep the patient calm in the ambulance, and thereby save their social workers the labor/expense.
Doesn’t 90839 sound like a fabulous idea? You could pay a therapist quite a bit of money for a 90839 and still save oodles on hospital bills.
You know how much a 90839 pays? $0. To my knowledge, there is no insurer at all who pays for it. If Medicaid or Medicare started paying for it, it’s subsequent to May 2014 when I attempted to bill against it to find out the answer to that empirically. So my clinic gets stuck billing for a 50 min hour even if a patient shows up in crisis and absorbs 4 hours of my time. (Not an invented example. Yes, I’m bitter.)
So I think I have a reason to suspect they’re not really attentive to how emergency room usage is driven by inadequate compensation of outpatient providers. And allow me to point out how I manage the economic fact that compensation from insurers is so inadequate to cover the expenses incurred by many of their patients’ needs and their own coordinative communication demands: by regarding all insured patients as charity cases/quasi-pro-bono work, and limiting the number of patients I accept insurance from. I.e. by not taking very many of them. I work a fixed number of hours at a clinic for the indigent (pretty much All Medicaid, All the Time), and everybody else gotta pay me cash on the barrel-head. Because that way I don’t have to live in a cardboard box under a bridge, which is what happens to health care providers who accept insurance when patients need four hours of your time and their insurance only pays for one. But more on that below.
It may be that payers (insurers) literally have no idea what the consequences of their policies are. Why would they? Those consequences all play out on the other side of an opaque organizational boundary.
All of which is the next thing not to love about the proliferation of organizations. If the purpose of organ-ization is to manage the costs of coordinative communication by routinizing it and limiting it, then necessarily organizational boundaries are opaque boundaries, through which little stray information passes. If one organization multiplies the expenses of another, it may not ever know. It’s happening to people they do not talk to and whose affairs they really aren’t party to.
Which brings us to the thing that may be the most horrible of all. All the above, though counterproductive to keeping overall health care costs down, at least are counterintuitive unintended results of good-faith attempts to reduce costs. But in addition to those, I even see evidence of parties increasing other parties’ coordinative communication not to actually (attempt to) reduce their costs, but to seem like they’re doing something. They impose requirements that incur coordinative communication costs for the good of... well, the good of something other than keeping costs down.
For instance, in mental health care today in Massachusetts, various payers and authorities (e.g. the state) require certain documentation be made and stored by treaters, but not actually submitted to them – or used by anyone.
By "require", I mean, it's made terms of payment/authorization to treat that treaters manufacture this documentation, and hold it for the requisite time period (many years), and, also as part of the terms of payment/authorization to treat, the payer/authority can conduct audits to verify that this is being done. Which they periodically do, spot checking a random handful of patient records.
Example: I mentioned in passing in Part 2 that in my job at the clinic, I am (well, the clinic is, but we therapists get stuck doing it) responsible for “coordinating care” with the patients’ primary care physicians (PCP, aka GP in the UK). I have at least one form that I have to send off asking the physician to send a report back as to the health status of my patient.
Now, I’m sure this sounds like one of those fabulous ideas. “I know! We should require therapists and doctors to collaborate for continuity of care! It will be totally great for the patients!”
But let me tell you a secret: I am not a medical doctor. As an LMHC, there was nothing in my highly-state-specified course of training that had anything to do with understanding physician’s reports. In fact there is nothing about physical health in the program of study specified for the LMHC in the regulations. I managed to score a course in psychopharmocology, but that was an elective, and I only had the open elective due to the very weird course of study I was in – there were only three other students in the class, and one of them wasn’t a clinician in training (science teacher).
When it comes to the practice of good old fashioned somatic medicine? I, like every other non-MD, non-RN member of my profession, am just as much a layperson as the guy who drove the bus to take you to your physical. And I, like every other LMHC, LICSW, LMFT, and AFAIK PhD and PsyD, have about as much business interpreting non-psychiatric medical information as that bus driver does.
Meanwhile, I can only hope that the MD on the other end of my correspondence had a psychiatry rotation, back in med school, however long ago that was.
I, as a non-MD, have no idea what if any information a patient’s PCP might want from me. When I detect interesting medical problems – it is not that unusual for patients to disclose to me things they haven’t told or taken to their doctors – I route patients to their MDs, and even run interference as necessary. But other than, “Hey, your patient is having problems urinating and is too embarrassed to tell you”, I’m not sure what they want of me. (And this completely ignores whether the patient wants me conferring with their PCP. For some reason, many of my patients diagnosed with substance dependence aren't keen on their PCP being notified of that fact.)
Nobody cares. We just have to have the paperwork. I send the PCP the form asking their report, and they, sometimes, send it to me. In some cases (NHP/BHS, actually) I also have to fill out a form about what I’ve diagnosed the patient with, and send it to them. Then we each file the paperwork we receive, so it’s in our respective charts. Neither of us is required to understand a word of what the other says. Or be able to read it – some physicians hand-write their responses and then fax them. “Pt + for smudgeitis, scrawlalgia, scribbledrome.”
But by gum, the payers/authorities, they can say that we have it in the charts. Such a good job they're doing at making us health care providers responsible! And best of all, they don't have to pay to collect or store or review a byte of it; they only have the cost of having a few people do an audit once a year, at most.
And if for some reason it’s useful for them to be able to find the patient’s annual physical report in the patient’s therapist’s records, they got that too: they can have this information if they want it.
And they have gotten this wonderful feature for almost "free" – meaning their expenses didn't go up to cover it. They have offloaded almost all this reporting burden onto providers. That burden includes not just the labor costs of producing and organizing that information, but the cost of securely storing the ever-increasing body of highly confidential medical records – which includes not just those of present patients, but those of ex-patients, who the health care provider isn't even being paid to treat any more.
I'm not saying it's wrong to require that (or any other) information to be made or stored, though I will admit that that example has a particular absurdity to it. I'm saying that it costs a lot of money and nobody has ever done the ROI to decide whether it's worth it. I’m saying that it’s actually quite a huge cost that gets invisibly off-loaded onto providers and provider organizations, and that has consequences.
The very opacity of organizational boundaries means that when organizations impose costs on other organizations in the system, they don’t see the consequences for themselves, and that makes it incredibly tempting to them to do that for the most trivial and specious of reasons. It invites Othering of other organizations and their members, the dismissing of others’ concerns and problems as illegitimate or unimportant. “Oh, those doctors, always whining about paperwork!” “Oh, those insurance companies, always trying to pinch pennies!”
In this example, the payer/authorities get to pretend that information is free by ordering treaters to generate it without compensating them for doing so. Treaters have little to no option to refuse, so they have to eat the cost to accept insurance/keep the institutional license, i.e. stay in business. But of course, the treaters – both treating institutions and treating individuals – can't absorb infinite off-loaded expenses. They'll be driven into bankruptcy. So they have to increase prices to compensate.
Which is exactly one part of the phenomenon everyone’s puzzling over: why the “sticker price” of medical care is so much higher in the US.
I think, though I am not certain, that all of these observations are either problems or potential indicators of problems which are specific to subjecting healthcare to capitalism.
Outsourcing, and the organ-ization of industries, is, well, industrial. It's attempting to use the market to solve problems of cost-control. The relationship between an organization that outsources and the one they outsource to is contractual and financial.
My impression is that single-payer countries don't have this problem: they might proliferate organizations, but there remains a central authority with the power to resolve Nash equilibria amongst them that start hemorrhaging funds.
This suggests a potentially useful line of research: is there, as I suggest, a correlation between the proliferation of organizations in healthcare and the cost of health care, across nations? For that matter, do single-payer states have less proliferation of organizations?
Some of these observations I make here (e.g. cost shifting) are reasonably obvious within the health care sector, but not widely known outside of it. Some of these observations (e.g. the perils of outsourcing) seem to be obliviousnesses specific to health care that other industries would recognize immediately. I think the discourse about health care costs is better served with them coming to light.
None of these observations are “smoking gun” conclusive evidence that out of control death-spiraling positive feedback loop driven coordinative communication is what is driving the cost of health care so extremely in the US. It’s all circumstantial. But I think it’s very suggestive.
These are some of the things that I observe that incline me to my hypothesis that the Two Things Happened. These observations I’ve itemized here don’t prove anything, but they certainly to me seem to be pointing in the direction of exploding coordinative communication, and crying out for investigation.
TO BE CONTINUED
This is the fourth part in a multi-post series about a hypothesis I have about the nature of the escalation of costs in the US health care system. (Part 1, Part 2 Part 3) We are now up to 14,980 words – 18,680 if you include Massless Ropes, Frictionless Pulleys – and still climbing.
The next segment, Part 5, which has the working title "The Proliferation of Industries", is going to tackle the other category of observations – the proliferation of industries – to provide even more examples of how the previously discussed proliferation of coordinative communication interacts with the down-hill rushing cataract of premiums. (Spoiler: absorbantly!) Stay tuned.
I can only afford to take the time to write like this because of the generosity of my patrons. Thank you all for giving me the opportunity to do this.
If you're not one of them yet, and you like what you're reading, please consider funding my writing through Patreon.
This post brought to you by the 49 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.
Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!