Site of care: A longitudinal review

- [Moderator] All right, well go ahead, let's go ahead and get started now. Thank you so much for taking the time out and joining today's "Site of Care: A Longitudinal Review" webinar. But before we get into today's content, I do just wanna walk through a couple of housekeeping items on the next slide that you'll see during your webinar. For managing your audio, there are two primary ways that you can log into and listen to this webinar. The first is through your telephone, and this is the method that I typically have the most success with. However, you do also have the microphone and speakers on your computer as well. So if you can hear me, that's wonderful, but I will go ahead and leave this screen up for just a second in case anyone is having any difficulty at this time. And while I do this, I also want to highlight your ability to ask questions throughout the session. Within your WebEx panel on the far right of your screen, you should see a Q&A section towards the bottom of the panel. If there are any questions throughout today's presentation, please feel free to go ahead and type your questions in and send them to us. We'll be monitoring them throughout the session and saving time at the end as well. All right, and with that, I will go ahead and turn it over to our presenter, Brooke.- [Brooke] Wonderful, thanks Lily, welcome everybody. Good afternoon for the East coasters and I still think we're morning for Central Pacific Coasters, but I'm joined here today by my colleague Allison Garrett, I'll give her a second to introduce as well. My name is Brooke Cardile, I am a Director here at Optum over our value management team and I came to Optum by way of the advisory board, started with them back in 2017 and have been with Optum ever since. Looking forward to talking to you about site of care today.- Hi everybody, I'm Allison Garrett, I'm a Senior Director over our value management team as well. Just like Brooke, I came over as part of the advisory board originally and excited to talk to you guys about what the data is showing about the shift to various settings of care in the outpatient space.- Great, and so let me go over a quick agenda and then we'll be jumping right in. And so as our topics consist today, we're gonna do an overview of site of care landscape from the provider perspective, then we'll jump into honing in on what is driving ASC growth and service outlook, moving to how does that service outlook impact ASCs versus HOPDs, and finally, what is the longitudinal market data telling us and how can outmigration affect your hospital? So there are several site of care shifts, some emerging and then some longstanding that are poised to impact providers overall. Surgical care that you can see bucketed on the right is going to impact providers the most. Predictions are showing that within the next five years, ASCs are likely to grow into higher complexity services associated with higher revenue and profit. Today we will focus in on ASC trends and marketing considerations. But first, I'm gonna spend some time reviewing these other four domains. Diagnostic services, so health plan steerage committee is expected to set the pace of shifting imaging volumes out of the HOPDs. Imaging has all of the makings for a service that is right for shift. It has high price, high volume, elective, and less differentiation on quality. Despite these factors, the HOPD setting really remains the dominant site for advanced imaging for approximately three quarters of the markets across the country. Plans have adopted more aggressive tactics to steer patients to cheaper sites such as waiving copays or removing coverage for HOPD. Many of these tactics have been implemented nationwide for several years and are likely to persist and expand. Other areas slated to expand are convenient care clinics in digital health. Both are poised to help move the needle on the overuse of the ED. And top factors include social determinants of health, lack of patient engagement and education about other care options for common reasons, voted by providers for current misuse. There really is no quick fix, excuse me, to reducing inappropriate ED utilization. But there's a concerted effort to address these root cause issues, as well as new approaches such as virtual first health plans could help to make progress. Physicians may acknowledge ED avoidance is critical to improving care and cost, but it's really unclear if they look at virtual care as an advantage to them. I also wanted to share this slide where sweeping innovation in telehealth isn't currently an option to replace in-person care. I thought it would be useful to share a Rural America growth model, and this is covered by Aspirus. Aspirus is a health system in Wausau, Wisconsin, where they're focusing on critical access specificity because although the goal is to expand, they also need to be able to do so on a delicate balance between staffing pipeline and also providing care that's attainable for patients. Through that critical access specificity, they've established frontiers and then super critical access hospitals. The frontiers are EDs with a few beds in clinics that maximize the ability to offer onsite care to those rural communities. And then they have those super critical access hospitals that encompass outpatient surgeries, orthopedic surgeries, OB, et cetera, to be kind of the point of care for more generalized care that's not too close, but not too far from those centralized patient regions. They also, again, back to that delicate balance point, sites can't be too dispersed because that's inefficient, but care should remain as local as possible so access is attainable. A good example of this is cancer patients, obviously they can't drive hours for intravenous therapies that they're receiving weekly or biweekly. Challenges here still persist with staffing pipeline. I know this is kind of a topic we consider to continue to talk about, but worker shortages are a nationwide issue. Aspirus is particularly targeting this by working with local community colleges to create feeder programs, looking to employ talented young people before they leave the area. Another area where staff pipeline is crucial is the home health space. Providers are optimistic about the opportunity to deploy home-based care models, although research is still showing that only 1% of inpatient volumes nationwide have moved to homebased. So there are significant challenges with scalability. Staff retention is a major concern, other things like access to technology, supply chain coordination, physician and patient adoption, and then sustainability and the reimbursement model are other infrastructural hurdles that will need to be balanced. All right, so making it to our final point, the surgical care space, let's double down on the implications for procedures and service line shifts, given this is still projected to be the largest individual factor changing the landscape of site of care. Surgery has been shifting to ASCs and there are a number of reasons. One is policy and regulation, so CMS continues to approve more procedures for ASC payable. Provider competition, docs own ASCs, which naturally influences provider preference to treat patients there, there's purchaser preference, so there's specific payer incentive programs, in order for patients to be shifted to the ASC location. And then overall innovation technology helps ensure quality of care is maintained. ASCs can facilitate both efficient and effective care, which sums up nicely why they can be so compelling for regulators, payers, and consumers. This slide is more food for thought. I thought it would be interesting to look at how specifically doubling down on health tech innovation will cause shifts in surgery. Notice a couple of the ones that I've highlighted in blue, that flexible hybrid operating rooms will increasingly be the standard of care for inpatient surgery. So moving towards how can we, although operational complexity persists for surgery, how can we shift our locations to have those more flexible and hybrid operating rooms? And then the other bucket under increased competition is again around surgical robots. Another tech space that we've spent a lot of time in in the surgery world will help to multiply, sorry, excuse me, will multiply ambulatory surgery centers across the globe. So we can expect to see more surgical cases being done, surgical robotic cases being done in the ASC. Wonderful, I'll turn it over to Allison to cover how each player can prepare for procedure shifts.- [Allison] Absolutely, so jumping in at this point, we wanna sort of talk about, this actual shift into general outpatient settings. We're using ASCs as one particular setting just to sort of do this deep dive and sort of show you all of the ways that we analyzed this shift starting with sort of, what is shifting, what do we project to continue and do we see that actually playing out in the market as well as some of the financial implications for it. So let's just start with assuming that this shift to outpatient, this shift to ASC is coming, how can you prepare? So health systems we think should really hold, they hold the procedure market share currently. It's not surprising to say that it's worth considering whether you should build or partner. If you're thinking more about like independent providers, there's an opportunity to capitalize by offering more access points for procedure care and push to something like a freestanding setting. And then from the payer perspective, we're thinking they should preserve their specialist independence and capitalize on lower cost care settings. But most importantly, we think that in order to be most prepared, you need to weigh a multitude of factors and that includes looking at growth rates, looking at procedure offerings, looking at the actual trend in the shift to outpatient that is both sort of the maturity of your market, the competition in your market and market size. And then let's actually look at some claims data to show what's happening in these various settings currently, where is there outmigration, consumer behaviors, cost benchmarks, the whole run. So that's what we're gonna be looking at next. Moving forward, to determine if you should expand into ASCs in particular as your outpatient shift strategy, we think it's important to start with an understanding of your current market with respect to capacity. There's probably two important questions to ask as a starting point. The first one is, what is the maturity of my market? That graph on the left there is based on survey data from about 400 healthcare leaders. That big takeaway is saying that 68% say that the market is immature. Meaning that there is an opportunity to add ASCs, physical, new buildings. But then the second question is, all right, if you wanna grow, should it actually be into new locations or should that growth be just through new services in existing infrastructure? We are seeing that only about 20% are saying that the opportunity is greater in new sites versus the overwhelming majority saying the opportunity lies in more in new services. I mean that's not really all that surprising to me that that's where sort of the percentages shifted out, it can be hard to make a clear capital plan for investment. New infrastructure like new buildings and new facility planning is a long journey and sort of an arduous road. But then that idea that there's quite a lot of opportunities still in the market taken from that left graph means, all right, well what really should we be doing in order to capitalize on this space? We have a couple takeaway questions for you guys. Things like think about your own market and what is the current maturity, as well as also what are some of the success factors if there are some ASCs in your market or in comparative markets, what do you think, what have you witnessed that has been successful both in actually building or in just actually making those physical spaces successful as well. We also wanna make a nod to imaging and diagnostic services as their own sort of component of outpatient and especially ASC strategies. Have those sort of services been moving together or differently from the rest of the different sets of procedures and services? There's a couple other interesting questions to sort of jot down and think about if you are looking at sort of growth into new spaces like this, such as the decision making process, what is that process for adding new sites and services? Who's involved in the decision? Who makes the proposal, who approves that proposal? We think in general that to make a robust outpatient growth strategy, it's important to start by understanding your market. This is sort of that national lens where we are seeing people say there is room potentially to add ASCs, but then we're also seeing that very few are looking to actually execute on that as their strategy in the near term. So if the research is saying that there could be room for growth here, whether that's new build or new services, let's actually spend some time now on the services themselves. So next up here we're going to actually look at a list of some services, our advisory board colleagues used Medicare claims to analyze a number of procedures and they scored those procedures based on the extent of the current shift into ASCs as well as the growth prospects. So you'll see that sort of services, that second column and then they did some of that scoring, they then came up with about four categories to try and say, all right, are these currently already very dominant in the ASC space or are they less dominant, less just prevalent and what is their expected growth rate? We have highlighted here that differentiator category as a potential set of services to really focus on and those two differentiators are EP and joint. Now the reason that we sort of focused on that category in particular is because these are services with less current ASC adoption relative to the others, but they have high ASC growth potential. So these would be things that potentially your competitors or other ASCs in the market may not have in that setting that would really set you apart and we're expecting them to grow. In short, let's spend the rest of our time here maybe targeting joint and EP as offerings and take a look at how that might be playing out in your current market. Before we do that, I wanna take another view of these projections. This is the same information just laid out a little bit different to try and make the point a little bit more clear, it's got those four buckets as you can see. Just to lay this out, we've got our Y axis is looking at the projected growth and then the x axis is the current volumes, which means, we've got sort of middling volume and really high growth rate in that differentiator category, that's where we are seeing EP and joint, I don't think those two services are gonna be surprising to anybody here. If we're saying hey there's probably some opportunity for joint replacement to move to the ASC, I think everybody's probably nodding on that one. It's good to see though that the data does sort of play that out as well. I think EP is an interesting one, we've got some notes on what we think might make that successful versus not successful. So I think those are two interesting ones to compare and contrast as we hone in on the data from a particular market. I think before we move forward though, there's sort of a question of, all right at this point, is it a good next step for you guys to go back to your leadership and say, hey, we need to go build an ASC and we need to put joint and EP in it, that's the solution, that's our strategy. I think let's first double check on the growth rate and then we'll also check on current volumes. So here we're honing in on that growth rate potential. If we have projections saying that we think that these services can grow and they can grow in that setting, let's sort of analyze that a little bit further. These are the growth rates for three procedures. We've got spine, joint, and EP. This is presented in a percent format for growth. And what we're seeing here is we do expect these services to grow and we actually expect them to grow in ASC volume faster than HOPD volume. So that is an interesting projection that would also sort of indicate that there's opportunity to add these services into existing ambulatory settings. But I think the ultimate question is just because these can move to ASC spaces, will they? So that is sort of the question I wanna interrogate a little bit further. Here, we have a number of procedures that were approved for ASC, but the data suggests that they're still predominantly performed in the HOPD setting. I think our question is why? There's a few possibilities, we've got those listed out on the left. Infrastructure is a big one, I don't think that's gonna be a surprise to anybody. Cath labs procedures, that's an emerging technology in the ASC space. It's also a situation where ASCs, that infrastructure, it takes expertise, it takes time, it takes resources to build. So leaders may choose to take their time before deeming that investment as really worthwhile. There's also an interesting component of physician alignment. Think about hospital employed physicians don't have any real incentive to shift cases to these settings. Another contributing factor can be logistics. Physicians may need to hit a threshold of procedures in the ASC in order to add that facility setting to their schedule. So there's a couple components here all making this shift though possible, just not happening as much as we might initially expect. As a result, we've seen more of a shift to HOPD than to ASC. That's actually contradictory to our predictions. So the next step here is, all right, well how can I get a good view of what's actually happening? So what is, instead of projections and our theory for what's going to happen over the next couple years, what's currently happening? And for that, let's go to the data. On this graph, this is our sort of longitudinal review, this is using data from the Optum Market Advantage product. So this is claims data, this is claims data from two national payers in addition to Medicare, state is available at the zip five level. And using this, we can analyze the shift by site of care for a given procedure in any market. We chose DC as just the area that we wanted to hone in on. I know, I come from the DC market so it was very familiar to me. We have our old advisory board headquarters there and here we've got the percent of outpatient joint replacement procedures that are happening in HOPD, ASC clinic and ED settings. So only joint replacement being, occurring at these particular settings over the last couple of years. And then we are trending those over time and saying how many or what percent of those procedures happened at each of those settings. For DC, the data indicates that HOPD's share of actual joint claims was increasing up until 2021 and then kind of holding flat at that point. I have to say this graph in particular is something that I see pretty consistent across markets. There might be a little bit of fluctuation and I'll explain why, but for the most part, the HOPD is still that dominant space across the board and it is usually dominant by a high margin here. So even though we are saying great things can shift, we're also saying they haven't shifted yet and that is not happening as fast as we thought it would initially. One of the reasons that we think that this sort of ASC line is as low as it is, that it's not having as much share is some usually due to something like capacity, and I mean that in a couple of different ways. For most markets, when I dig into the actual, county level data, I will see a pretty flat line for the percent of volume happening at an ASC right up until the quarter in which a new ASC in that market opened and then those volumes go way up. It's all capacity, so if you are doing, every single case that you can in each of these settings and there's, you're addressing all that latent demand as well as you can, you're only gonna see the increase in the ASC volumes when there is a new ASC offering those services. So it's a little bit of a description of the supply rather than an estimate of the demand for these types of services. That is the biggest thing that I see when I'm looking at the data for various markets and I think the DC market illustrates that pretty well. So what we are seeing here basically is that there is a little bit more information that we can get for the current market size for ASC that we will need in order to understand if we added a new ASC, would we see that number go up or is there no latent demand, it's all already captured by this supply side? So how can we get a little bit more information about the demand? Before we move on, I'd sort of leave you guys with a couple questions here. Things like, does your market look similar to this? Do you know how many ASCs are currently in your market? Do you know how many are offering various services? And do you have any information about ones that will be opening in the future? You could do the same thing for the other settings of care as well, not just ASC, but I think those would be some important questions to plot out on a timeline and sort of compare and contrast to data like this at a very granular procedure level. So those are some things that I would keep in mind. You could also do this for, any of the other procedures that you wanted to, we could have done EP for this trend, joint is always a good one to look at. So like I said, this gives us actually a better view of the supply than it does the demand. So let's shift our focus from looking at the current volumes by setting of care and instead let's try and get some sense for leakage, specifically, let's look for some information around outmigration. There's a lot of information here, so let me run this down a little bit. This is also Optum market advantage data and what we're trying to do here is quantify how many patients leave their home market for care. So essentially how many people are outmigrating, they're not able to get the services that they need close to home and there would be demand in that local market if it could be met, but they have to go elsewhere in order to get that care. There could be some branding things going on as well, but let's sort of put a pin in that for now. Let's start with that first grid on the left. This is the same information that we were just looking at. This is saying outpatient joint replacement procedures happening at HOPD, ASC clinic and ED settings. It's doing one more thing, it's now telling you the patient's origin market and we split that up with DC, Maryland and Virginia patients, that's their home. And then said, where is their destination? So where are they receiving those joint replacement procedures across those various care settings? Using that first line, that first blue box as an example, what it is telling you is that patients from DC with DC as their home market, 52% of their outpatient joint replacement procedures are happening at facilities in DC. You can contrast that to the next line down where you see from Maryland, that line is telling you that Maryland patients, 94% of them are able to get that outpatient joint replacement care at a facility in Maryland. There's about 3% of them that are having that occur though in DC, so 3% outmigration. Now to me, having been a DC resident, that is not all that surprising, I know that I was someone who was always sort of shopping around, especially for some of those procedures that are more easily shoppable and it would not be uncommon for me to pick a facility in Maryland even though I lived in DC. Those are very close together. But it is interesting that people from Maryland are not looking to go into DC in order to receive that kind of care. They are finding everything that they need close to home. You can compare that though to this middle graph. Now we're saying we're still only looking at outpatient joint replacement, we're honing in on just ASC care. This is where you're getting into some of that supply question and you see in fact for the DC market, there is not ASC offerings where patients are able to go for that care. So that entire line is blank, but then there's still some interesting information where you're seeing, every single DC patient is going to Maryland for that care. For ASCs in particular most of the Maryland folk are able to get it in Maryland as well, but for Virginia there's still a significant portion of the Virginia residents who are actually traveling to Maryland just to go to ASCs for outpatient joint replacement. I think that's a really interesting comparative stat to say what are they not able to get in Northern Virginia? I assume it's Northern Virginia, we could always look at this at the zip code level. What are they not able to get close to home that they can get in Maryland? To me, there's probably two significant contributing factors here. One could be branding, Johns Hopkins is a really predominant, healthcare system in that area. But so is there something going on with the branding of facilities or the quality that is making them easier to get to or more desirable from a patient standpoint? And then the other potential factor here is things like access and capacity. And that is the ultimate question that we're trying to solve for. Is there some sort of latent demand in Virginia for a outpatient joint care in the ASC setting that is not able to be met? So I think if I were a facility or a hospital in that area, I'd be looking at my own capacity to say if we do have any spare capacity, if we do see that in our data, then maybe this is a branding question or an access question versus if we don't have any spare capacity, this could be a place where we say there is actually some latent demand and there's some opportunity. The final graph on this page, we just wanted to give some comparison to a different service just to see what that data looks like, is it significantly different? So now we're looking at that third graph at outpatient EP, only those procedures and we're saying show any of the procedures, those procedures happening across HOPD, ASC clinic and ED settings. So kind of opened up the aperture again for all of that outpatient space. And here we are seeing unsurprisingly, people who tend to stay close to home for this, that's maybe a service that you aren't really shopping around for as much as maybe something like outpatient joint that's, maybe an inference you could make from this data. But I do think it's interesting that with this information, when you look at Maryland, you do see few, relatively fewer patients staying close to home. So the compare and contrast across these procedures is a little interesting to me to say, what could be contributing to these services outmigrating when you compare services and then what is outmigrating when you compare the actual setting of care. So outmigration, this could be one way to understand if there's opportunity to offer services in the ASC setting, that could be a way to retain patients from outmigration and it could just be as a process, another way of estimating the demand and opportunity in your market. Now shifting from the sort of, claims volume of demand, let's now move into a little bit more of the marketing side. So this is taking data from our consumer acquisition services tool. It is looking at propensity modeling, now it's trying to also give you an estimate for the total demand on that left graph. It is using those propensity models to say how many consumers have a likely need for joint replacement and then it's sort of giving you that color coding. This could be a helpful element to also layer into that demand side. I'd like to know what's going on down there in Virginia Beach, that seems to be a pretty dense area needing some care, but we do also see that line in between Maryland, Virginia and DC with a little bit more of that higher and likely need. And then on the right, this could be another interesting piece that you layer into your strategy. Things around health attitudes and behaviors. So if you were to offer outpatient or especially ASC care, what types of patients are you trying to attract? There's a pretty even distribution across those top three categories for this market where you've got some people who really are just relying on their doctor for advice, I would expect to see less outmigration, both from a geography standpoint and a network standpoint for that type of patient. Their provider is trying to keep them, likely keep them in network and they're really looking to that provider to give them advice. But those second two categories could be people who are shopping around a little bit. They could either just be looking for, a place that has really good branding, really good quality or they could just be pretty tech savvy and quite frankly just easy to shop around. So a couple of different things to consider to look at your own market and say, what type of consumer am I looking to attract and do I think there's actually some demand with the consumers in my market? But that's a lot about the sort of supply, the demand, the consumer, the marketing side. I think next we wanna go into some of the actual cost data. So I'll hand it back to Brooke now.- [Brooke] Thanks Allison. Yeah, so doubling back on our point about avoiding outmigration, one of the main proponents of this is is you need to know your cost. How can you reduce cost variation internally and also better understanding your competitors, to know if there's something that they can offer cheaper, specifically when thinking through supplies that are needed for procedures? So the analysis you see on the screen is taken from Optum's surgical profitability compass module, and what we're showcasing is different procedures by specific services that we, typically see operate in both the hospital and ASC locations. And then in the two buckets to the right, we have the, our proprietary benchmarking with our ASC cost per case and then the all site cost per case. And so in understanding more about cost, I doubled down on a couple of examples here. You can see the one highlighted in green is the shorter, excuse me, shoulder arthroscopy procedure. When doing it in the ASC location, if you're operating in the 90th percentile, which is like our top 10% of performers, they're doing that shoulder for about $760, and keep in mind this is all just supply cost per case. Where looking at the all site cost per case, we're jumping up relatively close to $1,300 plus on average. Looking at this, we can definitely tell that the shoulder is being done in the ASC location is, beneficial and fruitful. But then jumping down to the next example, which is gynecology and this is, a type of hysteroscopy done at the ASC location versus the all site location, we're actually seeing it being done a bit cheaper in the main hospital than at the ASC. And so in this example, shifting things to the ASC location might not be as fruitful, for this specific procedure or this service. Doubling down even further on one of our other solutions, the Optum Enterprise Intelligence Suite, looking at similar procedures done in the inpatient, outpatient and the observation space, not just what does it cost, but also, what are the implications of quality outcomes being done in those different care settings? So this example is taken from an existing client initiative that was run over 2020 and 2021, where they were looking at where was the most fruitful location to have their total joint procedures done, and so while the ASC and HOPD average cost per case may be lower in the outpatient setting than inpatient, it's also important to consider outcomes for each setting and the associated costs. So looking at the visual, we can see in 2020 that the vast majority of the joint cases were being done in the inpatient setting in 2020 and then they made a quick shift in 2021 to doing over 80% of that volume in the outpatient procedure setting, which would be a really quick shift over a year timeframe. And then you can kind of see in the bucket below that the cost different as a result of shifting those majority of elective joint procedures from inpatient to outpatient was about $166,000. But jumping to the next slide, when considering this shift, not just from a cost perspective, but also looking at things like outcomes, we could see that the percent of outpatient procedures within ED revisit in 30 days kind of skyrocketed in 2021 when we saw those joints procedures being shift more to the outpatient setting. And actually, one organization found that the percent of the AD visits within 30 days of surgery was nearly four times higher for outpatient procedures than for inpatient procedures, which helps them reevaluate what specific locations, sorry, specific populations should be sent to different locations for point of care. So although the ASC, or excuse me, the outpatient procedure setting might have looked like the right fit from a cost perspective, the enterprise intelligence suite can give a more holistic view at those quality outcomes that kind of inflect the right point of care and also look at the right patient specificity to be held at the right point of care. With that, we just went through a number of examples that were either taken from existing client relationships and programs here at Optum. So we thought it would be helpful for viewers to just get a quick summary of, our Optum analytics portfolio and what we're really designed to show you the full picture related to, service line, marketing, surgical and quality outcomes. And so starting left to right Optum Market Advantage, Allison went through a lot of this data in great detail, but they are a web-based market intelligence tool that provides health systems with substantial visibility into their healthcare market with the primary focus of helping you drive growth and market expansion as it relates to areas like physician loyalty, referrals, primary care alignment and service line expansion. CAS is Consumer Acquisition Services, kinda enables marketers and planners to get a 360 degree view of every customer and consumer in their market. Surgical Profitability Compass, is aimed at helping maximize procedural revenue and reducing cost. And we provide offerings from, capacity management of your operating room, looking at your rooms running and staffing capabilities and really empowering surgeons to make timely decisions around procedural cost reduction and capacity management. Our enterprise intelligence suite, which was that last point I just made, is a tool that we can proactively track quality outcomes and understand root cause with Optum's AI enabled insights that influence action directly at the point of care in conjunction with providers helping with development, we've been able to develop a streamlined physician review process with our best in class measure library, and then we also help with optimizing resource utilization by identifying wastage and related high cost drivers in treating patients. If you have any questions about any of these solutions, please feel free to leave us a note in the chat or the Q&A at the end and either Allison or I, could reach out to speak to you more about these.- [Allison] Great, well we wanna leave everybody today with, whether you're looking to stabilize or to explicitly grow your outpatient market and really how to navigate some of these site of care shifts, some of these site of care trends. Most of the research across both forecasts and across surveys, we see there's a lot of potential for growth, a lot of potential for shifts and expansion in not just the outpatient space, but in the specifically ambulatory settings. So we're seeing that potential and we are also seeing that growth, it's not uniform, it's not uniform across procedures and it's really not even uniform across patients. As you just heard Brooke say, focusing in on specific, types of patients when you're considering those quality outcomes, that could be a really important component in navigating a successful ambulatory strategy. So even though we're seeing a lot of this potential to shift, like you also saw through a lot of our supply data and across those longitudinal trends, it hasn't necessarily all shifted yet. We're seeing a lot of capacity in ASCs come online across the nation this year, next year and in the coming years. So it'll be interesting to see who is actually making those care settings successful, both from a quality and then of course from a financial standpoint. A couple of those things to keep in mind that we think will be important is that price competitive element. Be careful when you are deciding what procedures to place in which places just because it is a lower cost of care setting. If you're a hospital-based health system, that still may not actually save cost overall. One potentially, well-known, but important strategy to consider on the top right is think about your partnerships. Do you need to actually build or is there a way to have some sort of JV arrangement for, to make sure that there is some capacity in the ASC space in your market that you are not necessarily owning or operating. That actually is a strategy we are seeing a lot of folks deploy today. And then one thing that we think is really important, again for those hospitalbased health systems is the, to exploit your product advantages, that ability to have centers of excellence for your complex care, this has been pretty successful for the people who are doing it with a lot of intentionality. You saw maybe from that marketing data that there's a significant portion of the patients who are still saying, Hey, I want either really high quality or I want to be told to what to do by my provider because I trust them, I have a good relationship with them and I'd like their advice and guidance. A center of excellence could be the way to sort of solve for all of that and continue to sort of promote your brand as well. So that might be one good way, I think there's pros and cons of that, but we do think that it is a potentially good strategy to consider. And then make sure to also optimize your current network, that's sort of that offloading of low acuity cases if and where necessary. Keeping in mind all the complexities that we also walked through about, all right, well is this actually going to be beneficial? Both from that readmit and the length of stay components. So when we take all of these things together, there's a lot of information, like we said, there's a lot of growth potential, but then the actual individual components of how to be successful come down to what specific procedures are you looking at? What are some of the logistic challenges, both from a, actual build and expansion standpoint and from what physicians are you gonna have in that space? A lot of those items are going to be really critical. Then from a data standpoint, we think it's important to look at just what is the maturity of your current market in addition to what are the trends in capacity and is there potentially latent demand somehow? So trying to get some estimate of that supply and demand, try to understand your consumers as much as possible because that will help you navigate which type of strategy of growth you go after. And then take a look at your cost, quality and outcomes. Those are going to help you also determine, are we shifting everything? Let's not have one uniform approach, let's make sure that we are being careful and being intentional about this.