Getting to the heart of travel healthcare.

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Polysomnographer Amy Riley joins Cardium podcast to share her personal story of the California Camp Fire of 2018 that swept through Paradise, California and the surrounding area.

PDGM Explained: A New Paradigm for Therapists

March 18, 2020


Voiceover: Welcome to Cardium from Aureus Medical, the podcast that gets to the heart of travel healthcare and asks, "What's your why?" With each episode we explore the topics and issues that impact healthcare professionals in the fields of nursing and allied health. Now here are your hosts, Sunny and Matt.

Matt: Welcome to another episode of Cardium. If you are a subscriber, welcome back. Thank you for being part of our Cardium family. If you're a new listener, thanks for stopping by. We hope you enjoy this podcast and we would love for you to subscribe so you can enjoy our future podcasts. Joining me as always, Sunny, how are you today?

Sunny: I'm great, thank you. How are you?

Matt: I'm good. As usual, I'm good. Excited about our topic again today. I think it's one that we've spoken about in the past that it was coming and we knew that it was going to be a topic that we would cover but we had to wait for the stars to align, for the event to happen, and here we are. So I think we've got some interesting information that we'll be able to deliver out there today and discuss and really talk about.

Sunny: Yeah. But we know that the last time that we had our guests on really had great feedback and a lot of great information that she was able to provide, and a lot of great comments and a lot of discussions that stemmed from that, from our listening audience. So without any further ado-

Matt: I think we should introduce …

Sunny: We’ll just go ahead and introduce her and jump right in. So with us today is Ellen Strunk. And so for those that are new to us today, Ellen Strunk is an experienced leader in the field of physical therapy and has worked in various roles and settings as a Clinician Manager and Director. She's the owner of Rehab Resources and Consulting Incorporated, which specializes in helping customers understand payment systems and the home health and skilled nursing facility settings, as well as outpatient therapy billing for all provider types. Ellen lectures nationally on the topics of regulatory compliance in the post-acute space and other clinical related topics within rehabilitation therapy. Ellen is a member of the American Physical Therapy Association, the American Healthcare association and other professional organizations within her specialty. She's an expert in payment models within the scope of therapy, including PDGM, the Patient-Driven Groupings Model. Thank you and welcome Ellen.

Matt: Welcome Ellen.

Ellen: Thank you. Good to be back.

Matt: We're glad to have you back.

Sunny: Glad to have you.

Matt: Yeah. And we have a second guest today, another guest. Joining us also today is Reid Johnson. Reid Johnson is an Account Manager with RES Medical's Therapy Division. He's been dedicated to assisting PTs, OTs and speech therapists with their career journey since he joined the company four years ago. Reid is originally from Minnesota. He and his wife have two boys and a third on the way. Congratulations Reid.

Reid: Thanks Matt.

Matt: In his spare time, he enjoys visiting family and friends in his home state and playing hockey every chance he gets. So again, welcome Reid. Thanks for coming by to the studio here.

Reid: Thanks for having me.

Sunny: Yeah, welcome. Thanks.

Matt: Well, today's topic, we're hoping that we get a lot of information from you two. I think that our audience out there, therapists are really intrigued about the recent changes to PDGM and what that means for all of us, what it means for the therapists in the field. Especially it went into effect from my understanding right there at the first of the year, so first part of 2020 we are really looking at some changes to the Patient-Driven Groupings Model. So again, thanks for stopping by and talking with us. Ellen, I'll go right to you right away if that's okay. Can you give us and our audience just an overview about what is PDGM?

Ellen: Sure. Well, just as with the Patient-Driven Groupings Model, PDGM represents a really significant change, a big change, probably the biggest in the last 20 years. And essentially what Medicare is doing is they're continuing this theme of getting away from paying for volume of services so that they really want to begin to pay for all health care services, not on how many you deliver, but on patient characteristics. That requires a whole lot of research and statistical analysis because obviously that is not something that we have consistent data on. And much of it is biased by historical volume use. So what PDGM does is it doesn't change the basic benefit structure of home health services. And that's priority for all of your listeners to be aware of is number one, if a patient needs skilled services and they are home bound, they have a right to receive them. That's critical and number one.

Ellen: They must be homebound however, and that means that there's a complex definition, but essentially it's a considerable and taxing effort because of their medical condition to leave home. They also must have physician certification. They must've seen their physician actually face to face either within the 90 days leading up to the home health episode or within 30 days post. So those things are not changing. The only thing that is changing is how they calculate how much to pay the home health agency.

Matt: I see.

Ellen: And what they are using is some new... Based on their analysis of a whole bunch of claims information, they are going to pay differently depending on whether the patient is admitted to home health directly from a hospital or an institutional setting such as a post-acute care entity or a psychiatric hospital, and/or whether they're admitted directly from the physician's office. They notice that there's different amounts of money required depending on which one is the referral source.

Ellen: Then they're going to group it by clinical grouping and they've divided those into 12 categories based on what is the primary reason that they need home health. Then they're going to add a comorbidity adjustment to it. So does the patient have very minimal co-morbidities or do they have comorbidities like a Parkinson's disease and a diabetes that make them more at risk for re-hospitalizations or negative events.

Ellen: And then lastly they are going to base payment based on their functional level, and that's also a very critical piece. That's a carry over from the old system. So if they have very low impairments versus very high level of impairments, that will also make a difference in how much they are paid. And so that's essentially... All those are magically calculated up. And the other last big change that they're making is rather than paying agencies for a 60-day episode, they're now changing it to only paying for 30 days. And that also is projected to have some significant impact both on home health agencies' cash flow abilities, and then also on how many episodes or periods the patient actually receives.

Matt: Yeah, that's really interesting. We want to dive deeper into the complexity there for sure, but I think the big question that we... we spoke about this last time when we spoke with PDPM. What can we expect as far as impact to patient care? Because I think first and foremost when we're talking about a change like this, what directly can you see from your point of view is the impact to the patients that the therapist would be caring for? Is it improved? I know that that was a big thing that you hit on last time, in the improvement of patient care. I think as they're achieving the goal, there's the purpose of getting there, but do you see it as being a positive towards patient care?

Ellen: Well I think that the goal of the model much as it was for the Patient-Driven Payment Model, the goal is a good one. We should all work together, we should all plan accordingly, and we should think about what does this patient really need rather than how many visits do we need to get to a magic reimbursement level? Right?

Matt: Okay.

Ellen: So the goal is a good one. Now, just as with everything, it's how you operationalize it.

Matt: Sure.

Ellen: What do providers do? And much as we did with PDPM this first month with the PDGM, you're seeing and hearing negative things. And it is hard to know how much of that is real, how much of it is just fear over change. But if we are to believe everything we read, then there are some bad decisions being made out there. And so certainly, we want patients to receive the right amount of care when they need it. And so I think that unfortunately, from what we're hearing, some patients may not be receiving what they need, but we hope that they will. There's no way to really know until we get data in, until we actually have proof and Medicare is locked in hand, or has to wait to make any change or to determine whether this is working or not. They have to wait for more data to come in.

Matt: From a data point of view, do you need a year for that? Do you need six months? What's ideally the amount of time that you need to... or do the drivers of this model do they need to determine if this is a success or failure?

Ellen: I think that it will likely be close to a year. And that's because of the fact that the delay in giving claims and OASIS data is a time lag. So the home health agency uses the outcome assessment and instrument set or OASIS, for their patient assessments. And from the time they collect it, they have timelines to which they have to submit things. So it can be up to a month before they actually get that data. And then of course, when claims are filed, agencies, especially home health agencies, they have to wait for every single outstanding order to come in before they can file claims. Now all claims have to be submitted within a 12-month time period. So all claims for January, it may be the end of February, the end of March before they get it. And so that also delays the time that Medicare is able to actually analyze data.

Sunny: Got it. Just switching gears a little bit. I'm wanting to ask Reid, looking at the impact in your side of the world with travel, how does PDGM impact the travel industry?

Reid: I think you're seeing a lot less jobs. It seems that a lot of home health agencies are all of a sudden overstaffed because of the changes. So we're seeing a lot less in that regard. I think there's still contracts out there. It's just a Matter of being a little bit more flexible in how you approach your job search.

Sunny: Okay. And that's a good point, and Ellen I want to address this question to you. You are here as our guest talking about PDPM and we were talking about the unknown and what PDPM was going to bring about. And there was a lot of news articles about the thousands of losses in jobs by physical therapists and there was a lot of blow back after this in Skilled Nursing News and other news sources such as Modern Healthcare. And so I want to hear your thoughts about it now that a few months have passed, and what you're hearing now.

Ellen: The question is a good one because we are five months in now, and there are a lot of therapists that I am talking to that feel really good about where things stand with the Patient-Driven Payment Model. They feel like certainly they've made adjustments and there may not be the number of [ERN] people that they used to use necessary anymore. And much of that is due to the fact that prior to October one, we had these arbitrary levels to meet. And if a patient got sick or went out and stayed late at a doctor's office and could not receive therapy that day, then there was that pressure to make those minutes up just so that the nursing facility still got their payment that they needed.

Ellen: And that was not the intent of the model, but unfortunately when nursing homes are struggling to stay afloat, and many are, then there were those incentives for the wrong reasons. So now there is not that pressure. If a patient says, "You know what? I had to stay at the doctor's office too long. I really don't feel like participating." And it's not going to be a benefit, then we're not doing it. And so you're seeing slight reductions in average minutes provided just simply because of that, right? Not seeing average drops, like drop-offs in most facilities, but just little bits. Then there's also the aspect of the new definition of group therapy, so that new definition provides a lot more fReidom to do things.

Ellen: Now I will say that in my opinion, a slight difference between home health and the skilled nursing facility is in the skilled nursing facility you have staff that come there every day generally, unless you've got a rural place. So they come there day and they are a part hopefully of the interdisciplinary team. They're facing patients every day, they're facing nurses every day, they're facing administrators every day, and so you have that opportunity to interact more. Home health doesn't provide as many opportunities for that face-to-face kind of interaction, and it is very nursing-driven still.

Ellen: So many times at the home health agency, unless you have a therapist in an executive level or in a management level, then the therapist may be just waiting to get a referral. And that decision is made by someone other than therapists. And again, that's where we hope that people operationalize things well, but that's kind of some of the things that I'm hearing. A couple of weeks ago, I was talking to some home health therapists and they were relaying to me some very concerning practices that are going on in their agency with regards to how therapy visits are being managed and how therapy referrals are being managed. And so some of those things are very scary and you try to offer them suggestions and you give them Medicare phone number to call, but that's something that is concerning to me.

Matt: Yeah, I think it's interesting to hear some of the unintended consequences when we speak about changes like this. And obviously with any change, change is difficult, and with unintended and unforeseen things, I think there's a lot of that, anytime you see changes in the licenser certification and these models themselves. And I think that to your point, it's going to be a year before we really see how the data washes out and really look at results and do the patients benefit at the end of the day? And I think that as you mentioned, Ellen, as we start to see data rolling from PDPM, where do we see that going? Hopefully we're able to work out some of the problems and some of the unforeseen stuff and that that will not be a problem when PDPM is a year old in this October.

Matt: So I think there's a lot to be spoken about that, which leads me to my question to you, Reid. You had mentioned about the flexibility and we've spoke about PDPM and it requires flexibility from therapists. And you'd mentioned it here earlier. Can you kind of expand on that? I mean, what are we talking about for flexibility? You're seeing less jobs, that type of thing, but what does it mean to a therapist to be flexible?

Reid: Sure. I think PDPM definitely has to come into this discussion about PGGM as well. Because when PDPM came into effect, and we talked about this, a lot of candidates flooded the market. So I think a lot of people tend to think that only skilled nursing is going to be affected by that, but it the affects whole market. Now that we're getting hit again, where a vast majority of home health agencies are overstaffed, all of a sudden overnight, jobs are going to be fewer and far between. So I think in terms of flexibility, back to your question, the bigger cities are going to be tougher. You're going to have markets that are already saturated that are further saturated. So in terms of flexibility, looking at your location, looking at what setting you want to go into, how much money you would like to make, you have to realize that you're more than likely not going to get all three. You're going to have maybe one. And if you can hit that one, I think you're in good shape in this market.

Reid: It sounds like really expanding what jobs you're hearing. Make sure you're listening to your recruiter out there about opportunities as far as specifically for travel contract. You can't get your hopes up on one location. You really have to have that recruiter go through many of their jobs. Especially license has a lot to do with that, but really if you're licensed in an area, you need to have your ears open. I mean that sounds like to be the biggest takeaway from a travel point of view and the days of being selective are over for the time being that we see it.

Matt: Sure. In the short term.

Reid: And I'm certainly not saying sacrifice on your ideals or your priorities, but also be open to understanding that you have to be flexible with the market.

Matt: Yeah. At least hearing it, at least hearing it. Now, are you seeing that with the therapists you're speaking with today? I mean it's been just a little bit since PDGM went into effect, but again we spoke about PDPM went into effect on October. Are you seeing the therapist that you speak with, that you recruit? Are they opening up and you guys are having those conversations?

Reid: Absolutely. I think a good majority are, and I think that the ones who aren't, are getting left behind. It's one of those deals where you have to get on the bus or it's leaving. But again, not sacrificing what you're wanting to do. But yeah, we have seen that and I think it's important to just listen to different opportunities. It might still be a no, but take a look at it, put some thought into it and see if it's something that would be good for you.

Matt: Yeah, at least hear it out. That's really interesting. And so Ellen, if you could give advice out there for the healthcare professional overall, we spoke with Reid on the travel side of things, but what would be your advice to the therapists out there that are working, whether they're in contract or they're working full time with these changes? Do you have advice that you'd like to pass on or you wish everybody heard?

Ellen: Yes, definitely. Number one, I think that they need to understand the model that they're getting into. I think that they need to make a commitment to themselves that, "I am going to take this job because I want to impact patients in this community, in this location." And not look at it as just, "I need to get lots of visits in, I need to get lots of hours in." And remember why you got into the health care profession, right? that is the number one thing. The next thing is that I think that they need to be good communicators. I think that they need to be able to convey an objective and clear terms why they feel like a patient needs therapy.

Ellen: So using evidence, third thing to understand their patient, really spend time examining them so that they understand what's going on and then they use the evidence to be able to say, "Okay, this is an appropriate dose of exercise. This is inappropriate intensity of visits or therapy that I need to deliver. These are realistic goals that we are going to achieve, and every visit I am going to make sure that I'm spending time doing something that really matters." Outcomes are the currency that we have to work in now. It's no longer minutes and visits and dollars, it's outcomes. And the more that we can change our paradigm to think in that way, I think the more successful therapists will be because then the agency they're working for, the facility, the clinic, they will know that, "Look, they understand what I need and what I need measured on, and they are working hand in hand."

Matt: Yeah. It sounds like patient advocacy continues to be the number one thing, Ellen.

Ellen: Absolutely.

Matt: Your words are much more eloquent than mine, but patient advocacy from a healthcare provider position, it should be the top of mind thing. And I don't think that we've ever wavered from that in all of our discussions, but I love the fact that you hit on that and that is something for folks to keep in mind with all of these changes. I love it.

Ellen: Absolutely.

Sunny: And it sounds like it's definitely good advice, not only just for travelers but for anybody in the healthcare realm that is, in these areas. Whether you are someone who's new to the field or someone who's been practicing for a while, who has been maybe kind of doing things a certain way or have been forming a certain habit that they need to really go back to those evidence-based practices, reminding themselves of those treatment interventions and relying on recording to those interventions and showing those outcomes and making sure that those residences in those post-acute areas are meeting the outcomes that they were promising or hoping that they're going to meet. Is that what you're saying?

Ellen: Yes it is. For years, whether you're a PT, OT or speech therapist, it's unfortunate and I'm not saying every therapist has been in this position, but many therapists have been in a position where we have kind of allowed ourselves to be used as a revenue center or home health agency for an outpatient clinic, for a skilled nursing facility, whatever you're working in, because so much of these systems were built on how much therapy was provided. And so we have to acknowledge that, and with these changes we have to be honest in discerning, "All right, are we upset because our hours are being cut? Or are we upset because truly the patient is not getting what they want?" I'm sorry, what they need, I should say. Their patients aren't getting what they need, and that takes a very hard look at yourself to really understand that.

Ellen: There are plenty of patients out there that need therapy services, right? There are plenty of them out there, and just as Reid was saying that it might not get the exact location that you want. That the patients may not be... Maybe it's a certain patient population you haven't felt comfortable treating. So maybe go out there and get education so that you can provide treatment to that patient rather than just sticking with what you know and what you're comfortable with. We all have to go outside our comfort zone from time to time. So that's what I just try to encourage therapists everyday to really be honest and say, "Okay, not all change is bad." We have to ensure patients are getting what they need, but let's acknowledge the fact that the past is not something that we needed to continue. And so some change needed to occur.

Reid: Ellen, I did have a question for you. In a lot of the reading I've done about PGGM, I hear the phrase practice at the top of their license, a lot. Do you see therapists needing to bring more value that they otherwise wouldn't have done before January 1st? And if so, like what different activities can they bring to the table?

Ellen: Oh sure, sure. Yes. Those are things such as really understanding the need for care coordination, understanding the role that we have. And so that therapist again, do you really understand what the social determinants of health are? Do you understand how they impact readmission to the hospital? And then talk to your supervisors and administrators about what are you going to do? How are you accommodating for those? Are you addressing health literacy when you are teaching a patient, or do your notes just simply say, "I educated and queued without really explaining how you did it at their level? If a patient has a problem with resources in the community. So are we recommending that they go get services or that they do certain things at home that they just don't have the money or the ability to, because they're worried about where their next meal is coming from.

Ellen: So are we trying to address that? So it's really kind of looking at all of those things that... I read an article a few months ago that said that health outcomes are primarily driven... 80% of health outcomes are due to social determinants of health, and that only 20% of health outcomes are actually due to specific interventions that we do. And yet a lot of therapists think that, "Well if they don't get this visit, they're not going to have as good of an outcome." So we got to think outside of that and look at all of those other areas that may be a value to an agency to look at those.

Ellen: The other thing is really addressing those outcomes. So in all of our post-acute care settings, functional outcomes are very important. So maybe talk to them about how they are measuring that. Is there a copy program they've put in place to measure that across time? And let me put in programs that I think that we can improve on that, and let's work together by making sure that we're providing appropriate services.

Matt: That's gold. Cardium family, if you did not catch that, rewind. That is absolutely gold. And Reid, maybe you should take over my job. That was a great question. That's a great question. That was great. I have one more question because I know Sunny is giving me the evil eye because she's got stuff to add to that. But Reid, could you take us down the road six months. What you've seen with your experience, with this change, travel-industry specific. We get through the first six months jitters of PDGM, we're working through PDPM, what's the market looking like for you, and if travelers out there either traveling today or potential travelers, people that are thinking about it, spring's coming or whatever from this PDGM, and I'm ready to step off into this travel world, what do you see the world looking like?

Reid: I think it's going to be uncertain. I don't think anybody who says they know exactly what it's going to look like in six months is telling you the truth. From looking at the past, I've tried to do a lot of research on this and looking at what happened the last time Medicare changed things, and it sounds like things were similar. We saw a loss of jobs, a lot of candidates flooding the market, but then things started to even off and get on an even keel. So in six months I hope to see home health agencies, skilled nursing, all different settings start to realize how to work within these new models and start to even out staffing. So I'm hopeful that in six months we'll have a lot more contract jobs than we have today, which there are still some, but we've definitely seen a reduction.

Matt: Thanks Reid.

Sunny: Okay. So mine is like going back into what you were just talking about, Ellen, about holding therapists to like, "Are you really doing this because you want your hours, or are you doing this because of the patient outcomes or the resident outcomes when we're talking about post-acute?" And I can't help but see, and maybe it's because of my ignorance, and forgive me if it is, but I can't help but reflect back into my way early days where it reminds me of residential treatment as a mental health therapist or a substance abuse therapist where you have limited time, where you have those interventions and it's based on outcome, it's outcome driven. And you have time to... Everything that's based on meeting those outcomes, I have to write an intervention plan, "Here's when I expect for my patient to reach that intervention."

Sunny: And then I write a new intervention goal, but I have a set amount of time to get that. And I'm seeing it like into where the physical therapists are right now and you have a certain amount of time, but it's very outcome-based driven that you're hoping to get them to that goal. And it's for the patient, but a very limited... but a time to do that. So am I wrong in saying that it just kind of reminds me of that.

Ellen: Not necessarily, no, it is, because it is very goal oriented. We are in a world where you really do need to measure the effectiveness of what you're doing. And if therapists are not doing that, then they are a few steps behind where they need to be. But that is something that we all need to do. It starts with the initial evaluation. Again, whether you are a PT, OT or speech therapist, rather than just saying you want to see somebody three times a week for TherEx gait training and therapeutic activities, okay, what therapeutic exercises? It needs to be specific.

Ellen: Now, certainly if you are the one coming back, then you can say to yourself or you can rationalize it with, "Oh okay, I'll figure it out when I get there." But still that is not planned. That is not really objective because you're probably going to see about 50 other patients between then and now. That might be an exaggeration, but many. And so do you have a plan when you walk into that patient's house or are you just kind of taking it as, "Well, what you feel like doing today?"

Sunny: Exactly. When I was a therapist, I was substitute therapist, it was like, okay, I had to have a plan of ABC. These are my goals for you as a patient. And then we had to move on once we think we've achieved this goal and then I've given you these coping skills and move onto the next thing and added on. And so it just sounds like that's the hope of these models is that we're adding to the quality of the resident and the caregiver, and that the therapist is supposed to be helping them with that. And that the model, although it has the word payment, it also maybe should have put the word quality somewhere in there as well for this model. [crosstalk] for a patient model, yeah.

Ellen: Yeah. Medicare is very transparent about the fact that they say they're using quality to be able to monitor the effects of it. But you mentioned something that reminded me, I'm sure that you encountered this in your practice, but engaging patients is a big [crosstalk] of what we have to be good at. And sometimes again, I find that therapists struggle with that. It's like, "Well, they just won't do it." I'm like, "All right, you got to figure out how to change your approaches to them. You can engage them."

Sunny: Oh gosh. There were times where patients would be like, "I'm just going to sit here and not talk." And then I'm like, "Well, I'll just sit here and not talk with you." Until they did. And then you found something that they would talk about. You know what I mean? You've got to find a way to engage them at their level. It's meeting them at their level.

Ellen: Exactly.

Sunny: So, yeah.

Matt: I'll tell you, I think we could probably talk all day on this topic.

Ellen: Let's get a coffee here.

Matt: Yeah, and I think a lot of it really comes down to we need to see what the data brings. We need to let this kind of soak and see how PDGM washes out. And so Ellen, we invited you back last time, we might have you back here as this thing develops, so be prepared for that. And I really want to thank you both for joining us today. I think there's a lot of great information and I think our Cardium listeners of the Cardium family really will be helped by this. This is our part of our podcast where we'd love to ask the question of all of our guests, and Ellen, we've heard yours, we want to remind her of yours in a bit, but Reid, we want to ask you before we let you go, Reid, what is your why?

Reid: That's a great question. About five years ago I lost my dad to cancer. He was a detective up in Minnesota, and one thing that really struck me was at his funeral, somebody came up to me and said, "Your dad was a terrible detective." And I was taken aback and I asked why, and he said, "Well, while all of us would be kind of separate emotions from that, he couldn't. He was always involved with his cases, and many cases he followed up with victims years and years after the incident." A year later after his death, I became a dad to my son Brooks. From there, I kind of remember that, and from that day forward I thought about being a positive influence for him and making, a positive impact everywhere and trying to go above and beyond and look at others in their situation.

Reid: So I try to do that every day outside of work, inside of work for therapists, for clients and for my coworkers. I think it's something that having sons now on my own, it's amazing to try to live up to what he did. That's my way.

Sunny: And you too Reid.

Matt: It's a great why man.

Sunny: It's very good.

Matt: Thank you for sharing that with us. That's very noble. Thank you.

Sunny: Thank you.

Matt: Ellen, before we let you go. Just as a reminder, your why, why do you do what you do every day?

Ellen: Well that's a hard one to follow.

Matt: Yes it is.

Ellen: Yeah, very powerful. But mine is somewhat similar to Reid's. My father. My father is still living, I'm very thankful for that. But he's a retired obstetrician and gynecologist, and I cannot tell you from the moment that I became aware of things, there were women and husbands and children always coming up to me and saying, "Your father is a wonderful man. He helped me through my pregnancy, difficult birth." Whatever it was. "I didn't think I could have kids, and he worked with me." And he worked long, long hours, but I always knew that he was making a difference in the world and that's what I wanted to do. I was also fortunate to have a very, very close relationship with my grandmother and she taught me what growing old well meant. And so that is why my passion is in the older adult population, and I want to make that difference.

Sunny: That's beautiful. Thank you so much Ellen for sharing.

Matt: Thank you.

Sunny: Well, thank you guys for listening in as always, and thank you both for joining us again today, it was a great podcast. And we love to hear from our listeners, so please drop us a review and let us know what your thoughts are on today's topic or anything else you'd like to discuss. And thank you, Matt, as always for being a great partner.

Matt: Yeah, thanks Sunny and bye bye everybody.

Sunny: Goodbye.

Voiceover: You've been listening to Cardium from Aureus Medical with your hosts Sunny and Matt. We're the podcast that gets to the heart of travel healthcare. To subscribe, access show notes, or to learn more, visit Or wherever you're listening, be sure to rate us, review and subscribe. Thanks for tuning in. Until next time.

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