Health care systems are a major economic driver, and they play an essential role in the region’s overall well-being. In this latest roundtable session, we hear from area leaders about the impact of our health systems, evolving policy choices and the importance of networking with the community at large.
It’s one of our region’s largest industries and it encompasses some of the area’s largest single employers. And yet, it’s easy to take for granted just how essential our health care systems are to our economic well-being.
With health care policy a constant debate and each of our area’s health systems making multimillion-dollar investments in new facilities, we were curious to hear more about the economic side of health care and the influence our systems have on this region’s pathway to prosperity.
This July, we invited executives from each of the area’s major health systems to join us for an in-depth conversation. Leaders from three area health systems – OSF HealthCare Saint Anthony Medical Center, FHN and Mercyhealth – graciously joined us at Greenfire Restaurant, in Rockford.
Can you tell us about your background in the health care field?
Carynski: I have been in health care since 1985. I received my nursing degree from Saint Anthony School of Nursing in Rockford and started at OSF HealthCare Saint Anthony Medical Center. Cardiac is my clinical expertise, and within three or four years I had started down the management track. I’ve taken multiple positions throughout the same organization. The past six years I’ve been the president of the organization and for 15 years prior I was the chief nursing officer. I’ve now been with OSF Saint Anthony for 33 years. I’ve loved every minute of it. I’m intrigued by how complex health care is. The competitive landscape is constantly changing, and that’s what I find so fascinating.
Gridley: I graduated from high school in 1988 and enrolled in college/seminary, but I couldn’t afford it. So, I enlisted in the Army and did seven-plus years there. I started out as a combat medic. It was my first exposure to health care. I realized how serious my work was, and how rewarding it was. I became a licensed practical nurse. While I was stationed in a general surgery unit at Walter Reed in Washington, D.C., I complained a lot about administration. A charge nurse said, ‘Mark, you’re a really compassionate guy, but I’m going to ask you to be quiet unless you’re going to do something about it.’ So, I went to administration. I realized I really wasn’t speaking the same language. As I left the military, I knew I needed to understand better the business of health care. So I did my undergraduate and graduate schooling in business. I worked with private practices through school and worked as a general operations manager for some great physicians. There, I started to learn more about health care economics. I joined Aurora Healthcare, an excellent large system in Wisconsin, and I worked as an administrator and market executive. I felt like it was maybe a little too big of an organization for me. I’ve been in Freeport for just about 8 years now. I came in as vice president of the physician group and worked there for three years before I became chief operating officer. This is my second year as the CEO for the system. Having that clinical background, I understand what it’s like to have a patient in front of me.
Dorsey: My family had a lot of health issues. My parents died before I was 14, and there were a number of people who were ill in my family. I was exposed to the medical field very early in life. I admired what they did. I grew up in Connecticut and went to George Washington University for medical school. I came to Rockford working at Crusader Clinic and what was then Rockford Memorial Hospital. I then joined an independent office and, after Rockford Health System was formed, I joined the system. I was on the board of the old Rockford Health System and started taking a leadership role. I got what they call a Certified Physician Executive Degree around 2000, which is kind of like a master’s degree. I, too, complained a lot about administration. I had a very good internal medicine practice and balanced administrative roles. About six years ago, I was asked by my boss at the time, Kevin Ruggles, if I would step into full-time administration. I told him I wanted to stop doing administration because it was interfering with my clinical practice. We talked and then six years ago I joined leadership. Three years ago Kevin left, so I was asked to be Chief Medical Officer.
Our health care systems are constantly investing in medical advances. What recent advances have your teams made?
Carynski: OSF Saint Anthony Medical Center recently became a designated comprehensive stroke center. It’s difficult to achieve. With the large aging population and their increased likelihood of experiencing a stroke, we wanted to provide the best care for the community. We recruited two neurointerventionalists. There aren’t many of these subspecialists available throughout the country, and they’re difficult to recruit. However, we were successful in bringing two to Rockford. They have the ability to go above and beyond, doing some very advanced and remarkable interventions to remove clots. The outcomes have been remarkable.
Gridley: It’s not as clinically focused, but in our mind it’s just as important. Our chief nursing officer, Kathy Martinez, has done a terrific job with a program we call Connecting the Dots. We’re bringing in the community – such as nursing homes, assisted living facilities, churches, local governments and schools – and we’re trying to coordinate care for the people we’re serving. As health care systems, we need to be a leader in wellness. We want to make sure that, when people are leaving our hospital, they have the support mechanisms in place to ensure they don’t come back any sooner than they have to. When they leave the primary care office, the provider can put them on the right path. But do they have the resources to follow that path – whether that be access to medication, access to groceries or basic social supports? I’m really excited about the way we’re having a more collective discussion. It’s going to take all of us to make a meaningful difference in the places we work. Our patients are living outside our doors, and there are people who can impact and influence them in very meaningful ways – if they have the right tools and they have the right direction. Health care providers can lead the charge, but we cannot do it alone.
Dorsey: At Mercyhealth, we’re building our second campus, on Riverside Boulevard, and we’ve opened some primary care offices. Programmatically, we also have been focusing on strokes; our bariatric program just got certified. We’ve hired over 200 physicians who have joined us within the past few years. We’re also adding new services, like gynecological oncology. It used to be that a woman with a mass had to go to Wisconsin, Peoria or Chicago to be treated, but now we have gyneumcologists at Mercyhealth who commute between Janesville and Rockford, so there’s less traveling for patients. At the same time, we’re focusing on doctoral residencies. We’re starting two primary care residencies in July 2019: one in family medicine and one in internal medicine. We’ll have 75 students when it’s fully populated, and we think it’s a pretty big deal for the community and our patients.
How does the northern Illinois/southern Wisconsin area stack up with other places in the country?
Gridley: It’s more favorable than we give ourselves credit for. Once you move to the southern part of the state or many areas of the United States, the ratio of primary care physicians available per population tends to be a bit weaker than in northern Illinois. We have a patient experience survey where we’ll ask about their experience with access. We rank fairly well – perhaps around the 75th percentile. I know, from having worked in parts of southern Wisconsin, that was not always the case. It was very difficult to get an appointment there. When we compare our region nationally, northern Illinois has some very good medical systems. We have a good number of medical services for a community the size of Rockford, and we really appreciate it in a community the size of Freeport. That’s atypical. ‘Time to third appointment’ is a metric we use on a regular basis, and we tend to do fairly well on that, compared nationally. Centers for Medicare & Medicaid Services (CMS) has surveys. In national surveys, we are far from the bottom. In many areas we’re in one of the top quartiles.
Dorsey: We’re probably below the national average in terms of ability to access mental health services, which is a huge problem, as depression is so common. Part of that may have to do with Medicare/Medicaid reimbursement. On Rockford’s west side, there are greater access issues than on the east side. We need more primary care providers and certain specialists, which Mercyhealth is working hard to fill. But access is a problem all across the U.S. because of lack of insurance coverage or poor insurance coverage.
Carynski: On the behavioral health issue, there are a limited number of psychiatrists who will see inpatients. At OSF, we have partnered with a group called Regroup. They provide telepsychiatry consultations. This allows patients to have access in some form. While those needed services are not typically reimbursable, it’s important to make certain people have access to the right services. There are many outstanding services provided in our communities. Rockford has a children’s hospital with great subspecialists. OSF has Mayo-trained cardiovascular surgeons. I believe that, because of the University of Illinois College of Medicine-Rockford and residency programs, we are increasing access by producing really excellent physicians.
Gridley: Kudos to OSF and its School of Nursing, as well. We have a number of nurse practitioners at FHN who have come through that program.
Dorsey: We’re just a microcosm of the same issues that play nationally in delivery of health care. In some ways, we’re better and in some ways we’re not. But access is a problem across the U.S. If you have resources, you can get care. If you don’t have resources you sometimes don’t get care.
Carynski: Our traditional models for accessing health care are being shaken up. A recent study I read said that 51 percent of millennials don’t even have a relationship with a primary care physician. What they want is that urgent, get-me-what-I-need care. So, they walk into a retail clinic and quickly get what they need. Or, they can easily get information or a physician consultation on their phones. Those are good things, but they’re changing the way we think about our traditional delivery models. The digital environment is forcing all of us to rethink traditional models.
Gridley: FHN recently issued digital scales to certain patients who were accessing our ER on a regular basis. We did this for one woman who’s in a rural geography and has a hard time traveling back and forth. She said, ‘This is great, but I don’t have internet. How am I going to use this?’ We learned that you can’t presume that everyone can or will use technology. We gave this patient a scale that has a cellular function. Now, when she steps on her digital scale, that cellular signal gets sent to the nurse at the primary care office. The nurse can see what’s happening with the patient’s weight. The nurse noticed after one weekend this lady had a lot of weight gain, and that prompted the nurse to call and ask, ‘How are you feeling?’ The patient had chronic obstructive pulmonary disease, and she said she was getting a tightness that was making it difficult to breathe. So, the nurse practitioner was able to adjust her medication a little. In two days the patient’s weight was back down. We called to check in and she felt much better. Typically, that situation would have escalated such that a rural ambulance service would bring her into the emergency room.
The programs you’ve mentioned are targeting improved outcomes, yet, according to the County Health Rankings study, there’s a disparity in health factors and outcomes. While counties like Jo Daviess and Ogle rank higher, Winnebago, Stephenson and Rock counties rank lower. What are the most readily available changes that can be made, to impact outcomes?
Carynski: We all participate in the Community Health Needs Assessment, and you’re right: some numbers have gotten worse, when you look at obesity and risky behaviors such as teen pregnancy and smoking. Our health systems try to collaborate with all community health agencies to address care gaps. But we also have to ask what programs can mitigate some of those high-risk behaviors. There are many challenges. An example is where grocery stores are located, so that residents in all areas of our community can buy healthy foods. Additionally, food pantries are limited from distributing fresh produce. Those limitations are not helpful to promoting healthy eating and behaviors. Health care systems need to pull social agencies together to make a healthier community, but it’s a huge challenge.
Dorsey: If you look at the big picture, most health care is not really delivered in hospitals or clinics. It’s day-to-day choices such as what you eat, whether you smoke, how much you exercise. We can influence those choices, and I think more progressive organizations are starting to ask, ‘How can we affect the community in a way that’s going to impact positive behaviors and outcomes for our patients?’ I was at Mount Sinai Medical Center in Chicago a half-dozen years ago, where they noticed they had a high instance of kids with asthma getting readmitted. What they found was that these kids were often living in apartments with no air conditioners. So, Mount Sinai started giving air conditioners to these families. That was an example of community engagement. We’re blessed as a region to have wonderful health care systems and support. But we have to get the message out: How do you stay well? How do you minimize the potential for sickness? I think improving the socioeconomic climate in Rockford will improve health care delivery and access to care, as well as the motivation to make a change.
Carynski: We’ve gotten more conscious about impacting our own employees. Health care systems are often one of the largest employers in a community, and that’s the case in Rockford. We are self-insured, so what are we doing internally to make certain our own employees are exercising healthy behaviors and choices? What are we providing in our vending machines? What are we serving at our cafeteria? Are we motivating our employees to lead a healthy lifestyle? We are working on all of these issues internally.
What other avenues might be useful in engaging the entire community?
Gridley: It’s called Community Health Needs Assessment. It’s not a hospital or health care system needs assessment. That tells you who are the key stakeholders. The people being impacted need to be very much a part of that active dialogue. We heath care professionals can provide coaching, collaboration and tools, but we need to work as a community to address this. We need help from city and county government, our religious organizations and civic groups. We miss on that personal accountability piece. Where is the personal accountability in pursuing healthy habits? Where are the role models? It’s important for health care systems to be role models. But in somebody’s church group, is that role modeling happening? Do we have people in civic organizations talking about this issue? How much time is being spent teaching good food choices in our schools? There are healthy choices available in school cafeterias, but where are the kids gravitating? Is anybody saying, ‘Maybe an apple would have been better than that brownie’? To make significant movement on the Community Health Needs Assessment, it’s going to take people talking about this and agreeing to walk hand-in-hand.
Carynski: Everybody needs to be asking, ‘how do you make healthy choices easy?’ We have to have public and community policies that make it easy to be healthy. For example, where are our walking paths? Would you walk down East State Street to go to a store? Most likely not. If there are no walking paths we will have no other options but to drive. Therefore, it’s not making healthy choices easy. That’s why OSF is having those philosophical discussions – healthy choices in the vending machines and employee challenges. We want to motivate people. I love the green bikes in the community. If I want to ride a bike, I now have access and choice. If our public policies and our thought processes make healthy choices easy, we might see a shift in our metrics.
Dorsey: People are a product of their environment and what they’re exposed to, so if you don’t have access to healthy foods and you don’t have easy access to transportation you’re going to go to 7-Eleven. Those stores aren’t designed to have fresh produce. But even if you have healthy foods, you’ve got to learn how to prepare them. In food deserts, in particular, there’s a lack of experience preparing foods. That becomes a real problem. It goes back to something we said earlier: health is something you take for granted until you don’t have it. Look at the list of things that motivate people. The top 10 are rarely health. This is not socioeconomically related. It applies to everyone. The solution is in embedding a sense of wellness and health, and focusing on the day-to-day behaviors outside health care systems.
Gridley: I think as an organization, we can set the example. Do we have walking meetings? Are we inviting the community to learn with us? Are we getting to the food pantries, where we can coach people on the choices they’re making? Food pantry workers are great people who are giving a lot of their time, but they’re not typically registered dietitians. So, how do they have that conversation with someone that this box of cereal, which is high sugar and high carbohydrate, isn’t best for managing your insulin levels? It’s going to be very multifaceted, but the important thing is talking about it on a regular basis.
Carynski: In our recent hospital addition, we built a demonstration kitchen so we could offer cooking classes to patients. We can partner with schools in teaching parents to cook healthy snacks for their children, because childhood obesity ranks extremely high in Winnebago, Boone and Stephenson counties. We need to make incremental steps to building that healthy landscape. Smart public policy would be great. Communities that do this well have community gardens everywhere so citizens can be encouraged to grow and eat healthy foods. These gardens usually fit nicely in vacant spaces where there were abandoned homes. Turning these vacant lots into community gardens for good food. There are so many ideas out there that people are starting to embrace, but it takes the whole community coming together to make conscious choices.
Dorsey: There’s so much more to health care than what we can do as a health system. It’s all integrated, so as Transform Rockford transforms the community, there’s going to be a halo effect that will raise our overall health and well-being, and we will continue to do everything we can. We’re on the delivery side, but there’s so much more. The violence in this community; opioid abuse and suicide. Hospitals deal with the effects of these, but we’re not always able to affect the underlying causes. I think we’re starting to affect those things by getting into the community and engaging. But we’re not capable of doing it without the greater community and government.
Changing the paradigm sure takes a lot of voices.
Dorsey: Look at smoking. I don’t know what the percentage used to be when I was a kid – seemed like everybody did it – and now maybe 18-20 percent of Americans smoke. So, habits change over time, and I think we’re clearly on the right path, but it’s going to take a very concerted effort to get there.
Gridley: That’s a great example with smoking. What did it take, and what paradigms needed to change, in order for us to make that progress? It was decades of work. That’s what it’s going to take with some of these other large initiatives.
The region’s health systems have been making numerous investments in their physical plants over the past several years. What do your organizations’ recent investments indicate about the future of health care in our region?
Dorsey: Mercyhealth just completed and opened a new facility on Alpine Road, where we’re replacing an existing facility. This is where we’re going to put our family medicine residents. Someone from the Rockford Area Economic Development Council recently estimated Mercyhealth has put about $1 billion into the community in the past few years. Now, half of that is the new hospital opening in January 2019, but we’ve also remodeled clinics, opened another clinic and hired over 200 doctors.
Carynski: I hope the message it’s sending to all of our communities is that we are committed to making sure we provide great health care services to everyone. We still live in a Certificate of Need state, where you have to apply to the state and go through a process where the state deems that those services are needed. You have to have data backing your application. We’re sending the message that you they really don’t need to go anywhere else for health care.
Gridley: In Freeport, we recently opened up a Physicians Immediate Care, and that was based on our need to have a convenient retail option. Our emergency room volumes were experiencing serious pressure, and we knew there was a demand for accessing physicians during nontraditional hours or afterhours. We opened on April 30 and we’re exceeding our expectations. Rather than being a health care system that just opens its own urgent care, we partnered with an organization that has been doing this work in a successful manner. FHN is also investing more in human resources. We’re sending our nurses and educators to locations that typically don’t have health care services, and we’re doing things like blood pressure screenings and checking sugar levels at food pantries or churches. And we’ve invested more in chronic care management, knowing that some nurses can do work that doesn’t require a face-to-face visit with a physician or nurse practitioner. They’re just making regular phone contact to manage that patient’s care under the guidance of another health care professional.
Turning now toward jobs, we know that the health care sector provides more than 10,000 jobs across northern Illinois and southern Wisconsin – and that number is growing. Can you elaborate on the efforts to supply these critical roles?
Gridley: All of our systems provide educational assistance, which really makes that cost equation more manageable for someone who is working and wants to pursue a job in health care. If somebody graduates from high school and wants to become a nurse, we can pay to help train them, and they can become an associate degree nurse and a bachelor’s degree nurse and a master’s degree nurse – all the way to being a doctorate in nursing. Much of your education will be subsidized.
Carynski: OSF Saint Anthony’s School of Nursing started out with bachelor’s-prepared nurses, and over the past two or three years they’ve moved toward providing master’s-prepared and doctoral-prepared nurses. Our ability to partner with Rock Valley College is positive. We’re starting to see general education students excited and saying, ‘I can go to nursing school right here at Rock Valley.’ We sponsor clinical rotations for health care students and offer education to local schools, so that students can learn about health care careers. Many of us have great internal tuition reimbursement programs to help our employees advance their degrees.
Dorsey: There’s a nursing shortage, and a lot of nurses are nearing retirement. Mercyhealth has a minority nurse scholarship program. We encourage our nurses to get advanced training, which we pay for. I think we all educate students from Rockford’s medical school. Our community is enriched by medical students who come to this region to practice. They get exposure to practicing physicians, and many times they stay.
Gridley: We offer a lot of other professional paths or employment opportunities outside the clinical world. Not everybody has a calling to go into medicine, nursing or pharmacy. But we employ CPA’s, we have facilities engineers, we have biotechnicians, we have huge IT resources. A lot of people don’t connect to that. When they think of health care systems, they think of the clinician. They’re not looking at all of that support structure. We’re trying to get into the high schools, talking to freshmen. We should be partnering with our technical colleges and local universities to grow talent locally. We should be saying, ‘Did you know that one of these health systems would love to have you?’ But wait a minute, I’m studying IT. Yeah, exactly.
Carynski: Technology is going to disrupt the way things have been, and those innovations will excite a lot of young people. OSF now has an innovation center in Peoria, and they’re examining how to improve outcomes and access, and deal with this issue of aging in place. How are we going to care for our aging baby boomers and do it in a way that keeps them in their homes longer?
How does the business side of health care affect your bottom line? How do you balance business realities with your mission?
Carynski: It’s challenging. The public aid reimbursement rate is becoming less and less, yet health care needs continue to grow. Living in the state of Illinois is challenging, with some of its reimbursement philosophies. So, we continue to press ourselves to do more with less. That’s not to say there aren’t opportunities. We have eliminated redundancies. We’ve developed a process improvement team that looks at ways to improve efficiencies.
Gridley: Illinois is ranked 50th in the nation as far as federal Medicaid beneficiary dollars. That’s based on 2015 CMS data. To give you a little perspective, Illinois gets about $3,252 per Medicaid beneficiary. Missouri, believe it or not, is in the top three states, and it’s close to $6,448 per Medicaid beneficiary. Indiana and Wisconsin also do well. There’s also a national movement toward higher deductibles. If you are a working family with a good job and an income of $80,000, but you have a high deductible of $10,000, that becomes a stretch when something happens. How are you going to pay? We’ve been engaging in significant process improvements and year-to-year reductions of costs and waste. This is an ongoing initiative. Each of us at this table is looking at how much more we can remove from our expenses while funding our mission, which is keeping people well and employing the talent that makes it possible. We have tighter margins than ever. The Illinois Health and Hospital Association released a statistic earlier this year that over 40 percent of all hospitals in the state of Illinois are operating on thin or negative margins. That’s clearly not sustainable. We can’t solve this on our own. How do we work together to lower the cost of care? At the same time, we have an elderly or aging population that continues to grow, so we’re seeing people shift out of commercial insurance policies into a federal plan that doesn’t reimburse as well. Education costs for highly trained individuals continue to rise. It’s not unusual for a physician to have a quarter-million dollars in student loan debt. We need to offer them wages that will allow them to pay that debt.
Dorsey: The margins in health care are much less than other businesses. People ask, ‘Isn’t it nonprofit?’ Well, if you don’t make some profit you can’t invest in technology and new programs. At Mercyhealth, we have no ability to negotiate rates on perhaps 60 to 65 percent of our patients. They’re on Medicare and Medicaid. Now, you can charge $1 million per person more, but for 65 percent of your patients it doesn’t matter. And even on the ones that are negotiable, commercial insurance providers aren’t exactly generous. We’re very limited as to how much we can truly affect our incomes. And yet we still have to pay salaries, expand workforce and expand programs.
Gridley: When it comes to insurance, not only do we have to provide high-quality care with good outcomes, but we have to do it in a way that provides value to the employer. It’s no insignificant cost when you look at that health care item on your income statement.
Dorsey: The whole fee-for-service model doesn’t really help patients. If you buy a TV and it doesn’t work, you go back to the store and they give you another TV. We’d be pretty upset if we went back to the store and they said, ‘Here’s your second TV, and by the way that’s another $1,000.’ But health care is like that, right? You pay for every visit.
There’s a special relationship between a patient and their personal care physician, especially when they’re in the hospital and care is being guided by a hospitalist. How is that one-on-one patient relationship being affected in today’s climate?
Dorsey: As a practicing physician, you might have had patients at five different hospitals, so you were spending three hours of your day driving to see them. With a hospitalist, you could spend more of your time in the office seeing more patients. There was a practical impetus for the hospitalist movement. One of the biggest challenges I hear about is care continuity and communication. Electronic medical records help because both parties can see what’s been going on in the clinic. At the time of discharge, the receiving physician can see what happened in the hospital. I’m an internist, and while I practiced, I followed my patients in the hospital. No family practitioners do that anymore. The fundamental issue I see is that, when you’re at your sickest, you’re given a provider you have no knowledge of, and they’re guiding you through this challenging time. I don’t know how to make that easier. Now, having a hospitalist is also in the interest of the patients, who can be seen more quickly and have greater access as well. Not to mention, these folks are highly trained in acute care medicine, whereas a general practitioner is not.
Carynski: The nurses will tell you they love the hospitalist model. The hospitalist typically works 12-hour shifts. If a patient’s condition changes, nurses can call the hospitalist – who’s in the building – and he or she comes right up. They might see a patient three or four times a day. With the other model, the doctor would make rounds one time a day and try to manage a patient’s care on the phone in between seeing office patients. Having someone who can concentrate and readily be available for changing conditions is really good. The key is the hand-off. It’s making sure that, when the patient is admitted, the hospitalist looks at the patient’s records or calls the primary physician. And, after discharge, the hospitalist calls the primary physician to hand off care for a smooth transition.
Gridley: I think it’s about the team. My physician can say, ‘Mark, I need you to be admitted, but Dr. Parks is going to be the hospitalist. He’s excellent at what he does. He’s going to write a note, and I’m going to see what he’s doing every day you’re in there. Once you’re back, we can continue your plan of care.’ It’s important to have that continued care planning conversation so you don’t feel lost.
What do you think our readers might be surprised to learn about the health care business in our region?
Dorsey: At Mercyhealth, we have a lot of joint commission surveys visits, and this last time I made the rounds with a doctor. It was amazing to go into the little areas of the hospital. We met the people who clean the scopes for the GI team and the people who do the laundry. All of these amazing people contribute to the ultimate care of the patient. Doctors would be nowhere if they didn’t have support from nurses and people cleaning the rooms, and things like that. They don’t get recognized enough.
Gridley: I think folks might be surprised how many people they socialize with who are actually working in health care, and how many friends and families they’re connected with. If we walk through this restaurant today, I feel confident we could find somebody who was health care-related in some way.
Dorsey: We’re all competitors, but we all like each other. We all respect each other, and we collaborate. When we had water in the basement of our Rockton Avenue hospital this summer, there was a disruption to some of our services. OSF and SwedishAmerican Health System stepped up with certain oncological services that we couldn’t provide.
Gridley: Earlier this year, we were having problems with one of our sterilization units. We put in one call to Mercyhealth, and they let us use their sterilization services.
Carynski: I think the community might be surprised to know that Peoria is the site of OSF Healthcare’s innovation centers and simulation center. It was just named one of the top simulation and innovation centers in the nation. What’s nice about having that forward-thinking center is that we in Rockford get to take advantage of all the things being researched, simulated and invested in. It’s looking toward how we improve outcomes through technology and innovation for all of the communities we serve.