Navigating Telehealth with Dr. Jonathan Neufeld

He's a senior research associate at the Institute for health informatics at the university of Minnesota and the program director for the great Plains tele-health resource and assistance center, which is part of the national consortium of telehealth resource centers. Dr. Neufeld. Thanks so much for joining us today. It's a pleasure to have you on a virtual view. Dr. Jonathan Neufeld: Great. Thank you, Cam. Call me Jonathan. Thank you, Jonathan.

We're really excited to be able to have you be a part of the show today. It's a rare occasion that we actually get to have someone who has been a part of the UMTRC before in the past. Jonathan, do you mind telling us a little bit about some of your past history with the UMTRC. Dr. Jonathan Neufeld: sure. Boy, it goes back a ways and I'll probably get the dates a little mixed up, but we, I know that we first wrote, I joined.

I was in Indiana at the time, still live in Indiana, but connected with the folks at Indiana rural health association for some grant related work I've been doing tele-health I know that Don Kelso at the time and others on staff were interested in tele-health work. And so I wrote a grant and evidence-based telebehavioral health network grant with Matt and he was there. And we did that for three years. And toward the end, we saw the announcement for the. Telehealth resource center grant come out.

And we saw that Ohio and Indiana and Michigan and Illinois weren't covered yet. The tele-health resource centers grew one section at a time. And those four states just hadn't been claimed. So Matt, I. That grant to for the UMTRC originally. And then I was the clinical director while Matt was on staff and he was the titular director of the UMTRC for the beginning. And then after Matt left, Becky took over and we worked together for a while until I left for Oaklawn Indiana.

It's great to be able to have someone that, really understands the history of the UMTRC on our podcast years later. And. tell us a little bit about so now you work at, one of our sister tele-health resource centers GP track. Tell us a little bit about your journey to becoming the program director at GP Track. Dr. Jonathan Neufeld: So after I left UMTRC and you may have heard this from others. It's a wonderful community of people. Wonderful set of grantees.

I think we're somewhat unique if you can be somewhat unique, but I think we're unique among grantee programs, at least at HERSA, just because we're collaborative and congenial. So it was a really tight organization when I left UMTRC I still had some sort of pending obligations to attend some meetings and help do some trainings. And my new CEO said, yeah, great. Go ahead and do that. Stay connected because it was one of the things that.

That I brought to Oaklawn was this connection to the world of telehealth as well as expertise in it. I continued to be in touch with the TRCs and the former principal investigator and director. At GP track Stuart speedy decided to retire. He had been at university of Minnesota for a long time, was very instrumental in the growth and development of the informatics program at Minnesota, which is 50 years old. And it's an amazing program.

And Stuart was retiring from IHI Institute for health informatics. And he knew me from UMTRC days and just kinda tap me on the shoulder and actually with some help from others around the TRC community, who said, Hey Stewart. Yeah, you gotta see if you felt interested. So that one thing led to another until I came to the university of Minnesota virtually, I still live in Indiana, but took over.

After Stewart retired as director of the great Plains tele-health resource and assistance center with and kept a fabulous staff there who are still with us now. Yeah, I can reiterate, it's a very close-knit community amongst the tele-health resource centers, both nationally and regionally. And it's cool to see, those connections that you were able to make just by working on another TRC, even being able to make that connection and just moving over to a different region.

I was curious your background is as a clinical psychologist. So how did you first get introduced to telehealth and what really drew you into actually wanting to pursue, full-time work focusing specifically on telehealth. Dr. Jonathan Neufeld: So when I. Did my post-doc at UC Davis medical center, which is in Sacramento, just a few miles up the road from Davis. I was in the department of family and community medicine.

And. Just, it just so happened that the postdoc position that they that I applied to and that they provided there, was supervised by a man named ed Callahan. Also a psychologist who was in family medicine at UC Davis. And ed had had worked with a number of other researchers at the university and the department of psychiatry who. Some early, early is relative in tele-health right. This was late nineties.

So Medicare had passed its rules and UC Davis had an active telemedicine program with folks like. Don Hilti, who is a widely published psychiatrist in the tele-health world, actually, while I was there, Peter, who's a former president of ATA joined UC Davis faculty, and he's still there. And it just so just in my work with Ed and said, Hey, there's these guys doing this interesting stuff over in psychiatry, are you interested in working with them?

And so I got connected there and when I joined the faculty, then after my post-doc. I actually joined first, as an analyst in psychiatry, they had a behavioral health capitated plan that they ran out of the department of psychiatry and they brought me on as an analyst for that plan while I was finishing. Doctoral hours licensure hours in the family medicine clinic. And then after I finished and was licensed, then they brought me in, on faculty at UC Davis in the department of psychiatry.

And I got to work with Peter and Don and Jim Marson from emergency medicine. You still around quite a bit. And A lot of just got a lot of exposure. They had the first tele-health learning center I think Kathy was involved at the time there. And just was, became immersed in that work that they were doing there. So then when I left UC Davis and came to Indiana, it was one of the things that I just wanted to stay in touch with.

I wanted to keep finding out what was going on in tele-health in Indiana. So I made a lot of cold calls, met some people through the folks in California because Greg Beck, who had been working for children's in Indianapolis Had been trained at UC Davis and was doing a telehealth program down there. So I called him up and met him. We hit it off. And then a group just started meeting and talking about telehealth in Indiana for a number of.

And that led to meeting Matt, writing the grant with Indiana rural health association and et cetera, et cetera. I was always interested in the technology. I was interested in tech stuff. One of my first projects at UC Davis was working. Palm pilot the precursor of the cell phone, or the, of the, yeah, the little handheld device, their personal digital assistant.

And so I wanted to stay involved in technology and I just had some great opportunities there at UC Davis to do that and ended up hanging on to it had ended up having some great opportunities in Indiana to continue. No, that's great. It sounds like early in your career, you had seeds. Different ways that you can get plugged into tele-health where you know, that interest grew over time.

And as you got involved to really leading you where you are now and you gave a little bit of background of how you seen, tele-health kind of grow and change over the course of your career. So you know, what have been some of the biggest changes that you've seen in telehealth? Over the past few years, Dr. Jonathan Neufeld: The biggest changes that have driven it are in the mid nineties when Medicare started paying for it. And actually it really didn't hit its stride until about 2000.

When Medicare finally decided to pay for both intakes and therapy in behavioral health. And since that time, behavioral health has been the majority of what Medicare pays for in telehealth until Covid. But still the largest single specialty, the longer largest single lump of encounters that Medicare pays for telehealth.

But the biggest things besides that reimbursement in the technology world are first of all, the public internet when I started, we were paying multiple ISDN lines or multiple DSL. Lines to various sites or there's another acronym I'm forgetting now with gang lines. But anyway, UC Davis is paying a dollar a minute for connectivity. So you can imagine what it would take to make a telehealth program sustainable when every hour it's 60 bucks. Your first 60 bucks just goes for the connectivity.

Not to mention the little set top boxes from Tanberg and poly-com that. Upwards of three, four, $5,000 to plug them into , your ISDN lines. The fact that you could get to the point where, your connectivity was basically, a hundred bucks a month or 200 bucks a month, whatever it was when we first started getting a more ubiquitous internet, that was a huge change in how those expenses impacted tele-health. The other thing is just.

Just the rapid transformation or the rapid advances in video compression and transmission technology. When you first started to be able to run, video calls on a generic computer running software. Polycomm had software for awhile that was H.323 compliant. But it was clunky and it was hard to use. And web based video platforms really changed all that. And I really have to say, I have to emphasize that even the algorithms and code that we had zoom coming onto the scene, zoom.

Change generationally before COVID zoom was around before COVID, several years before COVID. But when zoom came on the scene, their video algorithms were just a generation ahead of what else was available. The age the H.264 advanced video codec had come out, but zoom really took that and ran with it and provided a markedly better throughput markedly, better video markedly, more adaptable. It was just a real game changer in a lot of ways.

And everybody has caught up or a lot of people have caught up to a certain extent. But those things made it possible to really do high quality ubiquitous, just kinda click a button and there you go, kind of video. And that really has changed the world of telehealth. And then, you can't underestimate the impact, that COVID-19 had on it because we had a solution there waiting, and then all of a sudden, boom, national, international situation where we needed tele-health. Absolutely. yeah.

Before the pandemic. How many people knew and utilize telehealth services. I was just on a student panel this week and I had a student who asked me did telehealth exist prior to COVID-19 and yes, it's had a very vast history. The father of telemedicine can be traced back to the seventies. People really didn't know that the services were being utilized and in what ways they're being utilized. But now it's commonplace.

Dr. Jonathan Neufeld: I've said in other settings too that most, of course most people's view of telehealth is telehealth since March of 2020. And it, and most people think of it as, live video to your home. And in fact, before March of 2020, almost none of it was live video to your home. And we could do that, the technology existed, but you couldn't get paid for it most of the time. Just the year prior to that, I think it was Medicare started paying for mental health services to the home.

Other than that Medicare didn't pay for it. And most commercial payers, didn't either, there's some dabbling here and there, and some Medicaid payers that were pretty progressive did. But you were going into an office somewhere to do a live video telehealth call until mostly until COVID-19 until the pandemic. And then all of a sudden, everybody realized, oh, this is telehealth. This is where my doctor sees me at home, sitting on my couch with my cell phone, it's wow.

Yeah, that's cool, but we couldn't do that a month ago or, whatever. The other interesting thing that I think even folks in the field don't realize is that most of the telehealth that has happened since the beginning of the pandemic would not have been reimbursed before the pandemic would not have existed without the flexibilities during the pandemic.

And it's why there's such pressure to make those changes permanent, because I we know what it's like to operate with one hand and one arm and one leg tied behind our back. It's okay, we can go back to that. But nobody wants to do that, but that's, those are the permanent laws. They're still on the books, when we go back from the COVID-19 relaxation.

So yeah, it really is critical that we examine those rules and think about, okay, how do we want to support virtual care going forward, both as a policy decision, but also reimbursement at whatever payer levels. Yeah. And I'm glad you brought that up, especially with, the most recent edition that we had of the physician fee schedule from Medicare.

One of the big wins that we've seen through the course of the pandemic is, the lifting of geographic restrictions when it comes to telebehavioral health. But to your point, there's still lots of other specialties that we have a lot of evidence-based.

So their effectiveness of being able to offer it through, Modality, but still, there are some of those restrictions that are in place that it makes it hard for a lot of healthcare providers who did all this work to implement this new service, potentially hired staff, got the technology on board. And now all of a sudden they're in this weird limbo I've done all this investment.

Our patients want it now, our providers enjoy, providing this service, but now I don't know if I'm going to be able to get reimbursed for it. Long-term. Dr. Jonathan Neufeld: Yeah. Yeah, there, there is a lot of movement there. And I think that pressure is being felt. And to the extent that anything gets through Congress, this is definitely up there as one of the things that's critical. Telehealth has always been a remarkably bipartisan issue at the federal level.

So to the extent that, anything can get done, both sides want it to happen. But, it doesn't guarantee anything. It still has to be acting, be passed as a piece of legislation that somebody is supporting and somebody is offering and somebody is going to get credit for that. And if we just keep wrangling about who's going to get credit for it, then, and it doesn't get done. So yeah, it's a, it can be a challenge, but I suspect. We're going to see that change happen this year. Yeah. absolutely.

And I think, especially if you can see some of those changes from the federal level, I know here in the Midwest, we tend to see a lot of our Medicaid's tend to mirror Medicare. After they've made some decisions. And especially if we can see some of those changes at a federal level, even if it may not be instantly at a state level hopefully we can see, some of those state changes in Medicaid as well.

Cause I know that can be a huge barrier, especially if your main patient base is Medicaid to be able to have the same reimbursement that you may have through Medicare. Dr. Jonathan Neufeld: Yeah. Yeah. I've been very impressed with Medicare for the most part, actually CMS, I mean, they're aware they know the situation. They are a bit restricted because the original Medicare statute is in statute. If the original telehealth payment is in statute.

And so CMS, can't just say we're not going to do it that way. Congress has to say, or at least give the administrator of CMS, the authority to do that. It is a pretty hard limitation, but CMS has been remarkably creative in wiggling around those restrictions or at least I don't want to make it sound nefarious, but they have figured out how to support an awful lot of virtual.

In spite of the fact that an awful lot of it is restricted in the original legislation When the first Medicare coverage was put into place. One of the, in that 1996, 1997 act I don't know if you've heard the story of how OMB scored telemedicine and I don't know the numbers, but I definitely have the impression OMB scored it it's just, this was just going to be a bank Buster.

If we let people from all over the country, see their doctor by telemedicine, this is just gonna put Medicare in the red. So they were very restrictive in what they allowed. And since then I did an analysis a while back. Since then Medicare, despite growing by double digit percentage, and in fact up until 2020 was growing at about a 30% or more per year rate.

And so he had this logarithmic growth, but even so the peak of it was still less than 1%, less than a 10th of a percent of Medicare beneficiaries. Had any kind of a telehealth encounter. So it was really just a tiny trickle tiny rounding error at the bottom. And so those predictions about busting the bank never really came to fruition. I did, an interesting kind of comparison when I did some of that analysis.

I wanted to find something to compare telemedicine to all of telemedicine in 2019, with Medicare, Medicare spent less on all of telemedicine in 2019 that it spent on Holter monitors. There's cardiac monitor. You take home. It comes in a box. You'd wrap it up, put it on for a few hours, it sends a reading to your doctor. We spend more on that than telehealth and the whole country we being CMS and Medicare.

So at the time when I wrote the article, I said, the Medicare telemedicine program is really nothing more than a pilot program. A couple of people pointed that out and said, Ooh, that's pretty strong statement, how do you, less than one 10th of a percent, how do you call that, real, a real program? Nobody wanted the pandemic to come that's for sure. But but it certainly has changed that, especially in the world of behavioral health, Yeah.

we now suddenly have, some of the biggest use cases that we've ever had for telehealth with what you just quoted with Medicare and seeing, after we've had these big peaks and now that we've seen tele-health utilization still remain significantly higher than it was prior to the pandemic we're really looking at that and seeing what the actual outcomes are. What does some of the emerging research coming out of the pandemic look like? When it comes to tele-health.

And I think that will be a really fascinating thing to monitor over the next few years and just look back at moments like you just mentioned and just Based off of what we found, that seems just real far off the mark.

Dr. Jonathan Neufeld: When the pandemic first started, a few months in 3, 4, 6 months in everybody was taking a breath and realizing, okay We had done, we started doing telemedicine, just tons of telemedicine all over the country, a number of researchers and regulators and payers and others were starting to say, okay, great people are being seen, offices are operating. We're all doing telemedicine, but the big concern was, what about quality? Is all of this tele-health is going on.

Is it, has it significant, significantly damaged the overall quality of medical care. And we worried about that for awhile. And a number of studies have tried to look at that. The challenge in my mind about that is that number one, we don't measure the quality of healthcare very well. Anyway, so it's hard to do a better job of measuring quality and tele-health, and we do measuring health care. Generally, you don't have a comparison an AB a legitimate comparison there.

The other thing is that there's this sort of implication in that question that, yeah, we shouldn't do tele-health it's not as good a quality. We should just go into the doctor in person. Like we have been doing well when that's not possible anymore. And in the old days, it wasn't possible for other reasons, it's not that you just couldn't drive across town. It's like you couldn't get to a doctor. There was none in your region.

The comparison is not, we should just fall back to in person, the comparison is we should do nothing. We should not see the doctor. And when you compare it to that, we haven't had to make that comparison for a while now. We've moved past that. It's a measure of how far we've moved past it but tele-health definitely beats nothing whether it's pandemic or it's just, far distance I think that what we're finding with regard to quality, at least where the world is.

It's sorting itself out now is that yes, there are things you can't do in a telemedicine encounter. And there are especially things you can't do on a phone call with a patient, but you can do some things and those things that you can do; A, you can do more than you think.

And B if you use telemedicine to do the things that you can do, you end up getting an awful lot of care, taken care of for way lower cost and way more convenient and great satisfaction because the patient is satisfied, with the convenience. They're satisfied with the care of course that they got care. But the thing that really kicks it up is that I didn't have to, take a day off work. I didn't have to drive across town. I didn't have to arrange for childcare.

I didn't have to do all those other things that, that telemedicine makes it possible to avoid. Yeah. And that's an interesting point. And I think a lot of times you hear this all or nothing approach, it's either all telemedicine or it's all in-person. There are certain specialties where it might make complete sense to do it all on telemedicine. There might be others that make complete sense to do it all. In the office and like thinking of.

Certain scenarios where it makes more sense to provide that type of service. I'm thinking of, telestroke services in particular, a lot of times that has the most benefit and rural areas where patients don't have easy access to the neurologists, those hospitals may have difficulty recruiting and not to say that those don't have a place in an urban setting either, that tends to be the most common place that you find it.

Because perhaps if you live in an urban center, you might have more access to a neurologist and be able to actually see that individual in person. Really being able to understand and know when are the times that this patient needs to come in person and what are times where this can be done over telemedicine and really understanding should it be a hybrid approach or should it be an all or nothing, but it doesn't have to just be all or nothing.

Dr. Jonathan Neufeld: And because telemedicine in primary care specifically primary care, has been what we have come to see now in the pandemic. The thing that really happened that hadn't been happening before is telemedicine for primary care. Obviously we had other specialties too, and all of healthcare moved there but we tend to think now in terms of primary care and there's questions about how much telemedicine should there be versus in-person, what's the ideal mix.

And I have some comments about that too, but. When you look at more historical or you go back a few years and you think about what are the real successes before the pandemic? You mentioned telescope, which is definitely one of them. And the fact is that without telestroke, without some rational and even aggressive application of telestroke care, there is no way that we're going to have stroke outcomes at every hospital in the country. That meet the standard of care.

Physically, it could happen, but we have to train an awful lot of neurologists and an awful lot of them would have to be sitting around on their hands for an awful lot of their time. And that it's just not going to economically or professionally make any sense at all. There aren't enough stroke cases to use somebody like that full time in a rural area. And so you have to, one of the things telemedicine is great at aggregating demand. You have to aggregate the demand.

To the point where that one neurologist or that team of neurologists can be serving a much larger geographic area or multiple centers in an urban area, whatever it takes to aggregate demand to the point where you can then staff 24/7 neurology and have somebody calling and have those people busy 24/7 whatever it takes to make it a viable service. That aggregation of demand is another part of tele-health. It doesn't get talked about a lot.

We talk about aggregating geographically, but also over time and, making it possible to sustain a practice for a sub-specialty and allow that sub specialist to, then they can actually start to migrate out of the urban areas because they can draw a map on, draw a line on the map and say, okay, that's my service area. And I'm going to virtually connect to all. I don't have to live in an area where there are enough patients to support my practice.

I can live anywhere and just find a geographic area that will support my practice. And I'm personalizing it, but it's more, we do it more realistically in groups, but still that aggregation of demand is a huge benefit for those subspecialty practices like tele-stroke. That were, the rockstars before the pandemic and had been showing us an absolutely critical area that we need to move in.

Even before the pandemic being able to capture and serve a larger area through the utilization of telehealth and, see that in variety of different disciplines. And, even with, within the context of Indiana, we have several mental health, professional shortage areas.

And we have a few behavioral health providers that cover big chunks of Indiana, even though they don't live in those areas, but because they're offering it through tele-health, they can have that larger service area versus just being restricted to the one city that they're geographically located at.

Even with that, being able to serve a larger patient population, but also for that hospital or clinic that's providing the services, opening up the number of patients that they can bring in for even their own business our own sustainability of their programs, which is huge as well.

But with that, for some of our listeners that are just curious with tele-health, we talked about a few different disciplines, but just, in general, what are some of, The we've already talked about strengths, but what are maybe some of the weaknesses or limitations of telehealth. Dr. Jonathan Neufeld: The biggest challenges I think that telehealth faces, and this is this is a, it's not really a weakness of telehealth per se.

But one of the biggest challenges is, to do what you're already doing, or just mimic what you're already doing virtually. Some of the more progressive organizations and providers are starting to bump into this and realizing, we gotta take this to another level. Telehealth doesn't just enable us to replicate the in-person encounter virtually and doing it at a distance. It does do that, but if we do that, then we're leaving an awful lot of the value on the table.

Tele-health doesn't really come into its own until you start doing what I call refactoring the encounter or refactoring the contact between the provider and the patient. And I don't mean just an individual provider, but in the clinic and the patient or between the group and the patient. So that patient can get various components of the services they need through various modalities.

So if all you need is lab results, you get a phone call about that, or you go online and you check that asynchronously, or you get a message. Hey, your results are available. You can check now. And if what you need is a followup or you need some sort of an intake and we just need to exchange some information, we can do that online with a video. We can do an awful lot virtually.

And then when it comes to the point where we need to see you to take your appendix out, or to provide that in a injection or do whatever we have to do physically, then you come in and you, and we do that physically. It's a variation of the old stepped care type of idea where you want to engage at the least restrictive. And I would add most cost-effective level. Possible for every service that has to happen.

Now, if the service is an in-person encounter and you don't differentiate it any further than that, then yeah. You're going to be limited that you have to do a lot of those in person, but if you can. Break down that encounter breakdown, that level of service into a few of its components, like teaching and information exchange and lab results, explanation. And there are a lot of those things that don't have to happen in person at the doctor's office.

The weakness of tele-health is using it to do what we've always done by video. The strength is when we start to rethink what we're doing by video, and what we're doing to deliver care, what it takes to deliver care and using the virtual channels that we have to do the things that they do well, and then use the in-person channels that we have to do the things that are necessary to do, That's a great point.

Using tele-health is going against the status quo of the way that healthcare has been done and delivered for centuries. So really being able to think of now that we have this new way, that we can deliver this care. Are we actually thinking of it as a unique offering? Or are we just trying to do just like you said, are we just trying to provide the same service now it's just on video and not in person.

Versus really trying to think through how does us offering this service through tele-health make this unique, how can we make this service better? Because we're providing it through tele-health or better fit for the patient or the provider versus, Kind of checking my box. I did my visit. I'm good to go. It's the same. And so really challenging some of that status quo. But because it's new for a lot of people the tendency is just to follow what you know.

So if that's how you've provided care for your entire career, and now all of a sudden you have to learn how to do it over a tele-health platform, there's a learning curve attached to that. Dr. Jonathan Neufeld: Yeah. There's a lot of change and it is not simple. I don't ever want to give the impression that, oh, all we have to do is X. And then, that'll solve problems. Healthcare is complicated and delivering individualized healthcare is challenging.

Even in the best of circumstances, we've developed our skillsets and our ways of providing care. Just on the assumption that the patient is here. And it will take a while to Recode reorient to the ways that we can provide health care if the patient isn't here. It's also important to underscore the fact that.

Healthcare also develops according to what's reimbursable because ultimately, you can provide an awful lot of healthcare, but if you don't get paid for it, you're not going to be doing it for long. And so telehealth has this, like any, I think probably any part of healthcare, it's absolutely dependent on the circulatory system that runs underneath it, that the infrastructure underneath it is the payment system.

And if that in-person encounter is what has been conceptualized as this is what we pay then you have to kind of stuck trying to replicate the in-person encounter to get paid. So it's going to take some creativity on the part of payers as well, or some more vertically integrated capitation and quality-based payment arrangements that allow providers and organizations to be a lot more creative about how they provide services.

Yeah. And I'm just gonna take a second, just for some of our listeners who may not know some of those innovative or different kind of value-based care payment models. Tell us a little bit about capitation payments and what that model looks like in a healthcare practice. Dr. Jonathan Neufeld: Yeah. So a capitation payment is just a per member per month amount that a provider gets to provide a certain range of services.

It could be, any healthcare they need all the way up to and including hospital care, but usually it's broken into outpatient and then other services, inpatient and others are paid separately, but a primary care group or an ACO or some organization may have primary responsibility for all the outpatient health. It might improve behavioral health and might not, but and then get a single payment per person.

And then the provider it's up to them to provide the care that's necessary and that's way over simplified. But the idea is that it motivates the provider to both be proactive and efficient . So they want to, not just test everybody all the time and they don't want to just waste care when it's not needed. But also at the same time, if they just did a test last month and they need it again this month, where they need that information.

They get more efficient at finding the old test and saying, oh, okay, we've already got this information. We don't need to do it again. Or they get more effective at saying let's reorder these services or let's figure out how to provide these in a more efficient way as well as let's do it now instead of a year from now, when it's going to be a much more complicated process or the person going to be much sicker.

The outcomes will be much worse . The provider is motivated because of that overall payment that doesn't change unless, their population changes. But basically I'm going to get the same amount of money for this person. It's way cheaper if I keep them well, than if I let them get sick and then intervene. That's the holy grail of capitation is that everybody's motivated to really provide high-quality preventive and interventionists care in the most cost efficient way.

And most cost efficient usually works out to be best for the patient as well. you for that explanation, Jonathan.

Yeah. it really will be interesting to see, As the year progresses and wherever the pandemic lands and some of the public health emergencies, as well as some of the waivers that have been extended during the course of the public health emergency, it will be interesting to see, some of these different innovative payment models that will come and hopefully, we'll see some of these waivers begin to become permanent past the public health emergency.

I want to thank you so much for coming onto our show. And I want to give you a little bit of time. I know you have a upcoming conference. So go ahead and just give our listeners some details. Dr. Jonathan Neufeld: Yeah it's a ways off yet in May end of May 23rd to 25th. And it's in Minneapolis. We are fingers crossed, but very excited to be back in person for the last two years, we haven't been able to have an annual conference and we have a very.

As you mentioned before, and as I said, a very collaborative and collegial group up in the great Plains states, Northern great Plains states that love to get together and share ideas and solve problems. So May 23rd to 25th at the Radisson Blu mall of America. So I'm going to have a day and a half and have some fantastic keynote plenary speakers already lined up and people can find out more about it at gptrack.org/conference that's where people can find out more Thank you, Jonathan.

And with our show notes, we'll make sure that we also share the GP track website. So any individuals who are interested can signup for your conference thanks so much for joining us and thank you all for listening today. Dr. Jonathan Neufeld: great. Thank you, cam.

Finally a special thanks to the health resources and service administration. Also known as HERSA. Our podcast series a virtual view is sponsored in part by HERSA's telehealth resource center program, which is under HERSA's office of the administrator and the office for the advancement of telehealth. The content and conclusions of this podcast are those of Cameron hilt of the UMTRC and should not be construed as the official policy of, or the position of

nor should any endorsements be inferred by . HERSA, HHS, or the U S government. Thanks for listening and have a great day.