Okay, thank you. Now we're going to be talking about a very important panel, Developments for Aging in Place. It's going to be moderated by Dr. Rebecca Stern, one of our teammates here at Gabelli Funds. We also have Ben Adams, CFP at InnovAge, Joe Kimura, Chief Medical Officer at SCAN Health Plan, Marcus Landsner, President at Signify Health, and finally, Pippa Schulman, Chief Medical Officer at DispatchHealth. Thank you all for being here. My mic on? Yeah. Thank you all for being here, and thank you to the panelists. I'm looking forward to our discussion. People are living longer than ever before, and our cost structure for aging is evolving. The health care system needs to accommodate now 30+ years of post-retirement life. Gabelli recently published a report on longevity investing, and as individuals are living longer, I would love to hear your feedback about what you see as the biggest inefficiencies in our current system of aging care, and how can we address these to make longevity more economically sustainable. Take it away, whoever would like to start. Why don't I? I'll start. We'll go from this side. Let's go from that side. I'm Pippa Schulman from DispatchHealth, where we are one of the largest providers, or the largest providers of acute care in the home, really trying to bring the full continuum of hospital-level care from emergent care through hospital at home, SNF at home, and transitional care into the home. To me, one of the biggest inefficiencies, and this will not be a surprise, and I think some of my fellow panelists will agree, is the complexity and difficulty of getting care into the home and of patients receiving care in the site and venue that they prefer, which is generally the home. We say home, but sometimes it's a place that may not be their home, but is not a facility-based care. Reimbursement is confusing. Medicare does not pay for the right things, and we can get into that. The regulatory environment is a maze. I think that is one of the things that really plays into that. As you think about the longevity conversation we're going to have, I think a lot of the solutions people are seeking is a reflection of their inability to get care where they want it. Yeah. If I jump into that, Pippa, too, I think. So I'm Joe Kimura, I'm the Chief Medical Officer at SCAN Health Plan. We're on the West Coast, and we're a Medicare Advantage plan, not-for-profit Medicare Advantage plan. Taking it one level up, Pippa, I think sort of there's also this aspect that got touched on in the last panel around, I think there's increasing complexity in just matching all the resources. I think there's a lot of solutions out there, but as you get older and as you live longer, I think we know most of the things that were acute are becoming chronic, and that complexity just expands, expands, expands. And trying to figure out how to match best sort of the needs of those individual patients and members to all the myriad of things that could potentially help is becoming even harder. I think that complexity and that fragmentation of those resources is leading to a lot of waste, both administratively and sort of elbow grease-wise, unfortunately. Yeah, I totally agree. I actually even think the last panel talked about, I think Joe mentioned, lots of spending on longevity for people under 35. Lots of people here look pretty fit and healthy. The people who are interested in Function Health, which is not cheap, and Peter Attia, it's not cheap, are the people who probably don't need it. And there's a lot of people who aren't really aware of that and need it. The solve needs to be not just like the people who are going and working out every day and caring about their longevity, but solving the problem collectively for people who maybe don't have as kind of full understanding of what that looks like and needs. It starts with then their collective self. Signify Health does a lot of home visits to support members. One thing that happened at a member just two weeks ago is we identified a need, and we were connecting that person to care management. The patient said, "I'm really low on minutes in my cell phone, so I don't want to call." That is a real problem. It happens all the time. That will not, if we leave, so our clinician actually said, "You can use my phone." Once they leave, they're going to back into that problem. You have to really think about the collective solve here. It can't just be, "We really wish everyone joined function medicine or went to the gym more. Yeah, you know it's interesting. I think probably all of us are sort of believers in our own business models, which are all sort of different shades, sort of going after the same problem. You know, I think what I've observed more than anything else is this sort of fundamental disconnect between the payment models and the care models. This was what Pippa was alluding to a moment ago before about sort of Medicare paying for the wrong things. The other thing is, even within the delivery models, this fundamental lack of coordination across all the different areas, right? You don't have someone who really helps navigate the patient. You've got a lot of discrete services that are delivered, maybe fee for service, maybe not, but they're not set up in a coordinated fashion. We deal with, our company deals with people in the PACE program, which is a terrible acronym, but it stands for the Program for All-Inclusive Care of the Elderly. What it really means is we take care of, on a fully capitated basis, complex duals, and we cover everything from pharmacy straight through to primary care. We are a center-based model. We have had some success by having control over 40% of the spend ourselves, and we sort of prescribe the rest. Our model is very small. There are 80,000 patients in the United States out of a much larger eligible population. Each one of us has these models, I think, that are kind of interesting for going after the problem, but they often are not aligned with the care models. They are subscale, and the payment models are a mess. Not to be too encouraging about things, but there's a lot of work to be done, but also an immense amount of opportunity. Great, thank you. What role should private capital and public-private partnerships play in scaling aging-in-place health care models like yours? All right, I'll try. I would say it's actually really important. My background, I was an investment banker for 20-something years. Actually, it's one of my old partners sitting here. I spent a lot of time working with private equity firms before becoming a CFO, for now my third private equity-backed company. This one happens to be public. What's been really clear to me is that the not-for-profit sector does a great job at some things, but they're not very good about developing a model, driving it to scale, and pushing it out to the broader population. The way you really can do that is with private capital. I know for, and by the way, I'm married to a physician who's also a medical school professor. We have slightly different views of the role of private capital in health care. I would say that without private capital funding these things, they just do not get out there quick enough. That is at least been my observation. Yeah, I mean, I don't, look, I've got a few physicians on the panel. I think we agree with you. Because when you try to innovate within a health care system, you have to ask everyone in the system for permission, from the custodian to the CEO. Any one of those people can say no, and your project is killed. I think that that's where the shift comes when you are privately funded and privately backed, you can go faster, exactly. I think there's that also that alignment, right? In our model, too, we actually have a lot of delegated full-risk contracts. You're trying to make it seem like those delivery systems have all the incentive in the world to make it happen. Yet to Pippa's point, it's a hard churn, right, to get up there. Again, to move care, and I think this is one of the latter questions, but to move care into the home, they are still sitting on very expensive infrastructure. How do you make that leap, I think, is where that partnership can start to figure out what those glide paths are going to be. All right, cool. It's funny, I'm going to say sort of like I agree with everything, and private capital is super important. If you're really going to think about long-term longevity, there's a structural challenge. Most of our clients are health insurance companies. There's AEP going on. There's lots of chaos that's happening right now. My business is not incentivized for 2028. We're barely incentivized for 2027 right now. We're reacting to what our clients are saying, and our clients are reacting to what is happening today and planning for tomorrow and maybe the next year. Somebody just mentioned, right, the average tenure of a health insurance member on health insurance is 18 months. As much as we want to have this happen, where is the incentive? Today, it lies maybe with CMS for a longer-term investment. Yeah, yeah. I mean, it's a great point. I mean, there is a lot of, obviously, huge amount of uncertainty in the system right now. When we think about our business, we sort of plan out over the next couple of years. We know there are going to be big changes to reimbursement post the midterm elections. So we've got pretty good visibility for the next 12 months-ish. After that, I mean, there is a lot of volatility in the system right now. After that, you don't really know what the economic model is going to be like, especially if there are substantial cuts that get pushed through to various parts of Medicaid. I mean, that's going to be a big, it's going to be a big limiter, I think, for innovation for all of our businesses, even if we're private equity-backed or private capital-backed, because we sort of look at it and say, are we going to commit this many dollars to put this model out here if we don't even know it's fundable in 12 months or 18 months? At least we're spending a lot of time wrestling with that. Yeah. I think that cycle time point, Marcus, is a good one, too, right? Because on the clinical side, we think a lot, like all of the STARS, CMS, HEDIS measurement stuff in that 12-month measurement window, when we're trying to figure out how do we actually incentivize preventative care, which has a much longer window on some of that stuff, we're disconnected, right, in terms of the things that we believe truly generate value for the population, for patients, for members, and kind of how our systems are set up and the administrative structures that we're all trying to operate in. Opportunity. Thank you. We've heard a lot about technology and AI already, but I am excited to hear from all of you about how tech, and especially AI, can serve to identify new patients who are suited to home-based care and also to treat the existing patients who are receiving care in the home. I love this topic. I know all of us can jump into this space, right? Because one of the most inefficient things, I think, is we have a bunch of tools and interventions to try to match, but I think it came up in the last panel, too, where it's not always matched to the people that benefit most, much less the people that are ready to accept and engage in those solutions. We waste a ton of time just going through this merry-go-round of trying to find those areas. That makes the cost of everything much more expensive. If we can find a way to better match not just the clinical need, but then also the aspect of, is this member patient ready, engaged, and able to take advantage of these great resources we can bring to bear? I think it'll start to open up those greater pathways. I think that came up in the last one around consumerism as well, too, about those capabilities. I'm excited about the ability of these models to start doing that much more robustly. You know, I think about, you're looking at this group, and I think we all are taking care of high-risk, high-needs populations generally. For us, as we look to bringing complex care into the home, yes, the identification of patients, I think, is very, very important and very manual still to date. It is also about anything that patient needs, whether when the physician has ordered it, the nurse practitioner brought to the home at any time of day or night, it's really hard to do. One of my colleagues in the field said it's easier to get, you can get a pizza at 2:00 A.M. in New York City, but you can't get oxygen at 2:00 A.M. in New York City. In fact, that's what we have to perfect, because if I need something in the middle of the night, I need to be able to get it there. Now, fortunately, you do not need it that often, but it's hard to do it at 2:00 in the afternoon. It's hard if you've ever had to get durable medical equipment for a relative. They often say, "Oh, it'll come tomorrow or the next day. Good luck. Goodbye. God love you." We really focus on how can we simplify the logistics and the fulfillment, which is, as a physician, not something I thought I'd be really into, and now I'm really into it. How can we use what we know about our patients and what we know about the patients we've already cared for to predict what the capacity of our system is going to be? Because the other thing about caring for folks in the home is that it's a finite resource of people that are going in the home, of supplies that are going into the home. You can't aim it at everyone. You have to pick your right population, and you have to know you have the capacity to treat the people that need it. That is where I think AI and technology can really be aimed to help with that. Where we're really looking at that, not only to perfect our software platform, but thinking ahead to how can we predict the needs of the population over time and better manage the whole network. Yeah, I mean, I couldn't agree more with everything you said. I would also add, as you think about a lot of the stuff that's coming out with AI today, it's no more speaking to humans at call centers, right? How do we automate this task away? How do we automate that task away? In many cases, those can be wonderful. In health care, what you're seeing is this continued degradation of face-to-face human time. What I hope you see is that AI starts to say, "You know what? Fine. You don't have to worry about manual claims processing. You don't have to worry about that." I actually have humans who can spend more time with patients. How are you going to make this more successful? It's getting towards that, getting towards trust. Sort of it was interesting. We talked a little about OpenAI. Do you trust it, right? I think that is very true. Do you trust longevity? Do you trust this? Do you trust that? One of the most effective ways of getting somebody on the right track towards care is spending enough time with them that they trust what is going to happen next and that they feel empowered to then move forward. That is today just not going to happen with nine minutes in a doctor's office. If you can use AI to get rid of a lot of that other stuff to allow people to spend more time with patients, you can really start moving it in the positive direction. Yeah, I was going to say for us, we've really seen sort of three different use cases for AI. There's the first one, which is sort of just financial stuff. That's pretty easy and pretty well understood. Picking up on Pippa's point, one of the things that we've spent a lot of time, we're spending a lot of time on right now, is just the whole logistics element, right? Because you can make yourself infinitely more efficient. You can take a lot of cost out of the system. And then you've got that margin you get to play with. You either get to sort of invest it back in patient care or a broadening of services or obviously delivering it back to shareholders. The interesting thing for us is really sort of what do we do next, right? We take care of these complex seniors I talked about before. Complex duals are generally sort of some of the sickest of the sick. What you end up with is these exhaustive medical records, right? If you're a clinician, you're trying to sort all this stuff out, you've got thousands of pages of documentation sitting in Epic and other places. What we've spent a bunch of time, we actually did this at our last company, too, but we're spending a bunch of time on is finding a way for AI to come through all that data and synthesize out care plans. It doesn't mean that you don't have to have clinicians go through and review and validate the care plans. You can take work that often would take days, and you can do it in hours at that point. The great benefit of that is once you make it more efficient, to the point you were raising before, that time can get put back into patient interactions, which is really where the greatest value is generated. Yeah. I think a model like yours has been, right? We've got two PACE programs as well, too. That efficiency also expands the differential, right, for clinicians and the team and PACE to be thinking much more broadly of like there are things that are dropping below this heart failure or these other clinical things that could be bigger drivers of the problems that they're having. That openness or increasing that aperture using these tools to surface that allows some of the preventative things to get higher on the priority list, which is great. Yeah. I would bet for you guys for risk stratification, too. It's very interesting because you can look at a population and say, "Okay, we've got a bunch of Medicare folks who are dual eligibles that are sitting in a health plan for us." That is not really the place they should be because they're really complex. They belong in PACE. For you, using that technology to be able to drop them out of a regular dual eligible DSNP or something like that into PACE, not only is it a better model for them, the reimbursement is more appropriate or better or more appropriate for the risk that you're taking on a fully capitated environment. For you guys, I would think there'd be a great opportunity because you're in both businesses. Yep. Yeah, it's clear that as more complex care moves into the home, logistics and supply chain management become a more central issue than we've really appreciated in the past. I want to touch on something that Marcus started to address, which is a general question about what lessons have you learned from serving older adults about what matters most to them in terms of feeling cared for from a health perspective. Sure. I think it's time and trust. I think that, and again, I'll bifurcate this, right? One of the things that's really interesting is how do we think about people and how do you think of equity and spending time. There are people who we engage with who are like, "I'm married to a doctor. I am a doctor. My kids are doctors. I run triathlon. Great. You are going to be great taking care of yourself." There are other people who say like, "Here's all my medications. I don't know what they do. I'm not sure where they are," right? How do you dedicate the right amount of sources, time for them to build that trust? I think, again, if you think about longer-term longevity, there's a population of people who have fallen off of the health care system and taking care of themselves and understanding what to do. It's hard for them to figure out how to get back on. The biggest thing that we as a society and all of our companies are sort of trying to do is to get back in control and make that person feel like they have an ability to trust who they're engaging with and then know what to do next. It's a really hard thing to say like, "I haven't been to a primary care physician for three or four or five years. Okay, what do I do?" Getting that support, and that takes time. It's not just like a six-minute phone call with somebody or a text message or an email from your health insurance company that says, "Please go do this," right? It takes time to build that rapport and then to get somebody to start moving in that right direction. I think if you have time and trust, you can make the right progress. I think part of the time and trust, too, because one of the things in my previous life, actually, full disclosure, when I worked with Joe, we did actually an ethnography project. It was incredible. We got to spend a lot of time interviewing patients in their homes, in the hospital, post-acute facilities, etc. What they value, and this was all patients over 65. Over and over and over again, what we heard was, "I want whatever you're offering me, for the most part, stay out of my life. I want help when I have a problem." That is very obvious sounding, but so many solutions that are sort of fired at older folks are, "RPM, and we're going to monitor you and call in, and I've got this intervention. I'm sending this person to your home." It is like, "I did not ask for that right now. I do not have a problem right now." That is not necessarily building trust. I think there are different ways to build trust. That post-acute, coming into the home, risk assessment, that is a time to build trust. I think that is why the Signify visits often work really well in that scenario. I think when you have an acute issue and someone can come to your home and see you in that place, a guest, a visitor in your home, and you are kind of in control of that, I think that is why PACE works so well, because it is a wraparound service that is providing you not just a medical intervention, but a full social intervention. Help when I have a problem with low-life impact. Our system is not always set up to offer people help when they have a problem. It's set up to sort of monitor and then not always intervene at the right time. I think that is part of that trust piece that's so, so important. I just keep hearing a lot of people want to throw sensors and monitors and things, and that's actually decreasing the trust and decreasing the opportunity. No, no, go ahead. I was going to say just as you extend that pivot, too, you think sort of as patients are getting older and as their needs start to increase and they start pulling, then you also get into that situation where they're asking for things, but they're asking for things in isolated sort of ways, and then they're getting solutions. We imagine a world in that consumerism talk, right, where the member/patient is the one that is somehow more empowered to integrate all of this and figure out what is best for them. One of the biggest things we hear at the health plan of all the calls coming in is like, "I'm getting overwhelmed now. I can't keep it all straight," right? "Help me navigate through this." When we think about the AI tools now, I mean, we're saying, "As physicians, we're overwhelmed. We need AI tools to figure out what to do on our side. I think there's a paucity of things that are truly helping the patient/members equilibrate some of their understanding and education to be more equal partners in the care team. I feel like we're kind of just dumping more and more on them, and it's going to get harder and harder. Yeah. I mean, I think it's an interesting point. I think Pippa used the word socialization or something like it, which I think is a big part of what happens as you really get old, right? It's all of a sudden you're overwhelmed with all those decisions. There needs to be this ability to pull someone into an environment where they feel comfortable talking about these things, where they're not having to make decisions on discrete services themselves. There's someone who's kind of coordinating in their care, who—they pick up the point about trust—who they trust. I think it's the continuity of the relationship, and it's also the social element that comes with it. I mean, one of the things that's interesting about our company is we have 375 buses, right? We bring in people into our centers all around the country every single day. They come in the center, and they'll see a primary care doc. They'll see a physical therapist, maybe a behavioral therapist. They'll come in, they'll have meals. They'll socialize. There is an environment that's created there where they feel like somebody's kind of looking out for me. That, I think, is very important when people move beyond that point where they can make those discrete decisions and they start to get overwhelmed. You mean it's not the emergency department? It's not the Not the I also think the ability to titrate what that level is so important because there are, I loved our friend in the back who's like, "I've got my iPhone. It's here. Oh, you're in the front now. Yes. I've got my iPhone and my Apple Watch, and I bet I've got my own network, and I want to see your network and your life. There are things you need that are very different than the 85-year-old next to you. Our system does not do a very good job of addressing people as individuals. We sort of smear across, and we peanut butter spread. I think that also does some harm. We have some really wonderful interventions like PACE for a group of folks that's not going to be great for you. We have some great interventions for super healthy people that's not going to work for the other end. The middle kind of is left a kimbo. Yeah. Remote patient monitoring was brought up a couple of times. I think it's actually very interesting when you think about, again, you think about healthcare as its own individual thing and don't zoom out. You see State Farm ads about plug the thing in and get discounts. When you talk to patients about monitoring, they say, "What are you going to do with that? Yeah. When you take something away, what are you going to monitor? Right? That gets back to trust. We do not today have a society. It starts also back with health insurance plans changing the benefits every day to deal with the cost structure and everything else. You have a person on the receiving end just not trust. You are going to put this thing in my home, and what are you going to watch me sleep? What are you going to do with this information, right? People do not, we are not in a trust-first society. We are not in a place where people think that this thing that is going to be done is for my benefit. I think we just have to understand that. Until we change that paradigm, it's on every single person who's trying to do this to say, "I'm starting from a place of distrust. Yeah. There is a lot of confusion about payment models, too, right? I mean, we are going through open enrollment right now. I guarantee you everybody sees every morning on TV an ad for Humana's MA plan. They probably say, "We have got a cash card. If you join, we will give you $300 a month to spend or whatever you can do." People get drawn to these shiny, whatever the seasonal or the hot one is now, without really sort of having a chance to sit back and say, "What does this payment system really do for what I need?" I think there is a lot of misallocation of people across payment models as well, too, that we all see in our own businesses every day. That perverse side, right, of the supplemental benefit as you're using that to sort of pitch and sort of figure out if members will actually choose you as a health plan. At the same time, it's an expense. There's sub-optimization of the use of that sort of supplemental benefit, right, on the health plan side. All these things are oddly set up right now where, again, we have potentially great solutions, but the system is just not well constructed to actually allow patients and communities to take advantage of that value. Thanks. If we reconvene in five years from now, what do you think are, what do you hope are the leading innovations or just fundamental changes about how we think about or pay for aging in place? I'll start. Five years. First of all, I would say I'm generally optimistic. I think about when the models that were in place when I had started in the healthcare industry as Investment Banker years ago are vastly different than the way it is today. Today, we have much better use of data. We have a much better understanding of what a participant needs. We have a much better sense of how to coordinate care. There have been leaps of improvements. I think there are a bunch of really interesting business models that are out there, too, which everybody's trying. There is a lot of desire. There is a lot of private capital formation in the sector. There is every reason it should do well. I think what you'll see is you'll see much more tightly coordinated care. I think you'll have simplified payment models that may be a little bit more than five years. But I think you'll ultimately have simplified payment models. I think you'll find a way to get technology that's assistive in developing care plans and isn't intrusive on people's lives, like you were talking about before. So I think we're headed in the right direction. One of the things I always found interesting about healthcare is the business models are changing all the time, and we're kind of iterating in on the right solutions. It's going to go far beyond my lifetime. There's incredible investment opportunities in it because of it and incredible opportunities to do good. But I think we're going to get to a much more tightly coordinated care delivery model with sort of a simplified payer structure. And that's probably where we need to end up. Yeah. Here's to hoping. There'll be twice the enrollment in PACE programs in five years. God, we're hoping for next year. Yeah. But yeah, to me, I'd say there's this awesome opportunity now. We think about the coordination challenges. Right now, it feels like everyone's dumping into this thing. I kind of feel like 10 years ago, remember when everyone was like, "Just put all your data in a data lake. Trust me, it'll get organized in that space." We're doing that with interventions. I feel like the power of the capabilities in AI will help us really cut through that coordination challenge because it feels like it's a pretty good match of both tech enablement as well as the problem that it could solve. I'm super optimistic we'll be in a better place with better tools to facilitate this matching in three to five years. Yeah. Five to ten. I agree. I think the coordination with AI and making sure you are able to take the hospital with everyone that's down the hall from each other in a place that can be done at the home is way more complicated than we often thought it was. A weird combination of, I actually think AI and humans, if we do it well, will make this population feel less lonely. One of the major problems is aging in place. It should also say aging alone because that's actually what that really means for a lot of people. That is really a sad place for many people. One of the things that will make aging in place more successful is if people feel less alone and isolated. I'm not saying everyone's going to have a, what was that movie with the. The Gears? Yeah, yeah, right? But some combination of AI supporting people and freeing up tasks that other people can spend more time on. People, if we make this population feel less alone, we will have succeeded in a lot of ways in getting that to being a healthier population. Sounds like a great place to be in five to ten years. This is good. Woo-hoo. It's a weird time to ask because literally the government reopening meant that the payment model for a big core of my business restarted yesterday. In five years, I'd like a permanent payment model for hospital at home. That would be one tiny thing that I would wish for. There's a lot here I agree with, and I don't want to repeat everything, but I do think the reimbursement for care in the home, some rationalization, both from the primary care at home end of the spectrum to the acute care at home end of the spectrum. I would like to see, obviously, more of that care shifted into the home and seeing hospitals really used for what they're best for, which is our highest complexity care and making them, in fact, more age-friendly as we're doing that. I think both things can happen. Yes, I actually, I really appreciate that you brought up the loneliness factor and the ways that AI can improve both our time spent with patients, but also potentially decrease that. Thank you. That was good. That's a good point. Thank you. We have time for some questions from the audience. If you could raise your hands. Oh. The Oh. The audience has some questions. Wonderful panel. My name is Mahima. I'm a student. She has a mic. Her mic is not on. Can you hear me now? Okay. Yes. My name is Mahima. I'm a student at Mailman School of Public Health. Thank you so much for your time. I'm wondering if you can expand on the role of health communication and digital media to guide our consumers in understanding their health. We talk a lot in healthcare about what we can do on the clinician side or the healthcare administration side to build trust, but I'm wondering if you can elaborate on how we can persuade our consumers to trust our processes. Fun time to be asking that question right now, right? I do think if we just take two steps back and think about what happened over the past 12 months, thinking about vaccination policies, et cetera, there is a need, right, to say, as we're moving our population society forward, how do we level set on what sort of is clinically appropriate, evidence-based, whatever we want to call that? Right now, it feels like we are arcing in different spots, right, which is making it even harder as clinicians, right, to be like they're frozen in paralysis because they're seeing multiple different avenues of information coming at them. I do feel like there is a powerful way. I mean, PSAs are great, but I feel like every one of us is probably doing some level of health education to try to get that knowledge base equilibrated. I see it as important, but I don't see it's necessary, but not sufficient to get that activation going. On the flip side of it, when it is fragmented, it just makes it 10 x harder to actually get that activation going. I don't know if I had a full answer to how to solve it right now, but it's an important cog of what we're doing. Ideally, I'm hoping that we'll get back into alignment where we're really thinking about what works and then aligning our communications and education efforts in that way. There's always going to be discordances, but I think we're amplifying some things in a very challenging way today. I would add, it was either The Wall Street Journal or the Financial Times this week that had a headline. I didn't read it. It said, "Walking longer, not walking more is healthy." I was like, "I don't know what that even means." We have gotten to the place that it is like there is a right answer and there is a wrong answer. We need to just come back to the fact that there are better choices and worse choices and the continuum of those things, and getting back to a place where we could be okay with eggs are good, eggs are bad, eggs are good. Just like there are things that are better and things that are worse. We as a society can say there is somewhere along this spectrum, we can make those decisions. Because today, we are still back towards good, bad, good, bad. If you are there, you end up with a lot of mistrust. Yeah. You know, it's interesting. I find in our business, the role of technology and communication actually isn't super important, right? Because I think what happens is when, again, our population is complex duals. So they're old and poor, right? And often, if you're not economically advantaged or if you're elderly and you've got some issues associated with technology, you find that it just doesn't work very well. I just think about my mother, who's 99, when she tries to answer a call on her cell phone, there's a fair amount of button pushing before she'll get to the right one. The volume's too low. What we find is that it's the socialization element, a little bit of getting away from being alone at home with a screen that really is the thing that really helps. There's a point, I think, in that sort of the utility of electronic communications that breaks down at the end. You have to be able to step in with those personal interventions because that technology doesn't get levered all the way through. We're all going to talk, but this is good. I think this is an area, too, where going back to user-centered design principles is really helpful. I agree with my panelists here, but I also think there's ways to create interventions that can be used by a broader spectrum of the population if you design them properly. For instance, what we leave in the home, we sort of designed it with the archetype of a tech-naive 92-year-old with a fever. Someone who's sick and needs to be able to trust that someone's going to be there when they have a question or a problem and that they're safe and all of those things, but doesn't need to know how to do anything. It also needs to be able to respond to my friend here in the front row, who's probably going to want to monitor his vital signs and trend them over the course of a few days and know who's coming today, tomorrow, and the next day. We had to make it responsive for both because that's how we're going to be able to communicate with both folks. I think designing right for those groups of people is going to be really important. Thank you. Next question. We have one there. Yeah. Thank you for sharing, Grace, those. When I launched a pilot program to achieve aging in place in South Korea, it was really hard to define the target customer because the demands varied by person, severity, or types of disease. I think aging in place should be much more than that, merely managing chronic disease, because elders want to be aging in place instead of staying in the hospital. My question is, who truly has demand for aging in place and who is your target customer in the future in terms of severity or types of disease or disability or any other things? I don't know if this answers your question. I agree with you because I think part of the disconnect you have is nobody sees themselves as a diagnosis or a set of codes, right? They see themselves in terms of their functional status and what the things that they want to be able to do in their daily life. We know for people over 65, if they touch a facility, their functional status is likely to decline. You enter a hospital, you're likely to leave using a loss of one or two ADLs, right? Our target audience is we want to work on patients with one or more chronic conditions who are at risk for hospitalization to prevent them from going to that bricks-and-mortar hospital so that we can prevent them from loss of functional status because that's what keeps people aging in their homes and staying independent, right? That's the goal. I think if you're asking people what their goals are, their goals are, "I want to stay independent as long as possible. I want to enjoy my life activities, whatever they are, as long as possible. Going to the movies, being with family, dancing, whatever it is." For some people, that might be watching Jeopardy. To be able to make that happen, we have to prevent the decline. We know what causes the decline, right? are lots of things, but hospitalization is a big factor in what causes that decline. SNF stays cause that decline. Illness causes that decline. How can we prevent those things from happening? That is our target audience, who is at risk and folks who have chronic illness, who have been hospitalized. That is where we are looking to aim at. Every major hospital system in New York has got a home health business: HHC, Montefiore, Northwell, Sinai, everybody. For these systems, is this a good long-term business? Do you have any sense of what systems do the best job at aging in place in New York? Who wants to take that hop? I guess I would say, I would just say, again, not being a home health expert, but somebody who uses home health services, we provide them internally. The models are so different by community, right? It's very hard to sort of look at home health, I think, as a broad thing because the way care gets delivered here in New York City versus where it gets delivered in Southern California or in Michigan, it's all very different models. I think the idea of having people in the home interacting with participants as a proxy for being in a nursing home or an assisted living facility or as a way to divert from an inpatient admission or things like that is a great thing to do. I think there's a really good ROI in that business, but it has to be included in a larger coordinated payment model for you really to get the most out of it. That program really works well. In Pennsylvania, they've got a big paid caregiver program down there, which members' family members or close relatives can get paid to take care of people in the home. It is both a combination of a medical program and a social program, really, is what it is. There is a lot of currency in those models, but they can't exist as a standalone business, at least not officially. Next question. I have a question over here. This question is for Ben and then for the larger group. My name is Andrew Siegel. I was the former director of long-term care in New York State, and I had oversight of the PACE program. I am very interested in the PACE model. During my tenure with the state, we had a lot of difficulties in growing that model. I am very impressed by what InnovAge has done. I am just curious, is your perspective as what have been the limitations on the growth of the PACE program? Is it based on geographic accessibility? I know there have been issues around the physician, primary care, some access to their physicians, or has it been kind of the site limitations of the PACE model? I guess to the larger group, my question is, what are some of the policy levers at our disposal to get people into coordinated care programs like PACE? What do you think the limitations have been on doing that till now and things like PACE Innovation Act? Yeah. I mean, with PACE specifically, I think PACE is sort of an interesting industry because it existed as a not-for-profit model, right? When it gets started, and until actually we got privatized, I want to say in 2016, Welsh Carson was kind of the sponsor in that, there really wasn't a for-profit model, right? Profits generally don't, as we talked about earlier, don't invest a lot of capital, don't grow the footprint as aggressively as other for-profit models can do. I'd say when we think about the business today, the growth side doesn't come easy for us. We have to work really hard. A couple of things. You have to find the person who would otherwise be in a nursing home, because that's the criteria, as you know, for nursing home eligible care. You have to find that person. Then you have to convince them that this sort of little-known model that's out there is actually really good for them. You have to compete against everybody who's out marketing and open enrollment and offering them free money to go into their health insurance program. Lastly, in places like in Pennsylvania, I mentioned before, you're competing against the paid caregiver program. They're saying, "Look, my son or daughter gets paid to take care of me at home. Not only am I getting my care coordinated, but it's actually helping the social welfare of my family. There are a lot of impediments because the model is by nature somewhat complex. You've seen it do better in certain environments. We've had great success in Colorado. Southern California has been really good for us. Pennsylvania is really tough because of some of the dynamics. Unfortunately, because of the way the payment models are set up and the marketing is set up, you're not getting the level of adoption we probably think you ought to see. We can grow well, but I mean, we work for that growth. Yeah. I mean, we see, I think, to the point of watching patients and members develop those needs to get to nursing facility level of care requirements. Before they actually make those choices, introducing the model, which then is an insurance change as well as a provider change, there are a lot of things that need to then get introduced. We try to start thinking about education a little bit earlier, right, to say these are options that can become available because I think it is a lot, even though our AI algorithms can find those people and be like, "There's a trajectory that's happening." There are a lot of choices and decisions that they need to be able to make. I would say that in most PACE programs, when you actually have people walk through the facility, it's pretty amazing. People are like, "This is actually very nice. This would be a great place. People do not know that overall. Just clicking on videos, etc., does not always provide that. I do think it is a challenge, even though you can start setting up all those criteria. I think there is more we need to be doing to try to make it available as an option and potentially a superior option as people are developing more and more needs. I mean, PACE is also only available in 37 states. There's a lot of barriers. I believe it was the long-term care industry that was lobbying against PACE in the states where it's not available, which is too bad because it's a proven model. I mean, there's a lot of evidence around PACE. The fact that it hasn't spread is one of the quite great mysteries, actually. It's a capital-intensive model, too. Yeah. Sure. Like when we build a center, it'll cost us by the time we're done with site selection and development and construction and all that stuff. It's a $15 million-$20 million enterprise. It's going to take us two to three years to break even in it. It's going to take us five before it's optimized, right? It's a really capital-intensive model. You've got to be willing to put the dollars in, and you've got to have the runway to get it to maturity to sort of get your investment to pay off. It's trickier from that perspective, too. Thank you for your insights. I work at the intersection of healthcare and technology and developing funding, commercializing innovation in that space. A couple of you mentioned the issue of trust with sensors and RPM. On the innovation side, we're observing some of the different momentum, and there is interest for certain population types. I'm curious, from your perspective, where do you see there are opportunities? Where do you see there is openness to this type of technologies and monitoring? How do we solve for that trust issue? I mean, yeah. I think the opportunity is great. I think the point comes around how you're going to use it, how you're going to set it up, and then at what point you engage. There's a number of interesting companies that you've had a hospitalization. I'm going to come to your home. Oh, by the way, do you mind if I put a cough sensor in, a toilet sensor in, a bunch of other things? You say, "Wait, wait, wait. What just happened? And how are you going to pay attention to me?" Right? I think the alignment needs to be then, what are you going to do with these sensors? How are they going to fit with the broader care that we're being delivered? What am I personally going to get from it? If it's something you really care about, I can monitor it. I think it needs to be more than just the truth is, again, I'll get back to it. It's like the sensor makes you healthy, maybe. Maybe someone believes that. Maybe they don't. How do you have somebody who's coming in and engaging say, "This is a really helpful thing to get you to watch more Jeopardy, go to your son's bat mitzvah, go to a wedding," whatever that thing may be. It has to be about that person and not about one very narrow specific disease state or condition. I mean, one interesting point, I think we're talking also about some pretty high-tech sensors. Lifeline, which is what's often advertised on television, "I've fallen and I can't get up." Call that early technology, right? It's sold everywhere. Many health plans pay for it. Lots of people put the Lifeline on either their wrist or their neck. The 30 days after they get their Lifeline, something like over 60% of folks have put it on the cabinet, hanging on the back of the door. After two months, it's like 90% are not using it anymore. People actually love Lifeline. I'm using a brand name. I apologize. It's like Kleenex. I happen to have gone, I live in Massachusetts, and I've gone to the actual Lifeline call center. I think it's my retirement job. I'm going to sit on the phone and talk to older people all day. People love calling that call center. What problem was it solving and for who, right? It's usually solving an anxiety problem for a child of a person and not always that person. Now, sometimes the person loves it, and they push it every day, and they talk to the person in the call center. For most people, it's not. I think that's your issue, right? I use that example because I think it's so good. It's not the cough sensor and the toilet sensor because those are even further on the spectrum of like, "Who needed this?" It goes back to, is this useful for the individual? If not, what problem are you trying to solve, and how can you make it so that it's actually achieving a goal? I think that those goals are achievable, but we just have to ask better questions. I also think that when we are talking about some of these sensors and monitors that might be useful, many of them were tested in environments that do not look like where our patients are living or how they're behaving or what they're doing. They become less useful as well because you're getting a lot of noise and not a lot of good signal. That is a whole different conversation. Thank you. Thank you all so much for a thoughtful discussion. That was not a great last word. That was a good last word. Good job. We're going to take a very quick break, and then we'll be back here to talk about vaccines. Thank you.