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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;01 - 00;00;30;20
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. Medicare Advantage plans are privately administered insurance plans that provide an alternative to the traditional Medicare program which allows enrollees to see any participating provider. In exchange for a restriction on choice, enrollees can receive various benefits, such as lower premiums in cost sharing and supplemental benefits like vision and dental care.
00;00;31;05 - 00;00;53;03
Alan Weil
As of 2022, about half of Medicare beneficiaries were enrolled in a Medicare Advantage, or what we sometimes call an MA, plan. Now, there are longstanding concerns that MA plans are paid too much, although what is “too much” is very much in the eye of the beholder. Those concerns have led to a variety of proposals to reduce spending on MA plans.
00;00;53;03 - 00;01;20;16
Alan Weil
We'll discuss one of those approaches today. What would happen if we reduced the benchmarks used to set MA payment levels? That's the topic of today's episode of “A Health Podyssey”. I'm here with Michael Chernew, Leonard D. Schaeffer Professor of Health Policy in the Department of Health Care Policy at Harvard Medical School. Dr. Chernew is also the chair of MedPAC, the Medicare Payment Advisory Commission, although he's not speaking on behalf of MedPAC today.
00;01;21;07 - 00;01;46;11
Alan Weil
Dr. Chernew and coauthors published a paper in the April 2023 issue of Health Affairs, examining the effects of lower Medicare Advantage benchmarks on plan, generosity and benefits. They found that a $1,000 per year decrease in the benchmarks would lead to only moderate increases in annual premiums, deductibles and co-pays. We'll discuss these findings and their implications in today's episode.
00;01;46;28 - 00;01;48;29
Alan Weil
Dr. Chernew, welcome to the program.
00;01;49;25 - 00;01;56;02
Dr. Michael Chernew
Alan, it is great to be here and I'm glad to be able to reach your listeners. And as always, it is just wonderful to talk to you.
00;01;56;17 - 00;02;18;19
Alan Weil
Well, I introduced you as Dr. Chernew, but I've known you long enough I think I can call you Mike, and I have always enjoyed our interactions. I am sure today will be no different. We get to talk about one of the really thorny, complicated issues in health policy, as if there weren't enough. In order to talk about the implications of policy changes for Medicare Advantage,
00;02;18;20 - 00;02;42;20
Alan Weil
we have to start with some baseline understanding of how MA rates are set and what the role of these payment benchmarks are. So I know it's sort of an impossible task, but for our listeners, can you explain what is a Medicare Advantage payment benchmark? How are they set and why does it matter if we're going to talk about MA
00;02;42;22 - 00;02;46;02
Alan Weil
benefits and payment levels?
00;02;46;23 - 00;03;13;04
Dr. Michael Chernew
Sure. So the benchmark system is the foundation of how the government sets what it pays the private plans, the MA plans. And in every county a benchmark is set as a multiple of what the enrollees in the fee-for-service portion of Medicare would spend. So in expensive counties, it's a little bit less than fee-for-service spending and less expensive counties,
00;03;13;04 - 00;03;47;02
Dr. Michael Chernew
it's actually a bit more than that. Once the benchmark is set in a county, the MA plans bid for what they will accept. If the plans bid above the benchmark, the beneficiaries have to pay that gap as a premium. If the plans bid below the benchmark, and most do, 90% plus do, a portion of that gap between the benchmark and the bid can be used to finance these extra benefits that you mentioned for beneficiaries: lower cost sharing, lower premiums, etc..
00;03;47;13 - 00;04;15;26
Dr. Michael Chernew
So when benchmarks go up, it's easier for the plans to bid below them and give benefits to beneficiaries. And if the benchmarks go down, there's less of a gap between the bid and the benchmark and the beneficiaries would conceptually get less. Before we talk about that in more detail, it's also important to note that this payment to the plans also reflects the health status of the beneficiaries that enroll in the plan through a system that's known as risk adjustment.
00;04;16;09 - 00;04;30;01
Dr. Michael Chernew
And the payments also reflect plan performance on a bunch of quality measures, sometimes known as the Stars program. So the benchmarks, the stars and the coding and the multiple of fee-for-service all contribute to what MA plans get paid.
00;04;30;18 - 00;04;56;02
Alan Weil
Well, that was crystal clear to me, and I think it probably will be to our listeners. So what you've described is an environment where you use the fee-for-service cost as sort of a starting point, and then there are some modifications to that. But it turns into this benchmark, and since most bids are below benchmark, that creates some space for the plan to do something for the enrollees.
00;04;56;02 - 00;05;24;11
Alan Weil
With the gap between the benchmark and what their bid is. So you've already described that it's highly typical for the bids to come in below. What happens with those? Let's get a little bit more specific. These rebates come back to the plans. How do they play out in terms of reducing premiums or providing extra benefits? What do plans do when they when they bid below the benchmark?
00;05;24;29 - 00;05;51;07
Dr. Michael Chernew
So there's a lot of variation across plans and across areas. But as a general rule, they will often bid so that premiums go down. So they might, for example, reduce the Part D premium. There's many examples of plans that offer more benefits, but they do so with zero cost to the beneficiary. That's called a zero premium plan. Medicare itself is not a particularly generous benefit package.
00;05;51;18 - 00;06;20;19
Dr. Michael Chernew
Patients have to pay a lot out of pocket when they seek care and the extra funding for the MA plans, or the gap between the bid and the benchmark, can be used to reduce what beneficiaries have to pay when they see their doctor, go to the hospital and things like that. In addition to those financial uses of the rebate dollars and the payments in general, the plans can offer supplemental benefits.
00;06;20;19 - 00;06;28;29
Dr. Michael Chernew
You mentioned some vision, dental, hearing, transportation, fitness membership. There's a lot of these types of benefits.
00;06;29;12 - 00;06;57;18
Alan Weil
As you noted, most of the bids come in under and that creates sort of this natural question here, which is if you're trying to save money on Medicare, which we always are, and particularly if you're trying to save money in Medicare Advantage, if you make the benchmark lower, then there's less space between the benchmark and the bid, and that creates less givebacks to the enrollees.
00;06;57;27 - 00;07;21;01
Alan Weil
And of course, enrollees don't want to give anything back in the plans, don't want to lose the marketing advantage of saying, “Hey, sign up for our plan, you'll get all these goodies.” So if your goal is to save money by reducing benchmarks, you worry about what's going to be lost. And your study, this one, you've done many, but this one that we just published looks at what would be lost.
00;07;21;02 - 00;07;22;24
Alan Weil
So what do you find?
00;07;23;14 - 00;07;49;28
Dr. Michael Chernew
One thing to keep in mind is that right now the rebates, which is a measure of the generosity of plans, are essentially at an all time high. And what we find is when you cut the benchmarks, we use $1,000 in our paper just as a metric, it’s about 10%, when you cut them, you, in fact, do see less generous coverage, as you suggested.
00;07;50;02 - 00;08;16;17
Dr. Michael Chernew
But the effects aren't very big because there's a lot of adjustments. The plans, for example, can lower their bids in response to a lower benchmark, which enables them to continue to offer much of the benefits they were offering before for less. And so the tension in the narratives around this is often between an accounting framework which often holds the big costs and says, you're going to lose all of this,
00;08;16;28 - 00;08;29;23
Dr. Michael Chernew
and what I would argue is more of an economics framework, which assumes there’s going to be a whole bunch of equilibrium adjustments, and those adjustments offset to some extent, not completely, the impact of those lower benchmarks.
00;08;30;20 - 00;08;52;28
Alan Weil
And just to be clear, we're not a journal club here. We're not going deep into methods. But just to be clear, the way you reach this conclusion was by looking at, as benchmarks have increased over time, you see what gets added and you sort of flip that and do the inverse and say, given what tends to happen when they go up, this is what we would expect to happen as they go down.
00;08;52;28 - 00;08;54;17
Alan Weil
Is that a close approximation?
00;08;55;14 - 00;08;57;29
Dr. Michael Chernew
I'm going to say that's an approximation, Alan.
00;08;58;09 - 00;08;59;25
Alan Weil
Oh, I thought I did better than that.
00;09;00;14 - 00;09;27;06
Dr. Michael Chernew
Well, we do that. But it's more that we exploit variation across counties in the rates with which they go up and variation across counties in this multiple of fee-for-service spending. There's a lot of things that are causing variation in what plans get paid that are in the regulations, some very nuanced regulations to determine the change in benchmarks in any given county.
00;09;27;18 - 00;09;31;02
Dr. Michael Chernew
And we use that variation to do essentially what you said.
00;09;31;03 - 00;09;44;29
Alan Weil
Okay. So I'm going to take that as a friendly amendment, which is there's a lot of variation both over time and across county. And you take advantage of that variation to understand the effects of benchmarks. Yes. Okay. I didn't want to be too far off.
00;09;45;01 - 00;09;45;15
Dr. Michael Chernew
Yeah, that's perfect.
00;09;45;15 - 00;10;02;26
Alan Weil
Okay. And so you just mentioned that the rebates are at an all time high. Is that the primary motivation at this point for people looking at the question of whether they should come down or are there other factors going on right now?
00;10;03;07 - 00;10;30;18
Dr. Michael Chernew
You know, there's again, a lot of different perspectives on this topic. I think there is a general sense that from the inception of the Medicare Advantage program, the philosophy was that we would make it, put it in cost parity with fee-for-service. We believe that the plans could deliver benefits for less because of some of the restrictions that you mentioned, they do prior-auth, they have narrower networks.
00;10;31;02 - 00;10;51;04
Dr. Michael Chernew
And we would take those savings and share them with beneficiaries in terms of more generous benefits. That was sort of the basic notion, and that's a reasonable view. And so what has happened for a range of reasons, some of which are intentional, like the multiples being above 100%, some of which are unintentional, like the way the coding is working.
00;10;53;06 - 00;11;13;29
Dr. Michael Chernew
The plans have actually never been paid a parity with fee-for-service. The estimates now, again, depending on where you get the estimates, I’m going to give you a number that’s loosely a MedPAC number, give or take round numbers, 5% more than fee-for-service. So there's a narrative which is, we need to save money, and if we're going to save money, we should put these two programs at parity.
00;11;15;12 - 00;11;41;25
Dr. Michael Chernew
Maybe you'll ask me later there's some other sort of second order problems if they're not at parity and everyone joins the MA plans. I think most people like the fact that individuals get more benefits, so no one I know, no stakeholder I know wants to cut the payment simply because they want there to be less benefits. It's all driven by a fiscal concern and by a perceived lack of balance between more paying in the fee-for-service sector and more paying the MA sector.
00;11;42;20 - 00;12;16;19
Alan Weil
Well, that's a great framing for the discussion I want to have about the implications of this. I want to have a better understanding of the pros and cons of different levels of payment and how we figure out whether or not, if we are paying more, it's worth it. We'll talk about some of those topics after we take a short break.
00;12;16;19 - 00;12;43;04
Alan Weil
And we're back. I'm speaking with Dr. Michael Chernew about the effects of reducing Medicare Advantage payment benchmarks. As we learned before the break, the actual direct effect for the enrollee in terms of the premiums and deductibles are actually pretty modest, which would suggest that this is a place you could go to pull some money out of the program without having huge negative effects for the enrollees.
00;12;43;05 - 00;13;12;27
Alan Weil
But anything that is seen as a takeaway is not desirable. And there is, of course, controversy, as we discussed before the break, about how much the payment rate gap is between fee-for-service and Medicare Advantage. So I want to try to now put this more in a policy context. And again, very mindful of your role on MedPAC, certainly not asking you to take a position here.
00;13;12;27 - 00;13;42;16
Alan Weil
But one of the things we talk about a lot in health care is if you pay more and get more, maybe that's okay. What you don't want to do is pay more and get less or pay more and not get any more. So this looks like one of these situations where if we're paying more but the enrollees are getting more, that creates a sort of a policy quandary, which is, is it worth it?
00;13;42;19 - 00;14;06;00
Alan Weil
Like, are they getting the right amount more? Are the plans benefiting inordinately from it? And what about the people who aren't in MA? Are they getting too little? So I know you've given a lot of thought to this. If I just want to even make sure I've got the right question. If I were a policymaker saying, yeah, we're paying more, but they're getting more, is it worth it?
00;14;06;01 - 00;14;10;04
Alan Weil
How would you guide me to even think about a question like, is it worth it?
00;14;10;14 - 00;14;48;25
Dr. Michael Chernew
Yeah. Well, first let me give you a little bit of a sense of the magnitudes of this. The rebates have roughly doubled since 2018, so I'm not sure in 2018 we would be having a conversation about whether or not we should double the rebates and spend that extra money. The challenge is answering whether they are worth it, that whether the added benefits are worth it is complicated because we don't know for some of the supplemental benefits how much they're being used, how much they're valued by beneficiaries, what the trade-off use for those dollars are.
00;14;49;10 - 00;15;22;28
Dr. Michael Chernew
You were nice enough to note that I'm speaking in my role as a professor, as a researcher, but the MedPAC recommendation has been and continues to be that there should be some modest cuts to the program to create more parity between MA and fee-for-service payment. One reason why I think it makes sense to start with modest cuts is we can begin to assess what is actually lost and how we do that instead of making large one time cuts.
00;15;23;14 - 00;15;59;10
Dr. Michael Chernew
But again, there is no free lunch. The reason why benefits are at an all time high is because payment is much higher. It should not be surprising that if you lower payment back down, you will lose some of those benefits. And so we just have to decide the extent to which we believe that the role of the Medicare Advantage program is to cover up the gaps in the Medicare benefit package, which are large, or beyond that that could be financed with simply program or plan efficiencies.
00;15;59;26 - 00;16;29;19
Alan Weil
Yeah, so that seems to me like the puzzle here, which is, do we want people on Medicare to have vision benefits and hearing benefits? We do, but we haven't been able to pull together the political will to add it to the traditional Medicare program. So is it equitable to say, well, you only get those benefits if you're willing to accept the limitations inherent in an MA plan?
00;16;31;05 - 00;16;34;25
Alan Weil
Is that, I don't know. Do I have even the right question?
00;16;35;04 - 00;17;01;00
Dr. Michael Chernew
Well, I mean, it is certainly the case that the current system favors those who are willing to accept the efficiencies of the MA plans, the network restrictions, the prior authorization. And again, the original conceptualization of Medicare Advantage was exactly that, where if you were willing to make some sacrifice in terms of some of those other things, you could be rewarded in sharing in some of the efficiencies in that program.
00;17;01;23 - 00;17;32;26
Dr. Michael Chernew
Whether that's equitable or not is, I think, a little bit of a semantic question, but that was sort of the goal. What has happened is that the government subsidy of the Medicare Advantage plans now exceeds that for folks that are still on traditional fee-for-service. That seems a little bit more problematic. So you're getting those extra benefits not simply because of the efficiencies that the plans are creating, but you're getting them because of sort of policy decisions that were made that favors people that are willing to accept those restrictions.
00;17;32;28 - 00;17;55;18
Alan Weil
Yeah, so that seems like a really helpful way to think about it. So if I'm giving up something, like choice, to get something, that's my decision. If I can only get a benefit because I'm over in a part of the Medicare world that's getting extra money due to policy, not due to efficiency, then that does seem inequitable in a certain way.
00;17;55;18 - 00;18;19;04
Alan Weil
I think that's probably more than semantics. But let's go to this question then. You alluded to it earlier that, of course, MA is now half the program and on track to continue to grow. Some of that presumably is for exactly this reason. If there's more of a subsidy to it, people are going to head over there.
00;18;19;12 - 00;18;43;00
Alan Weil
But at the very beginning, you describe the benchmark as being based on the fee-for-service spending. And as that shrinks, that becomes a harder and harder base on which to design your program. So is the whole structure sort of need to be, does the whole structure sort of need to be rethought as the share of people in MA has gotten this large?
00;18;44;01 - 00;19;07;20
Dr. Michael Chernew
The answer is yes. The question is when. Mathematically, you can't have a Medicare Advantage program if you don't have a fee-for-service program. And there are some markets where the Medicare Advantage share is actually much larger than the 50%. You mentioned the 50% on average. But of course, that's a range. CMS has a number of mechanisms that they use to adjust for that.
00;19;08;02 - 00;19;26;17
Dr. Michael Chernew
We can debate how well those mechanisms work and how well they will continue to work. But right now, Medicare Advantage is a very good deal for beneficiaries. The plans are probably, I don't know, give or take, 10% more efficient than fee-for-service. Take that money, add it on top of the extra payment, that's a lot of added benefits.
00;19;26;17 - 00;19;52;09
Dr. Michael Chernew
It’s a pretty good deal if you're willing to accept some of the restrictions that MA puts in place. And that continued growth challenges the core math that the program was built on. It was designed to be a small part of what is basically a fee-for-service system. Soon you’ll have an MA system that’s the dominant form of Medicare with a somewhat smaller and shrinking fee-for-service system by its side that it's all based on.
00;19;52;09 - 00;19;59;16
Dr. Michael Chernew
And I think that will necessitate some changes to the MA program and it's just a question of when you will have to do that.
00;19;59;24 - 00;20;46;08
Alan Weil
So you keep referring to it as the fee-for-service program. And I've heard people say that's not even really the right term anymore because of all of the alternative payment models and there's a lot of not fee-for-service on the traditional side of the ledger. So that seems to me to be both helpful and maybe makes this even more confusing, which is, if your benchmark isn't fee-for-service anymore, if some of those alternative models are attractive and can create savings, if some of those went back to enrollees as well, could we sort of have a parallel traditional that isn't just the old Medicare fee-for-service, but isn't exactly MA.
00;20;46;25 - 00;21;16;18
Dr. Michael Chernew
Yeah. So first of all, thank you for calling me out in front of all your listeners. Always a joy. You are, of course, exactly right. I use the term fee-for-service because it's a commonly used and it's easily accessible. Sometimes people call it original Medicare. Sometimes they call it traditional Medicare. My spellchecker always makes it, like, trademark, but in any case, your point about alternative payment models in the original Medicare fight is spot on.
00;21;17;03 - 00;21;36;28
Dr. Michael Chernew
In fact, the motivation behind many of them was to sort of cut out the middleman, cut out the plans, and just go straight to the incentives for efficiency. The ACO (Accountable Care Organizations) programs, in my view, by the way, have been successful not nearly on the same scale as the Medicare Advantage plans. They don't use the same level of prior auth.
00;21;37;24 - 00;21;57;21
Dr. Michael Chernew
They don't have the same network restrictions in the same way. But in any case, the challenge with passing benefits back to the people in fee-for-service in these other payment models is in a health plan, you know before you enroll you're in the plan. You know what your benefits are. A lot of these other models are,
00;21;57;23 - 00;22;36;19
Dr. Michael Chernew
people are assigned to them ex-post. And a lot of the coverage that people in the original Medicare program have is through Medigap plans, or med sup plans, or plans through their employer that control the benefits. They're not controlled by the entities that are bearing the risk on the fee-for-service side. So while it makes sense to think about how we could pass some of the savings on to those individuals who were aligned with, say, an alternative payment model like an accountable care organization, the actual mechanisms to do that are pretty complicated.
00;22;37;17 - 00;23;03;02
Alan Weil
So at some point you can't really replicate MA without it just being MA. And so why try? But it does seem to me that if you're looking to narrow the gap between the benchmarks and the bids, one way to do it would be to bring down the cost of the fee-for-service side of the program. And then by formula, the benchmarks would go down and the gap would start to close.
00;23;03;16 - 00;23;27;28
Dr. Michael Chernew
100%. If, in fact, the fee-for-service system became more efficient writ large. If a lot of the types of efficiencies that the MA plans are getting were achieved in the fee-for-service system, you would in fact find a gap between them. And by the way, in that context, you would still worry that Medicare beneficiaries are now faced with more out-of-pocket spending.
00;23;28;07 - 00;24;06;08
Dr. Michael Chernew
So you do want to bring down spending. But of course, there's a lot of mechanisms you could put in place to lower the benchmarks to get them to lower that gap. But I think this other narrative, which is increasingly prominent, is using the Medicare Advantage program in general to achieve access to some of these vision, dental, hearing, lower cost sharing with a lot of equity issues involved in that because of the impact of better benefits across the income spectrum sort of the types of people, you know, may find that more important than others based on, you know, income and other factors.
00;24;06;18 - 00;24;16;21
Dr. Michael Chernew
So it's complicated to figure out how to maintain this, how to get the efficiencies that the system can generate back to the beneficiaries and particularly the beneficiaries that need the better protection.
00;24;17;01 - 00;24;43;03
Alan Weil
Yeah, so that does seem sort of like, the theoretical model here is simple, and the practical, I shouldn't say simple, the theoretical model can be expressed and the practical expectation of it is almost, is very hard to envision. So we want people to benefit from the efficiencies that are created by a choice they've made to give something up.
00;24;43;13 - 00;25;11;15
Alan Weil
But we don't want extra dollars flowing for other reasons that can create inequities. Turning that into an actual program with people enrolled and all of that is much more complex. As we come to a close, I guess I'm going to give you the choice of putting on your MedPAC hat or your professor hat to think about where you would say we go with this.
00;25;11;15 - 00;25;44;12
Alan Weil
You mentioned that MedPAC has already said sort of incremental reductions in the benchmarks, but I'll let you be a little bit more expansive. You've mentioned the risk adjustment formulas. You've mentioned the fact that MA was conceived of as being a relatively small add-on to a much larger program. A lot has changed and how do we come closer to that theoretical goal of people benefiting from the efficiencies of their choices while competing on a level playing field?
00;25;44;13 - 00;25;45;14
Alan Weil
Where would you take us?
00;25;45;23 - 00;26;14;06
Dr. Michael Chernew
Yeah, so obviously benchmarks are just one lever. There's a bunch of more technical things that are very important around the risk adjustment system. There has been recently a change in the risk adjustment model that was just finalized last week, and I think that's important for there’s a number of further steps that can be made in that vein of what I would call just fixing certain problems with the way the programs operate.
00;26;15;29 - 00;26;35;19
Dr. Michael Chernew
And I think that’s certainly one step and MedPAC has a bunch of recommendations about how to do that. I think then there becomes a much bigger question about how to deal with the extra benefits from the benefit package and what to do if MA gets too big to really continue to build up a fee-for-service. As a plug,
00;26;35;19 - 00;26;58;22
Dr. Michael Chernew
there will be a discussion of this in the June MedPAC report. But some of the things we're considering include standardizing the benefit packages. For example, Medigap standardize the benefit packages to great success in facilitated choice, facilitated competition. So it wasn't just one benefit package. There were a bunch, but they were all loosely standardized. It's hard to do with networks and things like that.
00;26;58;22 - 00;27;25;26
Dr. Michael Chernew
But there are certain ways I think you can make some advances there. And then there's a question about if you can't build the benchmarks, if you can't build the MA payments off a fee-for-service based benchmarks, what do you do? The two predominant approaches, which I'm not going to advocate for one or the other, involve some aspect of bidding which hinges on how well you think competition in health care works.
00;27;25;27 - 00;27;26;28
Dr. Michael Chernew
That's another podcast, Alan.
00;27;27;10 - 00;27;27;28
Alan Weil
Okay.
00;27;29;08 - 00;27;52;25
Dr. Michael Chernew
Or what we call administrative benchmarks where the government takes a sort of more budgetary role and decides what level of benefits they want to finance. And they hold someone, a plan or a provider group, accountable for that. Many other countries use versions of that type of model where there's a budget, you get a set of benefits and the government moves it up or down and there's pros and cons on that, a lot
00;27;52;25 - 00;28;18;19
Dr. Michael Chernew
based on how much you think, how well you think the government will do that. But I think that's where we're going to have to go one way or another. We have harvested, I'm not sure that's the right word, but in any case, we have taken a lot of the savings we can get from lower fees to providers. In fact, I think a lot of the pressure that we feel now is that the fee trajectories in Medicare for providers, physicians, these hospital fees, are really quite low.
00;28;20;11 - 00;28;53;01
Dr. Michael Chernew
And so there's going be a pressure to increase, in my opinion, those fees. And so we need some way to support the system with efficiencies, and that requires us to make some of these, I think, bigger picture changes. We don't have to do them tomorrow. We don't have to do them the day after tomorrow. But I think sometime in the next several years, we need to think about how we want to reform Medicare and the benefit package writ large to make it much more consistent with where modern benefit design is, where modern coverage is, and the Medicare program really hasn't done that so far.
00;28;54;00 - 00;29;15;13
Alan Weil
Well, that seems like a good place to end. There are constant needs for adjustment and refinement, but there's also the need to step back and absorb how much the world has changed since this program came into existence. And doing that is really hard. But maybe we are due for it about now or some time in the next few years.
00;29;16;01 - 00;29;25;07
Alan Weil
Mike, Dr. Chernew, pleasure to talk to you. It's great to be able to publish your work yet again and thank you for being my guest on “A Health Podyssey”.
00;29;25;20 - 00;29;33;21
Dr. Michael Chernew
And Alan, or Dr. Weil, it is wonderful to talk with you as always.
00;29;33;21 - 00;29;46;19
Alan Weil
Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about “A Health Podyssey”.