Cathy Ackerman: Hey, welcome to Sweet Tea and Strategy, a podcast by Ackerman Marketing and PR, featuring business and community leaders throughout Tennessee talking about issues and trends of importance to our state and beyond. And sharing some of their very best sweet tea recipes and tea sipping stories. I’m Kathy Ackerman and I’m so pleased to welcome Dr. Lynn Massingale, co-founder of TeamHealth, as our guest today on Sweet Tea and Strategy. We’re excited to talk with you about TeamHealth’s amazing corporate journey, Lynn, but before we dig into that, let's talk just a little bit about sweet tea.
Lynn Massingale: Okay.
Cathy Ackerman: And first of all, are you even a fan? Did you grow up drinking it? You’re a child of the South, maybe, so I’m assuming that you had some sweet tea in your life.
Lynn Massingale: Yeah, about three cups of sugar per gallon was my mom’s recipe, I think.
Cathy Ackerman: Well, there you go. So that’s your recipe. Any favorite places that you’ve traveled that have amazing sweet tea?
Lynn Massingale: You know, my mom died this year, so that was my favorite place. Other than that, everything’s a distant second.
Cathy Ackerman: For sure, for sure. Very good. Well, let's jump in and let our listeners have a good grounding to begin with into some facts and figures about TeamHealth. If you could just trace us through real quick when the company was founded and what was your initial business premise for starting it? Just sort of trace us through the evolution and growth of TeamHealth over the years to become the very significant national player that it is today.
Lynn Massingale: Well, first thanks for the kind comments and for doing this. We started here literally 40 years ago in 1979 and then we got our first contract that started January 1st of 1980 and we started at UT Hospital and what at that time was called Sevier Medical Center, which is now LeConte, the Covenant facility in Sevierville. And that was 100% of the plan.
Lynn Massingale: Prior to that, in most hospitals in the country, there were no such thing as full-time emergency room doctors or ER doctors. The emergency department was staffed by nurses and they would call in doctors as needed. And up in Michigan, some doctors a few years before 1979 started working full-time in the ER. UT Hospital had some ER doctors and—and actually I worked there some for the group that had the contract.
Lynn Massingale: But in general, most hospitals in East Tennessee either didn't have coverage except by the medical staff or they had coverage that was suboptimal in—in their mind one way or another. So Dr. John McKay and I started the group and we contracted with UT and what’s now LeConte, and pleased to say 40 years later they're still our clients, so we're delighted about that.
Lynn Massingale: And within the first year, other hospitals in the region started calling and said, "We need this kind of service and would you come—come talk to us?" and we did. So we drew a two-hour circle in the car and that became the universe to get in front of a problem or an opportunity and we did that for 10 years.
Lynn Massingale: We would work—we worked 7:00 AM to 7:00 PM for 7 days, then we'd be off for 7 days. Then we'd work 7:00 PM to 7:00 AM for 7 days and then be off for 7 days. So you worked 84 hours every other week in the ER. And that gave us two full weeks a month to go work on the business. And in those days, I could make do on—on four hours sleep a night, so the week of nights I had about half a day. So we went out and talked to hospitals and recruited doctors and paid the bills. And we did that for 10 years.
Lynn Massingale: At the end of 10 years, we did a couple of things: we recruited Mike Hatcher, a CPA MBA to be our first non-physician executive and partner. And we drew a two-hour circle in—in a 37-year-old single-engine airplane. And that became the universe for five years.
Cathy Ackerman: And were you still practicing medicine at that time?
Lynn Massingale: Still practicing. Yes, working in all the ERs. In about the second year, Randall Dabbs joined us, Dr. Dabbs, and then about the fourth year we merged with a local competitor group run by Dr. John Staley. So it was the four of us and Mike for several years and then so we did that for a total of 15 years and then we decided to try to do it nationally, which we've now done for 25 years.
Cathy Ackerman: And that was a huge step.
Lynn Massingale: Big. Each one of those were big steps for us.
Cathy Ackerman: So when you decided to go national, what were the primary challenges?
Lynn Massingale: Well, the—the driver was that there was a big change in payment for all physician services in the mid-90s and that was a move from fee-for-service to capitation. And doctors all over the country were scared about that and they didn't understand it. It basically put the financial risk of care into doctors' practices, which most were not prepared for.
Lynn Massingale: So we went around the country, met with lots of good groups that, if we flattered ourselves, we thought they looked like us: they were doing good clinical work and they had good business practices. And our idea was that each of—each of us was probably doing something better than the other one of us and the goal was to pick each other's best practices clinically and administratively and then to combine them all over the country. And in about five years we did that and we grew about seven-fold in five years.
Cathy Ackerman: That kind of growth is impressive but difficult.
Lynn Massingale: Difficult.
Cathy Ackerman: What were the biggest challenges in the growth part?
Lynn Massingale: You know, I think the challenges were two or three things. One was picking—picking partners that you really felt at the—at the end of the day were the right kind of people, that they had the right ethical perspective, that they knew that—I know it's a cliché, but taking care of the patient is job one. If you don't get that right, nothing else matters.
Lynn Massingale: And we've often said here that the interaction between a TeamHealth physician or a TeamHealth clinician—doctor, nurse practitioner, PA, CRNA—and a patient and a family and an attending doctor on the medical staff at 2:00 in the morning is what it's all about. So all those groups were high-quality groups and they were ethical people.
Cathy Ackerman: So you were growing by acquisition at that time?
Lynn Massingale: Growing by acquisition and then growing those groups again organically after the acquisition. So, I think the biggest challenges were picking—picking the right partners and then second picking the right best practices among those new partners to roll out among all of us as partners.
Lynn Massingale: And then I think the last thing was to simply try to maintain what we at least thought was the right culture as we brought more and more and more people into the fold. And so those—those were really the hard things. The hard things weren't how do you practice good medicine or how do you get the bill out properly, it was more how to—how to maintain this culture that we thought we had and that they had, in fairness, no matter where they were.
Cathy Ackerman: So how would you describe that culture?
Lynn Massingale: Yeah, I think the culture's grounded on a whole lot of things. I think it's grounded on, again first and foremost, it's—it's about the patient care. I don't care how smart you are or anything else, if you can't get that right, then you know the game's over. That's the first thing.
Lynn Massingale: Second thing is I think there's a pretty—pretty high dose of humility here. We don't think we have anything figured out and we're trying to improve it every day and there's not a lot of big egos at TeamHealth I don't think anywhere in the country. I think that's a core part of who we are.
Lynn Massingale: I think there's a real strong sense of fair play and all the—all the cliché things about all the things I learned in life I learned in kindergarten. All those—all those things about how to treat people.
Lynn Massingale: And then I think I guess the last thing is just that there were periods where we could take on more growth and then there were periods where we just couldn't, we just had taken on all we could and we just needed to push the pause button.
Cathy Ackerman: And you knew when to do that.
Lynn Massingale: And having the discipline to do that. Now we certainly made lots of mistakes, we had lots of mistakes, but those were the core things I think.
Cathy Ackerman: So how large are you today in terms of number of employees, number of practices, number of states that you're in?
Lynn Massingale: Yeah, we're the second or third largest physician group in the United States now. There are about 12,000 doctors.
Cathy Ackerman: Not just emergency medicine?
Lynn Massingale: Emergency physicians, hospitalists, anesthesiologists, some general surgeons, some orthopedists, some laborists, a lot of primary care physicians. And then another 6,000 nurse practitioners, physician assistants, and certified registered nurse anesthetists, CRNAs.
Lynn Massingale: So about 18,000 of those folks and about 3,000—about 3,500 administrative team members in 47 states and this year we'll see about 28 million patients.
Cathy Ackerman: Are you international?
Lynn Massingale: We are not. We are in 47 contiguous states but we are also—45 contiguous states, but we are also in Alaska and Hawaii, but nothing beyond that.
Cathy Ackerman: Right, right. So what about the business side of the business? Because you've been through some interesting iterations in terms of who you have become today as a publicly traded company and all that that entails.
Lynn Massingale: Well, I think probably the best thing that happened about that early on was, very early, one of our hospitals was St. Mary's here in town, that’s now Tennova, and one of the sisters there who at that time was running the hospital, I went to her to talk about a little raise for the doctors and I was very nervous. And she knew I was nervous and she put her hand on my arm and she said what I guess may be a cliché in their world but I'd never heard it before, she said, "Dr. Massingale, there is no mission if there is no money. It's okay to talk about the money sometimes, let's talk about the money."
Cathy Ackerman: Perfect.
Lynn Massingale: So we talk about that here some in a way that says if we're going to be about this, if we're going to recruit the best doctors, make sure they have the best tools, if we can perfect the practice of medicine as much as possible by helping them, by staying out of their way when we should and providing tools when we can, that—that we have to be able to do that, you have to fund that.
Lynn Massingale: So we do try to have good business practices, we try to be ethical about that, we have a really strong corporate compliance program and we have outside board members who help us make sure we're keeping our nose to the grindstone about compliance if—if we don't, if we're not doing it on our own they'll help us do that.
Lynn Massingale: And so we have very strong business people on our team and very strong doctor leaders and I've said for a long time we have clinicians who can read income statements and balance sheets and we have business people who really understand quality of care and care a lot about that. So that's really what it's all about.
Lynn Massingale: Leif Murphy's our CEO now, I serve as chairman and Leif talks about five things in particular: he talks about quality and patient safety, he talks about clinician engagement and retention, he talks about metric-driven operational excellence which is a euphemism for you have to have some math to support a position, not just a hunch, and as physicians and scientists we—that’s okay with us.
Lynn Massingale: Contract retention and growth. Those are the five things. But those first two—quality and patient safety and clinician engagement and retention—that's really, those are the core mantras. And we have lots of metrics around those things.
Cathy Ackerman: So what is your vision for the future? Where do you see the company in five years?
Lynn Massingale: You know, we're going through a challenging time right now where some of the payers have unilaterally reduced reimbursement to us, so we're having to figure out how to adapt to that and combat that if we can because emergency physicians, emergency medicine is still about three-fourths of what we do.
Lynn Massingale: And if you take all the patients that come in the hospital emergency department, we are by federal law obligated to take care of every patient regardless of their ability to pay. In fact, we can't even ask their ability to pay until we've done an assessment and stabilized any emergency.
Lynn Massingale: So we're seeing all sorts of patients. About 20% of our patients have no insurance, no Medicare, no Medicaid. They are either homeless or they're unemployed or uninsured for some other reason. So for Medicare patients, Medicaid patients, and those patients with no insurance of any kind, we actually pay the clinicians more than we collect.
Lynn Massingale: The doctors don't get paid based on the payer status. A patient brought from under the bridge and a patient brought from the bank president's office are treated the same way by the doctors, which is the way everybody thinks it ought to be. But in terms of the business model, we have to get a higher than average rate from the commercial payers to offset those.
Lynn Massingale: And right now that's a challenge. So we're going through some challenging times with the payers and then there's some federal legislation that we're dealing with that has to do with surprise billing which is a very legitimate issue without a real simple solution.
Cathy Ackerman: Define that. That's a word that's being talked about a lot these days and I think people mostly don't understand what that means.
Lynn Massingale: Yeah, it's a really important topic and I think in the—the way that we would all agree that it means the following, and that is that if you go to a—if you have an insurance card from, pick—pick a company, Blue Cross, and it says that hospital X is in network. And you go there for an emergency or an operation and if the doctor doesn't have a contract with Blue Cross, you could get a bill for the full charge.
Lynn Massingale: Whereas if—if we did have a contract, we might get paid half of that or three-fourths of that, a meaningful discount. So the thing that we'd all agree with is that's terrible. The patient should not have to figure that out in the heat of the moment with an emergency.
Cathy Ackerman: Or be worried about it.
Lynn Massingale: Or be worried about it. That's exactly right. So we agreed that that ought not to be the case. The problem is really two things. One is we don't believe that the payers should unilaterally set the rate they pay us, that they should unilaterally say it's worth X. We think there should be a way to negotiate that, which has always been true.
Lynn Massingale: And then the second thing is that over the last several years, as deductibles and co-pays have grown and grown and grown and grown...
Cathy Ackerman: Dramatically!
Lynn Massingale: ...dramatically, more and more and more patients have a deductible that might easily be $5,000 or $6,000 or $10,000. A decision that they or their employer made. And so they'll get a bill from us in the hospital that's for a lot and they're shocked, they're surprised by that bill.
Lynn Massingale: And what we found is that in our situation, at least nine out of ten patients who get what they are surprised by as a bill is about the deductible or the co-pay. Not about our being out of network. We've chosen in almost every place to be in network and we have a few places where we aren't and when we aren't, our position is that we won't balance bill the patient.
Lynn Massingale: But we're in a—in a meaningful dispute with the payers about it, but the thing we all agree on is surprise billing needs to go away, nobody should have to worry about it, we're just fighting over the mechanism to determine the rate.
Cathy Ackerman: So do you have any thoughts on that mechanism?
Lynn Massingale: Well, we think that it ought to be set on something other than just what either one of us says. The insurance company shouldn't have to pay us whatever we want and we shouldn't have to take whatever they offer. That's just not the way life is.
Lynn Massingale: So what we think is that there ought to be some objective benchmark by a—by some third party. There are different third parties, there's an entity called FAIR Health, and that’s kind of the average of the in-network and out-of-network folks. There’s some other language called "commercially reasonable," exactly what does commercially reasonable mean and there's some debate about that.
Lynn Massingale: And then the last thing is that we think that you ought to be able to have the ability to arbitrate if we disagree. There ought to be a mechanism for us to have a—a friendly spat, we and the payer, we and the insurance company, not we and the patient. That's what we think is right. The payers don't want there to be arbitration and they want to set the rate.
Cathy Ackerman: So do you see us moving in a direction that's going to lead to a positive outcome along these lines?
Lynn Massingale: I think it has to get resolved, right? One way or another, it'll get resolved and it'll get resolved I think in the next few months.
Cathy Ackerman: So what—what do patients need to know? Patients as consumers of healthcare I think are confused, they're frightened, there's a lot of movement within that world that they don't understand. What do they need to understand first and foremost when they walk into an emergency room?
Lynn Massingale: Well, I think about that in terms of my own family and you know I have adult children and I have young adult grandchildren, so what I think they ought to know is several things. First of all, everybody should have a primary care doctor. And that primary care doctor ought to be the first line of defense and the first line of offense.
Lynn Massingale: Regularly seeing a primary care physician and when I say that I generally mean family practice, internal medicine, pediatrics, or OB/GYN. The OB/GYN docs provide a ton of primary care services to their patients, way more than just obstetric and gynecological things; women tend to utilize their OB/GYNs for lots of things, so we tend to think of them as providing a lot of primary care.
Lynn Massingale: So first of all, you need a primary care doctor and that’s both to prevent a problem that drives you to the ER and if you have a moment of question where "do I need to go to the ER or not?"
Lynn Massingale: Now, if you're having the worst headache of your life and you've never had it before, you need to go to the ER, you might be having an aneurysm. If you're having crushing chest pain that's going down your left arm and you're short of breath and nauseated, you need to call an ambulance to go the hospital.
Lynn Massingale: On the other hand, if you've had abdominal pain for four hours and it's kind of funny and vague and I'm a little queasy, that's probably a call to your primary care doctor to say, "Hey what do you think about this and where should I go?" and they might direct you to their office or their own urgent care or to the ER. So that to me is the—we're all about the critical role of primary care doctor.
Cathy Ackerman: How many—what's the percentage of the population that you think has a primary care doctor?
Lynn Massingale: Well, there’s two answers to that. Today apparently only about half the people in the country have a primary care doctor is what I would guess and the bigger issue is can you get in to see them? They're all booked up, they're all busy, and in my opinion most of them are underpaid. There's not great reimbursement, especially for pediatrics, and not great for some of the other primary care specialties. So the reality is it's very hard to get in to see your primary care doctor in a lot of practices, even if you have one.
Cathy Ackerman: So what about urgent care? What role do they play, should they play?
Lynn Massingale: Yeah, we think urgent care has a legitimate role and I think the challenge is knowing exactly what you're seeing. I think in a perfect world, if you go to urgent care, you go to one that has the same provider each time you go, it’s somebody you come to know. They kind of become the surrogate primary care doctor a little bit.
Lynn Massingale: I think the problem with urgent care and—and we have—we run some urgent care centers for hospitals. The problem with what we would call retail medicine like nurse practitioners and PAs in drugstores is in our experience the—the variability in the caregiver is extreme in terms of experience and training and I think it's way more of a crapshoot.
Cathy Ackerman: So would your company run that department for a Walgreens, for instance?
Lynn Massingale: No, we—we have done a little bit of that on a—on a trial basis, mostly what we do is we staff some urgent care clinics for our hospital customers. We own literally a handful of urgent care clinics, literally maybe two handfuls, but we staff quite a few for hospitals because a lot of hospitals have them.
Lynn Massingale: And those in my opinion are generally the better ones because you have a lot of the same oversight that you do at the hospital, that you don't have in every location.
Cathy Ackerman: What about telemedicine?
Lynn Massingale: You know, we all believe that there's a future for telemedicine and it has some great roles. The problem of telemedicine of course is that it's mostly not paid for by anybody. That's the problem. So my daughter in Nashville, who has two little children, she would a hundred to one rather pick up her phone, talk to her nurse practitioner about her child who has something that she knows what they have anyway and she knows what they need. She'd rather do that and she'd pay more for that than to have to leave work and go down there and wait in a waiting room with other sick people.
Lynn Massingale: So that's a good use of telemedicine I think in some circumstances, particularly for the known patient. And the other great use of it is what I would call the partial full-time equivalent need. If you're a rural hospital that can't afford a radiologist who reads knee MRIs, but you need a knee MRI read, the ability to send that by telemedicine to a person who's reading a hundred knee MRIs today is terrific.
Cathy Ackerman: Is beneficial.
Lynn Massingale: Terrific. But in general, it has never been very well reimbursed and that may change over time. We think there's a great set of roles for it. We have a couple of sites now where we're staffing rural emergency departments with very experienced nurse practitioners or PAs, but with a doctor on the other end of a phone or a video connection.
Cathy Ackerman: So does it concern you that so many rural hospitals are closing?
Lynn Massingale: It's a terrible thing and it's happening all over the country as you know and it's happening for a lot of different reasons. I do think that if you go back to the Affordable Care Act, which in my opinion had some terrific features and it had some less than terrific features.
Lynn Massingale: Among the things that occurred in the Affordable Care Act was a declining rate of increases for hospitals from Medicare. So rural hospitals, all hospitals, have had a squeeze on Medicare reimbursement. The theory was that that would be offset by universal coverage, that everybody would have coverage.
Lynn Massingale: So in states that didn't expand Medicaid, those hospitals are all getting the Medicare squeeze but they're not getting the lift from expanded Medicaid. For the record I vote both sides of the ticket, I vote for Democrats and Republicans, I don't vilify or love either one, but I do think that expansion of Medicaid in—in states is in fact the best thing for the population and the way to lower cost not increase cost.
Cathy Ackerman: What about recruiting doctors? Is that becoming harder?
Lynn Massingale: It's a big deal. We recruit about a thousand new doctors a year. So it's a big big big part of what we do. And you know, as important as recruiting is, it's retention.
Lynn Massingale: All these doctors are in short supply, they all have lots of options of places to go work and so we try to make sure that we're providing the best possible opportunity we can. Again we talk a lot about perfecting the practice of medicine and we try to do that as best we can and we do a lot and I think they would say that and they help—they help us figure out what we need to do.
Lynn Massingale: So we have a big recruiting team. We start a lot of that when they're in training. We have a residency recruiting team who, not surprisingly, mostly happen to be young people because the residents are mostly young. And then we have lots of other recruiters who are recruiting doctors who are moving from one place to another or who might be open to considering a move. So it's really the lifeblood of what we do is recruiting and retaining doctors, nurse practitioners, PAs, and CRNAs.
Cathy Ackerman: So what kind of person wants to go into emergency management? How would you describe that person?
Lynn Massingale: Yeah, in terms of the practice of emergency medicine, I think it's probably, it used to be somebody like me, and now it's different. When I—when I went to medical school, I wanted to—I went to medical school wanting to be my family doctor. I wanted to be Herb Whitlow.
Lynn Massingale: But I did an ER rotation and absolutely fell in love with it. I fell in love with the adrenaline, I fell in love with the intensity, I fell in love with the just the whole thing...
Cathy Ackerman: With the lack of sleep?
Lynn Massingale: With the lack of sleep, but it was there's enough going on there in terms of excitement that that's what I wanted to do. So now, I think that's still a big driver. But the other big driver now is that from a lifestyle standpoint, it's a—it's a pretty good gig in that your life is completely scheduled.
Lynn Massingale: When you are off, you are off. You never have to go back to work, you're never on call unless you've agreed to be on backup call. We have some places that we have backup call if it gets franticly busy. But in general, you can work 12 to 14 twelve-hour days and have 16 to 18 days a month off.
Cathy Ackerman: Which is really appealing to a lot of people.
Lynn Massingale: It's very appealing to a lot of people. The downside is about half your time is after 5:00, because that's just the way the calendar is, right?
Lynn Massingale: Or—and you work about every other weekend. So it's hard to coach a Little League baseball team, it's hard to teach a Sunday School class, you—there's some tradeoffs for that.
Lynn Massingale: But—particularly for a person who wants to have scheduled time off, it's a terrific profession for women because of that. We have a lot of female emergency physicians, a lot of female anesthesiologists, a lot of female hospitalists.
Cathy Ackerman: Anything else that you want to tell our listeners? This is such a huge and important world that we're talking about right now, it affects everyone. Is there anything else you want people to know about the changing world that you live and breathe in?
Lynn Massingale: That's a long, complicated question, but I guess there's two or three things. It's, you know, it's easy to be pessimistic right now about a lot of things, world's kind of a little bit of a vitriolic place and so it's easy to be negative and pessimistic.
Lynn Massingale: But from my perspective and—there's a lot of things about healthcare that don't work well. The delays don't work well if you're waiting on a pathology report and think you might have cancer, the wait is the longest wait in the world.
Lynn Massingale: My—I won't tell you how old she is, but one of my favorite aunts who has a few years on her went to her doctor's office recently and had to complete a new electronic medical record on a tablet, was very and she's very savvy, she's very cool and she did it and she effectively tossed it on the counter because it was so terrible and she said, "Y'all need an app for that."
Cathy Ackerman: Oh how funny!
Lynn Massingale: So we're dealing with all these electronic medical records, the pros and cons of that. So now when you go to your doctor, he or she is very often sitting typing rather than he or she is talking to you, which is not what most patients had in mind and not what most doctors had in mind.
Cathy Ackerman: That's right, the eye-to-eye contact is no longer there.
Lynn Massingale: So there's a lot of stuff about healthcare that's aggravating, and that's before you get to the cost. What's terrific about it though I think is this: there are still an amazing number of really bright bright students who go into it.
Lynn Massingale: I probably today couldn't get into what I got into because the competition is so much. I know for instance that in the most recent dental school class, because dental health is important to overall health, most recent dental school class in Memphis is 100 students and they had 1600 applicants.
Lynn Massingale: So you got really good students. So you have smart people who are doing this. We have the best drugs we've ever had.
Cathy Ackerman: Aggravatingly too expensive!
Lynn Massingale: For sure!
Lynn Massingale: But terrific. We have fabulous progress on things like the human genome. We get more and more close to really good personalized medicine. Not "here's a chemotherapeutic plan that works for most people with your cancer," but "here's a—here's an oncological plan that's specifically tailored to Kathy Ackerman's specific problem."
Cathy Ackerman: Is yours. Right, right.
Lynn Massingale: And so I think the future of healthcare is really bright in terms of—how well we're going to do as patients and how long we're going to live, if we don't kill ourselves with smoking and obesity and other things that we self-inflict, which is still a huge problem. So I'm really bullish.
Cathy Ackerman: That's great, that's good to hear.
Lynn Massingale: I'm really bullish about—about the future of healthcare. And I will tell you in this community in Knoxville and in Tennessee we have we have really good healthcare. You know, I—we work all over the country, we see it lots of places, it's not—it's not perfect everywhere, it's not perfect anywhere probably, but we're really blessed here with good hospitals and good clinicians.
Lynn Massingale: And—and the state I think's very blessed. I think the outlying counties have—have a real challenge. You know, I'm from a small county and our local hospital that actually loaned me the money to go to medical school is now just an ER and a nursing home.
Cathy Ackerman: Right, right.
Lynn Massingale: Now, thank goodness for that! Now there is a full-service hospital 10 miles away. So it works. But—but my biggest concerns about healthcare right now have to do with cost and accessibility. I think quality and the incredible progress that's being made about clinical treatments is really, really, really room for all of us to feel good.
Cathy Ackerman: Oh that's exciting! And good to hear from somebody who's right in the middle of it all day every day.
Lynn Massingale: I'm a believer.
Cathy Ackerman: Lynn, thanks so much for being with us on Sweet Tea and Strategy and thank you for sharing your thoughts and your wisdom with us. We look forward to continued growth and success for TeamHealth and we are so proud to have you as one of Knoxville's most prominent corporate leaders.
Lynn Massingale: Thanks, I'm very pleased to be included in this. Thank you.
Cathy Ackerman: Thank you.