2018 was a big year for health care antitrust, and that trend is expected to continue this year. In AHLA’s inaugural Expert Insights podcast, John D. Carroll of King and Spalding LLP and Alexis J. Gilman of Crowell and Moring LLP detail last year’s biggest developments and highlight what attorneys should expect to encounter in 2019. From AHLA's Antitrust Practice Group. Sponsored by First Chesapeake Group.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Hello everyone. Welcome to the American Health Lawyer , associate Lawyers Association first ever Healthcare Antitrust podcast. Uh, we are brought to you today by first Chesapeake Group. The first Chesapeake Group was established in 1987 to provide consulting services to senior executives, lawyers and government officials, and the healthcare industry who are responsible for leading their organization in today's complex and changing environment. My name is John Carroll. I'm a partner at King and Spalding in the Antitrust Practice Group here in Washington, DC and I'm joined by Alexis Gilman. Alexis, could you please introduce yourself ?Speaker 2:
Hi, I'm Alexis Gilman. I'm a partner in the Antitrust Group at Kroll and Mooring in Washington, DC .Speaker 1:
Thanks, Alexis. Alexis and I are excited to be recording the first ever , uh, healthcare Antitrust Practice Group podcast. Uh, this year we're gonna start us off , uh, and the first one by providing an overview of the top developments of 2018 and the healthcare antitrust world, roughly ranked from 10 to one, although that was a challenge to put together. And then we're gonna talk about what's in store for 2019 in terms of the top , um, uh, developments we think will be , uh, occurring in 2019. Of course, many of these are contingent on our federal government's reopening and the partial shutdown <laugh> being concluded. So gonna be a little bit speculative for a number of reasons. Um , you know, 2018 before we get started was a, was a really big year, and we think that there's a lot in store coming up , uh, number of themes here in the healthcare antitrust arena consistent with themes generally in the antitrust world, which is that , uh, transactions and conduct have been under significant scrutiny, not just by the federal government, but by , uh, various state ags and of course , um, in the litigation world with private plaintiffs. So, without further ado, we're gonna go ahead and get started. Um, we hope that you enjoy today's podcast. Uh, we would appreciate any , uh, would appreciate any feedback from folks who, who download and listen to this. Our goal is to make this , uh, both informative and accessible. And by that I mean not just to antitrust lawyers, but certainly to healthcare lawyers, and also of course to non-lawyers as we continue to roll out a number of new initiatives , um, at the Antitrust Practice Group of A H L A , uh, and helping to , uh, keep up with the times and, and provide our subscribers and those who may be interested in the group with , um, new and exciting , uh, information in our world . So, starting off with development number 10 in 2018 , uh, last but not least , uh, the ftc, the Federal Trade Commission , uh, their pre-merger notification office issued new guidance on reporting requirements for nonprofit entities. And so in November of last year , uh, the FTC made some changes to their HAR Scott Rodino reporting rules , uh, and the Hart Scott Rodino statute or act , uh, is that act that requires parties to file notification with the FTC and doj , uh, when putting together a transaction that meets certain requirements, both in terms of the size or value of the transaction and also the structure of that transaction. Previously , uh, before this change, the party's obligation to file under the H S R ACT turned on whether the combination would result in a change of control of the board of directors of either party. However, as our audience well knows, hospital affiliations are often structured to form a new corporate parent for both hospitals, meaning that board control may not change really at either entity. So as a result , uh, antitrust practitioners had previously assumed that hospital affiliation structured this way , uh, that did not involve a change of beneficial ownership, and consequently, no HSR filing would be required. And so, recognizing this and recognizing that potentially , uh, reportable combinations would occur even where there's no change of control at the board. The p and o announced that beginning , uh, at the end of October, of last year's last year, it would look at nonprofit combinations , uh, of hospitals and outside of hospitals by focusing on whether one party had gained beneficial control over the assets of the other party, thus increasing , um, materially perhaps the number and type of transactions that now would require H S R filings, thus requiring, of course, a potentially a 30 day waiting period and affirmative notice to the government before they could close their transactions. Alexis,Speaker 2:
Thanks John. Development nine, Siemens settles with U N C Court certified Class. Uh , hot topic in the antitrust bar generally is so-called no poach agreements. Uh, these are agreements between two companies not to solicit, hire, compete for each other's employees. In 2018 , we saw some no poach developments in the healthcare context. As background. In 2015, a Duke Radiology professor Danielle Seaman , filed the class action against Duke University, the dean of the University of North Carolina Medical School and others alleging that Duke and U N C had agreed not to poach each other's medical faculty. Semen alleged that in response to her inquiries about a , uh, job at U N unc , she was told that the Duke and U N c Med school deans had agreed not to recruit each other's medical faculty. Defendant's motion to dismiss was denied by a district court, and their attempt to immediately , uh, appeal to the Fourth Circuit was denied as well. In January, 2018, U N C settled U N C agreed among other things not to engage in any agreements that restrained hiring or recruiting of employees, and had agreed to cooperate with the plaintiff's case against Duke. In February, 2018, the district court certified a class of 5,000 plus faculty members with medical appointments at these schools. That case is ongoing, John .Speaker 1:
Thanks, Alexis. Now we're on to development number eight of 2018 in healthcare antitrust. The FTC charged and secured a consent order against a therapist staffing agency and its competing therapist staffing agency for price fixing over therapist wages. Interesting here for a number of reasons. Uh, basic facts are that at the end of July, the FTC announced the settlement with your therapy , uh, and a competing staffing agency for price fixing . According to the FTCs complaint, the two owners who were competitors agreed to lower their therapist pay rates to the same level, and they also invited several other competitors to lower their rates in attempt to keep therapists from switching to staffing companies that paid more. The FTCs complaint alleges that they entered into the agreement after learning that a home health agency planned a significantly lower rates to therapist staffing companies for therapist services. So interesting here , um, there is of course , um, the ability in jurisdiction had by the DOJ to bring criminal , uh, antitrust actions. DOJ has that jurisdiction uniquely, however, in the civil side for, you know, things like invitations to collude and civil price fixing , the FTC is able to bring actions like this. And this one serves as a reminder that things like no poach agreements agreements regarding pricing, particularly in the healthcare arena , uh, are receiving significant scrutiny and that practitioners, practitioners should take care when advising their clients on , um, whether they can be engaging in these , uh, types of agreements . Uh , AlexisSpeaker 2:
Development , uh, seven Mass Ag settles with best Israel lehe . Uh, 20 eighteens also saw a large multi-hospital merger approved in Massachusetts. Subject to however, a settlement with the State Attorney General , uh, which then was followed by the F T C decision to close an investigation in November, mass Ag Mo Healy approved the combination of Beth Israel Deaconess Lehe Health System and other area healthcare providers. Uh, as a condition of that approval, though, the parties agreed among other things to cap price increases for seven years and to make over 70 million in community healthcare investments. There are a couple interesting things about this matter. Uh, first, back in 2015, attorney General Healy did not support a similar agreement negotiated by her Adam predecessor AG Martha Coley , that would've settled concerns about the partner's Healthcare South Shore Hospital, hallmark Health System merger after her election. General Healy said she would challenge that partner's South Shore Hallmark merger if the Massachusetts State Court did not approve the settlement. Ultimately, the court did reject the settlement and the merger was abandoned. Uh , much different result here. The second interesting thing, I think, is the FTCs response to the settlement. Here, the FTC has repeatedly expressed concerns with so-called behavioral merger remedies like the one agreed to. Here, the FTC thinks that such remedies are difficult to craft, implement and monitor, plus they usually expire in its closing statement. The FTC noted its concern with behavioral remedies and said that it's decision to close the investigation was not an easy one and quote a close call. The FTC also said, or perhaps even warned that this merger might be a good opportunity to retrospectively study the effects of the merger. Don .Speaker 1:
Thanks Alexis. Moving on to development number six and healthcare antitrust for 2018. Back in April of 2018 , chief Judge William Smith denied summary judgment to Blue Cross and Blue Shield of Rhode Island on all counts in an antitrust case brought by plaintiff Stewart Healthcare System , uh, which allowed the case to proceed to trial. The plaintiff Stewart Healthcare System had alleged that Blue Cross Blue Shield had unlawfully blocked Stewart from entering the Rhode Island healthcare and health insurance markets by thwarting its acquisition of Landmark Medical Center, which was a, or is a Rhode Island Community Hospital , uh, that was in , in some financial trouble. So Stewart had sued , uh, blue Cross , uh, its allegations included that Blue Cross had illegally refused to deal unreasonable reimbursement rates , uh, with the intention of stopping Stewart from entering the Rhode Island market. So it was a really interesting, lengthy opinion from the judge that seemed to reverse what he had indicated he would do previously , uh, in denying summary , uh, judgment and the case would have proceeded to trial, but for the fact that the parties , uh, settled the matter , uh, a couple of months , uh, after this opinion came out, unless we don't get the benefit of having had this go to trial, but , uh, the parties decide to settle it , nevertheless would suggest , um, that those who are interested , uh, in refusal to deal actions and in private antitrust litigation, take a look at this opinion because there's a lot of a lot going on there , uh, and some pretty detailed analysis. Alexis,Speaker 2:
Thanks John . Development five California Sues Sutter , uh, a case in California may tell us about the antitrust implications of anti steering and anti steering provisions in contracts between large hospital systems and payers. In March, 2018, California sued Sutter Health and State Court alleging that Sutter was requiring health plans to include terms in their contracts that allegedly stymied competition and, and resulted in higher healthcare prices. In particular, the complaint alleges that Sutter, which was described as a quote , must have provider in certain parts of California prevented payers from steering patients or tearing their networks to prevent or penalize payers from directing patients away from Sutter to lower cost providers. The complaint also alleged that Sutter would only negotiate with payers on an all or nothing basis, meaning that a pair had a contract with all Sutter providers or none, and that the Sutter providers all had , uh, all the contracts with Sutter providers had a single expiration date. Sutter , of course, contest the allegations in this fighting this suit. Uh, I think in addition to the mayor's question about whether when anti steering , anti tiering provisions can be a law unlawful, the other interesting aspect of this case is the remedy of the California seeking is asking for dis discouragement of profits that Sutter be required to stagger the terms of their hospital physician and other provider contracts, and asking him that Sutter creates separate contract negotiating teams for its hospitals, physicians, and other providers. So a case to watch.Speaker 1:
Thanks, Alexis. Counting down further to number four , uh, two vertical mergers that were cleared by the Department of Justice and ftc C s Aetna and Cigna Express Scripts. Um, there's been, of course, a a lot out in the atmosphere about how aggressive , uh, the agencies are with respect to transactions. I'm sure folks remember that not too long ago, the DOJ successfully blocked what was considered a complete reorganization of the health insurance industry , uh, involving two, you know, mergers of the major health insurance companies. Out of the wake of that, we see , uh, transactions being signed between CVS and Aetna and between Cigna and Express Scripts. The CVS Aetna deal is subject to certain conditions, but both deals , uh, being cleared. Uh, and, and these will , uh, go a long way, I think in , uh, reorganizing in in many important ways , um, the healthcare industry. And it'll be interesting to see, you know, how the industry continues to evolve, not just from an antitrust perspective, frankly, or even a legal perspective, but just from an overall industry perspective as healthcare continues to change. And as part of that, of course, as the antitrust laws , uh, and the enforcers , uh, continue to try to keep up with, with all that's going on in the industry. Alexis, back to you for development number three.Speaker 2:
Yeah, DOJ settles with Atrium , uh, in , uh, in another case, which is a close cousin of the Sutter case I I mentioned , uh, the DOJ and State of North Carolina sued Atrium Health, which was , uh, previously doing business as Carolina's Healthcare System. Uh , in 2016 , the DOJ in North Carolina alleged that Atrium, which was said to have a 50% share of the inpatient hospital service market in the Charlotte area, had imposed anti steering and anti tiering provisions, and payer contracts sound familiar , uh, in exchange for some modest price increases. Uh, the government also alleged that Atrium prevented payers from providing truthful information to consumers about atrium prices and quality. One of , uh, atrium's defenses , uh, in response to the allegations was it was merely protecting the benefits of the bargain that it negotiated with payers. In other words, these terms really just prevented payers from at obtaining discounts from Atrium based on certain patient volume expectations, only to have the payers turn around and steer patients away from Atrium. After the District court denied atrium's motion for judgment on the pleadings, the parties ended up settling the case in November, 2018 that settlement Barr is atrium from enforcing or seeking , uh, anti steering restrictions in its contracts with payers . John .Speaker 1:
Thanks, Alexis. Now we're down to number two, but quickly before I do that , I think I may have misspoken when speaking about CVS in sign's Express Scripts by mentioning the ftc . So hopefully our friends at DOJ will forgiving , um, both of those cases. Those transactions were reviewed by the Department of Justice and neither was reviewed by the Federal Trade Commission. So back to development number two , uh, a judge had ruled against , uh, blue Cross Blue Shield in a market allocation mdl. Uh, one , uh, note for our listeners who are subscribers, you will have gotten , um, in January and a H l a email bulletin describing this case. And that's just one of the many benefits of becoming a member of the Antitrust Practice Group, is you get really great content that describes what's going on , uh, in the healthcare antitrust world , uh, for those of you who are not , uh, members and didn't receive the bulletin. Quick description for you. Uh, back in December 12th , uh, of 2018 , the 11th Circuit issued a brief order that denied a request for interlocutory review by the Blue Cross Blue Shield Association and ongoing antitrust litigation over territorial allocation among its 30 36 constituent companies, which you all know as the Blues. The Blues appeal , uh, came from a 2018 district court ruling, a granted partial summary judgment on the standard of review, meaning whether per se or or rule of reason to the plaintiffs , uh, which determine that the Blue Cross's agreements should be reviewed for antitrust violations under the per se illegality illegality standard. And so this has been , uh, enough to enough of a development, and this case is enough of a case where we could have multiple podcasts just talking about this, because if the plaintiffs win, if this, you know, assuming this goes, does, does continue to go on to trial , um, this goes to the core of the operations of Blue , of Blue Cross Blue Shield, and that is how they do business across their associations. And so while this was , uh, just a brief order denying or request for an laboratory review, it was not accompanied by an opinion, it makes , uh, certainly our top 10 and comes in at number two, given the implications for this case as it moves forward. And with that, Alexis will take us home with the top development of 2018 and healthcare . And Troy ,Speaker 2:
Please concerns about consolidation. Uh, 2018 , uh, brought increased scrutiny in healthcare consolidation from the Trump administration, the media and other quarters. Uh, just to mention a couple, one , the Trump administration issued a report on quote , reforming America's healthcare system through Choice in Competition. Uh, in 2017 , an executive order called for this report by H h s and other agencies about various issues, including the extent to which state and federal laws, regulations, and policies impeded healthcare competition. It also called for recommend recommended actions that states and the federal government could take, including by limiting excessive consolidation. In the report that was published last month, the recommendations included one, continued village vigilance by the antitrust agencies to prevent any competitive transactions. Two, that states repeal or scale back certificate of needs, c o n statutes, which the report blamed for impeding entry by new competitors. And three, that states discontinued certificates of public advantage are COPA laws, which the report says shielded anticompetitive provider mergers from antitrust scrutiny. And second, just last month , uh, in November, the New York Times published a lengthy story about hospital consolidation. One of the many news stories on , on <inaudible> consolidation, the Times which had engaged academic researchers to study 25 mergers from 2010 to 2013 , wrote that hospital mergers have, quote , essentially banished competition and raised prices for hospital admissions , in most cases end rather than resulted in savings for consumers. Uh, the report did note almost parenthetically, that large systems acquisition of struggling hospitals can provide critical capital investment and management skills to the acquired hospitals. So that's our top development for 2018 , uh, which seems like it's not gonna ebb any time soon. Uh , with that, I'll turn it over to John.Speaker 1:
Thanks, Alexis. So now let's talk a little bit about what we think is gonna happen this year. We're 22 days in the government remains closed, which , um, goes to the , uh, lack of developments to some extent that the ftc d oj although of course, essential staff are working hard on a number of matters and , and litigations. And as , uh, former FTC lawyers, both Alexis and I , uh, certainly feel sympathetic to those having to work without pay at this time and, and complete and, and fulfill their obligations under the mission of both agencies. Uh, with all that said , um, a lot of what we're, we're looking at , uh, in terms of predictions for 2019 and what we're, what we recommend we look for in 2019 is really, you know, developments on a number of cases and enforcement decisions by both agencies. So we're gonna go through these relatively quickly. Um , many of them, given that we only have a few minutes left , uh, starting off with the first one , um, Fresinius next stage , we're waiting on a , on an FTC enforcement decision there, this was a deal that's taken quite some time. It's a 2 billion transaction between , uh, two dialysis providers. Next stage being an at-home dialysis company. Uh, this , uh, I think the parties that hope to have a decision and potentially close by February of, of this year, we will see what happens , uh, given the shutdown . But that is something that we'll be looking for, particularly if there's any corresponding , uh, analysis or guidance that we can review that comes out from the FTCSpeaker 2:
A L J decision. In re otb , we're also waiting for a decision from an administrative law judge in the FTCs challenge to a medical device merger. In December, 2017, the FTC challenged the consummated merger of two prosthetic knee manufacturers, AACH and Freedom Innovations. As in many mergers, one of the key issues in the case is product market definition. The FTC alleges that the merger will harm competition in the market for microprocessor needs , which , uh, as I understand it , use a microprocessor to adjust the stiffness and position of the knee joint in response to a user's movement and ground conditions. The merging parties, on the other hand, argue that the market is much broader and includes other types of prosthetic needs . The litigating parties completed post-trial briefing at the end of November, 2018, and we're awaiting a decision from the a lj , which has been delayed by the government shutdown . This will be the first A L J decision in the healthcare merger case since an ALJ decision in 2011, blocking ProMedica Health Systems's acquisition of St . Luke's Hospital.Speaker 1:
Thanks, Alexis. The third one is we're waiting for another FTC ALJ decision, but this time in a dental distributor , uh, group purchasing case , uh, in February of last year, the FTC filed a complaint against the country's three largest dental supply companies. Uh , the FTC alleged they violated the antitrust laws by conspiring to refuse to provide discounts to, or even to otherwise serve buying groups representing the dental practitioners. Uh, it'll be interesting to see , uh, what the aalj decision looks like here, and you will , uh, certainly be getting some analysis from the A H L A antitrust Practice Group when that decision is issued. AlexisSpeaker 2:
Eighth circuit decision in FTC Verts Sanford Health in 2019, we could expect a decision from the eighth circuit in the appeal of the FTCs successful preliminary injunction action blocking Sanford Health's acquisition of Midco Clinic, a multi-specialty physician group in the Bismarck, North Dakota area. At the end of 2017 , a district court entered preliminary injunction blocking the proposed transaction. The merging parties appeal to the eighth circuit. While there hasn't been a provider merger case decided in the eighth circuit since 1999, the last case decided there was a decision by the eighth circuit to reverse a district court decision in joining a hospital merger in Poplar Bluff, Missouri. So the eighth Circuit may offer the best opportunity for healthcare providers to break the FTCs wind streak in litigated provider mergers. On the other hand, if the F eighth circuit affirms the decision in the FTCs favor, the FTC will have secured favorable decisions in provider mergers from the third, sixth, seventh, eighth, and ninth circuits in the last five years. John ,Speaker 1:
Thanks. And I ha I can't help but point out that Alexis had something to do with that wind streak as he added the , uh, division at the FTC that oversees , uh, provider mergers for a number of years. Moving on to our sixth , uh, thing to look for in 2019 in healthcare antitrust, another FTC enforcement decision that we're eagerly anticipating, and that is in United DaVita . Uh, that transaction , uh, being interesting to see whether the FTC does anything there or just clears that transaction without conditions. Again , uh, stay tuned and , uh, to the extent the FTC does , uh, do anything by way of an enforcement action, you'll certainly , uh, be hearing from the A H L A Antitrust Practice Group . Uh, Alexis, back to you for number five , jurorSpeaker 2:
Number five , uh, competition hearings. So , uh, in June last year, the new FTC chairman, Joe Simon , uh, Simons announced a series of hearings on consumer consumer protection competition and consumer protection issues. I'm sorry. Um, and it's gonna use those hearings to study the FTC short and long-term enforcement policy agenda and perhaps identify areas where the FTC might , uh, adjust its enforcement policy and , um, perhaps the agency's process and other areas , uh, that might warrant additional study. The hearings are general in scope and hunt something of a tech focus , but the FTC did solicit public comments about competition issues and specific industries such as healthcare . And one comment that was submitted was one by the American Hospital Association, which said that the FTCs approach to reviewing hospital transactions, quote is over broad , does not properly credit the many pro-consumer benefits hospital transactions, and ignores key realities in the marketplace. End quote . Um, so while I'm not expecting big changes to the, how the FTC approaches healthcare provider mergers, it will be interesting to see if the FTC does adjust any changes to its broader enforcement approach , uh, that may affect healthcare . So , uh, stay tuned , John .Speaker 1:
Thanks, Alexis. Um, we're now onto , uh, our next development, which is any decisions or updates in the Washington C hhi Franciscan case , uh, and October . In August of 2017 , uh, Washington Attorney General Bob Ferguson filed a federal lawsuit and the Western District of Washington against C hhi Franciscan , uh, the doctor's clinic in Westtown Orthopedics, seeking to undo what it alleges are unlawful agreements between , uh, and among those competitors that raise prices and decrease competition in an area of the state of Washington. Uh, we will see what happens. Uh, this is a reminder that there are actions , uh, taking place in , in , by the state , and that it's not healthcare. Antitrust is not just a matter or does not just concern federal , uh, enforcement. Alexis ,Speaker 2:
Uh , returning to , uh, case we mentioned earlier, California v Sutter , um, that suit challenging Sutter Health Contracting terms made our list of top developments in 2018, now that the DOJ and North Carolina suit , uh, against Atrium settled. Uh, if there is a decision in settlement or a settlement in the Sutter case, that's definitely gonna be one of our top stories of 2019 to see , uh, how anti tiering and steering provisions are treated there. Uh, John, take us home.Speaker 1:
Thanks, Alexis. So we got one left , which is , um, we, we think is number one, but again, these are in no particular order. So maybe it's just the last one we're covering. And that is , uh, congressional investigations and , and actions by Congress more largely in the antitrust arena. Uh , there has been a lot of news about this, and this is continuing our number one development , um, that Alexis described for 2018 . And that is that antitrust seems to be for, for lack of a better description in the news , uh, and trending. And we saw with the democratic majority coming into the house, they put forth what they call a better deal plan. And in that antitrust featured very prominently , um, antitrust has certainly been a part of political platforms from both parties in the past. But this is unique with respect to the attention that antitrust received , uh, in particular in a congressional platform. Uh, I went back and looked at 2006 when the Democrats took over, were back, even back , uh, back to 1994 on the contract from America when Republicans took over the Congress , um, during that midterm election. And this is really the first time in a very long time that antitrust is featured so prominently. And so what does that mean? Well, it means that there are going to be investigations and hearings into a number of sectors, of course, and perhaps most , most notably the tech industry, but healthcare's not far behind. And that includes, you know , certainly pharmaceutical pricing, but also as , um, was mentioned in the ATS report that Alexis described in, in the healthcare industry, in the provider industry, whether that's consolidations, copa laws, other things that people are concerned are restricting competition. There's also a broader , um, perhaps less likely to be successful attempt to examine whether the antitrust laws are , uh, according to some outdated. And so , uh, just recently we saw a number of Democrats saying that , uh, the Sherman Act and , and , and FTC act and other antitrust laws were enacted back when , uh, you know, the most prominent industry in the United States were , was railroads and to clamp down in certain, you know, trusts and other anti-competitive behavior. And there are questions out there about whether , uh, the antitrust laws have kept up with the times. We'll not opine on whether that's the case, <laugh> , because we do not have time on today's podcast. And it's a really interesting, difficult question. But just the fact that this is , uh, being discussed will have implications, you know, if you're looking at doing a deal or if you're just in the industry and you get a subpoena , uh, from a house committee , uh, that will perhaps , uh, drastically affect what your 2019 looks like for a number of reasons. And so as things progress, whether it's on the , uh, whether it's , um, hearings or, you know, potential , uh, changes to the regulatory landscape by, you know, among other Senator Klobuchar and the Senate , uh, we'll be keeping a close eye on this and continuing to inform , uh, our subscribers and members and the Antitrust practice group . So with that , um, this was a great fun , uh, podcast. Uh, thanks very much to Alexis to helping put this together. And to the folks at H L A , this was our first one. So please excuse if there are anything , uh, you think we could have done better. We look forward to your feedback and I strongly encourage you not just to join the, the practice group, but also , uh, to follow us on Twitter. We are at a H l A underscore antitrust. We tweet almost daily, if not more than that. Check out our tweets, tweet at us. Uh , let us know what you're thinking. There's a lot going on as we keep saying. And so we , um, look forward to engaging in a, in a serious discussion with those who are interested in healthcare antitrust issues. And we love doing this. So we look forward to , uh, getting this podcast up and getting people's feedback and of course to ref , uh, to recording , uh, additional podcasts on a number. So look forward to hearing you and thanks .