Episode Transcript
Speaker 0 00:00:07 No shame, which moment next man. Good.
Speaker 1 00:00:19 I'm Dr. Robert groves, your host for the groves connection podcasts, the groves connection brings you intimate conversations with pundits providers, patients, leaders, and late people all to help us understand a contradiction. How can our healthcare system be both magnificent and yet so deeply flawed. We're going inside healthcare to talk candidly with those who know what they have to say, may delight, surprise frustrate, or at times even anger. But I invite you to get curious and listen to the truth about healthcare and those who want to fix it. Maybe the answers have been there all along. We just need to make the connection.
Speaker 1 00:01:16 In this episode, I introduce you to Missy. Dude. Melissa is one of those stories that inspire today. She has awards and accolades too numerous to count a bevy of peer reviewed publications and a slew of community and leadership service recognitions. Today, Missy is a senior pharmacy executive in a $10 billion integrated delivery system, but that's not how the story began. Her path to this role was characterized by many obstacles from humble beginnings to failed dreams. Yet nothing could keep Missy from realizing her potential and ultimately making a big impact on care delivery in her market. And she's just getting started with her doctorate in pharmacy, her commitment to value and a work ethic honed in the trenches. This is a woman who is committed to being a part of the solution to the healthcare challenges we all face. So join me as I sit down with Dr. Missy Duke to unpack her journey to healthcare leadership. Are you ready to connect?
Speaker 0 00:02:27 Yeah,
Speaker 1 00:02:37 Couldn't get the groves connection as promised I am here with, uh, Missy skeleton.
Speaker 0 00:02:42 Welcome. Thank you. I'm really glad to be here. Yeah.
Speaker 1 00:02:45 You know what I often start these out with is questions about how you got where you are. So, so take me back to, uh, I don't know if it's junior high or grade school or, or you first got the notion that you were a sciences kid and, and second of all, that maybe healthcare was something you wanted to do. And then we'll, we'll talk about how you got into pharma.
Speaker 2 00:03:11 Of course. Sure. So my, most of my childhood, I had a very specific career goal and that was not to become a pharmacist. It was to become a veterinarian and, uh, that was not rooted in my love of the sciences. I do have pets. I do have pets. I had hunting dogs growing up and cats, and anything else that my dad would let me collect, including salamanders in the house, um, which I got from a fishing store, water dogs turned into salamanders. And once I learned about this, uh, I said, well, I need a couple of those. So we had a little bit of a farm in my house growing up. And, um, that was where I developed that desire to become a vet. It was not rooted in a love of science or chemistry or anything along those lines. And I grew up here in Glendale in, I would say, uh,
Speaker 1 00:04:01 Wait a minute. You're actually from the area in front of the area, one of the few people that I've met, that actually is from here.
Speaker 2 00:04:08 Yes. Well, I have to clarify. I was born in Texas. So the, the, the, I think that there's a connection, Dr. Groves, Dr. Clark. Yeah. There's a definitely a Texas theme here, but my family is from East Texas. I was born in the Fort worth Dallas area and I moved here when I was two. So I identify as an Arizona and I grew up here. My sister, my little sister is a native Arizona in which is fairly rare amongst people of our age. And so, um, yeah, growing up in Glendale loved animals really wanted to be a veterinarian. My, my upbringing was fairly humble. Neither of my parents went to college. Uh, we had very limited income. And so I was putting myself through undergrad. And so that required me to work full-time and go to school full-time and, and balance a lot of the responsibilities, sort of all of in that same 24 hour period of time. All of this, I share as an excuse.
Speaker 1 00:04:57 So did you put yourself through undergrad? Is that right?
Speaker 2 00:05:01 Yeah. I worked full time as a veterinary technician. Um, yeah,
Speaker 1 00:05:04 That's impressive though. I mean, it's not easy to do. That's a little more, it was not easy. Yeah. I'm sorry. I interrupted your train of thought, but yeah, most of the folks that I have interviewed so far, not that many, but I've had a leg up, you know, to get where they're going. So that's interesting that you've had to actually put some elbow grease into it to get to the first step even
Speaker 2 00:05:26 That's right. I, I very much did. And it, I can point back to personality features that I have today that, that I got when I was that age and, and the focus on value and efficiency and time efficiency is all stuff that I can trace back to my early college days. Um, I worked full-time at a vet office and went to class and I remember purchasing books and thinking, gosh, I really need this book and really kind of budgeting, um, semester to semester and trying to push through. And I share all of that to make an excuse for myself, which is that I had a, I had a good GPA. I had like a 3.3 or 3.4 GPA. I thought it was fine. Um, but vet schools there at the time or no vet schools in the state of Arizona, they tend to be ag schools and they have a strong state preference.
Speaker 2 00:06:14 And so I was applying out of state everywhere and I applied two years and was not successful. And getting into vet school was fooled. I know I tried, I knew I was going to be a vet. I just could not convince the admissions committee that I was supposed to be a veterinarian. And so I was finishing up my undergrad studies and, uh, realizing, coming to terms with the fact that I wasn't going to be a vet soon and had to kind of re pivot my career around and really rethink things. And at that time, my mother who had had multiple sclerosis most of my life, um, in the primary, uh, sorry, relapsing remitting form, which is the most common form where you have good days and bad days, her diagnosis, um, was upgraded to secondary progressive, which basically means you have mostly, you have symptoms on almost every day and then you have worst days. And so
Speaker 1 00:07:06 How old was she and how old were you at this time? In my early twenties when she was diagnosed, or
Speaker 2 00:07:12 I actually was a child when she was diagnosed. And so I kind of grew up with this understanding. In fact, I remember, uh, as a, as a small child, um, going with my mom and dad for her to get her for a scale of denim study, where they were able to diagnose her neurologically, um, as having multiple sclerosis. And that happened in the early eighties, I want to say mid eighties, maybe. And so she had always had it and she was getting worse. And, um, so at that time I was kind of rethinking my career and she was getting started on drugs that were brand new at the time. And she had good health insurance. She was a public school employee, uh, but navigating through the authorization process was challenging. And at the time the drugs that she was put on came with a whole host of side effects. It was basically described as you're going to have the flu for two days a week. And then, and so she took her medicine on Friday, and then she felt terrible on Saturday and Sunday. So she could start work on Monday and our family was dependent on her income. And so she had to keep working as long as she could.
Speaker 1 00:08:14 Missy, I, I just, I have to stop here for just a second because I am impressed with the number of obstacles that you've already encountered. I mean, what no, seriously. I mean, first of all, you have to find the money to make your way through college. Second of all, you have to deal with the disappointment of, you know, applying for something that you thought, you know, really would serve you and, and not getting it, you know? And, and I also want to recognize your courage for, you know, for talking about that. Most people don't, I, you know, I have failed countless times in my career. In fact, failures, outnumber successes, probably, I don't know, five or six to one, and most people don't talk that, but if you want to be a success,
Speaker 2 00:08:57 You got to fail.
Speaker 1 00:08:59 And then the third thing is your mom, this had to be, uh, starting from childhood a pretty challenging time.
Speaker 2 00:09:07 It was a very formative experience for me. Yeah. Do you have brothers and sisters? I do. I have an older brother who was a nurse now. He retired from a full career in the military and then went to nursing school. He's actually on his way to become a nurse anesthetist. And my sister got her degree in criminal justice and she is a tactical safety instructor for the department of probation. So she trains probation officers. And so I, at the time I was the first person in my family all the way back to go to college and graduate. I'm very proud of my brother and sister and, and other members of my family have, have followed along and now have multiple degrees. And so that's really neat, but, um, we didn't know what we were doing. You know, my, my parents couldn't help me negotiate the college world.
Speaker 2 00:09:49 And so I kind of had to figure it out by trial and error. Um, there was I'll show I'll share with you one other quick story here. There was a time that I was going to three different community colleges in one semester. And the reason for that was I really had a goal to graduate. In four years. I had this timeline that I had set for myself to get into vet school. And so you have to take a progression of classes. You got to take chem one before you can take chem two before you take biochem. And so, uh, with my work schedule being what it is, I couldn't find a single community college that had everything that I needed to take at the time I needed to take it. So I was going to southbound community college and paradise Valley community college and Glendale community college to try and get everything in.
Speaker 2 00:10:30 And, um, I re I remember one time I had fallen asleep in class. It was a Friday afternoon class, and I had been, you know, work and school and work in school. And it was Friday afternoon and I was just out like a light in class. And I just thought, this is, this is silly. So I did sort of make a change in my senior year. I took out more student loans than I ever really wanted to. And I said, I'm going to prioritize my coursework. And I did that, and I just worked a little bit on the weekends, and that was one of the best years of my life. So really got to have that college experience and, and enjoy that my last year of undergrad. So that's,
Speaker 1 00:11:04 And, uh, it was, uh, uh, hard earned a little bonus there to be part of the college social scene and actually have some friends maybe. Yeah.
Speaker 2 00:11:13 Yeah. I mean, I had so much fun. We had a great time. I was taking a lot of class, but really got to participate in school organizations and activities. And, and so I got a little taste of that, and I think that that kind of framed up what I wanted my pharmacy school experience to look like when I, when I am interested in it
Speaker 1 00:11:31 Back to the transition. Now you've been, you've been, uh, frustrated with your attempts at veterinary school and Arizona doesn't have one at the time. So, so how did you land on pharmacy?
Speaker 2 00:11:42 Sure. Well, I kind of had to do with my mom, you know, I watched her struggle through those challenges from a payment perspective, from a side effects perspective, she had multiple that had to communicate with each other. And of course at this time I remember going with her to a doctor's visits and she had paper charts that were, you know, is it a few inches thick at that point? And, uh, sharing information was just a huge challenge and she wasn't feeling great. And so it was a very formative experience for me during that time while I was thinking, okay, what am I going to do next? And I, at the vet's office that I worked at, I had done a little bit of research here and there on different pharmacology issues that came up and I thought, what about pharmacy? Um, I could help people like my mom. I could, uh, help my mom if I knew a little bit more about how to navigate this. And so I went into pharmacy school or in the, into the preparation and application process with, I don't want to say a chip on my shoulder, but I had a little bit of a, uh, an attitude about what I wanted to get out of pharmacy. And I didn't know all of the different avenues that existed within that career path, but, um, I related to people like my mom and, uh, very much wanted to help them.
Speaker 1 00:12:51 There's a recurring theme as I've talked to people about healthcare and it supports the notion that I've had for a long time. And that is that the vast majority of people that are in healthcare are here for the right reasons. We, you know, we, we wanted to help people in some way, and, and often they will have a story like yours. It's very personal. It's, it's either, uh, the person themselves or a family member or a dear friend. You know, there's always something there that triggers that notion that, you know, if I could learn about this, maybe I could be of, uh, be of some help. And, uh, uh, I, I th the reason I bring that up is because there's often a notion that there's some kind of bad guy in medicine. There are some, you know, uh, just like in any profession, I think there are fewer in healthcare for the reasons I just mentioned.
Speaker 1 00:13:45 And, uh, it's not that we need to point fingers at individuals, or even at companies, it's systems that drive our behaviors. At least that's my postulate, that's my working, uh, postulate right now. And, and part of the reason for these conversations is to see if I'm right, you know, and have, uh, folks push back if they disagree and, or supported if they agree. Uh, but at any rate, now you're at a point where you're entering pharmacy school, tell people what the training is like for a pharmacist. What do you have to do to become a pharmacist?
Speaker 2 00:14:18 Sure. It's, um, it is a, uh, three to four year program. It is, uh, all, all pharmacy degrees are doctorate level entry degrees. And so for many decades, uh, you could get a pharmacy degree. That was a bachelor's. And then you could, um, sit for your board examinations and practice pharmacy. Um, I want to see you in the nineties, uh, the profession made a decision to go to entry-level pharm D. And so it's a three to four year program. The three-year programs tend to be all year round and the four year programs take the summers.
Speaker 1 00:14:45 So everyone that's graduated since 90 or the 90, early nineties is a pharm D, which is how they're often referred to. Yeah. Yeah.
Speaker 2 00:14:54 And we're kind of in a unique time and that there are still lots of practicing, practicing pharmacists, great pharmacists who were trained with an RPH degree and, um, have gotten in various clinical roles. And so we do see a variation in the training, uh, amongst members of our profession. And so, as we do things like develop new programs and protocols, we want to make sure that everyone has been, has had appropriate competency assessment so that we can proceed in a uniform way. But yeah, from entry level pharm data for four years, the first three years are, uh, academic, uh, didactic training. Um, we do a lot of wet labs and compounding labs and things. We, we studied pathophysiology.
Speaker 1 00:15:32 Now tell us what a wetlab is.
Speaker 2 00:15:35 Lab is a lab, but it's, uh, it you're using samples. And so you're, you're actually drawing up doses. You're compounding medications, I would say, um, uh, surrogate medications, you're working with Celine and die usually rather than drugs themselves. Um, but you're, you're making dosage forms so that you get practice in manipulating the products. And so you can get out of school with some competency. So it's, it's those kinds of activities for the first three years. And then you have, um, your final year, which is a clinical rotations. Those are advanced pharmacy practice experiences, and they want you to get a variety of experiences. So you practice in a community or a retail pharmacy go to a hospital. You might be trained with a clinical pharmacist, who's decentralized your rounds with an ICU team or something. You can work in specialty pharmacy. There's lots of different things that you can expose yourself to as a student.
Speaker 2 00:16:22 And then you graduate with your, your doctorate of pharmacy degree. Now, most, I don't want to say most, but, uh, a pretty large proportion of, uh, entering pharmacists will choose to do a residency program, uh, which is post-graduate training. You can do, they tend to you, there tend to be one year increments of time. Although there are a couple of two year programs. I actually did a two year program. And so the first year out of your doctorate of pharmacy degree, you do a generalist training. So you're a licensed pharmacist. You're, uh, and, and you're precepted by more experienced or seasoned pharmacists. And you get very intense clinical training. Your first year is very much a generalist year. And then in your second year of of training, uh, you can specialize. So you might specialize in infectious disease or cardiology or psychiatry or, um, pharmacy administration, or there are lots of different specialties
Speaker 1 00:17:15 That do they do. Yeah.
Speaker 2 00:17:17 You make, um, a stipend it's, uh, tends to be about 30 to 50% of what a pharmacist would bank, um, in their role. Uh, but it feels like a lot when you're just coming out of school. At least that was my experience. So, uh, yeah, you do make a stipend and you have staffing requirements. And so you have to work a weekend. Um, usually every other weekend or every third weekend is, um, what you see in residencies in terms of staffing
Speaker 1 00:17:42 Yeah. Responsibilities. So, so it's, uh, it's a pretty rigorous process to become a, now I like the MD degree, I guess you don't, you can get your MD degree. You don't have to become an intern or a resident. You could stop there probably are not going to get a job practicing anywhere. Um, is that similar in, in pharmacy?
Speaker 2 00:18:05 Yeah. Um, it is for certain roles. I think there's some variety. So, um, oftentimes if you graduate with your form D you can work in a community pharmacy setting and the community pharmacies often have training programs that they put their employees through and, um, could season them up. And, and so they're ready to practice right out of school, um, for our more clinically oriented position. So if you want to practice in a clinic next to a primary care provider, um, we tend to recruit pharmacists who have a postgraduate, at least for one year of post-graduate training. Um, ideally two years of postgraduate training. So we can pull those, uh, the specialty skills, um, into the clinic.
Speaker 1 00:18:44 Yeah. You know, I was thinking back on, uh, when I was a kid growing up and that's when they still had Rexall pharmacies. I don't know if you were around then, but at any rate, I was struck by the fact that the pharmacist was the friendliest guy in town. I mean, they just, they knew everybody, they talked to everybody and frankly, I looked at it and it didn't look that hard to me. Now, remember the PDR was a tiny little book at that point. And, and my dad was a general practitioner and there were maybe six or seven drugs that he used on a regular basis. And beyond that, there just wasn't a whole lot. And the exception might've been antibiotics, they were starting to expand pretty rapidly. So when you look back on, when you first got out of training to today, how much has the complexity of the job changed
Speaker 2 00:19:36 Substantially? And I would say that there's been, um, uh, a decades long progression of that. And as, as you see in many industries and certainly in healthcare, the rate of change is increasing. And so we S we see the change coming at us faster and faster, and pharmacy certainly no different than that. I think where, where we sometimes have friction in that process is that our regulations pharmacy is a very regulated field inside of a very regulated field of healthcare. And so, as we have, uh, clinical demands, economic demands, technological advances, drug therapy, advances, practice advances, and new opportunities for pharmacists to add value. It's sometimes a struggle to keep our regulations up to par with all of that. And so one of the things that I have, uh, been able to instill into my career as a sense of advocacy and regulatory engagement, to say, we want to do this, and the rules don't let us do this yet. So let's go about changing the rules. And that's a really, I think, important, uh, commitment, um, that we all make, but it's also, it's been a lot of fun. That's all right. We don't like the roles. We'll, we'll just figure out who can change the rules and talk to that guy. So
Speaker 1 00:20:50 What was your first job after you finished
Speaker 2 00:20:52 First job? After I finished, I did a residency. So I did a two, a 24 month residency at Intermountain healthcare, which is based in salt Lake city. I was just infatuated with that organization. Yeah.
Speaker 1 00:21:03 Well, they've gotten a lot of national press. I mean, they've done some really cool stuff and you'll recognize the guy that I recently interviewed from, from that system. And did you know, uh, Dr. James Synology the seventies?
Speaker 2 00:21:15 I knew Dr. James now, I wouldn't say Dr. James knew me. I had an opportunity to observe him from afar and learn from him. And I think Intermountain has done a wonderful job of giving him a platform to share what he has learned and what he's accomplished with others, so that others can follow behind him. And I was certainly one of those. So, um, Dr. James is, is, uh, largely responsible for much of the success than Intermountain has enjoyed over the last several decades. And, um, I was able to participate in some of his advanced training programs and learn a lot of the skills that he has instilled in other clinicians. And that was a unique opportunity for me to have.
Speaker 1 00:21:54 So, so you went through the ATP advanced training program?
Speaker 2 00:21:58 I did. I was able to go through the four week program, which was, was just a life changing career changing experience. Yeah.
Speaker 1 00:22:05 I mean, I've said the same thing and said it to him, and it really is an amazing experience. So at Intermountain, what was your first role there?
Speaker 2 00:22:13 So when I finished residency, I took, uh, I stayed at the corporate office. So I've spent very little time, you know, in a direct patient care capacity. Um, I knew that I, I liked to work on systems rather than in systems. Um, I love policies and procedures and process development, and, and that was something that was, I think, fairly unique in a pharmacist. And so I was able to find a job that allowed me to spend
Speaker 1 00:22:35 A lot of time taking a human being
Speaker 2 00:22:38 Real nerdy. Um, so my, my first role was as a clinical pharmacy services manager. And so my responsibilities were to work with clinical pharmacists in the hospitals. And in, um, to some extent, the ambulatory setting in the clinic setting, we had very few pharmacist provided services in the ambulatory setting.
Speaker 1 00:22:57 You impress somebody that's a pretty big responsibility, fresh out of residency.
Speaker 2 00:23:01 It was, it was, I was able to spend a lot of my time in residency, working on projects that you get started and you, and you kind of get them to a point to where the leadership wants those to continue. And so I kind of was able to create a job for myself there and continue some of the work that we had started in my residency and right out of the gate, I was working on things like collaborative practice agreements, which are unique arrangements that allow sure, sure. A collaborative practice agreement in pharmacy allows a physician and a pharmacist to enter into a relationship whereby a physician can delegate certain aspects of care to a pharmacist. So pharmacists are not diagnosticians. The physicians do that. Great. And so if you're a primary care provider, you might say you to a patient you've got diabetes and your A1C is this, and we want to get your A1C down and I'm going to have you work with my pharmacist.
Speaker 2 00:23:52 And the pharmacist is going to focus on adjusting the doses of your medications. They're going to order labs to assess how you're doing, and they might start new medications. They might stop other ones, but we're going to just tweak those medications, um, slowly and carefully so that we can help to get your A1C to goal. And that pharmacist is going to keep me updated on everything that's going on with your care. And then the patient goes and works with the pharmacist. So we were able to set up some of those collaborative practice agreements around, um, anticoagulation, diabetes management. It was, it was, it was unique for pharmacy because physicians, I think in general, don't love that, uh, that part of practice, you know, managing warfarin, isn't their favorite thing to do. And, uh, pharmacists were super detail oriented. We know how those drugs behave in the body. And so we were able to come into a practice and say, we'll take this over for you. And you can focus on things you like better, and we'll make sure your we're anticoag patients are kept safe.
Speaker 1 00:24:46 I think a lot of people under appreciate the role that pharmacists play in the healthcare system today. I under appreciated it until in a practice of critical care. I was, you know, at the bedside taking care of critically ill patients and, uh, one fine day, they assigned a pharmacist to critical care and it dramatically changed my life. I mean, the time that I had spent going, uh, you know, looking stuff up and trying to figure out what's the best asking for the antibiogram. And for those of you who have not heard that term, every hospital keeps a record of the bugs that are infecting people and which antibiotics are most effective against those local bugs. And it'll vary sometimes across the street. And so it's very, very specific to a hospital. And, uh, you know, just, that's just one of the things to keep up with.
Speaker 1 00:25:36 There are drug drug interactions. Uh, there are patient parameters that can impact how you dose, whether the kidney function or the liver function is impaired. So there are just a whole host of complexities to Wade through, and being able to say to a pharmacist at my elbow, Hey, what do you think about this? I'm thinking about starting, you know, X, how would you dose that incredible advantage? And, and, uh, I was sold from that point on that there was a huge value with that expertise in an entirely different field that is highly complex, really is. So, uh, tell us now, uh, so you're, you're, uh, in a leadership position at Intermountain. And how the heck did you wind up at banner health? Yeah,
Speaker 2 00:26:24 Sure. Well, I, like I said, I loved Intermountain healthcare and very much believed in the mission and still do. I think they're a wonderful system and do great work. Uh, I had an opportunity to build ambulatory pharmacy services at Intermountain healthcare, almost from the ground up. And so we started with just a couple of FTEs and that has continued to grow my leader. My boss had in Mt. Healthcare actually was recruited to banner before I was. And when she left Intermountain healthcare to start pharmacy services at banner health, Tina, yeah, that's right. She, she called me on the phone and said, Hey, do I have a job for you? She knew I had grown up in Phoenix and my family was here. Um, my mom actually had passed away a couple of years before I came to banner. And so I, I, uh, wanted to be closer to family. And so she kind of put the puzzle pieces together and she goes, I know how much you love in our mountain, but if you're interested, we can, we can do something here. And I was, and so I had an opportunity to come to banner to build the specialty pharmacy.
Speaker 1 00:27:20 Now, now let's take a couple of steps back because you threw some terms out there that not everybody might be familiar with. So when you say you were developing an ambulatory pharmacy program at Intermountain health, you know, there's a CVS down the street, there's a Walgreens. Why would a hospital do that?
Speaker 2 00:27:38 Good question. Um, the ambulatory services, really, what that means is we put pharmacists in a clinic. And so to your, to your example, about putting pharmacists in an ICU where they're looking at all of the different medications and dosages, and making sure that the patients are kept safe from a pharmacotherapy perspective, there's similar opportunities in a primary care setting or in a clinic setting, even with specialist oncologist and cardiologist and various specialists where they manage their patients, oftentimes, uh, primarily with pharmacotherapy and really the goal in putting a pharmacist in a clinic, whether it be primary care or in a specialist clinic, is to make those providers more efficient, to make those patients more safe, um, and, you know, improve the, the quality of health care. So really out of the gate, we were looking at things like, like population health. We didn't necessarily call it population health, that term wasn't, um, around at the time. But our pharmacists were looking at who needs to come into the clinic. Who's going to run out of a refill next month. What do we need to do to, to try to re-engage patients that we've lost over the last several months or a year? Um, and so those pharmacists were able to, to jump in there and add a lot of value. So
Speaker 1 00:28:50 Yeah. Now, you know, you talk about population health. One of the, one of the principles that we talk about all the time in healthcare is that if you look at any given population, if it's large enough, uh, and that population can be defined any number of ways, right? You could say all of the, uh, folks who are employed at Walgreens, for example, that's a population, right. And Walgreens, or we could use CVS if you prefer, uh, you know, it is going to want to make sure that that population is well taken care of because they're footing most of the bill. So tell me how you think about population health. There's 5% of that population. We know roughly accounts for 50% of the total costs, and that's true across populations and time again. And it's, uh, it's not always five 50, right? It might be seven and 40, or it might be six and 55, but it's in that ballpark, which is really remarkable and pretty impressive. So, so how do you think about population health from a pharmacies perspective? Let's say in an ambulatory clinic,
Speaker 2 00:30:01 It's a great question. I think the first way that I thought about population health was looking at a panel of patients that were attributed to a clinic and that panel of patients, we could go into the EHR. One of the really great things about Intermountain was that they had an electronic health record that allowed us to query data in the early days of, of all of that. So we could look at all of the patients that were seen by providers within a clinic and say, let's pull their last blood pressure values. And let's find the patients who are under control and monitor them. But more importantly, let's find the patients who have hypertension and their last blood pressure was still very high and let's see what we can do to re-engage them. So I approached it maybe selfishly to try to grow opportunities for pharmacists to add value. Um, but really looking at patients who weren't in front of us at the clinic, the ones who were coming in and were right in front of us, we're easy to manage what we, we also were responsible for those ones that were not coming in. And so that was our first, I think, slice of population health. Um, we also, because an amount of health care has a payer, um, called select health.
Speaker 1 00:31:05 So that's really, uh, an insurance company that's wholly owned by Intermountain health. They're not partnered with anybody it's their insurance company, essentially.
Speaker 2 00:31:13 Yep. That's absolutely right. And so they were looking at things like their top 5% utilizers. And, um, and we started to be able to talk in partnership to figure out the best way to take care of this high risk vulnerable population. And we learned a lot in those analyses and I think health systems have continued to learn more about this and that is that people become, they, they get on that top 5% list for all different kinds of reasons. And we've got to be able to have solutions for all of them. And so when we started some of those very early discussions about, you know, let's find our top 5% and let's engage them in a different way. We had an opportunity to build what we ended up calling like an ambulatory ICU, which was just a very high intensity, uh, ambulatory clinic. And we were able to put a pharmacist in that clinic and we would get patients and the pharmacist would meet with them before the provider would come in and we'd have like a 15 minute block of time. And the patient would have 35 medications on their med list and 15 minutes wasn't going to cut it. So we were able to, to really experiment with the best way to, to take care of that population at it or not.
Speaker 1 00:32:16 And, and, uh, th th that's in contrast to the traditional individual one patient at a time care, and that works as long as the patient's in front of you. Right. But, but you're looking for those folks who maybe haven't been in, in a while, aren't all that compliant or adherent to the recommendations of the physician or the pharmacist. And you're trying to figure out what makes them tick and how can get them on the straight and narrow here. So that they're doing things that will protect their health incentives in that case are aligned between the colon plan sponsors. That's, that's who the businesses are in the commercial world that fit the bill for a large percentage of healthcare dollars, including a pharmacy. So they want that to be less expensive and they want their employees to be healthy. So they're, you know, happy and smiling when they show up at work for the day.
Speaker 1 00:33:07 And of course the patients want that too. So that's, that's, uh, a nice situation to be in where those incentives are aligned. And in this case, Intermountain health owns the insurance company. So they're essentially capitated. And when I say capitated, let me explain that term really quickly, too. Capitated simply means that you get a certain amount of money you're fully at risk for whatever happens to that patient. The way the risk is divvied up in a traditional fee for service world, where the delivery systems independent, uh, and, uh, uh, the, the insurer is independent is that insurer is often taking the risk. And so they're pestering you to get in and get your medications filled and all of those sorts of things and the delivery system really, they don't have much skin in that game. And so they're not motivated to go above and beyond to reduce risk or, or, or even to some extent if you, if you believe, uh, uh, uh, uh, quality waste theory, uh, improve quality. So, uh, that's a system that we've grown up under, and that's what we're all trying to change. And, and that's where population health comes in. And that's where Missy comes in.
Speaker 2 00:34:20 Yes. And select health and Intermountain, I think had a really early version of that. Um, and how that played out was in examples, like when, when our primary care providers were coming together to develop clinical guidelines and protocols that then they could distribute and say, this is our standard of care. Uh, we were able to have opportunities for select health to come in and join those discussions and say, well, let's look at the formulary and make sure the formulary matches this plan of care. Um, so that we could remove as many barriers from delivering that protocol and that standard, uh, as we possibly could. And so we did have a nice set of ingredients at that time, then at that place to be able to ask some of those questions.
Speaker 1 00:34:57 Yeah. So the formulary being the list of drugs that that particular plan is allowed to use for that particular population of patients you've been involved in, in defining formularies before, how do you decide what the formulary is? I mean, I, I'm sure there are lots of folks out there who are saying why isn't my drug on the formulary? Well, we're going to ask Missy. Yeah,
Speaker 2 00:35:16 That's a great question. So for, to your point, yeah. Formularies are our lists of drugs that are available to members of a health plan. And ideally a formulary has drugs on it that are a high value that are inexpensive to the patient and inexpensive to the plan, which those savings work their way back to the patient, um, and to society general in one form or fashion. And, um, and so that's really the goal. Um, but we know that there are lots of different thousands of drug products that are on the market, right. And not everybody, uh, in a population has the same response to a single medication. And so we have to create breadth on a formulary to be able to really meet the needs of the population. There are instances where we see, uh, drugs that come to market that we would consider high cost and low value. And so ideally your formulary management process, um, meaning the clinicians and the leaders who look at building the formulary and make decisions about what's on, and what's off, they can look at the value proposition of every one of those drugs and make decisions about whether or not to add a drug to a formulary, uh, because when you add a drug to a formulary, that means that it can be accessed by all of the members within that population. Um, and that can be very expensive without delivering the value that we want those drugs to deliver.
Speaker 1 00:36:35 Yeah. Yeah. I, you know, the, uh, the poster child for, uh, and you've heard me talk about, I see you're smiling already Duexis. I, uh, and, and if I'm upsetting anyone, I apologize in advance, but it is just, uh, I can't understand how you can take two drugs that you can buy for 40 bucks at most over the counter for Modine and, and ibuprofen, or, or, uh, you know, maybe called Advil, or it may be called Pepcid, but those two drugs, which are over the counter, you can buy them today, putting them in a combination, patenting that combination, and then charging thousands of dollars for them. I mean, that's insane. How does that happen? Do you get the, uh, rationale for our system, allowing that at this point,
Speaker 2 00:37:25 I don't, I don't understand the rationale. I have a really hard time finding a use case where that's a good idea. I think unfortunately there, while there are, you know, 99% of the stakeholders in healthcare share our mission of taking great care of the people that we serve. There are instances where it doesn't always play out that way. And so we have to be good stewards of our resources and really look at those, um, egregious pricing tactics and agregious business practices and, and be very careful about what we add onto the formulary and what we don't add onto the formulary. The thing that I would say about formulary management is that as we're describing it here in this conversation, it seems like it is a fairly simplistic decision-making process. You look at the clinical value, you look at the cost and then you make a determination.
Speaker 2 00:38:10 Um, there are other layers that go into building the formulary rebates, being a good example of those that kind of muddy the water. And so there is, there are, uh, pricing practices that you'll see where manufacturers will say, I've got these five products and maybe the, maybe four of the Fiverr are great high value products. And the manufacturer is willing to offer a discount to all five for all five of those products. If we will go ahead and add the fifth one to the formulary, that would be a low value. So those kinds of things can come up as well, which make it a little bit harder. It was junk bonds.
Speaker 1 00:38:45 You got some, you got some winners in there, but you got some real dogs too. And, and those practices are embedded in the process of, of, uh, pharmacy benefits management. They are really part of the fabric of PBMs. We've challenged that before in our own PBM and the response that we get as well, we're kind of hamstrung, as you described, sometimes it's bundling, uh, sometimes it's because they give big rebates. And so if you want to be competitive for somebody's business, you got to show what your rebates are. So there's all this complexity and almost all of it is because of the incentives. And the incentives in this case are monetary. A company can make more money if they do that bundling practice. And so they do, and it goes back to another factor that is part of the mix that is hard to get around. And that is the obligation of publicly traded companies is to their shareholders, not to population health. And if you ask them, how can you justify doing that? Oftentimes that's what they'll point to is like, well, that's what the market will bear, and that's bringing value to our shareholders. And that's my job, interesting philosophy. And, uh, one that we are wrestling with in this country now,
Speaker 2 00:40:04 That is an interesting conundrum. And I, to me, it kind of boils down to the non-for-profit versus poor profit medicine. And how do we reconcile those two things? And I think that's a big discussion for sure. Yeah. Um, I think I will just say that Duexis is in good company. Now. There are plenty of drugs like that, for sure. Yeah. It's the only one I can remember. Its ingredients are so well known. You know, we're all, we all know Advil you can buy anywhere and Pepcid is Pepcid. And so to, to have that price tag for just those combinations is hard to understand.
Speaker 1 00:40:41 Just one more comment, Missy, and I'd love for you to add on to this is, uh, it's not a market in the classic sounds because the end user, in this case, the patient is somewhat insulated from that price because they have insurance, right? And insurance will pay the bulk of that thousand bucks. A company might set up a nonprofit that is solely for the purpose of supporting those who are insured, not the uninsured, but the insured. And they say, Hey, if you're insured and you've got a huge copay or whatever, we'll give you this coupon, that'll cover that. So it can actually be less expensive to the individual patient to get the red flag drug, the Duexis than it is to go to the pharmacy and buy the other two. So there are so many layers of complexity than when you start to peel back the onion. It becomes really challenging to understand how we get all this stuff. Realigned.
Speaker 2 00:41:37 I completely agree with you. And I say this a lot to learners and to others when we get into these drug pricing discussions. And that is that it is very easy to do the wrong thing for the right reason, if you're completely focused on, on meeting a, an individual's needs, um, and the individuals right in front of you and you think, okay, well, you've got a $10 co-pay for your generic ibuprofen and a $10. Co-pay for your generic promoting, I can give you a coupon card and you can get Duexis for free then that, that has met the need of the patient in front of you. In that moment, the bigger picture is it tells us that that is the wrong thing from a population health perspective. It's not a great use of those resources. And so there are lots of examples in pharmacy and in healthcare where myopically looking at a situation where clinicians and we're serving the person right in front of us, uh, we, we can do something for a really good reason and it could break a rule or it could be more expensive in the long run.
Speaker 1 00:42:36 Yeah. And I would point out that, that, uh, that that person doesn't get off Scott free either because next year, guess what, there are enough of those. Your premiums are going to go up. We all pay for that one way or another. And that's a, that is a form of quality waste. And, and, uh, estimates are that 30 to 50% of the three point whatever trillion dollars we spend on healthcare is it's quality waste. And it's not all in that category, but there are similar categories, uh, across healthcare that are in desperate need of fixing, but the incentives simply don't allow us to sustain any of those fixes in the current environment.
Speaker 2 00:43:16 It's a very complicated scenario and, and it plays out in administrative waste and quality, quality waste, and inflation. I mean, there are so many consequences to that, but you're absolutely right that, um, you know, decisions that are, uh, the great, uh, an expedient solution may, may come back around and bite us,
Speaker 1 00:43:36 You know, uh, historically most of the costs of medical care in insurance plans, whether they're owned by a delivery system or in partnership with delivery system or independent insurance plans, uh, has been hospitalization. And pharmacy has been a, really a small fraction historically, but it has recently really accelerated. And I don't know if it's past 15% now, but it's 20%. Wow. Yeah, yeah.
Speaker 2 00:44:04 Depending on the population, I mean, it represents up to about 20 cents on the healthcare dollar and that that trajectory is, is growing. And so when we think about things like specialty pharmacy, and now what
Speaker 1 00:44:15 Specialty pharmacy
Speaker 2 00:44:18 Specialty pharmacy is unique in that it's defined in lots of different ways. Um, I would say probably the, the most common defining characteristic is the expense of it. So specialty drugs, as compared to what you would pick up in a regular pharmacy might cost 4,000, 5,000, $6,000 for a 30 day supply of the drug. Whereas most generic drug products that we take for things like high blood pressure or diabetes, they might cost anywhere between a few dollars in a couple of hundred dollars for a 30 day supply. So it's orders of magnitude more expensive. Um, the other main defining characteristic of specialty drugs is their complexity to administer. So these are drugs that require injections and monitoring and a lot of patient support, uh, to make sure we're taking care of the population that needs these meds.
Speaker 1 00:45:02 Is it, is it true also that very often, uh, specialty drugs are either a technological advance forward or they're designed for pretty small populations. And so in order to get there, the argument is in order to get their research dollars back, they must charge a much higher rate for those kinds of drugs. Is that what you hear?
Speaker 2 00:45:24 That is absolutely true. So specialty drugs represent, you know, 40 to 50% of the overall pharmacy spend. And when you look at a population, usually only one to 2% of a population would never need a specialty drug. So there's not that many drugs that, that meet that criteria, but they're very expensive. And from an economics perspective, it's a, it's an important consideration. So the newer drugs that hit the market are hitting in the specialty space. Um, they're drugs that tend to be biologic in nature, meaning that the molecules are large and complex and are grown in living organisms versus chemically synthesized small molecules. So they're the most advanced treatments that come to market tend to hit the specialty space,
Speaker 1 00:46:07 Give us a sense of why a healthcare delivery system would get into the business of, of specialty pharmacy. What's the advantage there?
Speaker 2 00:46:15 Great, great question. And lots of reasons, I would say from a clinician's perspective, when say if you're a rheumatologist or a neurologist managing a patient with multiple sclerosis, specialty drugs are a large part of that care journey for your patient, right? And so when you are managing a patient and you've got to send that specialty script to a pharmacy that you don't share records with, um, and that is difficult to call on the phone and figure out the status for your patient, then it can create this black box where you don't get to have insight into what's happening. Right. Um, and so from a clinician's perspective, having a pharmacy that's part of the system where the pharmacist and the clinician, the physicians can interact with one another, the pharmacist can see the medical history, the other medications that the patient is taking can communicate with the team easily adds a lot of value. It also allows us to take advantage of three 40 B drug pricing programs. It is a revenue stream into the health system, so there's okay. Of course. So three 40 B is a special drug discount program that, um, certain hospitals qualify for based on how much under insured care they give, um, or for free care that they get the write offs, basically. You're right. And so, um, it is unique program that allows us to bring in funds to help offset those costs that we incur in that process.
Speaker 1 00:47:35 So it's intended to sort of balance the playing field hospitals that have a lot of, uh, of challenged, uh, patients will get more from a three 40 B program than hospitals. That don't, is that right?
Speaker 2 00:47:47 Yep. That's absolutely right. The more, if you qualify as a three 40 B covered entity, then you can take advantage versus if you don't. And if you don't, that means you have a higher mix of commercially insured patients and they have a little bit of a better reimbursement rate. And so it's balanced out that way.
Speaker 1 00:48:03 Okay. Now, are there gradations within a three 40 B program, or is it a flat discount, either qualify or you don't
Speaker 2 00:48:09 Either qualify or you don't that's
Speaker 1 00:48:11 Good clarification. And so, uh, banner has embarked on all of that stuff, right? I mean, specialty pharmacy and three 40 B and, uh, clinical pharmacists and collaborative practice. And, and I bet you've had your hand in a bit of all of that, uh, from, from the start, when did banner start their pharmacy program? Wasn't that long ago, the
Speaker 2 00:48:32 2014. So I came to banner in April of 2014 and was one of the first banner pharmacy services employees. And we built the specialty pharmacy. We opened up a mail order or home delivery pharmacy to support our patients as well. And we built out our clinical pharmacy model and have grown where we can add pharmacist grown services since that time. And it's been a really fun ride.
Speaker 1 00:48:59 Yeah. Yeah. I bet it has. It's fun to look back on something that you've built, especially when it works. I have a question for you though. You have been a, a self-starter self-motivated, you know, I'm going to make sure this happened. Did you run into anybody along the way that was a real mentor,
Speaker 2 00:49:16 So many, so many I really have. And what I'll say about that, I'll name some people by name, because I think it's important, but I would say too, that I have learned by watching people from a distance. I learned a lot from Dr. James that he didn't know I was paying attention. And I learned, I learned a lot from Mark Bree soccer, uh, because he, and he's a physician leader at Intermountain healthcare. It really was a visionary. And I was able to, to just glean that passion and figure out how he, he was organizing things and how pharmacy could plug into that. So I learned a lot by watching, but I also have had mentors who have invested great amounts of time and lent their expertise to me and were so patient with me and, and helping to deliver me to where I am today.
Speaker 2 00:49:58 So I mentioned, Tina Aermacchi earlier, she was a wonderful role model and a door opener for me. She gave me opportunities that I did not deserve. And so I was committed to not embarrassing her and not embarrassing myself and making sure that, that I was able to deliver value for those opportunities that were given to me, Pam and the neighbor, um, is, uh, a long time banner health leader who has now since retired, but she was wonderful. She would set the bar so high for us. And I would just scratch my head thinking, there's no way I can do this. This is not going to fail. And sure enough, I didn't fail. And she saw to it that we didn't fail. And so, um, she was a wonderful facilitator in that respect. Um, people like Jason Brown, um, opened a lot of doors will Holland opened a lot of doors.
Speaker 2 00:50:45 You know, there's just so many leaders that were able to, to work with and collaborate with that have helped us to deliver the value that we've been able to deliver. Dr. Groves. I have to put you on that list as well. You don't, again, I watch, um, I've had opportunities to see, to see you speak and, um, I've, I very much appreciate everything that you, you say and, and your expectations that you set for how we as a system and us as a partnership should be delivering value and transforming care. And I remember the story that you told. I think it was at a broker event, um, about the jazz musician and, and how, you know, he was able to pull off some of his best work under duress, under terrible circumstances. And then you thought, well, we, we kind of have this situation in healthcare. We are under duress. We have threats coming at us from all different angles. And so now is the time to do our best work. And I remember you saying that and just thinking, all right, we've got to do this differently.
Speaker 1 00:51:38 So you're
Speaker 2 00:51:40 So welcome. I learned by watching a lot of other, other people,
Speaker 1 00:51:43 So that now that you have given me a compliment, I don't know if I can ask you the hard questions, but I'm going to try it. Okay. So the first hard question is you you've been exposed to healthcare for a long time. You've seen a lot of it and not just in the pharmacy. I mean, you, you sit in on meetings that discuss the full range of delivery services, et cetera. If there were one thing that could happen or you could do, or we could do to speed up our progress towards quadruple lane, let's call it. And for those of you who are not familiar, that's, you know, that's better quality, uh, lower cost, better service to our patients and members. And then so critical in a time of a pandemic is a better experience for our caregivers. What do you think needs to happen?
Speaker 2 00:52:35 I would say administrative simplification and I'll explain that. Okay. One of the major barriers that we all face is that we have inertia that is baked into our current processes that are inefficient and aren't working well for us, but the, but the energy that it would take to move that aside and redefine something is, is overwhelming. And therefore it presents a barrier to us getting things done. So I'll, we'll use rebates as an example, there is such a value. There is such a value in the rebate today in terms of we're getting w we count on this money coming to us in the form of rebates, that if we were to make a decision to forego all of those rebates so that we could create just this pure high value formulary, it would cost us money to do that. And, uh, our economic models are far away from that vision, that the inertia is a barrier.
Speaker 2 00:53:28 And I think oftentimes we have inefficient processes and systems that we patch over, and then we'll try to fix one thing. And then that causes another issue here. And then we try to fix that. And so our processes have become so complicated that it is very slow to make the change that we all can agree, needs to happen. And so one of the more frustrating things is when we're all sitting on a call and we think, gosh, we really need to do this. We really need to take Duexis off the formulary. And we just literally can't do it because of all of those, all of that sort of, uh, debt that we've accrued in making more expedient decisions along the way. So in short, I think administrative simplification will deliver more value to healthcare than anything else I can think of.
Speaker 1 00:54:10 Interesting, interesting, you know, um, uh, uh, our mentor, Dr. Jane and I, and I apologize for, uh, Dr. James for using your name so much, but, uh, he published an article in Harvard business review. He mentioned it in the podcast and went back and read it, and it's called the case for capitation. And it is an absolutely fascinating read. I would encourage those who, you know, wonder is, are we talking about HMO's in the eighties? And the answer is no, not even close. Um, so far, uh, beyond that. And the case that he makes is improvements in care improvements in efficiency. The administrative efficiency that you're talking about is almost always paid by a portion or all of the delivery system, and yet under fee for service, what happens is you actually get penalized for that. Uh, the example he uses in the article is, is they developed a strategy for newborns to keep them off ventilators, uh, nasal oxygen.
Speaker 1 00:55:16 You know, it's, it's under pressure, but nasal oxygen, instead of putting a tube down the baby's throat far less expensive, you don't have to put them in intensive care, but the end result of that for the hospital is they don't get to bill for intensive care, which is far more than billing for having the baby sitting in a nursery with nasal oxygen. And so the benefits actually don't accrue to the delivery system. They accrue to somebody else under fee for service. And that's somebody, else's usually an insurance company. That's right. If you go to bundled payments and there are those who argue that that's the best way to pay for health care, well, it's still volume-based. So a bundled payment means right now, almost all hospitals services are essentially bundled under DRG diagnosis related, related groups. So for a specific diagnosis, you get a flat rate, you get them out sooner, then you get to keep that money.
Speaker 1 00:56:09 If they go over, then you get to pay that money. But physicians have still been on fee for service at hospitals. And so there's an interesting conflict that that sets up, but the bundle payment strategy is for something like a hip or a knee, the get bundled into that too. Everybody gets a flat rate, and I guess they Duke it out over hell. They split it up, but no pun intended. And, uh, uh, the problem with that is you can, you can get a little bit more out as the delivery system because you can improve those bundles, but you're still volume based because the more bundles you do, the more you make, and the only system that rewards those who are making the investment is a physician based payment strategy with capita dollars. So I would encourage anyone who's interested in this topic, go back, take a look at a Harvard business review, just put in a Dr. Brent, James Harvard business review capitation. It'll pop right up and it's well worth a read. I'm going to ask a couple of closing questions here and, and, uh, what's the best book that you think you've read on healthcare?
Speaker 2 00:57:12 Oh, gosh. Well, this is going to be an obscure one. Um, perfect. It's an old book. I read it in grad school and it is called the social transformation of American medicine. And it is a history book. It talks about the, the primitive forms of healthcare and the beginning stages of our country and how things have evolved over time to deliver us to where we're at today. And I find it fascinating. I find when you can learn your history, you understand why pharmacy practice looks like this. And physician practice looks like this and where health insurance comes from and why Medicare and, uh, the, in the 1960s was so important and, uh, how health insurance was born post world war two. And it's really, it's really fascinating to understand all of that. And I also find a lot of utility in that to, to give us a context of, you know, how we got here.
Speaker 2 00:58:05 I had an opportunity to research right after the affordable care act was passed. The history of healthcare transformation in this country, really starting around the early 19 hundreds. And man, it is fascinating to see all of the attempts that have been made over the last hundred plus years to redefine how healthcare is delivered. And the fascinating thing is how unsuccessful all of those attempts have been highly political, very political. Everybody has a different idea of the stakeholders, have different ideas of how, what good looks like. And it's just been really fascinating to learn about that over the last hundred years. And so that's always a book that I recommend to learners or anyone who was really kind of interested in understanding the big, big picture of healthcare and how we got to where we are today.
Speaker 1 00:58:50 Great recommendation. Because once you go through that history, it starts to make sense. It, the system that we have is exactly what we've designed over time, not necessarily with intention, but within tensions, often at cross purposes and compromises and so on and so forth. We wind up with this clues that we call healthcare that is fragmented and unreliable and expensive, and has a sucked the life out of the middle class, at least the last two decades. And that's what we're here to fix, right?
Speaker 2 00:59:25 That's right. That's right. And I'm going to borrow from Dr. James once again, um, you know, he says that all outcomes are the result of perfectly designed systems to deliver that outcome. And if you get a poor outcome, it's because there was something wrong in the system. And so, you know, on the scale of our healthcare delivery system in this country, it, we are getting the outcomes that we've built. And we were going to have to change our systems in order to get different outcomes. And so it is a daunting task, but it's one that I think energizes me on a day-to-day basis and it energizes those around me. And I see the consequences of difficult to navigate healthcare and expensive healthcare. And I am committed to doing the work to try to make that better.
Speaker 1 01:00:04 Well, it is such a pleasure in these conversations to me, people like you are mission-driven who, uh, really are doing it for all of the right reasons and to are, uh, you know, bright and motivated and hardworking and making a difference every day. And, and sometimes we forget when we're watching the news, that's critical of everything in healthcare. We forget that there are a whole bunch of people out there today working really hard to try and tame this beast. And it's just a difficult process. I'm not sure that we can ever do it effectively without policy changes from Washington because Washington foots more than half the bill now, but that's probably yet another podcast. And we'll save that for later. I hope you will come back. I had a blast getting to know you a little bit better and, and, uh, I think you, uh, you taught us all. So, uh, uh, thank you so much for being here, Missy. Really
Speaker 2 01:00:57 Thank you for having me. I would love to come back. I could talk about this stuff for days, so really appreciate the opportunity.
Speaker 3 01:01:03 Okay, bye. Bye. You've been listening to the groves connection, your connection to the inside story on healthcare, featuring in-depth interviews with those who know you can find us on Apple podcast, Spotify, and anywhere else, you get your podcasts. If you like what you hear, give us a five-star review to keep the connection going and hit the subscribe button to be sure you never miss a beat. The groves connection is produced by Dr. Robert groves, original music editing and creative direction provided by Alden groves, production, support, content guidance, courtesy of Janae sharp and Elizabeth Barrett. Thank you for listening. The professional
Speaker 1 01:01:57 Ideas and opinions expressed in this podcast are mine and do not reflect those of any current or past employers. Thank you so much for listening and we hope you'll join us next time on the groves connection.
