Why Medical Transportation Is Healthcare's Next Strategic Frontier

<p>Hello everyone and welcome to the Strategy of Health podcast. This is Cole Lyons from the American Journal of Healthcare Strategy joined by two really special guests today, Ken Van Cara and Stephen Fox. Ken is the Chief Executive Officer of Alacura Medical Transportation Management and Steve is the Chief Growth Officer. So we have two experts here and they're going to talk about some of the challenges that they've been able to successfully overcome in this field.</p> <p>Uh Ken and Steve, please just do a brief introduction for our audience. How are you doing today? Great and it's great to talk to you, Cole. So pleased to be here and we always like talking about what it is that we're doing cuz it's an exciting space and I think you know we can make a real difference for patients here. &gt;&gt; Happy to have you, Ken. And Steve as well, I have to ask Steve what motivated you to come on and speak? I've been on the payer side for for most of my career.</p> <p>I started on the network side with Blue Cross Blue Shield of Massachusetts and grew up first in claims and then managing providers and building networks and then ultimately moved over to the strategic investment side before joining Carolon, what's now Carolon, through their benefit management division of Aim Specialty Health and then I was the the first growth officer for what's now Carolon.</p> <p>All of the different challenges that payers face on behalf of members and accounts and what I was excited to understand and learn and when I had a chance to meet and spend some time with Ken, in understanding this industry, I only had a perspective of this really from the network and the contracting perspective and really didn't understand how much of an unseen liability this was for payers and that excited me to want to come in here in really the last place in healthcare it feels like where it's it just hasn't been managed.</p> <p>There's lots of reasons why and Ken and I will get into that, but that is what excites me about being able to talk about the growth and the work that we're doing at Alacura. So, you had all this deep knowledge and and background on how it could impact things, and then Ken brought to you. Ken, tell us what what you brought. How did you discover this? I'll let you speak for yourself. Similar to Steve's started on sort of the health plan payer side.</p> <p>And so, I spent the first 10 years of my career in operations and and finance, really. But, the latter part of my career, I started looking at the clinical process side. So, I worked in oncology, I worked in palliative care, etc. And so, you marry those things together and you say, "How can we make health care work better?" And there's two components of that. Better care is less expensive than bad care.</p> <p>So, how do we make the care process work better, and how do we make the logistical process that surrounds that better?</p> <p>And the reason I was attracted to this space, I got a call from the board and they were recruiting for someone to do this, and I mentioned some of the other areas that I've been in, but when I started looking at what the cost of an air ambulance is, and how frequently that happens, and what it does to patients on the back end when they're not protected from those very big expensive bills, that's where I got intrigued by this, because I thought, "We can make this better, and we can simplify that, and it is about how do you make the logistics work better?" Hospitals, we'll talk about this a little bit more, but hospitals have become much more specialized than they used to be.</p> <p>And so, getting to the right place to get the care you need is a big component of that. Lots of patients get moved. And what we want to make sure is they get moved by the right by the right transport in a way that helps them and their family. So, we'll talk a little bit more about why transports happen.</p> <p>But really this is about making it clinically appropriate and making it easy and simple for patients and their families when they have to deal with this cuz they've likely gone through some sort of trauma and they need someone to help them move through this process in a way that makes the process not a barrier. So, you saw the process is broken. It's clinically difficult as well.</p> <p>You started really exploring the actual walking the journey of the patient, seeing how it was impacting the organization. You showed Steve this and Steve is like, I know that health systems need this I or health plans need this because you had seen the cost of it first hand. But I have to ask I've seen some from my experience how it's really expensive. I know that it was a large percent of costs from my previous roles, but I don't fully understand why it's so broken.</p> <p>Can you explain why is this managed transportation a problem in the first place? Why is it broken? From my perspective, the reason that it's broken is that patients need to move for any number of reasons. They need to move because there's an acute life-threatening situation. There's emergency care that has to happen in real time. There's also transports that are for planned events. I'm going to the hospital, I'm having I'm having a surgery that was planned.</p> <p>I need to be discharged from the hospital and I don't have a family member that can take me. Some transports are just done to get you to specialized care. So, we've got a kid who came into the ER, he's got a broken femur, it's a pretty bad break. He's 12, his growth plates haven't formed yet, so we want him to see a pediatric bone specialist. Well, we don't have a pediatric bone specialist here, so he's got to get moved to somewhere where that service is available.</p> <p>That's not an emergency, but it's critical and it has to happen in real time. And then routine and maintenance care. And often an ambulance today, and we're all working on this, but an ambulance only gets paid to take you to the ER. What if you don't need to get taken to the ER? So, we end up with low acuity patients in the ER. That's not a system that works very well. So, this is about triage and getting each of those needs met specifically what the patient needs.</p> <p>Yeah, I was about to ask you, Steve, on the payer side, what is that? Cuz I know like &gt;&gt; [clears throat] &gt;&gt; on the health system, I feel like it's always the tip of the iceberg. Like it looks challenging, and then when you look under the iceberg, you're like, "Wow, this is actually even more challenging than I thought." Let me tell you, when we meet with payers all over the country, their their gut is, "We don't have a problem." And that's because they can't see below the iceberg.</p> <p>They can't see everything that they don't have visibility into. These are difficult claims to find in the system, and there's lots of reasons for that, but when And And I will also say, Cole, most people assume this is There really aren't too many parts of the health care delivery system where there really is a disconnect between the acuity of the patient and the service that's being rendered. Most people assume when they see a helicopter flying over their head.</p> <p>I'd say the myth that we are seeing more and more, that's not the case. We're not talking about uh scene-based issues here. We're not talking about 911 calls on the side of the road where there's a really terrible wreck, or we've got somebody on the top of a mountain that needs to be med-flighted off. Those are a handful of cases, less than a few percent of the total transports. The majority of what we see are what Ken described. These are the transports from one hospital to another.</p> <p>They're moving out of one system to another, largely because they're just rearranging beds, they're freeing up beds. Ken's point about specialized care is accurate. The hospitals are the ones that are making those decisions to move patients. The plan is really not in the decision loop on that. And so, that becomes a part of the disconnect. We can you know, you want to call it fragmentation, that's a really good word.</p> <p>The hospital is focused on getting the patient to where they need to go from where they are, which could be in the emergency room or could also be in a bed at the hospital. And I think when you look at the average cost of an air ambulance, those flights can be anywhere from $25,000. The average rotor can be $50,000. When you start to get into fixed-wing transports, those are over $100,000 per per transport. You can see that these are costs that most health plans really don't expect to see.</p> <p>And then when you layer on top of that something that I know we'll probably cover later, this whole notion of dispute resolution and and the impact that the No Surprises Act has had on this industry and the explosion of settled costs, this quickly becomes a cost escalator for payers that they really didn't anticipate.</p> <p>One question I want to ask about this, too, that I'm starting to think of and be a little concerned about is this must drive the utilization and the costs up for the emergent cases for the insurance company and for the patient and for everyone.</p> <p>Because if you can't really distinguish the difference between an emergency that needs to be flown out, something that doesn't really need to be flown out, or could be done from a payer's perspective, because a payer, you're you're looking at like regional or national level. You can see the movement of these things. Does this cause just like from an economic standpoint, costs in in overutilization?</p> <p>And the really interesting thing about that is because this is fundamentally about transport and logistics. The hospital is concerned about freeing up the bed, freeing up space in the ER. They know they can't serve this patient here. But they don't pay the cost of the freight on it. So they don't pay for a helicopter versus a ground ambulance. They pay They just want to get the patient moved.</p> <p>So whether it's an air ambulance or a ground ambulance, they don't care as long as they get the patient moved to a great degree. And so what that's led to is when it's convenient using air ambulance, and so it becomes very expensive. And of course there are more more expensive ground transports as well. There's a couple of flavors of ground. There's basic life support, BLS. There's advanced life support, ALS. There's specialty care transport. And then there's acute care clinical care transports.</p> <p>And there are all those flavors, and sometimes those get miscoded to a higher level than they should be. But really the reason we started this is lots of people get flown on a rotor, and it's because it's convenient, and not necessarily because it's related to the time sensitivity or the acuity of their need. So I'm also interested in the finance part, because that seems like I don't know how you would even gain visibility into to really what's happening.</p> <p>So how do how do you solve all of these issues? How did you maybe from from the ground up as well? How did you even start thinking about solving some of these issues? We said you really got to get triage back into the system specific to the transport. You've got to be saying, what does the patient need and then let's match that patient need with the transport. It's gotten the transport has gotten disconnected from the acuity or time sensitivity question.</p> <p>Um and it's profitable for a private uh ambulance company to to fly a patient or use a more expensive mode of transport. So, someone needs to provide the oversight. This is the only area where there really hasn't been management involved managing care. And it's about protecting patients. So, what we do is we engage with the hospitals so that they know we're here. We can take their call in real time 24/7 365. We can do that discussion with the clinician that's ordering the transport.</p> <p>And what we'll often say is, that sounds like that would make sense for a ground transport. And they agree. They're more concerned about moving the patient safely than they are about this needs to go on a fixed wing or a rotor etc. And fixed wing is different cuz that's generally planned and it's often very long distance and we're getting you to a specialty center. Patients that are leaving by rotor are leaving from the ER.</p> <p>And so if we can have a quick conversation in terms of supporting that, we can get the documentation we need in real time and then get the patient on the right mode. But on a lot of these short trips, going by ground ambulance makes a lot more sense. One of the things and and I think Steve mentioned mentioned this, but when you think about air, you think about it being faster all the time.</p> <p>And the truth is, while it's while it is faster for for transport time, Generally speaking, air ambulance isn't faster under under 60 miles because they have to file a flight plan. All the pilots have to follow the rules of transport. So, generally speaking on a 60-mile transport, and I'm ignoring weather and traffic, but generally speaking, a ground ambulance gets there about 28 minutes faster. So, that's what we want to see happen. We want to see the patient supported in that move.</p> <p>And it does help that it's the difference between a $60,000 flight and a maybe a $4,000 ambulance ride. And what is that just just so for my clinical audience, who's on the other end of this? What is the discussion look like? So, we have a nurse or a doctor answering that call on the other end and having that clinical discussion about what does the patient need.</p> <p>Okay, so you guys have work frameworks or workflows that you have tested and wrapped in and there's a discussion that's had and then you figure out what's available on your end, what the situation is on on their end, and then you you come to a a decision. &gt;&gt; Yeah, first of all, we're really talking about situations that are not life or limb. Let's be clear.</p> <p>We know this for every patient that has to go by these forms of transport, these are some of the worst days of their life and we want to we want to be fast, we want to be responsive, and we want to be patient-centered and focused. When there is an opportunity to to have that clinical conversation, that's why we built our operation to be 24/7 because these calls do not happen at 2:00 in the afternoon. Sometimes they do. They happen at 2:00 a.m. on a Sunday and they happen on a long weekend.</p> <p>And our clinical teams need to be In order for this to work, we need to be responsive. We're tracking There is a live clinical person. These are our staffing. Most of our company is clinical and all of the clinical staffing is either emergency medicine board certified critical care ICU. Our nurses are trained flight nurses or emergency room critical care ICU and our nurses are managing these cases with the physicians. So this is a physician and nurse led conversation.</p> <p>That call comes in, it's handled in real time. That case is quickly assessed and we're doing a few things in that is a prop to the payers here is we've got integrated technologies through our platform where we're integrated with the payer. So we know who the patient is, who the member is, what their benefits are. We overlay the description that Ken had, what does the health plan's network look like, are these providers in network, are they out of network.</p> <p>We do all that real time as well as being able to have eyes to know what assets are available. So we're going to ask them what their preferred mode is. We'll then look quickly and then we also know based on the weather, based on the conditions, based on the traffic, can we if it's appropriate for ground, we can help them secure that asset. We can help the case managers actually find beds if needed.</p> <p>So we are bringing all of that and those cases are adjudicated within 6 minutes assuming that we have the clinical information that's needed on this pre-service call. So we're training, we're educating, we're helping in many instances these folks that are calling to better understand um what the options are for that patient that are obviously clinically the most appropriate, but also what's covered from a benefit so that we can minimize out-of-pocket costs for them.</p> <p>&gt;&gt; Yeah, that make that that's incredible because it's so funny you about it being often people's worst even if they're not necessarily having a severe emergency. I still remember when I worked in neurology, there was miscommunication around transportation and someone was transported to an outpatient facility with What was that highest level you were referring to? Critical care transport. Yeah, they were using critical care transport.</p> <p>So, they had a a full stretcher and all these people had to come in with them, but there was nothing critically wrong with them. It was very embarrassing and difficult for the patient, but that is just how it had to happen. And so, you think about the cost as well of of all of those staff members and complexity of that. And so, in a way you're you're kind of bringing this intelligence and expertise to bear when they give you a call.</p> <p>So, that must be a relief for the clinicians on the hospital side as well. One of the things that they love about working with Alacura is they're talking to someone that speaks their clinical language on the other end of the phone. Because our nurses come from, you know, ER and flight background and transport background, they speak exactly the same language and they can very quickly have a conversation.</p> <p>And, you know, they they like that versus speaking to someone who's in another clinical discipline entirely that may not get the situation in in real time. And to Steve's point, it's the platform that lets the nurse quickly assess the logistical piece of that, right? Where What assets are available, you know, what hospitals have the specialized care that this patient might need. All of that they can look up in real time. So, it takes that off their hand.</p> <p>They're not looking in their Rolodex to figure that out. It's It's in the platform and so, that makes for quick decision making. When you take a step back or look at the macroeconomics that we're talking about, you know, payers are under extreme pressure to find cost of care savings, to create premium relief for their employers, ultimately to benefit, you know, the members and and you know, with their out-of-pocket.</p> <p>The ability to put a spotlight on medical transportation and the ability for us to raise these issues has really created essentially an urgent need to quickly address this. This is a fragmented system in many instances. It's a broken system. We have a system where we don't have aligned incentives. We have a system where there are over 550,000 air transports that happen each year.</p> <p>And so if you think about the amount of flights that are happening you know, more unfortunately, there are cases where those flights are going to go because the equipment is there, not really because the patient needs it. And those are the conversations that we want to bring to the fore. There are plenty of actors in this space that are doing the right thing. They're in network. They want to participate. They're part of value-based arrangements.</p> <p>They are actually talking to us about building national networks where we can help payers point to these types of transport networks. But there are also plenty of others in this space that really are focused on revenue maximization. I was about to ask you about that. 2025 air ambulance was a $35 billion spend rising at about 7% a year. So this does matter and this does impact the economics that a payer is seeing through its claims.</p> <p>So that's one of the things that I was thinking about is when it comes to the No Surprises Act, right? There must be a lot of disagreement between payers, and I'm just guessing, and you know, the out-of-network benefit that was provided in terms of this transportation costs. I'm assuming that some of these costs might be overquoted or significantly higher than what the insurance plan would see as reasonable. And now, as you mentioned, this is recent, right? It's been pushed to IDR.</p> <p>So it's independent, you know, dispute resolution. Can you tell me a little bit about what that means for payers? Has that been a challenge? When you think about the No Surprises Act that was passed back in 2022, it it is, you know, a lot of it is is the way it should be. The whole goal here, patients were exposed to bills that they weren't not anticipating or expecting, hence the surprise.</p> <p>You know, you go to an emergency room, you you had no ability to choose the emergency room practitioner that saw you, they were not in network. You were having a surgery, you had an anesthesiologist, you didn't pick it, you were getting billed. So, it was really intended to protect those types of cases. Part of that waved in the concept of air ambulance as part of that No Surprises Act, kind of in the constellation of emergency services.</p> <p>And so, originally, when you go back to the thesis that CMS had, there was originally supposed to be 17,000 cases on an annual basis that fell into this category, right? They anticipated a small subset. And the goal was for claims that didn't meet criteria, there would be these independent dispute boards that would be created to essentially mediate what became an out-of-network payment dispute.</p> <p>Well, that 17,000 claims a year has has exploded into millions of claims a year, which was never the intended effect. And what it's turned into is a revenue-generating opportunity for a lot of these providers. About 40 to 60% of disputes that go through the process are not even eligible. Air ambulance represents about 1% of the total disputes in the process, but the awards are significant.</p> <p>These $40 to $100,000 base claims get settled eight to 10 times the value of that, well into the six figures and beyond. And so, the average There is a lot at stake for each of those cases. Those cases then have to be brought back into the payers to be processed.</p> <p>And the unintended consequence that IDR has had is it's taken a lot of the in-network providers that were doing this and essentially saying to them, "Why should I do this for the in-network rate when I can go out of network and get paid a multiple?" And so, those are the the challenges. And you know, some of the national numbers that you look at, there are experts that predict that this will add 20 to 200 billion dollars of cost into the ecosystem over the next 10 years. That is not sustainable.</p> <p>That was never the intent. And so, when you think about all of that, what Alliquid with our expertise, our clinical knowledge, what we offer as part of our our offering is we'll work with payers. We'll work with the clients that that are our We will provide the clinical documentation because from our perspective, it really is about It's not for us, it's about justifying the medical necessity.</p> <p>It's about helping the health plan show why this wasn't medically appropriate or necessary, but that flight may have gone and what the cost impact of that decision was. And so, we're working with payers right now to do that and to helping reverse those cases. What What you need to know and what the audience needs to know is that about 90% plus of these cases are settled in favor of the providers. So, the plans most often lose those cases. And there's a lot of reasons why that is the case.</p> <p>Disputes, these are run like businesses. They're bringing lawyers, they're bringing full business consulting in to work with these practices and transporters to help them make this case financially. The health plans don't have the time, they certainly don't have the expertise. And so we are coming in to provide that level of support. So again, there's a lot of great things with the No Surprises Act. There needs to be modifications to it.</p> <p>There are plenty in the industry that are focused on that, both through the Blue Cross Blue Shield Association, AHIP, major payers all over the country are focused on making these changes to it to make sure that the intended consequences are what's focused, not the unintended consequences. Yeah, because that's a substantial when you think about the scale as well, you know, these are not $50 $50, [laughter] you know, discrepancies that we're talking about here, right?</p> <p>What is the What is you I think you mentioned it. What was the the average kind of amount that we're we're looking at here? You said it was in the six figures? So you're you're you're starting with a case that if if this was an in-network claim, they already are paying, you know, could be 20, 25, 30,000 dollars, could be up to 80,000 dollars and beyond.</p> <p>Those cases, if they are out of network and being disputed at that rate, if they don't want to get paid that rate, if they don't like or feel that that was the appropriate rate, those rates can be settled sometimes eight to 10 times that. So when you think about the multiple of that, that $40,000 claim can now explode and and be well over a $100,000 claim when it's all settled. What's interesting about that too is what you're kind of also saying is this is just one part of it.</p> <p>Even if you're looking at that original number, which we said it was between 20 and 80,000, that might not even have been necessary. You might have been able to go with ground transport or something. So, you have to bring a lot of techniques to bear in order to to stay competitive. And one of those is AI, from what I understand, but you are kind of taking an ethical approach to this. And so, my question is how you know, where does AI fit in the decisions?</p> <p>You know, is it what kind of medical decisions is it not or is it making? What kind you know, how's it helping? And then where have you decided to kind of draw the line on on AI, if that makes sense? AI and how we can use it in this space. It is great for making transport more efficient when you think about all those logistics questions you have to answer in real time to move a patient. And it also can help us to approve transports faster, right?</p> <p>There are certain transports we are going to approve every time. So, let AI help us figure that out. Complex transports and it should never be making decisions about denials at the end of the day. I believe that to be true across the clinical spectrum. We can approve and approve those more quickly and let us focus the time on those that are inappropriate and you know, should be denied. What's the clinical criteria for why that that transport just didn't make sense.</p> <p>So, you know, AI should always be a human in the loop process and it should never be making decisions just on its own because at the end of the day it's it's not intelligence, right? It's a long It's a large language model. So, we think there's places for it. We think the efficiency it can generate in terms of improving the flow of care can be great. But, you know, it's it's not a denial machine.</p> <p>Do you think that that's why physicians and and clinicians prefer working with you guys is because when you know, there's a denial or there's a something that there's a discussion if they're actually dealing with a real physician and not just an AI denial letter. I can't imagine AI is being used for call management a lot responding to questions. The clinician on the ordering side, the physician who wants to move this patient AI is not set up to deal with them yet.</p> <p>Maybe someday, but what they really appreciate is a clinician that speaks their language on the other end of the phone. I think to that point, Cole, this whole model you know, it this is a patient-centered approach. We are not in there are plenty of parts of the delivery system where things happen to a member instead of with the member. And I think in the medical transportation space and in the fragmentation that we talked about patients didn't have a choice. They were not in control.</p> <p>They were told where they needed to go and how to get there. They and their families really didn't have a place and we believe that if you do the right things clinically we think if we do the right things clinically if it ultimately that leads to a better cost outcome, but more importantly it's really about a better patient outcome. It really is making sure that they and their family get the most appropriate care, the transport that they need and it it will lead to a better outcome.</p> <p>And as we think about the enablement of AI in the human-centered and human-enabled approach the whole the ability to really put more eyes on what we're doing and we're very excited about where the data will take us because that's really where the technology should be. We should be taking the technology approach leveraging all of the data. We have millions of records of claims outside of CMS. We have the largest transport database in the country and we have the ability to look at these claims.</p> <p>We can now see patterns. We can see where people are moving back and forth and using technology, helping AI to leverage surfacing very quickly who are the cases that we really ought to be paying attention to. Who are those members that health plans should be paying attention to because they may be on the verge of a really bad medical episode. So, what is that what's on the front here?</p> <p>Like, what is the next kind of technology that that you are really excited about that we should we should get excited about? Go ahead, Ken. We have over 100 million live worth of transport data. And we're analyzing that all the time and we're using these tools to say, what happens to these patients before and after the transport? I'll tell you something that's really interesting statistically.</p> <p>This will be a good example is and there are some published studies, but we've validated this with plans that we support. More than 50% of the time when a patient is is moved emergently by rotor, they are discharged on the same day often without any significant clinical interventions. Getting this right on the front end saves the patient more than just money. It saves them you know, time not well spent.</p> <p>And it's also important that I think where this is really going is as you think about the patient's care journey, how transport can help make the whole care journey better and more effective because the after you know, where they end up for care makes sense in terms of that patient's family and logistics, etc. And lowers the cost of care for the whole episode of care. And for the society as well.</p> <p>Absolutely, because we're all paying for the cost of cost of I think what's I think what's you know, when you think about that Cole, what's it really exciting for me is how do we take all this disparate data that exists and actually help leverage pop health platforms? How do we take this &gt;&gt; unseen liability we keep calling it. This is just data that's sat somewhere. How do we enable that and actually help payers do something with it?</p> <p>So, you know, can we actually get to true interoperability where hospitals and transport providers, ambulance providers all have an integrated data set that then can feed into payers so that the most vulnerable uh members can get identified early. We can work with there are, you know, non-emergent transport providers that that we work with today, folks like like Medi Drive. We work with others in the space like a like a Right Site Onsite in the patient home.</p> <p>There are niche players that we have an ability to help string through a true interop interoperability so that a member, and this happens in our data set now, we identify a patient who's been transported 47 times to the emergency department. And why is that? It's because either they don't have access to transportation, they don't have a primary care physician, and they know the only way they're going to get treated quickly is in the through an ambulance in the emergency room.</p> <p>But more importantly, they're they're they're lost in the system. Can we get a case manager assigned? Can we schedule transports for that member? And that can all be done with interoperable systems that put the patient at the center and surround them with support services. That technology is not far off, the ability to do that. It's just Alacura in the middle helping to bring the parties together. It's we're much more than, you know, just looking at a pre-service notification of of a transport.</p> <p>We really are bringing the integration and the management of transport into the ecosystem for the for the patient. One transport system versus multiple disparate systems working against each other. The goal is to the the Medicare stars and customer experience situations that I had seen at Jefferson Health Plans where, you know, Jefferson Health Plans competed by taking some of the sicker patients, especially patients, you know, who had a lot of social determinants of health issues, right?</p> <p>They were patients who maybe had poverty issues or lower levels of education. And one of the issues they dealt with was this transportation. It wasn't a satisfactory experience and they complained about transportation a lot. Have you seen by working with system or with plans that they've reported better satisfaction from their patients? We have a lot of interaction directly with the patient or with their family. Right?</p> <p>So, one of the key things is you don't just put someone on on an ambulance and they go and that's the end of the story. You really you need to talk with them when they're at the sending facility and also ensure that it gets finished on the other end when they get to the receiving facility. And so, we're regularly talking to patients and telling them what their options are and making sure that they know someone's there overseeing this process end to end. And I think that's a really important part.</p> <p>Actually, my very favorite thing since being at Alacura is the letters we get from families who say, you know, "We just had mom that had to be trans- transferred by helicopter, and Alacura made it easy for us to know where that was, know what our options were, know what was going to get paid for." It takes a lot off of their minds when we're able to do that.</p> <p>So, my very favorite thing has been seeing the letters when we get those in saying "that our nurse was so helpful in helping them understand and see through that process and making it simple and easy." I think it's early to to identify, you know, working with our payer partners to understand I I think we see a lot of directional data. And again, to Ken's point, our patient satisfaction surveys are extremely high, 95 plus percent, and and we are confident.</p> <p>I mean, we're a fully delegated, we're NCQA, URAC certified. So, we are the face of the payer when it comes to these clinical decisions. We are really focused on really enhancing the payer's experience for the patient and the member. We want to be the that intermediary that makes it all work, and then really helps the patient get to the next level. We think that will come, you know, but this is this is behavior change.</p> <p>And, you know, whenever you move the cheese in the health care ecosystem, you know, there are folks that, you know, really like what they're doing and want to keep doing it. And when we talked about all of the revenue that's at stake here, it creates a lot of pressure.</p> <p>And so, for us, it's really important that we stay focused on what we're doing and doing it well, that we make sure that payers understand this, that they brief their regulatory partners regularly, because, you know, there certainly are a lot of folks in the industry that really don't want to engage with a third party or don't feel that Alcura really has a place at the table to do the work that we're doing. And that's because we're enacting real behavior change.</p> <p>And so whenever you do that, you're going to meet resistance. And we are happy to be at the table. We partner with everybody we meet with providers in addition to payers. So we're excited for where this is going. And really it's the data that will lead us to be in the place we need to be on behalf of the patient. And that makes sense, of course, cuz stars data is like very laggy and and not clear.</p> <p>But those letters, I think, in the directional signals, I I would say that's a pretty good indication. At least for my short experience working in stars. But you said something interesting there that I want to ask about, and it'll be my last question. It People are are tired, I would say, of vendors. And you got you have all made a distinction that you like to be a partners. You don't you don't look at yourselves like a SaaS company just selling but your partners.</p> <p>But still, you pointed out there, people they don't really like change and they're really tired of working with partners and working with vendors. A lot of people are saying, "I'm just going to bring it in-house, you know. I'm going to handle it myself. I already have clinicians. I already have a prior off team. I I got all these people. Let me just add the staff. Why can't they do that?" So I think it's it's a really clear reason.</p> <p>And and I would know this, you know, having run some of these systems at a large, you know, payer in a prior life. Which is if you think about the the cost of medical transport. And I'm not including NMT here. I'm I'm really talking about ambulance transport. Generally speaking, that's going to be and I'm air and ground together, probably about $3.50 PMPM. Right? And a plan typically spends about you know, between 300 and 400 p m p m right, for every every member they're spending that on.</p> <p>So, this is about 1% of their total costs. So, they can't say, "Oh, we're going to have all emergency medicine nurses, you know, available to do this who are familiar with transport." They just can't do it. It's It's we're specialized and we focus on that 1% and nothing but that, you know. And I see with CMS, you know, &gt;&gt; Well, and and Paul, what did we say? When do these cases happen? And I would say, really the conversation stops there.</p> <p>You know, when I was at the health plan, really specialty drugs were up and coming. They were really were low volume but big dollars and we saw the year-over-year trend growing. The same corollary here in the medical transportation side. We're start We see huge dollars. The trends are now becoming more visible to the payers and and that's why there is this urgent need now. But the health plans do not have the specialized expertise that we do to solve for that case in the middle of the night.</p> <p>And we we have that conversation and the plans quickly figure out that although there is a vendor fatigue and the ability to really cut back on all of the outsourced services, they really need to This is large dollar claim opportunities that they need to look at that really has the potential to impact a patient their health. So, they're more likely to want to work with a specialized partner like Alacura and and frankly, that is where we expect most plans to be over the next several years.</p> <p>And I actually do really agree with partnering with Instat and it really is that clinician piece of it, right? I think it's really important that clinicians talk to clinicians that are trained in the same area. So, I think that's that's really awesome. Before we conclude, if we were to have you on the podcast again a year from now, where do you think you guys are are going to be at? What what kind of growth are you looking at?</p> <p>As the growth officer, I could say we're pretty excited and even in you know, in the time that I've been at Allcura over the last year and a half, we've really seen significant growth in our pipeline both of you know, our hard work but but also plans understanding that there's an opportunity in a post acute care environment that this is something they really need to pay attention to. So, we are really excited for the pipeline we have and the pipeline that we're growing.</p> <p>And so, in a year from now, we will have launched a series of clients. We will expand our footprint. We have a national footprint now and I think we will be fully penetrated into most of the plans that are available in our space and we will be at that point sitting on some pretty significant outcomes that we will be excited to share with you in a future podcast. And let me add one thing to what Steve said. I ultimately believe this is a space where no-one is going to end up doing it internally.</p> <p>Right? It's we've got to get to a platform-based system that serves all the constituencies here. Mhm. It serves the hospitals, it serves the plans and it serves the providers that move And what we're going to get to, I think, is where you know, there's one system for that. So, that's the long-term goal. Impressive. We have both the the bold long ultra kind of not ultra long-term, but longer term. Not that long-term. It's just not a year. I mean, we're going to hold you to it.</p> <p>I'm going to I'm going to you know, really come come knocking a year and then a year after that and I did the same thing with with Health Map and some of our previous people. I like to keep track and it's it's definitely a time of technological change, but I I think it's it's impressive that you both are willing to set your goals out on the public like this on the podcast. So, thank you Ken and Steve for both coming on. Really enjoyed meeting you both and and speaking with you.</p>