Helping Underserved Patients Get the Quality Specialty Care They Need
Episode 494

Daren Anderson, Director at ConferMED

Helping Underserved Patients Get the Quality Specialty Care They Need

Leveraging telehealth to provide better access to specialists

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Helping Underserved Patients Get the Quality Specialty Care They Need

Episode 494

Recommended Book:

Moby Dick

Best Way to Contact Daren:

daren@ConferMed.com

Company Website:

ConferMED

Helping Underserved Patients Get the Quality Specialty Care They Need with Daren Anderson, Director at ConferMED transcript powered by Sonix—the best automated transcription service in 2020. Easily convert your audio to text with Sonix.

Helping Underserved Patients Get the Quality Specialty Care They Need with Daren Anderson, Director at ConferMED was automatically transcribed by Sonix with the latest audio-to-text algorithms. This transcript may contain errors. Sonix is the best way to convert your audio to text. Our automated transcription algorithms works with many of the popular audio file formats.

Welcome to the Outcomes Rocket podcast, where we inspire collaborative thinking, improved outcomes and business success with today’s most successful and inspiring health care leaders and influencers. And now your host, Saul Marquez.

Saul Marquez:
Welcome back to the podcast. Saul Marquez here, and today I have the privilege of hosting Dr. Daren Anderson. He’s a director of ConferMed. Daren is a board certified general internist and has worked in safety net practices for his entire career. He’s published articles in several peer reviewed medical journals, including Health Affairs, The American Journal of Medek, Managed Care, The Journal of Family Practice and the Journal of General Internal Medicine. Dr. Anderson obtained his undergraduate degree at Harvard College and his medical degree from Columbia University College of Physicians and Surgeons. He’s an outstanding contributor to the telehealth space. We’ve got a lot of things going on right now. value-based care is one of those things. How do we deliver better on our health care dollar? Coronavirus is something that’s very live and a concern for many of our provider organizations and communities. And so today we’re going to touch on several of those things with Daren and also to learn more about what he and his company are doing to add value to health care. So Dr. Anderson, really appreciate you jumping on to join us today.

Daren Anderson:
Oh, thank you. I really appreciate the chance to talk with you and share some of the work you’ve been doing with your audience. Thanks a lot for the opportunity.

Saul Marquez:
Absolutely. So tell us a little bit more about your journey and what inspired your work and health care and in particular, your focus on safety net practices?

Daren Anderson:
Well, my journey really started back in college when I was trying to figure out what I wanted to do with my life and I’ll give the short version. But I became really inspired by some works that I was reading by various authors talking about underserved patients and their efforts to try to provide health care in safety net practices. And I kind of decided early on that I wanted to start a career that would allow me to work in a medical capacity in the safety net. So I really went through my training with that as a goal and after med school did an internal medicine residency training and then went right into the National Health Service Corps where I was assigned to practice in New Britain, Connecticut Community Health Center. And that’s how I ended up in Connecticut, which is where I live through this day. And, you know, I started off working full time as a primary care doctor, taking care of an inter-city population with a lot of a lot of complex problems. Most of my patients spoke Spanish and I think early on, even in my first year of practice, I absolutely love taking care of patients. But I was so struck, you know, even, even having gone in knowing a little bit about what was going on in safety net practice, I was struck by how inequitable the system was. And, you know, health care inequality is something that just greets you the minute you walk into an exam room and realize the opportunities that you may have or I may have with private insurance and the opportunities that patients who have no insurance or perhaps Medicaid insurance don’t have. And so sort of started charting a career at that point that took me more into the administrative and the research side of things, looking to try to derive solutions to help reduce health inequality and make sure that patients, regardless of where they were born, what language they spoke or what insurance they did or didn’t have. Finding ways to make sure that they got the best quality health care that we can provide in the US.

Saul Marquez:
Well, I think that’s that’s wonderful, Daren. And, you know, as we as we consider the topic of access and the challenges that surround that, social determinants of health, much of which we’re tackling, I think more seriously today and health care. I think that this is a great opportunity for for us to dive in a little bit deeper on what you’re doing at ConferMed. Tell us what it is that you guys are doing there to add value to the health care ecosystem.

Daren Anderson:
You know, so one of the most striking and obvious disparities when you start practicing in federally qualified health center, a community health center is when you need to send a patient to see a specialist. So many you may know and your audience may know that there is a network of over twelve hundred community health centers across the country. They’re called federally qualified health centers, but they are independent non-profit health centers that are run by a board of directors that’s majority controlled by patients. And these clinics have been around for decades and really developing a strong, effective primary care infrastructure. They were among the earliest to adopt the H.R. as the health center that I worked at has kiosk check in integrated behavioral health. Many of the things that you would expect to see in the best primary care clinic you could envision what it all comes to a screeching halt when you refer somebody or need to refer somebody out to a specialist. In back in 2012 when we first got the idea for what eventually became conferMed, my clinic was facing a nine to twelve month wait minimum to get one of our Medicaid patients in to be seen by an orthopedist or a dermatologist. And pretty much all of the special things had at least some degree of a delay. And this presents a real challenge for the primary care provider. You may have a pretty good idea of what we mean you need to do, but you may not be sure. You may need surgery. You may need a biopsy or procedure. But in any case, the only way to get answers to your questions or get a patient to have the procedure they need is to refer them into a specialty center. And no, unfortunately, uninsured patients and even those with Medicaid have great difficulty finding specialty care, because the simple fact is reimbursement rates are relatively low and many, most specialists, in fact, limit or completely don’t accept that all patients without insurance or Medicaid. And so that presents a really substantial challenge to us. And that was that that was the issue that we sought to address with infirmities.

Saul Marquez:
And that’s a that’s great. So it comes from a frustration that you had in your own practice and your patients not being able to get the care that they needed. I mean, nine to 12 month wait is is really not acceptable. And so you dove in, you rolled up your sleeves. Tell us what confirm it does today. That’s different than what’s available today to to solve on that specialist problem.

Daren Anderson:
So I think we tested that the process that ultimately became ConferMed. It was designed and tested by me and my my team of primary care providers and nurses and referral coordinators. And basically what ConferMed does is it allows the primary care provider to confer with a specialist virtually before they refer. And now it’s an asynchronous conferring, if you will. So it essentially it allows the primary care provider to send their question and some of the details about the case from the medical record to a special instance, they can get eyes on that consult question rapidly and in no more than two days that most of our specialists respond within the same day. 77% percent responded on the same day the question was submitted. And they’re able to put eyes on that consult, review the information that we submit and send back to that primary care provider, advice and guidance. So basically what we are is a virtual network of specialists around the country that are on standby, ready to answer questions and take a first look at all of the consult requests that the primary care providers have in pretty much any specialty. And as we’ve built out that network and developed the really the understanding state by state of all the different types of payment environments, all the different types of practices, we continue to see that a substantial percentage of the cases that get submitted to us in most specialties, upwards of 80 percent don’t need a face to face visit. It’s not because it’s an inappropriate consult to the PCV made a mistake. It’s simply because the nature of what the primary care provider is asking, the question that they have is one that is special. It’s getting answered by seeing their question, reviewing the data and sending back an opinion. And so what that does is it makes the system more efficient. It allows those cases that can be maintained and managed in primary care to stay in primary care. It allows those scarce resources that face to face visits to be allocated to patients who really need a procedure or hands on for some reason or another. And that’s basically we met all of that out and did a series of studies in Connecticut, in our health center to prove that it works and that it was safe and we’ll confirm it has done is take that concept to scale. And we’re now providing that service to over 1.3 million patients across the country.

Saul Marquez:
That’s fantastic. Congratulations on the scaling of it to the point you’ve gotten thus far. Dr. Anderson. And, you know, thinking through the efficiency that this provides much of what we need and health care is is the logistics and the efficiency and. And so you’ve created a nice fast lane to provide the care that’s needed. And if 80 percent don’t need that face to face visit. And I think that’s a great solution. So what’s the cost then? If somebody if a specialist is giving you their idea or their analysis of this, of the patient, what’s the cost?

Daren Anderson:
So the cost is way less than the cost of that specialist in their time and their overhead for seeing the patient face to face meeting. Think about it. We batch these there in an inbox and the specialists can review them. Imaging patients are in the evening and rattle off a significant number of them one after the other. Most e-consult responses take 10 minutes. There’s a range and we have we have some 50 minutes. But our average is 10 to 15 minutes. But if you think about it, all they need is a laptop or an iPad or whatever to do that. There’s no office costs. There’s no check in medical assist in any of the overhead costs that the specialty office has. So the trick, though, is so that the specialist obviously gets reimbursed. And we pay our specialist on a per consult basis and we have some degree of infrastructure and overhead ourselves, but it’s substantially more efficient. As you alluded to then, all of the inefficiency that goes into not only the cost of the specialist in their office, but if you think about it, when you send a patient to per face to face visit, many times they’re exposed to a co-pay. Many times they have to take some time off from work. They have to travel. They have to go to the specialty office. Often when they get there, there’s additional information the specialists need. So they get sent for testing procedures. They have to come back. So, you know, there’s a whole cascade of events that follow either the request for face to face referral that are known that that are no longer needed. When you can bypass that system for a significant percentage of your consults.

Saul Marquez:
Love it. Yeah. No, the savings you guys would have to connect with Darren to find out more about that. But I mean, the reality is beyond the line item cost of seeing the specialists. It’s everything around seeing that specialist canceling, not showing up, the wait times. And so the efficiency play here is between specialists and primary care providers. Love that you guys are focused there. What would you say is an example of how you guys have have improved outcomes or made business better?

Daren Anderson:
So before there was a ConferMed, we actually here in Connecticut at the health centers set up a randomized controlled trial. We partnered with the University of Connecticut and with our state Medicaid Department so that we could get good, solid outcomes before we weren’t at that point even envisioning any company like ConferMed. And we’ve published a series of now five different papers, all from from a variety of different aspects of that study. But they all have essentially built on the same story that when you keep, When you get primary care providers and patients in answer to the question or get the clinic, the process started that a whole series of positive things happened from a clinical and financial standpoint. I like to say we started off trying to solve an access issue in our first paper, basically showed that when you implement consults you make you get treatment in place much more rapidly. The second thing it showed, though, is that when you do that, the patients who had access to console’s had fewer emergency room visits. So we already got a sense that we were getting treatment in place or providing reassurance that meant the patients didn’t bypass the system and go to the E.R.. From a clinical perspective, the impact is substantial. In the second study that we did on dermatology showed that 80 percent of the patients or more than we were sending to a dermatologist to have their rash or their potential melanoma evaluated, never got seen at all. And whereas with e-consults, we were able to get a dermatologist looking at that rash and no more than two days. So, you know, each specialty different.

Saul Marquez:
Digitally?

Daren Anderson:
Sorry?

Saul Marquez:
Were they able to look at it through technology or live in the office?

Daren Anderson:
Yes, absolutely. They’re able to look at it. So we what we do is we we send an images, pictures. So.

Saul Marquez:
Got it. Got it.

Daren Anderson:
In the dermatology case. And that’s sometimes the easiest sort of example for how he consults work.

Saul Marquez:
For sure. No, that’s wonderful.

Daren Anderson:
And if I could just pick up on your questions, the financials and what we found. Like I said, we started off trying to solve an access issue. And what we ultimately found was that in addition to improving access for safety net, we were having a significant impact on the bottom line. The first study that we did showed that on an average patients we’re saving five hundred dollar system was saving $500 per consult. When we did e-consult for cardiology, we followed that up with a larger study that was in health affairs that showed it equated to approximately 80 dollars per member per month in savings for just four main specialties. So what they showed is really important, though the savings does not simply come from preventing an unnecessary individual face, face to face visit. The savings comes from all of the downstream costs that tend to occur when you send someone into the specialty tests, procedures, follow up visits, expensive pharmaceuticals, things like that. And so what’s changed in our business model has, as our business has benefited from this, as the health system is moving towards advanced payment models. We have at least part of a solution for the primary care practice that’s looking to take advantage of value based care and shared savings, because our tool gives them the ability to decrease costs from one of the most expensive things that you do in primary care, which is send patients into specialists.

Saul Marquez:
Yeah, I think that’s speaks volumes to be able to avoid those downstream costs. And even taking a look at at something so specialized as like understanding what the coronavirus is, right.. I mean, somebody shows up to the hospital. How do you guys work with that? Give me some thoughts around this thing that we’re dealing with.

Saul Marquez:
Yeah, I think telehealth platform like this. The best thing about a system like this is it’s scalable because of the fact that it’s not lives and it’s not a specialist on one and talking to a patient on the other. We can scale this much more rapidly. We already have thousands, tens of thousands of primary care providers out on the front lines seeing patients every day. And we already know from what we’re seeing, starting to have questions about cases, you know. Should I send this patient to home isolation? Does this need a corona virus test? All these basic questions. This this public health crisis is presenting us with a real challenge in that it’s the frontline primary care practices that are going to be on the front lines, seeing the cases and what the platform wants. Something like any console allows you to do as quickly get answers to your questions back from a special if you need guidance. And we’ve actually just before talking with you, is it really a planning meeting with our team, gearing up for what we expect to be a significant increase in questions to our infectious disease specialists. And we’ve already seen some hints of this, it’s not even always questions about a specific patient. Those basic questions about infection control. What should my telephone protocol be? How is if a patient calls in, they’re coughing? Should I tell them to come in or what should how should I handle that situation? So we’ve actually been building capacity to not only provide clinical advice from a specialist, but really infection control device advice, operational advice on how to handle your telephone system and things like that. So it really just demonstrates there’s a real need across the country and practices for advice and expertise on a wide range of topics. Unfortunately, you know, coronaviruses presented us with a unique challenge that really needs to we need to be able to gear up quickly to address it.

Saul Marquez:
Yeah, I think that’s that’s fascinating. And you guys are providing some great solutions for for what’s happening right now. So big kudos to you and your team. Dr. Anderson. And you know, a lot of what’s still happening out there is still fee for service. So, you know, one of the things that that goes through skeptical minds maybe listening to this is, well, if you’re reducing my specialist visits, then my overall revenue goes down as a provider organization. Who are you targeting this toward? Is it employers? Is it is it or is that skepticism not real? Like, I would love to hear your thoughts on some of that.

Daren Anderson:
Yeah, I think that’s a great question. And the answer varies state by state and even model by payment model. And it’s been we’ve had a fascinating tutorial in all the ins and outs and all the details of advance payment models and the way they’re evolving. So I think, you know, straight out of fee for service model, the payment. And so our very first contracts were with large commercial payers that reimbursed us and continue to reimburse us directly for e-consults. And since, you know, they’re fully at risk, they’re paying a fee for service reimbursement for every specialty care visit, they reap the benefits and they are the ones that reimburse us. So in that kind of a scenario, I think we probably are somewhat of a threat to a hospital system or a specialist who is doing procedures. In a candid moment, I’ve had specialists tell me we don’t want to reduce the number of patients coming to see us. We want to hire more staff and build out our team. So in that one scenario, I think that probably is the one sort of group or stakeholder for whom doing something like this is a threat. But what’s changing rapidly is that as our health system aligns around accountable care, as we implement more value based reimbursement models, shared savings, full capitation, those concerns are less. And when you align health care providers and practices around the total cost of care, something like this becomes a no brainer in that we are spending money more wisely and saving it where we can and really strengthening the primary care infrastructure and making the system work more efficiently. And so when you know, when the total cost of care is what we care about, this is kind of a no brainer.

Saul Marquez:
I totally agree with you, Darren. And I just wanted to go there because it’s the reality, right. And that one silo of many that exist on our health care economy. But it’s a great perspective that you’ve given us. But also, there’s another angle to it. Right. I mean, as a provider organization, you got to think about I mean, these patients are waiting nine to 12 months. Why? And that’s because you’re not doing it right. So Darren and team have a model where you could also help a broader part of the community that’s currently not getting that help that you need. And these folks are going to end up in your E.R. anyway. So some fascinating models coming up here, there. And I love I love what you and your team have created. Obviously, it hasn’t always worked. And it was a process at one point, as you as you mentioned. Tell me maybe one of the setbacks you guys have had and one of the key learnings that’s come out of that setback?

Daren Anderson:
I think our biggest setbacks have occurred when for whatever reason, we haven’t had the buy in of the front line providers. And it kind of alludes to what we were just talking about. Most primary care providers are still in a fee for service mindset, even if their health system that they’re a part of is moving towards value based care. On the front lines of primary care, we haven’t seen a lot of evidence that that has really trickled down into change in behaviors. So many providers. But sometimes when we go into a practice without really exploring this and really working with our primary care providers to help them understand what we’re doing and what the benefits are, not only to the system and to cost, but more importantly to their patients and how it improves patient experience. We are always welcomed with open arms. And so we’ve had a couple of really cases where we thought we could just kind of make this happen administratively. You know, the medical director is in favor of we’ll make it automatic and the provider, it will just happen. And you know, what we’ve learned is that, you know, health care is personal. It is between a patient and a provider in your primary care provider. And I’m one of them obviously needs to be onboard, needs to be part of the planning and needs to have an active role in wanting to make this work. So we’ve actually built a whole company around the principle of engaging our primary care providers and their staff on the front lines to not present them with a tan solution for how to make this work, but actually how to design a workflow that supports them, that makes it not more work, but actually makes it less work for them. And fortunately and unfortunately, that takes a lot of work. And so we’ve actually invested a lot on conferred with ConferMed on the ground team that an implementation team that really works individually one on one with each practice to map out what they do and make it as easy as possible for them. And if you don’t do that, you’ll have a great system that nobody uses. That’s happened a lot with telehealth in the past. So because our company is staffed with primary care people who do this for a living and have done it before on the front lines, I think that’s been our philosophy. And I think it’s led to our success over the last several years.

Saul Marquez:
What a great perspective there. Dr. Anderson, who wants a great system that nobody uses. I think the answer is cleared for all of us. So let’s take the other side of the table on that one. Employers talk about incredible value to somebody that is self-insured paying for these visits. Can you talk to how employers are benefiting from this?

Daren Anderson:
Yeah, I think, you know, if you look at all the various stakeholders that are involved in the whole health care scene, from the patient to the primary care practice, the health system, the hospital, the payer of the employer, I think the employer potentially is the one that will most want this and drives uptake and utilization because you as you alluded to, the employer is ultimately paying the bill. And I know from our own company that the cost continues to go up. And we are becoming increasingly desperate for ways to stop it from going up or at least reduce the amount that’s going up. So I think employers ultimately are the most, I guess the group of the stakeholder, if you will, that is most likely to support and want to get access to counsel. And I think we’re starting now to see a move. Our art, we’re very much a mission driven organization that has focused on homeless shelters, migrant clinician, farm worker clinics, federally qualified health centers. But we are increasingly seeing demand from commercial private practices, commercial payers, and are moving into that space, because even if you don’t have a nine month wait, even if you have a dermatologist or a cardiologist right up the street can see you next week. That’s still not the most efficient way to get the care that you need. And so employers are starting to see that. And a lot of our efforts now are focused on translating what we’ve learned in the safety net and making it acceptable and as effective in that commercial environment where I think payment reform is moving a little bit more rapidly. So and employers are leading that charge.

Saul Marquez:
Yeah, that’s. I’ll tell you, it is an incredible opportunity because that line item of health care continues to go up and the value for the health care dollar is not there. So if you’re an employer listening to this, this is a fantastic opportunity for you to gut check. Some of the things that you have going on the website is ConferMed.com. And even as a pair. Right, Right., if you haven’t heard of this, an opportunity for you to start looking at ways to add value to the lives that you cover, but also start limiting the waste that’s happening. What are you most excited about today, Daryn?

Daren Anderson:
Well, I’m not going to say Coronavirus because that’s not the topicin any of us where we will deal with. We’re excited that we’re able to help.

Saul Marquez:
Absolutely.

Daren Anderson:
Actually, one of our infectious disease specialists who works for ConferMed. I brought him into our we have a production studio here in Connecticut and we actually did a live video session with him and several of our other staff. And we just opened up the video conference lines to practices all over the country. And we only had three days to turn this around. And we had over a thousand people sign up to participate. And they were sending questions directly in by video chat using Zoom, the same platform we’re on today. And we just got a sense for just how much of a need there was for this and how much you could do with a scalable platform. So I’m excited that there is an opportunity now to deal with this epidemic different from the way we dealt with epidemics and anthrax and the H1N1 in the past where we didn’t have platforms like this. So it gives me a glimmer of hope that, you know, nothing any of us want corona virus, but that by connecting ourselves in different ways, using simple scalable technology, we can tackle the challenges of the future in a different way than we did in the past.

Saul Marquez:
I think that’s great. And, you know, it’s a testament to the work that you guys are doing, having this type of traction for a platform and a process that you guys have established. I mean, it’s adding a lot of value. So congratulations on being able to get it this far. And it’s exciting to think about where it’s it’s heading in the future. What would you say as is your is your favorite book, Daryn?

Daren Anderson:
So that’s an easy question for me, because it’s a book that I read in college and it’s right around the time that I was going through this sort of crisis. What am I going to do with my life? And it’s Moby Dick by Herman Melville. Yeah, I read it several times and continues to be absolutely my top favorite book of all time.

Saul Marquez:
It’s a pretty dense one. It’s it’s thick Right.. It’s a it’s a big book.

Daren Anderson:
Yeah, it is.

Saul Marquez:
What’s your main takeaway? What why do you keep going to it?

Daren Anderson:
Well, the less deep reason is I love the sea. I’m from the Northeast. The book is obviously said out of out of Nantucket in books about boats and sailing. But the deeper reason is to me, I think the book represents the intense struggle between good and evil, the struggle of, you know, its flawed character who has this unbelievably crushing weight on his back and sort of watching how that plays out. I like I like dark stories. I still identify with that with Ahab. But I love watching the way Melville describes his becoming totally consumed by this. You know what the white whale represents and sort of see how that plays out. And I love the interplay between the narrator Ishmail in Ahab in the boat. And it just. And I love the language and the way Melville writes. So lots of things about it. I could talk all day about it, but that’s another podcast, maybe.

Saul Marquez:
That’s right. That’s right. We’ll save up for part two listeners. We’ll dive deeper into into Moby Dick. But it’s fascinating. Thanks for that background. I mean, it definitely is a very interesting book. Great reasons to like it. And so as we get to the end of this, folks, you know where to go, outcomesrocket.health and the search bar type in ConferMed, that’s C O N F E R M E D or just go to ConferMed.com and find out more. But Darren, I’d love if you could just leave us with a closing thought. And then the best place for the listeners could get in touch with you to continue the conversation.

Daren Anderson:
So let me let my closing thought is I’m going to tell a very brief story. My son, he’s now in college. But when we first started doing ConferMed, I would drive him to school. And I always like to ask a little bit about what I do with for a job. And I remember telling him I have this really cool new thing. We started this company called ConferMed and I explained what we do, primary care providers. It’s a question. Specialists can answer it. And he looked at me and he said, Dad, that’s just e-mail. So then I said, yeah, but I have this and we have an app. And, you know, you can take a picture of a rash. And because as a patient, you can’t save that because it’s protected health information. And so as soon as the picture is taken, the picture disappears off your phone. And then we submit it to a specialist. And he said, Dad, that’s Snapchat. And so it made me realize that what we’re doing with e-consults is unbelievably simple. We’re allowing a primary care provider to communicate quickly, using a simple technology with specialist about the case. And the specialist is able to help give them guidance on the best and most efficient way to take care of it. The only thing complicated about this whole scenario is the health care system that we’ve built in this country and around in and around the world, but in particular in this country with, you know, who pays for it and it costs me money or saved me money. This is common sense. And so the complexity that we’ve been gradually unraveling is figuring out how to make common sense, easy to implement. And unfortunately, in health care, there isn’t too much common sense when it comes to things like this. And so that’s what we’ve been doing. And I think we’ve starting to really with value-based care, unravel that complexity and make doing something simple and obvious the right thing to do and the best thing to do the system as well. So I’ll leave you with that little anecdote.

Saul Marquez:
I love that story. Dr. Anderson. And you know, one of my favorite quotes is the only thing stronger than all the armies in the world is the right idea. That has come at the right time. And I think today is the right time for these types of solutions. And it’s super exciting to hear your story, to better understand the value that you’re adding to the ecosystem, which is huge. And I’m really excited to see where where this goes for you here in the next few years. So really appreciate you jumping on with us today, Daryn, and looking forward to staying in touch.

Daren Anderson:
Saul thank you so much. I really appreciate it. And my email is Daren daren@ConferMed.com. You had asked about that before so.

Saul Marquez:
Thanks for thanks for throwing that in there. I appreciate you doing that. So, folks, they have it. You have Dr. Anderson’s email, daren@confermed.com. We’ll also include that in the show notes. But get in touch. It’s a great opportunity Daren, thanks again.

Daren Anderson:
Thank you. Bye.

Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.com for the show notes, resources, inspiration and so much more.

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