Since 2005, the Milliman Medical Index (MMI) has estimated annual healthcare costs for people covered by a typical employer-sponsored health plan. To mark the 20th anniversary of the report, MMI authors past and present gathered to discuss how healthcare has changed over the past two decades. They reviewed the impact of the Affordable Care Act and the COVID-19 pandemic, the rise in drug advertising and outpatient care, and how trends might change again in the next 20 years.
Transcript
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Jeremy Engdahl-Johnson: Hello and welcome to Critical Point, brought to you by Milliman. I’m Jeremy Engdahl-Johnson, and I'll be your host today.
So the Milliman Medical Index (MMI) turns 20 this year, and it provides a unique lens to look at how healthcare costs have changed over the past two decades. For this episode of Critical Point, we brought together current and retired Milliman colleagues who oversaw the MMI over the past 20 years. We're going to be chatting about the origin story of the report, about trends and major healthcare milestones, and about what we think the next 20 years could look like.
We've assembled this prestigious cast of actuaries and authors. First joining me today is Bill Thompson, founding author of the MMI. Great to have you with us, Bill.
Bill Thompson: Good to see you, Jeremy, and thanks for testing my memory from 20 years ago.
Jeremy Engdahl-Johnson: We know you still got all of those details down. We are also joined by Chris Girod, who headed the publication from 2011 to 2020. Thanks for joining us, Chris.
Chris Girod: Hey Jeremy, thanks for having me here. It's great to be here.
Jeremy Engdahl-Johnson: Good to see you. And last, but not least, we have Dave Liner, who is the current lead author on the publication. Thanks for being here, Dave.
Dave Liner: Thanks, Jeremy. Great to be here.
Jeremy Engdahl-Johnson: All right. We're going to go ahead and dive in, and I'm not promising a full chronological progression, but we are going to start with the beginning. The MMI first launched in 2005. Bill, can you tell us a little bit about the origin story, and how the idea for the report came about?
What’s the history of the Milliman Medical Index?
Bill Thompson: I'll do the best I can with that, Jeremy. Back in 2005, what was important was healthcare costs, not a surprise, and there was a lot of different studies, some looking at the Medicare population, some looking at employee populations, some looking at individual, and typically looking at components. Nothing that really pulled everything together. And we came up with the idea of what about an index that really looks at the total cost of healthcare for a typical family that's covered by group insurance? Not only how much does the employer pay? How much does the employee pay? What is driving the costs? What are the components of costs? And we came up with the idea of creating that index, which now is the Milliman Medical Index.
And we also were looking at showcasing some of Milliman's expertise, and behind that is Milliman’s Health Cost Guidelines, which has been used as an industry standard for many years, looking at healthcare costs as being a foundation for that. So those are some of the components that we came up with.
How is the Milliman Medical Index calculated?
Bill Thompson: And we built the initial MMI in 2005 based on what we came up with as a “typical American family of four.” So getting into my actuarial hat for a moment, using the Health Cost Guidelines it was an average demographic factor of 1.0. So it was 4.0 for the family of four and an average nationwide geographic factor. We didn't get into different geographic costs at that point. And then looking at the components of care as developed in the guidelines, and then to get into plan designs and typical provider discounts and negotiations and things relied on surveys like the Kaiser Family Foundation survey and other things to give us sources to come up with how to split things into employer share, employee share, things like that. And that was really the genesis for the initial work on it, and came up with the 2005 Milliman Medical Index that then was promoted around and got a fair amount of receptivity.
What drove healthcare spending in 2005?
Jeremy Engdahl-Johnson: Well, thanks for the origin story. I'd like to situate that a little bit in terms of the industry at that time, and maybe talk a little bit about the stakes. What were some of the pressing issues for healthcare costs in 2005? And Bill, what were you grappling with as you wrote the inaugural report?
Bill Thompson: Well, not a surprise, healthcare costs were growing faster than the general economy and general inflation. Pharmacy was becoming a bigger and bigger part of things. At the time we were looking at, 2005, there was the initial work going around to create this thing in the Medicare world called Medicare Part D, which is the pharmacy plan, because at that point Medicare didn't even cover drugs. So pharmacy was becoming a bit bigger there.
You remember that it was in the late 20th century, 1997 I think it was, when direct-to-consumer advertising of pharmacy came into play, and we started to see a lot more interest in pharmaceuticals and patient demand of their doctors as opposed to being just taking whatever the doctor said because the ads were talking about things, and we're seeing pharmacy growing. So that became a bigger part of things at that time.
One aside: I believe in the 2005 MMI we didn't make any adjustment for pharmacy rebates, yet that was a growing type of thing that has gotten picked up and become a factor later on in things.
And then, just in general, medicine was not as corporate as it is today. But it was becoming more and more organized at the provider level, hospital level, and becoming more of an issue with provider contracting and things like that, which was affecting all other components of the healthcare dollar.
Jeremy Engdahl-Johnson: Chris, I'm curious if you have anything to add. I know you weren't an author on the initial publication, but you were certainly actively consulting to clients at that point.
Chris Girod: Yeah. Well, that was the genesis for the Milliman Medical Index, too, was the healthcare cost trends—so the year-over-year change in costs—were very, very high back then. You know, 10% was not uncommon. And so when I joined the MMI committee in 2010, even then trends were still running about 8%. And so there was a lot to talk about back in those days. Things have gotten different since then, and we can talk about that. But that was the story of the day, I think, was just very high costs, and those annual increases going up.
How the Affordable Care Act affected the employer market
Jeremy Engdahl-Johnson: Well, let's talk more about that era when you were involved and leading the effort. I mean, what were some of the big healthcare stories, starting in 2011? Nothing going on in healthcare at that period of time, right?
Chris Girod: [Laughs.] Right? So in 2010, as we all know, the Affordable Care Act (ACA) was passed, and that was huge and it impacted different markets in different ways. So the MMI, the Milliman Medical Index, talks about the employer market, which covers about half the people in the country. So it's big. But the MMI doesn't cover the other markets—Medicare, Medicaid, the individual insurance market—and that's where the Affordable Care Act had the greatest impact.
So the health insurance exchanges, which were instituted by the Affordable Care Act, didn't actually get implemented until 2014, even though the law was passed in 2010, and that didn't really also affect the employer market, which is what the MMI reflects. So the impacts of the Affordable Care Act on the MMI were modest.
There's a few things I can tick off that people commonly think about that, where the Affordable Care Act impacted the employer market. One is elimination of prohibition of lifetime limits and annual benefit limits that were dollar-based. So it used to be, an employer plan might cover people up to a million dollars a year, or even a million dollars per lifetime. The Affordable Care Act prohibited those types of limits, and so that shifted costs, effectively, from employees and their dependents to employers.
And the other changes that I think most people hear about are coverage of preventive care. So prior to the Affordable Care Act passage, plans didn't have to cover preventive care, or they could have cost sharing on them. You know, copays, deductibles, and that sort of thing. The Affordable Care Act said that we're gonna start covering preventive care, so well-baby checks, physical exams, immunizations, at no cost to the member, and so that again shifted costs from employees to employers.
And the third change you often hear about is the increase in the child age limit. So it used to be an employer plan might cover dependent children up to, say, age 18, and after that you were on your own. The Affordable Care Act extended that limit to age 26, which again took some of the costs that the family might have covered all by itself and transferred it to the employer. So those are some of the impacts of the Affordable Care Act on the employer market that's described by the MMI.
What did the Milliman Medical Index observe during the COVID-19 pandemic?
Jeremy Engdahl-Johnson: Thanks, Chris. Sticking with the topic of times of tumultuous change, even if some of the effects on the MMI were somewhat peripheral, Dave, I'm curious to hear about the more recent tumult during COVID and kind of how the MMI navigated that period and what we saw during those few years.
Dave Liner: Thanks. Jeremy. COVID was an interesting time, I'm sure for all of our lives, but as well for the MMI. And for the first time in the history of the MMI we actually saw costs decrease during the COVID period. Furthermore, what's interesting—and Bill, you mentioned the comparison of healthcare trends to inflation—healthcare trends have always been higher than inflation throughout the entire history of the MMI, going back to 2005. So not only were healthcare trends negative for the first time in 2020, they also fell below inflation. So this relationship that we’d seen hold pretty steady for 15 years was no longer the case.
I'd also add that the timing was quite challenging with our publication cycle, where COVID emerged, as I remember, in March 2020 and we published in May 2020, and I remember having quite a bit of concern given that timing, because we're pretty early in COVID and we're still projecting costs for the full year, and we had a lot of questions as to how the rest of the pandemic might play out. And again, these were questions we had not only with the MMI, but also in much of our consulting work as well. It was a very uncertain time. Things have stabled out since then. But yeah, that was quite a challenge for us, back in 2020, as well as ’21 and ’22, where you saw inflation kick up and the MMI trends did return to positive, but relationships that had held for decades prior no longer held during that period.
Jeremy Engdahl-Johnson: So you talked about the uncertainty at that point in May of 2020. How did we get past that uncertainty, or at least get comfortable with the numbers that we were going to be publishing?
Dave Liner: I think I'd be lying if I said I was comfortable, again because there was so much uncertain at that time. And again, as actuaries, we deal with uncertainty, right? Our job, effectively, is to quantify the value of uncertainty. But the level of uncertainty we were facing, as it pertains to projecting healthcare costs, were more than what we've seen before. And it's counterintuitive to many people, right? You think if a global respiratory pandemic hits, you think people are getting sicker, you think healthcare costs might accelerate. And what happened is deferred and eliminated care actually outweighed any incremental COVID spend from the respiratory pandemic, and that's what caused the healthcare costs to go down. So the questions were more related to the care. You know, how much of it is deferred, how much of it is truly eliminated, and at what point would it settle out on a going concern once the pandemic passes?
Jeremy Engdahl-Johnson: Thanks. And what did we see coming out of the pandemic? How did health costs behave? Did they start behaving normally?
Dave Liner: We had the highest year of MMI trend ever following 2020, as I think you saw a lot of the care that was, in fact, deferred come back in 2021, and then it sort of settled back to, I'd say, around the historical levels in ’22 and beyond. So I'd say, you know, the impact of COVID on healthcare costs for the MMI purposes really was a two-to-three-year cycle for us.
Why healthcare costs keep rising—and strategies to help bring them down
Jeremy Engdahl-Johnson: Got it. So we've talked about tough questions and kind of how we grappled with some of them with regard to the ACA and COVID. I'm wondering what else jumps out to all of you, and I'll start with you, Bill. During your tenure, what do you remember as some of the thorny questions that you had to grapple with?
Bill Thompson: Well, the common one was, why are healthcare costs so high? And what's going to be done to bring them down? And my crystal ball wasn't very good at that, and obviously other than the, I'll call it the blip from COVID, which was a deferred thing, the pent-up demand that caught up later, they continue to be high.
I was seeing new technologies coming in. Advertising of not only drugs, but the new cures for this, that, and the other thing that people were looking for coverage for, some of which would be good, some of them may not be. So you had a demand issue from the consumer side of it. The employer side you had the employers trying to manage their costs. So you might find a bit of a shrinkage of some of the benefits or higher payroll deductions to pay for some of those things. That would affect utilization of services, as well as if employers had different options available, people selecting maybe leaner ones if they were healthier because of payroll deduction. And little bit of antiselection going on on the employee side, affecting the employees where there are multiple options there all tied to costs. And then, I mentioned technology before.
And then provider contracting—what's even bigger today is the becoming more corporate healthcare delivery systems. I can remember days when you'd be negotiating with individual hospitals to try to get things or small individual practice associations of physicians that have grown to be much more organized, much more sophisticated in their contracting, that affects the cost as well. So those are things either back 20 years ago, or that have evolved since then and continue to evolve.
Jeremy Engdahl-Johnson: Chris, what makes your list as memorable questions from your time as MMI head honcho?
Chris Girod: Well, Bill touched on a lot of them, but maybe I'll add a little bit more color to some of these too.
One of the things that always struck me the hardest during my 11 years on this committee was the fact that trends started out so very, very high. They were around 8% when I started in 2010, and the costs were also high, and so the costs continued to increase, but the rate of annual increase began to come down finally. And so over that period I was on the committee, average trend rate went from about 8% per year to about 4% per year, which was much, much more comforting. The costs were still sort of alarmingly high. The MMI now in 2025 is over $35,000 a year for the family of four that we model. So they're still very, very high, but trends have gotten better.
Now the last few years, as Dave was talking about, after COVID we had a resurgence in utilization. We've also got price inflation mixed in here. The Consumer Price Index is higher. And there's new drugs, new technologies coming out. So the costs have kind of spiked back up again. That level is a little bit higher than it than ideally we'd probably like it to be. But we're slowly maybe getting to a better place. So that overall long-term trend is what strikes me the most, is cost getting very, very, very high, but the trend coming down, which is better. So we're making some progress in that area.
The rise of consumer-driven healthcare and high-deductible health plans
Chris Girod: One other thing I'll comment on is, Bill touched on plan design, I think, and in this time I think we've seen the emergence of high-deductible plans, which really shift a lot of cost from the health plan to employees and their dependents. The intended purpose was to have the employee and the dependents have some skin in the game financially a little bit more, so that they would share in the cost of care more for those first dollars and hopefully eliminate maybe some of the potentially unnecessary utilization that was happening and help control costs a little bit.
So we've seen deductibles come out these days that are very, very high, particularly in the individual market, not so high in the group market. But it's not uncommon to see deductibles these days of, you know, 6, 7, $8,000, and it's a lot of money. And so it's a very different type of benefit plan that is a little bit more common today than it used to be.
Jeremy Engdahl-Johnson: And Chris, picking up on that last point, I remember there were years where we talked about consumer-driven healthcare, and consumer-driven health plans, as kind of an emerging trend and something that you know maybe it wasn't affecting the PPO, but you know a direction that things were heading. And I think, looking at that long-term trend and the long-term change in deductibles, and so on—not that these are high-deductible health plans, but some of that activity is kind of built in with induced utilization, and so on, right? I mean, it seems like the PPO that we were looking at in 2011 is a lot different from the PPO that we're looking at in 2020. Is that right? Or is that just kind of an amateur observation?
Chris Girod: Well, you're right to a certain degree. And so, just to give a little bit more context, the MMI assumes an average benefit plan. So we want to try to maintain some stability from year to year so that we can look at how costs change.
And so each year we try to model what we think is an average benefit plan in the marketplace. And that is a PPO-style plan. It's a preferred provider organization-type plan where people can go to a preferred network of providers and get their care with lower out-of-pocket costs, or they can go out of network if they want to and pay more out of pocket. They have a choice on that.
A consumer-driven health plan is, you know, a different take on this. It's a combination of a benefit plan, talking about just the cost sharing, that has a high deductible on it: $5,000, $6,000, $7,000 a person. It's got a high deductible, and it's coupled with a savings account, a health savings account, or HSA, or there's different flavors out there—health reimbursement arrangements (HRAs)—where money is put into those savings accounts on a pretax basis and the employee can use that money to fund some of those first-dollar costs: the copays, the deductibles, and that sort of thing. But ideally, that money, like in an HSA, belongs to the employee, and so they've got some incentive there to save that money in the savings account and not use it and control utilization. But if they really need it, they can use it to help cover their costs.
And so the benefit plan underlying the MMI, I think, is still largely of the same style it used to be, because that's still a very popular plan design in this country, a PPO plan with a modest deductible. But there are certainly different flavors of plans out there in the market, and they do affect utilization and costs in different ways, and the effects can be very complicated.
So you mentioned the term “induced utilization,” Jeremy, which is something that we actuaries love to talk about. But it's the impact of a cost-sharing feature like a deductible on a person's behavior. A higher deductible, for example, generally results in less utilization of services, because people don't want to have to pay that deductible out of pocket. So that change in utilization that results from a different cost-sharing level is called induced utilization. And those are very much tied up in the genesis of consumer-driven health plans. The intent was to create more incentive for people to pay attention to their utilization by allowing them to have skin in the game with high deductibles and these savings accounts.
Jeremy Engdahl-Johnson: Thanks, Chris. I appreciate you taking me down that rabbit hole. Dave, what jumps out at you?
Dave Liner: Just to add to what Chris said, Jeremy, with the 20th anniversary of the MMI I went back and read the initial report and found it quite interesting to read about what the authors thought were important issues in 2005. And there was quite a bit of talk about consumer-driven healthcare and high-deductible health plans, and we'll often see headlines these days on some plans with extraordinarily high deductibles by historical standards, and I think what you might find is many of those plans are not the employer-sponsored plans that we're focusing on for the MMI. They might be ACA plans or other types of products offered in different market segments.
I also compared a lot of the work we did in 2005 to where healthcare costs are today, and I was somewhat surprised to find in the MMI numbers the employee out-of-pocket costs were about the same on a percentage basis. So they represented about the same portion of the total healthcare costs as we define them for the MMI. However, the employee contribution, so the portion of the premium that employees might pay in an employer-sponsored plan, that's increased quite a bit over the past 20 years of the MMI. So I found that to be interesting and somewhat counterintuitive to what I was expecting. But I think, to what Chris said, that goes to the nature of what we're modeling here. It's the employer-sponsored plans, and we're going for average benefit designs.
Why pharmacy costs continue to rise
Jeremy Engdahl-Johnson: Got it. Well, so you've already kind of introduced this 20-year comparison and looking at where we were in 2005 versus where we are now. Over that time pharmacy and outpatient care have been the biggest drivers of trend. I'm curious what you guys think about this. Maybe I'll ask you first, Chris: Any reaction to that being the big trend driver? Are you at all surprised? What's your overall historical take on those trend drivers?
Chris Girod: Yeah, I don't think any of us on this call are probably surprised. Pharmacy is an area where Americans have excelled at innovating. There's a lot of amazing drugs out there that can cure conditions. They can help people live normal lives who have very severe conditions. So the innovation has been fantastic. But it comes with a price.
And so if you go back 20, 25 years, drug costs were a much lower percentage of the total healthcare pie. And nobody was hardly talking about specialty drugs, for example. Specialty drugs are ones that, they're defined in different ways, but you can think of them as generally as very high-cost drugs. And so going back 20, 25 years, the slice of the drug cost pie that was specialty drugs was pretty low. It was below 10% of all drug costs.
I was looking back in the 2016 MMI report, and even by that time specialty drugs had become 35% of the drug slice and 6% of total healthcare costs. So specialty drugs were 6% of total healthcare costs in 2016. I imagine it's gotten even higher since then, but I don't have that number. So I think we're not surprised to see this. It's an area where we'll continue to see change, I'm sure, over the next few decades.
Dave Liner: I agree with what you said there, Chris. I think one big change that we made early in my tenure working with the MMI is accounting for the prescription drug rebates. So when the MMI first was published in 2005, prescription drugs represented a much smaller portion of the total healthcare costs, and specialty drugs were much smaller than what they are today, as well as the pharmacy rebates that manufacturers pay back to plans for including their drugs on formularies or list of drugs that the patients enrolled in the plan can take. And what we found is the way we originally defined the MMI did not account for these rebates because they were small, and I don't think they were expected to increase in 2005. But rebates are much bigger now, and prescription drugs are a much larger portion of total healthcare costs. So we've now quantified the value of prescription drug rebates, because in many employer-sponsored plans the value of those rebates, or a portion thereof, is shared back to the employers and the ultimate payers of the plans. That's not always the case. But these numbers have gotten so high that ignoring them or assuming that they didn't exist didn't seem appropriate to the committee.
How outpatient care affects healthcare cost trends
Jeremy Engdahl-Johnson: Thanks, Dave. So we've talked a little bit about pharmacy here. Can we talk more about outpatient care, and that as a trend driver? And, as I understand it, it is related to drug costs and drugs being administered in an outpatient environment. But can you expand on the role that outpatient has played in this, Dave?
Dave Liner: Yeah, what I've seen is two drivers of that, Jeremy. One, yes, there are an increased number of physician-administered drugs today compared to 20 years ago. And when you get those drugs administered, you're doing so in an outpatient setting.
Another driver of outpatient drug cost is the advancements in medical technology that now allow a procedure that once was an inpatient stay to be performed in an outpatient setting. So it's often less invasive. The recovery is typically better for the patient. But what you see is upward pressure on those outpatient costs as a result, because you now have more of these procedures that were once in an inpatient setting now performed in an outpatient setting.
Predictions for the next 20 years of healthcare costs
Jeremy Engdahl-Johnson: Interesting. All right. So we've gotten a nice historical perspective here, and I think, you know, as health actuaries, you allow the history to inform the future in some respect, with various caveats. But what do we see for the next 20 years in healthcare costs? What are going to be the big stories, you think? Bill, do you hazard a guess?
Bill Thompson: My crystal ball is pretty foggy. But my thoughts: Technology continues to grow. Dave just mentioned the technological changes that switched a lot of things from inpatient to outpatient, and I would say, some outpatient even to physician office. So change in locale as technology improves.
Drugs, if we continue to have drugs that are curative, and there can be diagnostics early on, we should see hopefully an improvement in health of people, longevity, which may defer some costs and may lower costs for the family of four of the actives, but it may create an increase in the older folks like me as you get into the Medicare side of things. So there may be some deferral of things.
I think that also there's been a lot more attention being spent on active lifestyle in the last decade or more, which is, as people embrace that, may defer the onset of certain conditions and things, which may help with healthcare but again affects longevity and may be a deferral of certain conditions as well.
So I see that combination of things that are going on that can improve costs. But I don't think that healthcare costs are going to be going down and will probably continue to be a major player and probably greater than the average rates of inflation, I'm afraid.
Jeremy Engdahl-Johnson: Chris, what's your crystal ball say?
Chris Girod: Similar to Bill. So I'll say something that's a little bit pessimistic, but then add a note of optimism at the end, I think. One is that, first of all, I guess the fundamental dynamic of healthcare finance in the U.S. to me is still a little bit broken, and the fundamental issue is that the people making the purchasing decisions, which are usually a patient and a doctor working together to decide what type of care is appropriate, are just too far removed from the cost impact of that. The employer is paying for it at the end of the day, but they're not in the room making the decision. And so we want people to have the best care they can. But we have to consider cost somehow. And so our system right now generally rewards physicians, hospitals, drug manufacturers, device manufacturers for all of the fantastic things they can create, the things that they can, you know, provide to patients. And it's all wonderful, but it comes with a cost. And so that disconnect between the purchasing decision and the paying for it still hasn't quite been fixed in our country.
We've made progress in some areas, like you hear about ACOs, accountable care organizations, which were an experiment developed as a result of the Affordable Care Act. They started out in Medicare, but now they're popping up in the commercial employer space as well. And so those types of things are trying to link those purchasing decisions with the financing to a certain degree also. So that's progress.
So I would consider or expect trends to continue to bump along at rates higher than general inflation, as Bill said, for the foreseeable future until we figure out how to solve this problem. And costs will continue to grow, probably, as a percent of gross domestic product or GDP.
And my one hopeful note is, I mentioned to one of my colleagues a few years ago that I said, you know, healthcare costs are getting up around 20% of GDP. It's getting pretty frightening. I mean, that's a lot of our economy dedicated to healthcare. And he looked at me and he said, “Chris, what better place to spend our money? What's wrong with that?” And so I think that's a good point. It's like, it's not necessarily bad, but there are probably still plenty of efficiencies that we can gain. We don't have to waste money, but we can spend it on ourselves and take care of ourselves. So there's some positive view on that, too.
Jeremy Engdahl-Johnson: Thanks, Chris. Dave?
Dave Liner: Warren Buffett once referred to America's healthcare costs as the tapeworm of our economy. And what I find interesting is that he provided that response when asked a question related to taxes, so it was a complete pivot and he went to healthcare costs. And I think, digging a level deeper as to why that might be the case, Chris, it gets to what you said in terms of 20% of our GDP is being put toward these healthcare costs. That's a multiple of what many other rich nations spend. And that's capital that could be allocated elsewhere, is sort of the theory behind that.
Looking forward in 20 years, as a result, I don't necessarily think the path that we're on is sustainable without reform at some level. And you're seeing that now, particularly in the pharmacy space with both states and federal government contemplating a reform of our system and pharmacy benefit managers in particular. Additionally, you see increased consolidation amongst providers. And that's a trend that I expect to continue at least for the foreseeable future. And you see technology actually I think helping things, in that with this consolidation, with better sharing of data, medical researchers and practitioners can get much better insights through much better sharing of healthcare data. And with the additional technology that's coming down the pike with artificial intelligence (AI), I think the combination of that can lead to some pretty cool outcomes. It's just a matter of how do we capture that value and make sure we're using it to responsibly address the healthcare costs in the path that we're on right now.
Jeremy Engdahl-Johnson: Thanks, Dave. All right, Bill, Chris, Dave, thank you so much for joining me. For our listeners who are interested in reading the 20th anniversary MMI, you can visit milliman.com/MMI.
You've been listening to Critical Point, presented by Milliman. If you enjoyed this episode, rate us five stars on Apple Podcasts or share this episode with your colleagues. See you all next time, maybe in another 20 years.