May 26, 2021
Sanjula Jain 0:03
Women make up 70% of the healthcare workforce but only 20% of its leadership. On Her Story, we’ll explore the careers of bold and influential women from Silicon Valley to Capitol Hill and learn how they’ve overcome the odds. I’m your host, Sanjula Jain and this is Her Story, a program where we explore what’s beyond the glass ceiling.
This morning I’m delighted to welcome Peggy O’Kane, Founder and President of NCQA. Peggy, thanks for being with us.
Peggy O’Kane 0:31
Happy to be here, Sanjula. Nice to meet you.
Sanjula Jain 0:35
You’ve been a pioneer in the healthcare quality space. Tell us a little bit about the mission of NCQA and who you serve.
Peggy O’Kane 0:42
Our mission is to improve the quality of health care and how I got here is an interesting story. I was a French major in college and I taught second grade. I was trying to find my career. I became a respiratory therapist. I worked in hospitals for five years and the quality issues were so evident that I would come home with my hair on fire. My husband would say, “You should go do something about the quality of healthcare.” At the time, there really was no good way of thinking about quality. There was a lot of peer review, which was doctors reading each other’s charts (usually when something bad had happened). There really was no way of engineering quality into the system, so I went to graduate school. I learned what I could learn about quality. It was at a time when corporate America had embraced quality. Continuous quality improvement was a big deal. Lots of corporate people had black belts in quality and so forth, so it was a convergence of things at a time when corporate America understood that the quality of health care wasn’t what they wanted it to be and we’re looking for a way to drive it towards better quality.
Sanjula Jain 1:59
Wow, so a lot to unpack there. First, quality is a construct we all have different definitions for. How do you define it?
Peggy O’Kane 2:08
“Did the right thing happen to the person at the right time and in the right place” is a nice way of thinking about it. A fancier way of thinking about it is, from what we know from medical science, “was the right thing done and done in the right way?” That’s a little more elaborate.
Sanjula Jain 2:24
That makes a lot of sense. It’s really interesting that you started off on more of a clinical track. What originally inspired the decision to go train to be a respiratory therapist? Where did the healthcare interest come from?
Peggy O’Kane 2:36
To be honest, I was looking for an easy way to get into health care without going back to school. It was at a time when respiratory therapists were trained on the job, it was a new field because ventilators were just starting to be in wide use. I went in, I trained on the job, I picked up a degree in Respiratory Therapy along the way, but it was an easy way to get into health care. To be honest, it got boring after a while, but it was an incredible learning experience with just powers of observation. There was also this emotional part of it that motivates me about quality. You see patients suffering unnecessarily, the quality of care not being what it should be, and what the consequences are. It’s really motivating. I draw on those kinds of stories of what happens when it isn’t good to motivate myself all the time.
Sanjula Jain 3:30
Did you grow up around healthcare?
Peggy O’Kane 3:33
No, I was the first college graduate in my family. I was born in Germany. My mother was German. My father was in the army. I grew up in Brooklyn, New York. As I said, the first college graduate, there was nobody professional in my family on either side.
Sanjula Jain 3:50
You trained as a respiratory therapist. You saw the disparities in quality. You decided to then go get another graduate degree at Hopkins where the thinking was Health Policy and Management. Was it straight out of grad school then? Where did the idea of NCQA then come from?
Peggy O’Kane 4:12
I started with an internship with the federal government and worked for the Health Services Administration, which is now part of HRSA. I worked with community health centers, and maternal and child health programs, and so forth. It was an office of evaluation. It was really interesting and population health was the theme and I was caught by that. Community health centers were way ahead of their time in terms of population health, a whole person focus, they were really pioneers. I took in all that, it became part of my value system. Then I worked for a research group at George Washington University and learned a lot about states. It was a state research group, and I was still carrying this Quality agenda inside me. But there weren’t good jobs and quality. There were these things called professional services review organizations, it was just right, nothing particularly good. Paul Elwood, at the time, was a big thought leader in health care. He was very much advocating for Health Maintenance Organizations. I had been a member of a health maintenance organization. At a time when I lived in Boston. The Harvard Community Health Plan was one of the first in the country. I always thought the idea was fantastic. Elwood was an evangelist for this idea. He recruited employers and even insurance companies towards this idea, so the idea of the accountable health plan was starting to shape itself in the employer community. I was working then at the HMO trade association and we were trying to figure out our quality agenda. I had all these ideas from graduate school about how to measure quality and how to think about it. But I needed an apple. I needed a way to make it happen, so we found the employers. They said, “It doesn’t make sense for us to be running around with our own consultants, everybody asking different questions, everybody asking people to measure quality in different ways,” so NCQA came together as a convergence of plants that wanted to demonstrate their good quality and employers who understood what that meant.
Sanjula Jain 6:34
We talked about the health services background and population health and quality, a lot of these terms we’re still talking about. When you were thinking about it, this was before the popular Institute of Medicine, “To Err Is Human” report. This was the early stage of the Clinton health era. What was the actual conversation like in the health care industry around equality? Was it actually something that folks were talking about?
Peggy O’Kane 6:56
Yes, because of the employers, because the employers were on this. First of all, as I said, many of them were trained black belts, or whatever belts they had, so they knew how to think about quality. I remember the Chief Human Resources officer at Xerox said to me, “I go visit our plans and I say, ‘Tell me, how do you do with taking care of people with diabetes?’ The plans would say, ‘Oh, we’re fantastic.’” She would say, “How many people with diabetes are in your plan?” and they would say, “Gee, we don’t really know.” The employers, through their training, understood that it was a numbers and measurement game. It was an “if you don’t measure, you don’t know where you are and you don’t know when things have gotten better,” but this was still a new concept in healthcare at the time.
Sanjula Jain 7:51
You formed NCQA with what specific mission at the time then?
Peggy O’Kane 7:58
Our mission statement was to improve the quality of health care but in fact, what we were doing was accrediting HMOs and measuring the quality of care that they gave. These were in two separate tracks and the employers helped us design the accreditation program helped us figure out what to measure and then mandated, so we went from an idea to a reality in a very short time.
Sanjula Jain 8:26
How does the organization actually work with other stakeholders across the industry? You have the employers, there’s also the government.
Peggy O’Kane 8:32
We have a multi-stakeholder board. We always have a consumer member, we have quality experts, we have people that have been consultants, we have health plans (a very small number of health plans actually on our board), we have a hospital CEO on our board. It’s multi-stakeholder. You need finance and strategic expertise on your board, so we have people with that. We have a fabulous board.
Sanjula Jain 9:03
Bringing together all those stakeholders is quite important because, as we’ve talked about before, healthcare is so siloed, so it’s really unique that you sit at this intersection of bringing all these groups together. How do you think about the concept of the fact that why did you form a nonprofit as the organizational structure?
Peggy O’Kane 9:20
It wasn’t even a question at the time because of the idea of doing quality for profit— I don’t think people would have trusted us. Now, today is a different story. There are plenty of for-profits doing great stuff in quality. There are advantages to being able to raise capital and so forth, but we will continue to be a nonprofit because we serve the public interest. People are looking for hidden agendas everywhere anyway. There’s a level of trust problem, so we just keep that one off the table.
Sanjula Jain 9:55
How are you working? Fast forward the evolution of the quality discussion in the industry. From your vantage point, are we making progress? What are some of the roadblocks you’re seeing?
Peggy O’Kane 10:07
We’re making progress in some sectors. Where we have clarity about accountable entities that are able to, and Value-Based Payment as part of it, where there’s an enterprise that has goals that are trying to do a good job, and they have the measures to prove it beyond what we measure, and trying to work within a budget, then you have what’s necessary to get to good quality. We tend to think of quality in healthcare. It’s because our fee-for-service system is a trade-off: you can pay more or you can have good quality, but you can’t have both. That’s so wrong. There is so much that’s wrong with quality and healthcare is because of the crazy incentives.
Sanjula Jain 10:51
Healthcare is so political so it’s interesting that you all have worked with both sides of the aisle, different administrations. How does that influence what NCQA is able to achieve as you’re bringing stakeholders together?
Peggy O’Kane 11:04
There are differences. The most important differences in the concept of universal health care coverage, which I do support, and I do think a lot of mischief comes about because people are trying to figure out how to offload the high-risk patients, which creates a lot of very bad dynamics. Other than that, everybody’s sweating about the cost of health care. It’s every state’s biggest spending item. We’ve been through a period when a lot more people showed up on Medicaid, and so forth. Medicare and Medicaid are on the hook for this money. They’re also scrutinized by the public about what kind of a job they do with the public dollar, so they are heavy drivers of our work. The employer scene is quite different than it used to be. Most employers are self-insured now, so they’re at risk, not the health plan, which also creates some funky incentives.
Sanjula Jain 12:07
There’s a little bit of a debate over the importance or effectiveness of measurement and metrics. The academic in me thinks a lot about Donabedian’s model and structure/process outcomes. You have a lot of business gurus who talk about “if you can’t measure it, you can’t manage it.” How do you view the balance of having the right measures? Are we keeping up to pace as we think about digital and telemedicine?
Peggy O’Kane 12:34
We spent a lot of money on the HITECH act to get electronic health records, we have data all over the place, and it’s where it’s not serving us and the practitioner that’s trying to do a good job often doesn’t have the information they need, even though they have this very expensive, very sophisticated medical record. It’s a shame. We need to do better. We envision a digital future when practitioners are given the information they need to do the right thing the first time and everybody can succeed at quality. Practitioners are trying to do a good job and organizations are trying to do a good job. Often it’s the lack of information at the point of care or the lack of sophistication about how to engineer their processes. Our ultimate goals are to get everybody to a level of performance that’s terrific and where we get the return on the investment that we put into healthcare.
Sanjula Jain 13:35
As you think about the last 20, 30 years in the industry, from where you started looking at quality on the employer side, then you had the HITECH act, now we have CMMI and value-based payments that are further incentivizing us to think about metrics and reporting. Are those initiatives or policy levers critical to accelerating this momentum? What do you see the next decade looking like in terms of solving the data issues?
Peggy O’Kane 14:03
We’re hopeful because there are a lot of people working on this and CMS itself, and the state’s Medicaid programs are on this. They’re very aware of how the system falls short, and they understand it, and they’re trying to drive change. So CMS has said, quality measures are going to have to be reported digitally by 2025, which is very ambitious. But there’s a lot of progress being made and a lot of systems, but it’s very uneven throughout the country, and particularly in classic Medicare, people have supplemental insurance, that data is separate from the Medicare claims data, there’s no accountability. It’s kind of a mess. Medicare Advantage has been a bright white of the right model in my view, but during COVID they backed off on a lot of clinical quality measures, so they’re much less heavily weighted now in the stores. We have a lot of work to do.
Sanjula Jain 15:01
As you think about the evolution of NCQA, tracking with the evolution of the industry, how have your priorities specifically as the leader of the entity changed to match those?
Peggy O’Kane 15:11
I always use the metaphor of being in a car on a foggy night. You can’t get out in front of your headlights. You’re learning. It’s one of the reasons I’ve been in my job so long. It’s so energizing and fascinating. It’s such a problem to be solved. We started off measuring very simple things like preventive services, because there was a very well-regarded Preventive Services Task Force that said, here’s who should get what and very, very specifically, so we were able to start with that, we moved on to chronic conditions. We’re very proud of the work we’ve done, it’s resulted in a life saved, and better quality of life for people. I’m kind of a glass-half-empty kind of person. Think about people who are in their 80s. Science is not very well done for people in their 80s. So the way the scientific enterprise of healthcare works is, we do clinical trials, they tend to be by Oregon system, even if you look at how NIH is organized, it’s by Oregon system. We test the drugs and the treatments on younger people without other conditions then we go out and apply this knowledge to people that are in their 80s or who have multiple chronic conditions and it doesn’t work so well. We’re working now on some stuff that’s really interesting about “patient-driven” outcomes. It’s funded by the SCAN and Hartford foundations. We’ve started with elders, but the concept works really well for other kinds of patients as well. Like, what are your goals? What would you like to have is your goal if your health allowed it? What elders tend to tell us is things like, “I’d like to go back to church,” or “I’d like to be able to walk around the block,” or “I’d like to go visit my children.” You can align that goal with things they can do to be more healthy like a little more exercise, perhaps, or something like that.
Sanjula Jain 17:23
You’re alluding to the power of data, the data to underlie better decision making, better practices, but as an industry, we have really struggled with that. We’re circling around it, we’re working with data. It may not be as usable, but how do you view the connection between using evidence to actually inform decision-making or strategies at the system’s level? What does it take to get our industry comfortable with that kind of thinking?
Peggy O’Kane 17:49
Let me go back to Donabedian because Donabedian remains a beacon to me. His idea was that there are three ways to think about quality: (1) structure. Are things organized? (2) Process. How are they doing what they think they’re doing? The last one is the outcome. We’ve led the charge on measurement. People see measures and it feels more real to them than structure and process. There’s this great outcry that we need the outcomes and we don’t need to know about whether they’re organized appropriately or whether they’re doing the right thing appropriately. That’s a mistake. If things aren’t organized right, you can’t even measure how well you’re doing. It’s more of a nuanced weaving together of structure, process, and outcomes that’s necessary. We’ve been doing work on depression. You have people organized to do the PHQ-9 as a screener, identify people with depression, then follow up with the people, put them on meds, do whatever it is to treat them, put them in therapy, and then follow up and see what the remission rate is. This is built on the pioneering work done by Juergen Unützer who’s at the University of Washington. Then you track the patient and make sure that it’s working. Luckily, depression is treatable and people can really do better, but if you’re not looking, the readmission rates are really low. Juergen Unützer doubled readmission rates in his scientific work. We’re taking that kind of a notion. You can apply that to other things as well. You can take people who were obese and work with them. The potential of using the outcome as the ultimate metric, but holding people accountable for doing the right thing. Did you follow up? If the intervention wasn’t working, did you try something new? That’s the way to think about it.
Sanjula Jain 19:59
That’s music to my ears. I spend a lot of my time on the structure and process so the conversations I’m having a lot with organizations is, how do you measure your strategy? Or how do you capture that so you can actually see which levers are influencing those outcomes and trying to get us to move a little bit more upstream? We talk about data and we talk about measurement, but we all define it a little bit differently. You’ve been relentlessly focused on this probably longer than most in the industry. A lot of people are looking at it from very niche angles, and they’re all important, but you have this system’s view of it. Take us back to the origin story a little bit. You founded this at a time when, yes, people were talking about it, but not intentionally focused on it in the way that you were where you said, “We’re going to form an organization that’s just focused on this.” You also did it at a time when we know there weren’t many female founders in the industry, even today are not, but when you started, even less. Tell us a little about that experience. Did people think you were chasing after something crazy?
Peggy O’Kane 21:05
It was a sneak attack because people underestimated me, partly because I was a woman. I wasn’t a doctor, but what I understood was that I needed other people to help. I’ve always had good luck hiring great people and having a wonderful Board of Directors, wonderful committees. We have the greatest brainpower. You just sit in awe. That’s how it worked. You have to be able to get people to want to help you and then take their best ideas and implement them. I feel humbled by the work because it is so complicated, but I also feel so empowered by the goodwill of the people that work with us and the people that run quality all over the healthcare system. Honestly, you can’t find a more dedicated group of people.
Sanjula Jain 21:58
The passion shows there. Something you said that’s really interesting is, back at that time, we would say “the physicians were our customer.” That’s how we operated the system. Now it’s “our patient and the consumer is the customer.” When you were starting, to your point, you were a clinician, but you weren’t a physician. How did you navigate that dynamic? You were in the business of trying to tell physicians how to—
Peggy O’Kane 22:31
Even today, I get hate mail. I get lots of rude tweets and so on. The thing is, quality is not only about medical science. It’s about the art of delivering care in a consistent way. A lot of it is not rocket science, some of it is. The part that isn’t rocket science is the part where we neglect it.
Sanjula Jain 22:56
Zooming out, if you think about the advice you would give other women today who are trying to create something, build from scratch, how do you push through that noise when people are telling you it might be a crazy idea or you don’t know what you’re talking about?
Peggy O’Kane 23:10
You have to have a thick skin. You have to be willing to have people look right through you. We all know about implicit bias that we deal with, and you’ve got to believe in yourself. You also have to have the ability to—when somebody calls you out for something you’re not doing right—to take it in and reflect and maybe do something different. That’s one of the things that’s really, really important. In a field this complicated, you’re gonna make mistakes, so you have to be open to that.
Sanjula Jain 23:43
If you were to build NCQA from the ground up today, in today’s era with the iPhone and the high-tech, what would you do differently?
Peggy O’Kane 23:53
I don’t know what I would do differently. The employers were so foundational to getting us launched I don’t think it would be possible today because the employers are all over the place. The strategy doesn’t feel as strong as it was when we were coming up. I would be working as we are, very closely with CMS, very closely with Medicaid. I feel like we got here by responding to the environment and keeping our core beliefs front and center. That’s what you have to keep doing. I would start with digital today because it’s where the action has to be. We’re spending so much money on data and it’s not even there for the most basic of usage right now. It’s pathetic, but again, that’s where we’re putting a high proportion of our intention right now.
Sanjula Jain 24:54
One of the things the data is showing very clearly and COVID exposed is the disparities that we have in quality and treatment and everything for certain populations. How are you thinking about health equity?
Peggy O’Kane 25:07
We’re very proud of the work we’ve been doing. The thing is people used to think, “There’s quality, and then there’s health equity.” This has shown us that they’re not to be separated, that health equity is the path forward on quality, that if you close those gaps, you’re going to have the biggest impact on quality. One of the things we’ve been doing is talking to other quality organizations—like the National Quality Forum—about how we can all get on the same page about measurement. We want to stratify our hottest measures by race and we want to see what the actual gaps are. We’ve been helped a lot by states that have been on this for a number of years. I would particularly mention Pennsylvania. Dr. David Kelly sits on our performance measurement committee. They have pioneered this and they have managed care plans. We have a program called Multicultural Health Care and they’re measuring the impact and they’re seeing the impact. The gap is not 100% closed, but it’s an incremental game quality improvement. What we’re doing is trying to get the quality enterprise to point in the same direction, we tend to have everybody running off in different directions, and it sends very unclear signals to the delivery system.
Sanjula Jain 26:34
The incrementalism point is really important because we move so slowly in this industry, and some of it is inevitable and each thing is a foundation for us to build on. As you think about the next decade, the post-pandemic health economy as it relates to health equity and measurement and quality, are there things we can do as an industry to accelerate some of this?
Peggy O’Kane 26:57
Absolutely. As an industry, it gets serious about the engineering clinical process. For the government, the challenge is to get clarity about who’s accountable and then persist in holding them accountable. Reward them if they do well, fire them if they do badly, or encourage them to do better. In the last 20 years, CMS has been one of the more important forces and Medicaid. Tom Betlach is on my board from Arizona, an amazing Medicaid program that he ran for years and relentlessly focused on quality and value. That’s what we need.
Sanjula Jain 27:41
A lot of that is a testament to what you’ve galvanized as an industry. You have been championing and educating the industry along the way. That’s a big testament to your work, so thank you for all that you do.
Peggy O’Kane 27:54
Thank you so much.
Sanjula Jain 27:55
Shifting gears a little bit then. You make it sound so easy. You’ve been at this and it’s been hard, thick skin, all important attributes. Tell us a little bit about your journey actually going through each of these steps. What support did you have along the way? Did you have mentors that guided you?
Peggy O’Kane 28:12
I did. Let me call out Gail Warden. When I met him, he was the head of Group Health Cooperative of Puget Sound in Washington State. He became the head of the Henry Ford health system. He’s been a mentor and selfless advisor to so many women I know. He was the chair of our board when we were starting up but board members along the way, fabulous people like Pat Naismith, the person I mentioned from Xerox. Helen Darling was also at Xerox and then was a benefits consultant. I can’t name all the people, I’m just calling out a few of the people that encouraged me and mentored me, told me when I was screwing up.
Sanjula Jain 28:55
Is there a difficult piece of feedback or advice that you’ve received over the years, whether it was from a mentor or someone else that you’ve been working with who shifted your perspective at some point along the way?
Peggy O’Kane 29:06
I don’t know if it’s difficult. It’s not my nature to be appreciative of the good things. As I said, I’m a glass-half-empty kind of person, but to experience the sense of accomplishment and joy that comes when you make some progress, you need that in order to keep going.
Sanjula Jain 29:26
I know you have two daughters as well, so a mother on top of running a large organization. How do you think about trade-offs, professional and personal, that you had to make along the way?
Peggy O’Kane 29:40
It was hard, and I was divorced so it was very, very challenging. I felt guilty a lot. They tell me now that they were very proud of me. When we had dinner at nine o’clock at night, they were okay with that. You have to let go of the idea of perfection in all that you do. If you’re doing a lot, and who isn’t doing a lot? Every woman that has a family is constantly having to navigate that.
Sanjula Jain 30:07
Absolutely, and this idea of “the ideal way to do it” doesn’t exist. A fun fact about you is how you’re so focused on measurement and precision but an area you invest a lot of time in is meditation. From my perspective, that is something that is more intangible, something you can’t really measure the impact that it has. Tell us a little bit about that outlet for you.
Peggy O’Kane 30:37
I teach meditation, actually. Once a week mostly, once a month for something else. It’s a great way to ground yourself and to be real about, like our human imperfections, and to realize that when you calm yourself, you’re acting from your best self. So it’s, it’s that it’s a kindness to yourself, and it’s a kindness to other people around you, which I don’t always succeed. But when I’ve been doing my steady practice of meditation, I’m at my best.
Sanjula Jain 31:07
How did you get into meditation?
Peggy O’Kane 31:11
When I got divorced, it was a hard time for me. I picked up a book and then I started going to sits and stuff and retreats, so I’ve been at it for a very long time. It’s made a huge difference in my life.
Sanjula Jain 31:26
One of the things all leaders would probably agree with you on is that leadership is an ongoing learning process. You’re constantly teaching yourselves different things and reading. As you think about both personally or professionally, especially in the quality space, do you rely on outside industry perspectives? Thinking about quality in the airline industry or another. What outside sources of information do you draw upon?
Peggy O’Kane 31:52
The level of customer service you see in some of the outside— I don’t know if I want to call out Amazon, but the level of customer service is truly remarkable. The airlines, not so much Ritz Carlton. There are a lot of people from Ritz Carlton who have worked in healthcare and tried to imbue the system with that dedication to the customer with mixed results. Healthcare is so complicated. Often, it’s been built around the—I don’t want to say in a judgmental way—convenience of the people that work in the system. It’s actually not even that because it’s too complicated. It’s hard on the people that work in it. Sometimes there’s a sense of they have to preserve themselves in order to do their jobs, especially when we look at what they’ve been through in the last year with COVID. We have failed our workers and health care, all of them, from the doctors down to the lowest worker. There’s so much that needs to be done.
Sanjula Jain 32:57
As you think about your personal agenda to go tackle these big feats, one of the things that is a testament to your commitment but also rare in the industry, is you have a founder of an organization that is very active in the day to day operations for as long as you have been. How do you think about the team that you’re building around you?
Peggy O’Kane 33:16
I have a very sophisticated group around me, who are better at what they do than I would ever have been. So believe me, it’s been a humbling experience to start out and not know how to do pretty much anything. The good thing about growing is you can bring in people that are really good at what they do. I have a team like that. They’re wonderful.
Sanjula Jain 33:38
That’s great. As we close then, what advice would you give your younger self?
Peggy O’Kane 33:48
Humility doesn’t mean that you’re “less than”. That’s part of it. Be willing to listen to people. Don’t expect to be perfect. You limit yourself if you expect to be perfect. If you only have to be perfect, then you can’t take in opportunities to do better and to grow or to supplement whatever it is you bring to the table. It’s about clarity and honesty.
Sanjula Jain 34:15
You’ve already roadmap this, but I think it’s interesting. Would you consider your entrance into healthcare leadership more accidental or intentional? How would you describe your journey?
Peggy O’Kane 34:33
It’s become more and more intentional over the years. It felt like an accident in the beginning. There were a lot of lucky breaks, but there was this intentionality about doing something about quality that was there from the beginning, but I’ve become more intentional about the details.
Sanjula Jain 34:51
As you think about the credible legacy you have already established for yourself (but we’ll continue to chart forward), one day we’re going to write the autobiography for Peggy. What would be the title of your book?
Peggy O’Kane 35:02
I am thinking of Elizabeth Warren’s book Persist. It is a lot of that. It’s kind of belief in yourself. I’m sure there’s a book called Believe In Yourself, but Believe in Yourself and Work With Others. Not a very memorable title, but that’s the theme.
Sanjula Jain 35:20
That reflects a lot of your journey and the perspective you bring. I want to thank you for all the work you and your organization have done in the industry as being one of the first movers in this space. We’re excited to see what else you all have to bring forward in the industry.
Peggy O’Kane 35:34
Thank you, Sanjula. It’s been a pleasure to talk to you.
Sanjula Jain 35:38
Thank you, Peggy.
Peggy O’Kane 35:38
Thanks so much.
Sanjula Jain 35:41
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