[00:00:00] Gary Bisbee, Ph.D.: Dr. Liz Fowler is the director of the CMS Innovation Center, formerly known as the Center for Medicare and Medicaid Innovation, or CMMI. The goal of the CMS Innovation Center is to develop and test new approaches for payment and service delivery. The Center’s alternative payment models are designed to reward providers for delivering high quality and cost efficient care. Underlying the alternative payment models is the shift away from fee for service and toward a system that rewards better outcomes for patients. We discussed how the Innovation Center utilized focus groups to incorporate the metrics that are most important to patients. Liz touched on how the Innovation Center approaches risk for providers and the importance of striking a balance between opportunities for providers ready for accountable care while also creating a pathway from more risk averse providers. Liz noted that healthcare transformation is a marathon, not a sprint. We discussed the recent Innovation Center’s Strategic Review that established new priorities for the center. They include driving accountable care, advancing health equity, and creating partnerships with public and private entities to achieve transformation. For young leaders, liz advised that you’ll perform your best and be most successful when you love what you do

Well good afternoon, Liz, and welcome.

[00:02:16] Elizabeth Fowler, Ph.D., J.D.: Thank you. Thanks for having me.

[00:02:18] Gary Bisbee, Ph.D.: We’re pleased to have you at the microphone. Of course you have a rich health policy background. And it’s very impressive, I will say. And I was thinking the other day, you’re really the ideal person to lead the CMS Innovations Center. I think the idea originally came about through Senate Finance Committee and Chairman Baucus, and you were the chief health counsel. Is that true?

[00:02:43] Elizabeth Fowler, Ph.D., J.D.: It is. Yes. Quite serendipitous.

[00:02:46] Gary Bisbee, Ph.D.: And then of course, after that, you were with our good friend Nancy-Ann DeParle in the White House and made sure that the Innovation Center was part of the ACA. So all in all, did you ever imagine you’d be the director of the CMS Innovation Center one day?

[00:03:03] Elizabeth Fowler, Ph.D., J.D.: No, I didn’t. But it is, like I said, serendipitous, and I’m glad to be here. It does feel like coming home.

[00:03:09] Gary Bisbee, Ph.D.: We’re glad to have you there as well. A very important part of CMS. So with that said, what was life like growing up for you, Liz?

[00:03:19] Elizabeth Fowler, Ph.D., J.D.: Well, in some ways it was very typical. I grew up in Wichita, Kansas, so very Midwestern and feels very typical for an American childhood. But in some ways it was atypical and I would say that because my mother’s Chinese and I was born in Taiwan and my father is American. So growing up mixed race in an area of the country that didn’t have a lot of Asians really shaped my perspective and worldview. So I’d say in some ways it was very typical and in some ways, very atypical.

[00:03:49] Gary Bisbee, Ph.D.: What did the young Liz think about leadership when you were maybe in high school, for example, what did you think about leadership at that point?

[00:03:57] Elizabeth Fowler, Ph.D., J.D.: I think I would characterize it as, you can only account for your own actions and decisions. You can’t always predict or compel someone else’s behavior or reaction, so you need to be the best that you can be to be transparent, honest, humble, and you do these things and you be the best that you can be without regard to thinking how someone else might react or how they might respond. So I really felt a lot of focus on trying to make sure that I was who I wanted to be, if that makes sense.

[00:04:26] Gary Bisbee, Ph.D.: Yeah. Sure. Well, you mentioned your parents. Did they influence your leadership style at all?

[00:04:32] Elizabeth Fowler, Ph.D., J.D.: Yes, very much so, and the direction, the course of my life, as happens with many kids. My father was a doctor and my mother went to college. She hadn’t gone to college before she got married and had kids. So she went to college while raising two kids and became an accountant. I would say my father inspired a love of all things healthcare. And my mother taught me that when you put your mind to something, you can achieve whatever it is that you set out for yourself.

[00:04:56] Gary Bisbee, Ph.D.: Yeah, very good. So what came first, your interest in healthcare, which I expect is the case, or your interest in health policy?

[00:05:05] Elizabeth Fowler, Ph.D., J.D.: Well, you’re right. I thought I wanted to be a doctor most of my childhood and somewhere that’s a security question for an online account. But it’s true. That is what I wanted to do when I was older. My father was a primary care physician. My grandfather briefly chaired the department of internal medicine at the University of Iowa. So I had suspected that I would become, somewhere along the line, a primary care physician.

[00:05:28] Gary Bisbee, Ph.D.: Of course, went to Penn. And then you went to the University of Minnesota law school. What was your aspirations coming out of Minnesota Law?

[00:05:37] Elizabeth Fowler, Ph.D., J.D.: It was a little bit of an afterthought. And I went to law school after graduate school. So, it was because I had moved to Minnesota for personal reasons and wasn’t sure if I’d get back into Washington health policy-making, so I kind of applied on a whim. And I started law school about two weeks after defending my PhD dissertation. So I wouldn’t say it was a long time career aspiration.

[00:06:01] Gary Bisbee, Ph.D.: Right. Onto J& J, after time in Washington, and you were head of global health policy there. What caused that decision, Liz?

[00:06:11] Elizabeth Fowler, Ph.D., J.D.: You know, I think there is value in having an experience in both the public sector and the private sector. And I really learned that having an understanding of one sector only enhances your performance and your learning and your understanding of the other. For example, I felt like I was a stronger public servant after spending time in the private sector. I had a better understanding of the impact that public policy had on organizations and companies, what it took in terms of resources and commitment to comply with new requirements and regulations, where there were gaps in policies that needed to be filled. So I’d say that’s sort of defined how I see the ability to translate one to the other.

[00:06:50] Gary Bisbee, Ph.D.: Certainly impressive, your range of experiences. Let’s move on to the CMS Innovation Center, which many of us know historically as CMMI. Think you’re thinking about the CMS Innovation Center as a more reflective title perhaps of what’s going on there. What’s you’re thinking about reorienting from CMMI to the CMS Innovation Center?

[00:07:15] Elizabeth Fowler, Ph.D., J.D.: Well, I think the acronym means something to some people, but it doesn’t to those who aren’t in the field. So, it’s a more descriptive term for the center. And you have the Center for Medicare. You have the Center for Medicaid and CHIP Services, the Center for Consumer Information and Insurance Oversight.

So rather than using the acronym, it seemed to make sense to go to the Center for Innovation.

[00:07:36] Gary Bisbee, Ph.D.: For those of us who may not be that familiar with the Innovation Center, can you just outline for us, describe the Innovation Center?

[00:07:45] Elizabeth Fowler, Ph.D., J.D.: Sure. And I can talk a little bit about why it was created because, like you said, it does go back to 2009 and the debate over the Affordable Care Act. And I think, at the time, there were a lot of members in the Senate, where I was working, who wanted to find ways of bending the healthcare cost curve and just as many members that wanted to think about healthcare spending as wanted to address the uninsured and expanded health coverage. And as staff, when we looked at policies to reduce health spending and increase quality, there really weren’t enough ideas on the table that had been tested and could be implemented. And so the idea was to create this center that would generate and test new approaches for payment and delivery system reform in Medicare and I think, to a lesser extent, Medicaid. And if they worked, they could be spread across the program. So were there ideas out there in the private sector that had been tried and tested that we ought to think about in Medicare? I think that was the impetus for the creation and the rest is sort of history. The idea is to move our system away from fee for service and towards a system, a health system, that rewards value and better outcomes for patients. So in the last 10 years, we’ve launched more than 50 alternative payment models and initiatives, but only a handful of those have really generated the statistically significant savings I think that we might’ve envisioned when the Center was created. And so after joining in March, what we’ve done is spent a lot of time looking more closely at those lessons, what we’ve learned from those 50 plus models and how we need to focus our efforts going forward for the next decade.

[00:09:21] Gary Bisbee, Ph.D.: So, what are your priorities then that came out of your review and you’re thinking about going forward?

[00:09:27] Elizabeth Fowler, Ph.D., J.D.: Well, we came out thinking that our vision for a health system is one that achieves equitable outcomes through high quality, affordable, person-centered care, and we landed on five strategic objectives based on a lot of the lessons learned. First of all, driving accountable care. It’s really the central goal of the Innovation Center to increase the number of people and patients in relationships with providers that are accountable for their costs and for improving their care. And this means doubling down on primary care and accountable care organizations, those sorts of total cost of care models. And I’d say number two is advancing health equity. I think if there’s one thing we’ve learned during the pandemic and over the last couple of years, it’s really the need to have a very focused effort at reducing disparities and advancing equity. And I know that term isn’t always familiar, but we’re really looking at a very concerted effort to build equity into everything we do supporting innovation, looking at ways we can innovate care delivery approaches. You know, what do providers need to succeed in alternative payment models? Address affordability. This is mostly thinking about patient’s affordability, for example, prescription drug costs, focusing on high value care, and eliminating low value care. And then I think the last area we’re really focused on is partnerships to achieve transformation. We really need to be working more closely with private sector payers. Medicare, I think, is a leader and the system isn’t going to change without Medicare, but we also need to be working in tandem with other commercial payers, purchasers, states, even beneficiaries if we really want to achieve our vision,

[00:11:14] Gary Bisbee, Ph.D.: Yeah, it’s a terrific lineup, the five priorities. Going back to number one, what about a total cost of care model, like let’s say, Maryland. Can the Innovation Center promote that sort of model?

[00:11:26] Elizabeth Fowler, Ph.D., J.D.: Maryland is unique. And you’re right. We have a sort of all payer approach to hospitals and we’re moving more fervently into the primary care space. And Maryland is unique because they have a history of this sort of total cost of care approach, and particularly, their all payer hospital approach. We are looking more at the population level, at the patient level, so ACO type approaches. So when we talk about total cost of care, we’re really thinking more about those sorts of models.

[00:11:53] Gary Bisbee, Ph.D.: Obviously fee for service is at the core of our health system. Changing that is hard, turning a great big super tanker around, right? So one of the things that I wonder about is the timing of the various programs that the Innovation Center will undertake. And what’s the expectation of providers, consumers for how long it’s going to take to show results? I worry sometimes that expectation is that you can undertake a program and next year you’re going to show results. Clearly it takes longer than that. But how do you think about the expectations for showing results from the various programs, Liz?

[00:12:36] Elizabeth Fowler, Ph.D., J.D.: Well, you’ve put your finger on one of our biggest challenges, which is that people want results and they want them quickly, but it doesn’t always work that way. And the tanker analogy is a good one. You know, it’s taken us 10 years and we’ve thrown a lot of spaghetti against the wall and, you know, I will say one thing I have learned in this job is that healthcare transformation is a marathon. It’s not a sprint. Even just the time it takes to put a model into place, it’s not a quick turnaround process. It takes about 18 months to two years from the time we conceptualize what sort of model we want to invest in and run, and by the time it’s implemented and launched. So it takes time to launch the models. And then, you know, it’s gonna take three to five years to start to get results back. So for those out there expecting this sort of immediate turnaround, it’s challenging to have to explain that to some of the leadership why things aren’t happening more quickly.

[00:13:25] Gary Bisbee, Ph.D.: Yeah, I’m sure of that. I know you’re interested in listening and, to the extent you can do it with COVID conducting something of a listening tour. What are you hearing from various constituents about the importance of innovation and sorts of innovative attempts or innovative projects that you might undertake?

[00:13:47] Elizabeth Fowler, Ph.D., J.D.: Well, I’ll tell you one thing we have heard is that our models can be complicated and that some of them overlap. So what we’ve heard from some of the larger health systems is that they’re trying to run a number of different models and sometimes the incentives conflict with each other, if you will. So it’s really part of why we’re trying to hone in on the things that work and really think of the portfolio and manage this portfolio of models in a way that’s harmonized, where they interact and work well with each other instead of competing. There’s a lot of enthusiasm for moving to value based care, but I’d say some of that enthusiasm has waned maybe in the last few years. That it felt like we were drifting back towards the status quo a little bit. And so, you know, I see that as part of my job in this role is to sort of reignite that enthusiasm that, yes, we are moving, you need to get on board, and here’s the direction we’re going, and we want you to be part of the journey. And that’s why it’s so important to hear why some providers either joined the models and dropped out or never thought to join in the first place. So we really need to understand a lot of those dynamics. How do we make it possible to get more providers, systems, payers into the models and being part of our process then have been in the past.

[00:15:00] Gary Bisbee, Ph.D.: Well, COVID has disrupted a lot of thinking. And it feels like, from the standpoint of providers and possibly the payers, that every day is just getting through the COVID experience. And hopefully we’ll be through that to the point where we can focus more on value and you can have you know, an impact at that point.

[00:15:21] Elizabeth Fowler, Ph.D., J.D.: Well, Gary, to all the listeners out there who are at the front lines of healthcare, we owe you a debt of gratitude. It really has been a long, tough two years, and I think there’s a reason that people haven’t really been focused on value based care in the face of a pandemic. But I will say, I guess from maybe it’s you know, the glass half full perspective. I think, you know, those of us at the Innovation Center are hoping that this will provide some momentum for value-based care because those providers who were part of a coordinated care arrangement, who were part of value-based care, maybe could have seen more resiliency in the face of what we’ve been going through the last couple of years. If they had the systems in place that were speaking to each other, the care coordination, the connections with patients that you see in some of these models. So we’re hoping that might reignite some of the interest in going down this path when we’re past the pandemic, of course.

[00:16:14] Gary Bisbee, Ph.D.: Yeah. I mean, I agree with that. And I don’t know if it’s within the province of the Innovation Center, but there’s probably several ideal case studies that could be written just on the point you mentioned that would raise visibility to providers. I know those health systems that operate a health plan, for example, definitely have fared better in terms of continuum of care and financial arrangements, and so on. A lot of people worry about the Medicare trust fund being depleted at some point in the near future. There’s still, what, 10 to 15, 20 million baby boomers that aren’t even on Medicare yet. So there’s going to be an increased cost pressure. Is that kind of a galvanizing fact that you can use to recruit more people into the Innovation Center programs or are people not focused on that?

[00:17:08] Elizabeth Fowler, Ph.D., J.D.: Well, you know, I think back in 2009 and 2010, during the Affordable Care Act, when we were able to push the solvency date back a number of years, I think we had more time and that if we were able to move the system towards value, it would mean that we’re paying for care that’s more efficient in a more efficient way, that we were bending that cost curve and seeing those better outcomes. I think, now that we see that it is this marathon journey that we’re on and not an immediate turnaround, I think we have a more immediate crisis. I think the solvency date is now 2026, which is, you know, a little bit of a reprieve. Some of us thought it would have been 2023, which would have been an immediate immediate crisis. But the way that, you know, the way that I think about solvency having worked on the committee that, that had jurisdiction over thinking about solvency on a pretty regular basis, you know, if you wait until the last minute to solve your problems, you end up with this sort of meat ax approach, where you do sequestration and everybody gets cut. And it doesn’t matter whether you were doing a good job providing care or a lousy job, everyone’s going to get the same cuts, versus thinking about, you know, this longer-term strategy towards more efficient, better care delivery, more cost effective care delivery. It’s a better way to try to curb spending over the long run. It’s just that we’re running out of runway. So yes, I hope that this reignites some of the interest, but I also realize that might be a pipe dream.

[00:18:31] Gary Bisbee, Ph.D.: You make the practical point that we’re not really very good at history. We’re not good at looking back and learning, and we’re not good at anticipating either. So hopefully wiser heads will prevail here. You mentioned your five priorities and you went through a review to establish those. Does that mean that you’ll be rebalancing the portfolio of projects for the Innovation Center?

[00:18:57] Elizabeth Fowler, Ph.D., J.D.: You know, I think we’re taking a look at where we’re investing in models. And I think we’re looking at them differently in terms of how we decide which models to pursue. I think we’re making sure that they’re aligned with the bigger picture and aligned with the strategy. And I think we’ve set forward, now, a new process for how we’re considering some of those models. So, on average over the last 10 years the Innovation Center has launched, I’d say, three to five models a year. We’re currently running 28 models, around about there. You’re not going to see an immediate turnaround in what we’re doing, but I think hopefully over the longterm by the time I leave, you’ll see the clear picture of the direction that we’re having. I think we’re in a little bit of a transition, though.

[00:19:40] Gary Bisbee, Ph.D.: Yeah, well, that’s good. I think it’s terrific, as a matter of fact. Hey, it’s hard, it’s hard, to anticipate and one thing with your time in Congress, I mean, it’s very difficult to pass legislation that has totally the effect you think it’s going to have because healthcare is just so complicated. You just can’t tell at any point how it’s going to work out. In that case, or in that respect, what about risk and how do you think about risk, particularly in terms of providers taking risk versus employers versus consumers? How do you think about risk Liz?

[00:20:20] Elizabeth Fowler, Ph.D., J.D.: That’s a good question. And Gary, I just have to say you’ ve put your finger on a lot of sort of key points that we grapple with, so, you really understand these issues well. You know, I’d say when it comes to providers, there is a legitimate disagreement within the provider community and even within the administration on whether bearing downside risk is necessary to make progress. And I appreciate when there’s disagreement because I think it’s a chance for better dialogue. And I think both perspectives are important. Personally, I think it’s important for providers to bear risk in order to make the changes that we’re seeking. But I also see that not everybody’s ready to do that, and we can’t push everyone into a place where they’re not ready. We don’t want them to be unsuccessful right out of the gate. I think that would create a really negative dynamic. And we also have to think that not all providers are in a place where they have the resources or capacity to be able to invest in this direction. In my view, the Innovation Center has to be providing those opportunities at the very high end of risk for those innovators, those disruptors, who want to come in and change things. But we also have to provide a pathway for those who want in the front door and ease them into this direction. So I think we’ve got to do both things well, so we don’t have to answer the question of whether risk is necessary, as long as we’re providing these opportunities and these options for both ends of the spectrum.

[00:21:45] Gary Bisbee, Ph.D.: Right. It’s clearly on the opposite spectrum from fee for service. As you’re saying, there’s the whole working up to risk to be carried by the providers, at least, because it’s just an entirely different model. But hopefully you’ll be able to encourage more providers to not be afraid of it and carry it. Another question that comes up is mandatory involvement course. And so I’m sure you’re hearing both sides of that issue as well, but where are you at on that, Liz?

[00:22:17] Elizabeth Fowler, Ph.D., J.D.: Well, that’s another area of legitimate disagreement. I’d say if you look at a lot of our models, most of which have been voluntary, you end up with some level of risk selection, either who comes to the door and joins, or who stays in the model. And as a result, a lot of our models haven’t demonstrated the savings that we had anticipated. On the other hand, mandatory models can be controversial and we’ve certainly had a lot of pushback when we’ve tried to move in that direction. We’ll try to push the envelope and see how far we get. I think some believe it’s absolutely necessary and some are a little skeptical. So another legitimate area of disagreement where we’re, you know, in those discussions on a daily basis,

[00:22:58] Gary Bisbee, Ph.D.: I think some of the previous projects would suggest that without mandatory being part of it, it’s just hard to show results. And so maybe data or evidence will help move people down the path there. What do you think about the whole patient at the center, which is a number of different terms to describe that, but I think we would all agree and most of the providers I know would agree, that the system really was set up more kind of by providers and for providers than it is for consumers, or customers, or patients. A lot of the providers that I talk with really have articulated that as a very important priority for them. It’s hard to change a kind of fee for service model. But how do you think about that Liz and your five priorities? How can you incorporate more attention to this patient at the center?

[00:23:57] Elizabeth Fowler, Ph.D., J.D.: If you look back at where the goals of the value-based care movement have been, it’s been about getting providers into APMS. The goal shouldn’t be to get providers in APMs if that doesn’t result in better care for patients. So I think what we’re trying to do is turn this a little bit back onto the patient and say what’s really important is for that patient to receive coordinated care in a way that leads to better outcomes and you know, more attention to, you know, the conditions that they’re facing, thinking about the outcomes that are important to them and the quality metrics that matter to patients. And as we were undertaking this strategy, we realized that, just, as you characterize, we spend a lot of time talking to providers, to health systems, to payers and purchasers and states, but we have not spent a lot of time talking to patients. And so we actually did focus groups around where we were leading with the strategy, and the terms don’t mean that much to patients or to beneficiaries.You know, accountable care, health equity. Like we talk about these things in a way that isn’t really meaningful to patients. So I think not only do we have to incorporate what’s meaningful to patients in the way that we’re doing our work, but we also have to be able to explain what we’re doing in terms that people can relate to. Wouldn’t you be happier if someone was paying attention to you after you left the hospital, to make sure that you had home care if you needed it, that you were making follow up appointments, that you were taking the medications, that all of this is really geared to putting the patient at the center of care, which I think is what providers were trained to do. So hopefully this brings them all back to where they felt like they were moving in the first place when they decided to take up a career in medicine and healthcare.

[00:25:38] Gary Bisbee, Ph.D.: We definitely hear from the caregivers that more opportunity to actually provide care would be desired. When you were doing the conducting of focus groups, how did virtual care and home care fair? I mean, did they articulate that whether you cut through the acronym issue, but did they articulate that as something that they wanted?

[00:26:02] Elizabeth Fowler, Ph.D., J.D.: Well, I think now in the pandemic, it’s become a much more practical and important part of care delivery. But I would say that you know, not everyone said it was a substitute. I think they still want that in-person interaction with their provider. And once we get past the pandemic, you know, maybe these means of virtual care are an option, but I don’t think it’s a substitute for actually sitting face-to-face with your doctor and sitting on that examining table the way that it’s been done in the past. So I think it’s a supplement, not a replacement.

[00:26:31] Gary Bisbee, Ph.D.: Yeah, I think that’s right. And perception of illness is really important, right? If it’s more of a minor thing, then virtual care is probably right. I’m sure you noticed that age came into that. I mean, if I look at my daughter, she would definitely overweight toward virtual care. If I look at my wife? She’d probably actually want to go in and see the doctors. So, you know, the age part of that might come into play as well.

[00:26:59] Elizabeth Fowler, Ph.D., J.D.: A lot of our focus group beneficiaries were in the Medicare population.

[00:27:03] Gary Bisbee, Ph.D.: Yeah.

[00:27:03] Elizabeth Fowler, Ph.D., J.D.: That is true.

[00:27:04] Gary Bisbee, Ph.D.: Yeah. What about Medicaid and CHIP in terms of, just thinking about health equity, that’s one way to kind of address the gaps, so to speak. So with the programs going forward, will you definitely want to integrate with Medicaid and CHIP?

[00:27:22] Elizabeth Fowler, Ph.D., J.D.: We do. It’s a complicated question because if you look at the statutory authority for the Innovation Center, we have a lot more ability to waive rules and regulations in Medicare than in Medicaid. And that was by design. We work closely with our counterparts in the agency who run the Medicaid program every time we want to do a Medicaid model. But I think the way that we’ve been doing Medicaid models hasn’t necessarily been successful. It’s, we want to do this, here’s our model, here’s the start date, you know, come join us and we’ll maybe get, you know, 5, 6, 7 states to join us, but it takes a lot on their part and I’ll tell you, just to be honest, some of the feedback I’ve gotten from the states that are participating is, it’s kind of a pain in the neck. You guys got all these requirements, it takes a lot of time and money, and we’re sort of short-staffed, you know, at the state level. We don’t have the, you know, the focus and the staff to be able to do what you want us to do, and we’ve made it really challenging. So I think, you know, we’re looking at new ways of working with states, in some ways, thinking about a multiplayer alignment, like maybe the state is part of an actor. You know, this goes back to maybe what you were talking about, the Maryland model, you know, where Medicaid and the state is, is one actor, but so are the other payers, and the states, and the purchasers, and Medicare along with it.

[00:28:37] Gary Bisbee, Ph.D.: This has been a terrific interview, Liz, I must say you have a refreshing practical view built into your rich health policy background. I don’t know if we can attribute that to your days in Wichita in the Midwest or that’s just the way you are, but it’s terrific. What would you advise a young person that was interested in public policy or health policy, and interested in a career in public service? What would you advise them, Liz?

[00:29:06] Elizabeth Fowler, Ph.D., J.D.: Well, nothing makes me happier than hearing about someone earlier in their career who has an interest in public service. And there are so many paths to a career in public service at the state level, at the federal level, even at the local level. And so many different avenues to get there. And I think, you know, look for what interests you, what areas of interest. If it’s healthcare, is it Medicare or Medicaid? Is it home care or hospital care, institutional care? Is it the tough policy questions or is it sort of these political questions and sort of how you solve problems at the legislative level or the administrative level, but there are so many different opportunities and so many places to really have a very rewarding and meaningful career where you feel like you’re making a difference in people’s lives. So anyone that’s interested in public service, I applaud that.

[00:29:55] Gary Bisbee, Ph.D.: Yeah, for sure. Just generally given your background, what advice would you have for up and coming leaders? No matter the sector.

[00:30:05] Elizabeth Fowler, Ph.D., J.D.: I would say, you know, you’re at your best and your most successful when you’re happy and you’re engaged, and you love what you do. And if you wake up in the morning and you think, oh God, I got to go to work and I really, you know, I just, it’s not rewarding it’s, you know, then you need to find something else. But if you find that job and you find that career path and that position that really excites you and you feel like you’re making a difference in the world and you’re happy, engaged, you feel valued, and you’re contributing, I think that’s when you’re able to perform at your best and you’re best as a leader in that circumstance as well.

[00:30:39] Gary Bisbee, Ph.D.: Great advice. Liz, I’m delighted that you’re there as the director of the CMS Innovation Center. You’re doing a terrific job and we’ll give you a solid thumbs up. Thank you for being with us today, Liz.

[00:30:52] Elizabeth Fowler, Ph.D., J.D.: Thanks so much for having me. I really appreciate it.