Doug Wolfberg: EMS Offload Delays (3/21/2023)

And we always appreciate that. So, Doug, thank you for that. And today what I asked Doc to come on to speak about was this issue that we have in ems, which I think is going to get worse. And I would love to hear Doug's opinion on this as he's speaking. But this Wall time issue I think is reflective of what's happening in the hospital. With the nursing shortage, a lot of people leaving the profession and the hospitals are struggling. So then it ends up on us. And then we. We need to determine what needs to be done on our end from the legal perspective, from a practical perspective, from a CMS perspective. So, Doug, I'm going to turn it over to you. I really appreciate you coming on. You've been such a great friend. I think everyone knows you already here on the call, but if you wanted to give a quick intro and then take it away, we appreciate you.

Sure. Thanks, Peter. My quick intro is my name's Doug. I'm a lawyer and I'm here to help you.

No doctor believes that, but no, it's true. I appreciate that. And we've been really privileged to work with Dr. Antevi in a number of capacities over the years and really enjoy talking with this group. I think we've had the opportunity to do this before, so it's great to be back and share some thoughts on this. So I've been debating about whether I'm going to flip on death by PowerPoint or not. I think I'm just going to start talking and, and maybe we can take some questions and get some dialogue going. But I know first off that some of you may wear multiple hats and you may see this problem from both sides. Being in the ER and being in the EMS agencies, I will say a couple of things up front. I am an EMS attorney. Our clients are EMS agencies all around the country. This is probably going to have a decidedly pro EMS flare. It's not meant to be an anti hospital. This is not bashing. But folks, at the end of the day, this has to be collaborative. And I just want to say that at the very beginning, yes, I'm going to talk about some things that I think EMS can unilaterally do that they can take upon themselves to do. And they don't need anybody's permission to do these things. However, this is a collab, you know, this has to be addressed collaboratively. This is a problem across the board for the healthcare system. And just because I'm going to talk about some laws that I think are very much in EMS's favor, in this issue, it doesn't mean we don't have broader responsibilities to the system and to our patients.

And I just, I always like to start this talk off with that. This is not an adversarial thing. That said, a lot of hospitals are abusing a lot of EMS systems with incorrect interpretations of the law that are primarily expressed as, you must stay here with this patient until we tell you you can leave until we release you. And that is the big balloon myth that we are going to pop here today. And so when I talk about collaboration, that has to start with a level playing field, right? Collaboration is the goal, but it's not collaboration if hospital administrators and hospital clinicians say your EMS practitioners are not allowed to leave until we tell them they can. Well, let's get the law understanding correct and then we can collaborate. Let's not collaborate from a position of, you know, the hospitals sort of coming at this from we tell you when you can leave, right? That's not how we start a collaboration. So anyway, so the playing field has to be level. The second thing here, I think, which is key is, is that this is an issue primarily of federal law, right? We all know emtala, and this is really the law that governs this situation. And, folks, this is not to take away from the problems that hospitals have with staffing. This is not to detract from the burdens that emergency departments face every day in overutilization as primary care sources. You know, all the abuses that take place in the er. You know, this is not to take away from any of that. But what this is, folks, is plain and simply, every unit hour or portion of a unit hour that EMS spends caring for patients inside of hospitals are unit hours and portions of unit hours that those ambulances are not available for response in the community. And that has its own set of cascading consequences and problems that really the net effect is transfers these hospital problems, as regrettable as they are and as maybe unavoidable as they are, it transfers those, those hospital emergency department problems and makes them ripple into the EMS system, right? So EMS staff subsidizes hospital operations because now our caregivers are providing care and monitoring of hospital patients even after, you know, we've arrived at the emergency departments. So that is a cost structure, if you want to put it in terms of economics, that EMS reimbursement rates are simply not made to bear, right? That unit hour downtime for extended handoff delays is not baked into the cost structure of ems. It's unsustainable. We can't we don't have the people, we can't afford the overtime. We, we can't afford the units out of service. Right. So there are all of those issues that we feel for the hospitals that have these problems. But we cannot let, as system stewards, you know, we cannot let that problem cause sustainability issues for EMS systems. So that's first and foremost. Now let me switch to the law here for a second because it's what I do. I'm a lawyer.

Right?

Under federal law, EMTALA makes it very clear that the hospital's duty to the patient is triggered upon arrival of the patient on hospital property. Hospital property is actually more than just the emergency department. There's a very convoluted definition of hospital property in the federal regulations that comes from a bad case in Chicago that essentially says it's the main building, adjacent buildings, and anything within 250 yards. So not only is it when we physically get to the emergency department with that patient, but really that EMTALA duty of care applies when that patient gets within 250 yards of hospital property. That is, and I conceptually think of this as a legal transfer of care. So there's a legal transfer of care and a physical transfer of care. Legally, it is indisputable black and white federal law that that patient becomes a hospital patient upon arrival at the hospital's property. Certainly once we get into the emergency department.

Right.

Now, we have been told from clients and others across the country that.

Well, EMTALA may say what EMTALA says, but it's abandonment. If you leave before we, before we take over. Well, let's look at that. So first of all, abandonment is one of those terms that people know what they think it means and have absolutely no clue what it means. Right. And it's a very inexact term. It's really a form of negligence.

Legally, it's very difficult to say that party a EMS committed abandonment when it delivered to a higher level of care a patient whom that hospital has a legal duty to take upon our arrival. Right. So I'm sorry, we took them to a higher level of care. You had the legal duty upon our arrival on your property and we abandoned the patient. So as a matter of law, I think that's a very specious argument, as we might say. And I always like to turn that around and say, okay, so if the hospital argument is we commit abandonment because we don't physically stay with the patient the whole time until you accept care, what are you doing with all the patients that you stuck in the waiting room for three hours, you're abandoning them as well because you're not assigning caregivers to each of those patients for the entire course of their time in the waiting room, right? So this idea that clinically we have to stand with these patients and cannot leave them is a fallacy. Now we know statistically, folks, all of you know this, that the percentage of patients that truly are critical and require advanced interventions is probably less than 10%. You know, it's probably in the 7% range. I'm not talking about all the, we started an IVD5W just because, right? I'm talking about truly medically necessary ALS interventions and critical or serious patients. So if we leave those patients upon, you know, we leave them, we report to the hospital, we give them the information, we leave it on a piece of paper, we tape it to their forehead, you know, whatever, but we give them that information and the patient is statistically extremely likely not to have any, to not suffer any adverse outcomes because we didn't stand by them every hour until they got care in the emergency department. The vast majority of patients will just statistically not have any adverse outcomes for that reason, right? Because the low acuity, they're not requiring advanced constant interventions or monitoring. They're really essentially no different than the patients who are sitting in the waiting rooms now, the ones who do require care and the hospital simply can't assign somebody to them. Let's not forget about the tort duty of care. So EMTALA is one thing, but personally I don't want to defend an EMS caregiver who listened to one of these lectures and said, Wolfberg told me I could leave, I'm out of here and the patient's in cardiac arrest or whatever, right? So we have a tort duty of care, I think, which is separate and apart, but that's our problem. That's not a basis for the hospital to say we can or can't leave, right? So I think medical directors should work with the agencies that are in their charge. As medical directors, we can develop protocols, we do it that, you know, you guys do it every day that differentiate between patients who are sick and patients who aren't, patients who can refuse and patients who can't. We're getting into telehealth and alternative destinations and non transportation. We can easily, I think you guys can all put together protocols that enable the EMS providers to distinguish between those patients for whom, just as human beings, we should stay and provide care to. That's going to be a small percentage and Those should be clinically determined decisions. We can't forget our patient care obligations, regardless of the legal entanglements of whose patients who. But for the vast majority of the time, those patients are not going to suffer adverse consequences. We can have clinically defensible protocols that allow us to make those determinations in a medically defensible way. We can do follow up on those. We can QA those, we can treat them like any other clinical decisions that we make. And I think we're going to find to a high degree of safety, specificity, accuracy, all those measures.

That we are simply not killing people when we leave those low acuity patients to keep our EMS systems running. And honestly, when people talk about the liability of leaving a patient, folks, I am worried about the liability of EMS systems not being responsive to the calls in their community because we were too timid to have clinically defensible policies that back up these decisions to say we're out of here. Right? We knowingly are allowing our EMS systems to be sabotaged and to fall short in meeting the needs of our communities. That's a clinical responsibility too. And I think we need to flip the script when it comes to the discussion about these overblown, baseless fears of liability if we leave low acuity patients when everybody in that waiting room again is not benefiting from continuous monitoring by a clinician. I just don't think our low acuity stretcher patients, quite honestly, should be classified any differently.

Can I just jump in real quick?

Yeah, yeah, sure.

Would you mind also addressing the hospitals who close their doors for 12 hours, eight hours and say we're on diversion? Can you talk about that real quick? And I see, I know Dr. Pepe, who's written papers on this, probably wants to make some comments as well, but would you mind addressing that one first?

Yeah, sure. So federal regs are pretty clear about hospital diversions as well. First of all, hospitals do have the right to declare diversionary status only when those hospitals lack staff or facilities to accept emergency patients. So the first thing is those can only be resource based. And if the hospital's out of beds and out of people, that's a legitimate reason to issue a diversionary instruction. However, in the very next line of the federal regulations, what we call black letter law, it says if the EMS staff disregards the diversionary instruction and shows up on hospital property anyway, the hospital's EMTALA duties apply regardless of whether or not that hospital had given that diversionary order or not. So at the end of the day, diversionary instruction Are really requests now, folks. Again, Wolfberg said, great, but if I'm being told that it is not clinically appropriate to bring a patient to a hospital because we are getting slammed. Your patient needs immediate care. We can't provide it. I'm not going to barge into that ER just because a lawyer told me I can. We still have a responsibility to make clinically appropriate decisions. That is one that should be taken into account. However, if we then show up on hospital property, the issuance of the diversionary instruction is irrelevant. The duty applies.

Okay, that's great. That's a very good explanation. Paul, did you want to jump in at all before Doug continues?

Can't hear you, Paul.

You're on mute.

Yeah, yeah. Not. Let him continue, but did you get my emails that you could put in the chat?

I was, I was looking for that. I'll look for them and I'll do that. That's what I was looking for a minute ago.

Yeah, two things is that. One is that. Just want to make sure Everybody gets the CME number for today, which is 17340. And. And then I sent the stuff that the CMS uses. And so. And I'll make a comment later if I. If we get finished in time about that. We don't work for the hospital and we'll talk about that later. But go ahead.

Done. Thanks, Dr. Pepe. Okay, couple of other things here.

Real quick.

Let me just spin out some EMS solutions. And again, I. I may be the contrarian or whatever, but, you know, again, I think we need to sort of flip the script about how we look, how, you know, you guys all look as the clinical leaders of EMS systems. You know, and this issue, like I said, of abandonment of patients is really the non issue. It's the red herring. And I think we're missing the obligations to our communities and our EMS systems by not really kind of asserting ourselves for the benefit of the system, for these, you know, again, misplaced notions of abandonment for somebody who is now clearly the legal responsibility of the hospital.

Okay, so we, we do advocate some solutions here, folks, for ems, EMS agencies in this problem. First of all, there is no reason, none whatsoever, that an EMS agency or an EMS organization can't, on its own, unilaterally implement a policy that it provides to its hospitals, its local receiving facilities that basically says what I've been saying here, that, you know, here is our policy that we expect to turn around these incoming units within, you know, 20, 20 minutes, 90% of the time, or, you know, whatever.

And in those situations, where it is clinically necessary to provide continuing care, we'll do that. These situations include the following. These will be continuously updated with medical, you know, evidence and that kind of stuff. But make it clear that that's the exception and not the rule, and that the hospital can make the request. We do not have the obligation. And then beyond that, I think if an EMS system has that capacity and wants to provide that staffing, there's also no reason that you can't enter into an agreement with the hospital to pay for that staffing and that time that your folks spend providing that care for those patients inside the hospital. And we do have a document out there on our website that's sort of a template sample agreement and a sample policy for those purposes, because this is an economic issue as well as a clinical one. And there's no reason EMS systems shouldn't be paid if they do choose to devote staff time to monitoring patients once they're inside the hospital.

So we can adopt policies that have that clinical component about making those stay versus non stay determinations. We can shift the economics because this is really auxiliary hospital staffing, if you want to think of it that way. And frankly, I have a concern under the anti kickback statute that if you're an agency that also gets non emergency transport referrals from that facility on the other end, if we're giving them free staffing on the ER end and then getting discharge referrals on the back end, that's a bit of a classic anti kickback conundrum. So you have to look at the totality of your business arrangements for your organization and you know, be very mindful that there is significant value in that monitoring that we provide in the emergency departments if that's something your agency gets.

Does.

And then lastly, let me just say I think that there's a strong argument to be made to stop feeding the beast. And what I mean by that is that we, I think as a system should be practicing, you know, deployment methodologies and practices that not only better differentiate calls for which, you know, traditional EMS deployment isn't even necessary, whether we can handle that through Omega or nurse triage or that sort of thing.

And then employ methodologies that once we get on scene and lay eyes on what appears to be a low acuity patient through telehealth, through non ambulance transport, through alternative destinations, we should really rethink the paradigm that every person who calls 911 gets a ride to a hospital. We are a healthcare service, not a transport commodity. And you can't walk up to a pharmacy counter and say, I could use some, you know, narcotic analgesics today. Great. You know, we still have to have a clinical rationale that a physician determined was appropriate and wrote in a prescription. Just because I call and want that transport to the hospital doesn't mean I'm entitled to it. And that's another paradigm that has to be flipped where those are clinical decisions and not entitlements that everybody gets simply for playing the home game version of VMs.

So I just think that's a paradigm flip that is a little bit more evolutionary than revolutionary. But it's a piece of this. And I didn't want to finish without saying it, so I wanted to leave some time for some more dialogue and Q and A. But, Peter, do you want to lead us through that?

Absolutely.

You make really some wonderful points that I think many of us are dealing with. And actually, let's go to Kim Landry before I ask my question. Dr. Landry up in the panhandle, you have a question. Go ahead, unmute your microphone.

Oh, boy, do I. All right, so actually, I'm a present. I'd like a point of clarification and I have a question. Point of clarification is I've got an ambulance service that services a rural community. So we don't. We have limited resources. We transport patients to the adjacent county, and inevitably we're held at the wall for three plus hours. And it could be anything from a minor low acuity to actually having chest pain on a cardiac monitor. And yet this hospital persistently offloads ambulances in their own county ahead of hours. And I get calls at 2 in the morning. They're on the wall, four and a half hours. And what should we do? I often instruct them to go ahead and find an empty stretcher or offload the patient, go put it in front of the nurse's station, leave a short form and ask them to give you a call when they're ready for report, and then you get back in service because you've got a county to cover. So that's number one. But number two, would it be inappropriate if our EMS crews offered to a patient that we delivered to a hospital and we're on the wall for three hours to offer them, to transport them to an alternative facility that they may be seen quicker?

Well, first of all, bravo to you. That was almost word for word something I would say in the longer version of this presentation, which is leave a short form. Leave the patient anywhere that is reasonable and safe for their condition. Let the hospital know that you did that and be on your way. You are absolutely within your rights to do that. No questions, ifs, ands or buts. And I strongly believe that more EMS agencies should do that. This is not a mother, may I situation. I think unilaterally taking that action is completely appropriate to protect the integrity of your system. And Dr. Landry, I applaud you for that leadership. Secondly, the idea of offloading patients by priority, I think is an outright wholesale EMTALA violation. And I mean priority of in county versus out of county, not by clinical, clinical condition. Look, the hospital has another duty under emtala, and that is to continuously assess and re triage if necessary. All the people that are in that emergency department, if there's three beds occupied with the sniffles, and I got three chest pain patients, they damn well better bump them up in the priority chain. So that is a continuing obligation that the hospitals have, the EMTALA guidance. Lastly, I'll say also very clearly says, if asking EMS to stay with the patient is your solution hospital, you have a duty to assess whether or not EMS can appropriately manage that patient condition for the period of time you're asking them to do that. So it sounds to me like a lot of those black and white duties that are clearly in writing right now are being violated with that kind of sort of discriminatory or differential offload policy.

Doug, are you having agencies, you know, to all the things you're mentioning now, are you having agencies coming to you, trying to kind of lock up their policies from a legal perspective? Because I think all of us have all these ideas. Paul's been talking about this for quite a long time. Angus has been talking about, you know, having a lawn chair and leaving the patient there. Is it smart for the EMS system to connect with someone like you or your firm to make sure that all the policies and procedures are tight before we do such a thing?

What are your thoughts?

Yes. Yeah. And not. I mean, thank you for that suggestion, Peter. We appreciate that because we are doing a lot of these meetings and having a lot of these discussions not only with the EMS systems to develop these policies and ensure that they're ready for primetime, but then to participate in meetings where these get rolled out to their hospital partners and to explain the rationale and the foundation for those policies. And I'll tell you, we've gotten reactions that go anywhere from, you know, wholesale pushback. But, you know, most of the time the rationale is so solid because this is black and white. You know, EMTALA guidance We're not making this stuff up. You know, just real quickly. We had a meeting like that just a month or three ago and the CEO of, you know, Behemoth University Health System was on the call and, you know, of course took, took control of the call, you know, 10 seconds out of the gate and I'm getting, oh, here we go. You know, I'm getting all ready for battle. First thing he said was, yeah, we looked at this, this is solid. We don't dispute any of it. We dropped the ball. This is on us. We got to do better. And that's what we're going to talk about the rest of the day. And I was just like, well, I'm useless here. But yeah, so, no. Both in crafting those policies and rolling them out. One thing, by the way, I forgot to say, in answer to Dr. Landry's question was the patient belongs to the hospital whether they're on the EMS stretcher, a hospital waiting room chair, a seat in the hallway, sitting in the restroom. Right. Hospital property is hospital property, no matter whose bed, whose stretcher, whose cot, whose lawn chair, whose camping cot or whatever they happen to be on.

I see Dr. Pepe has his hand up. Yeah, go ahead. Peter might be frozen, but.

Oh, yeah, okay, got it. Hey, just two things that I, we put in the chat. Some information from CMS that I have a direct ring done to the guy who's in charge of this for cms. Two things he made clear to me. Not only is it their patient, as soon as we go over the threshold, whatever you want to call it, 250 yards or whatever it is.

And despite the fact that we may have feel like we have an ethical obligation to make sure the patient's being cared for in that position. I think that's why we're mostly in this dilemma, because we wouldn't just leave them there for the most part. But the other thing we need to keep in mind, and our lawyers have to keep in mind and our risk managers have to keep in mind on the EMS side is that we are not credentialed to work in that hospital. You may be credentialed as a part time job that you work there, but if you're not on duty there, you're not credentialed to work there. CMS is responsible for the hospitals, not for ems, and so we shouldn't be practicing medicine there if we're monitoring a patient, continue to do an infusion or whatever. So that's an interesting and very compelling point of view that has to be kept in mind in all this, as you do it, we, of course, if you see in the chat, we wrote this up because it was beginning to be a problem when people got into this diversion mode, that it was okay to do a diversion. Hey, Keith, I'll call you back in five minutes. I'm on a call. I'm on a webinar. Thanks. It's Keith Lurie. So anyways, what I was going to say was that there's a stepwise fashion where you first talk to the people in the emergency department. If that doesn't work, then you go up the level. Eventually there's a place where it really goes to the point where you can talk to your city attorneys and sue them for theft of city services. But as David Purse was going to do in Houston a few years ago. But any event, the bottom line is that we try to do it in a very gradual because we do understand their issues, they do have them, but they have solved them. One thing also Doug should know is something very clever that the people in Palm beach did, Charlie Coyle up there and Dr. Shepke and Dr. Anteve and so on in that actually reported the wall times that people are doing at the various hospital. They made it public. They just put it out there and said how long they're there. And that really put a big dent in what was happening because it went out publicly. You know, it was became a public document. So, yeah, it's great after that.

Great, great point. Yeah, that which is measured is improved. And you know, in fact, California has been out front about methodology for ambulance patient offload type time measurement. And there's some good resources on the state EMS agency's website there. But. No, absolutely, we can monitor and track.

That since I have to go. There's one other thing, to be fair, is that everybody says it's the hospital, it's the hospital hospital. There are places and there are, let's say, individuals. You know, like any other system, there's good, good cops, bad cops, or whatever you want to say is that there are individuals who may be hanging out and trying to, you know, you know, make time, so to speak with somebody on the staff or whatever it might be. So some of the systems really do calculate how much time is given and what our folks are doing in that hospital, not just sitting at the wall. Okay. And so just to keep that in mind, too, that we have to be honest on our side as well.

Well, that's, that's true. And I've heard from EMS agency leaders that, you know, sometimes the crews push back about these quick return to service.

Requirements because they. Some of them like the downtime, you know, but. So there is that human capital issue that we have to think about as well. But at the end of the day, I don't think these guys signed up to be sitting around idle in ers. But you're right, there is some of.

That and none of them like it. I mean, great majority of them are. The great majority of them are there to, you know, to take good care of patients and feel really obligated to be there and stand by them until someone takes. Takes care of them. So I'm just saying. But I just. On the general picture, I want to make sure we calculate, we measure all that stuff. All right. Anything else?

Okay. No, I want to bring Angus in so we can get over to your side. So Angus has a state medical director. I know that you've. You've dealt with this situation. You want to make some comments and then we'll flip over to Paul's.

Sure. Thanks, Peter. So, yeah, I take a slightly different tact. I manage it very, very activ. As opposed to just saying, no, divert, whatever. We manage it very actively. We maintain 97% plus 15 minute or less drop times using those active strategies, having the numbers out there. I mean, every single day a report goes out that shows a hospital, any unit that stayed over an hour, and, you know, monthly, weekly reports go out with all of the information. I. I think we have also, by the way, on occasion, particularly during COVID just decided that we are leaving the patient there with a written report. And we actually also call in a verbal report on a recorded line as well to document that. This idea that stretcher patients can't go to the waiting room is somewhat unique to Florida. Many other places in the country, that happens all the time. The majority of the patients delivered by EMS in New York City are labeled as triage appropriate and go out to triage and get triage like any other patient. There's no reason why that can't happen. The medics in Florida, and I think it's a historical kind of thing. It's just not something we do often here or not part of the Florida EMS culture, but certainly that happens everywhere else without any kind of a problem. And then the last thing I had was just actually a question for Doug on a slightly unrelated topic.

Asking for a friend, of course, patient perhaps comes off the roof of a parking garage, hopefully of their own volition, or sadly of their own volition, and ends up with a major traumatic injury. On hospital property. Or perhaps the patient got run over by the valet in the hospital parking lot, again, asking for a friend. But.

Is there any issue whatsoever with not going inside to that er? And instead of. Instead of that, taking the patient directly to a trauma center, assuming that ER's property or that hospital is not a hospital equipped to handle that patient.

Interesting. There is actually a statement in the. It's an appendix to the CMS state operations manual.

Well, obviously that's why I saw it.

Yeah. And what it says is, and I can send this to Dr. Antevi and he could send it around, but it says if a hospital is merely being used as a transfer point, they're talking about what happens if we take a patient to a ground. Ground transport to a hospital only to be offloaded and then offloaded to an air ambulance to go to the trauma center. They say in that circumstance that the hospital does not have an obligation to do the mtal and medical screening examination. And in fact, that could delay definitive care. So CMS has sort of a recognized exception for that. I would say that. I mean, there's also. If the system's EMS trauma protocol would say, do not pass go, you know, do not collect $200, don't stop at a non accredited trauma center, go directly to an accredited trauma facility, that would also relieve that hospital of the obligation to take the patient even if the injury occurs on hospital property. So I think we get the patient to definitive trauma care without delay of a medical screening examination by a non trauma trained ER doc.

Yeah, I appreciate it. I've just had a couple. I'm aware of the one about using their landing zone, but this is the instance where the actual trauma occurred on hospital property. So I've had some interesting discussions with colleagues at hospitals over what their obligation is versus mine.

Yeah, I think the rationale between CMS's existing guidance on a trauma patient being able to bypass a closer community hospital and that AIR guidance that I mentioned all equal the fact that all we would be doing would be delaying definitive care, and that's not in the best interest of the patient. So I'd take that case every day of the week and twice on Sundays.

Awesome. Thanks.

Yeah, of course. And that's why everyone needs to have Doug on retainer, so. Doug, you're incredible. Thank you so much. Let. Let. Let people know how to get in touch with you if they need to. Or, I mean, I could always send out your information. And then I know that you speak at a lot of the national conferences and many of us see you in the halls there. But if you want to give us some parting words. And again, thank you so much for being on the show today.

Yeah, my pleasure. Dr. And TEVI people can just google PWW law and you'll find us and you can link to my email address from our website and we are all over your interwebs as they say, so you'll find us pretty easily. But it's D wolfbergww emslaw.com you can also ping me through Dr. Atevi. He loves to be the messenger for this kind of stuff I'm sure. But we're out there. You'll find us. And anything we can do to help your agencies, please let us know. And and Peter, thanks for the invite. Good to see everybody.

Thanks Doug. You're a wonderful resource and I really appreciate it. Thank you guys. All right, guys, thank you. And Angus will take us over to the other side. Have a good day everybody.