Today we’re presenting The “New Normal” for Managing Medical Office Space, presented by Hall Render with a few guests.

Joel Swider: Thanks, Julie. And thanks so much to those joining the call for investing some of your time with us today. I’m Joel Swider and I’m a healthcare real estate attorney at Hall Render. Today we have a very experienced and distinguished panel here to talk about The “New Normal” for Managing Medical Office Space.

Joel Swider: We at Hall Render have had clients ask for the past year or so guidance about reopening medical office space post lockdown. And the reality is that most of these spaces never truly closed. And so owners and operators of medical office space have really had to learn and implement new procedures on the fly.

Joel Swider: We’re not really concerned as much anymore with reopening or getting ready for COVID, but we’re dealing with operating in this new reality, which we’ve called the new normal that we all have to navigate. So our goal in our discussion today is that whatever your role is in this industry, that you will come away with new ideas, fresh perspectives. Something that you can apply to be more successful in your day-to-day role, as it relates to COVID preparedness and liability protection.

Joel Swider: So I guess at this point, I’d love to have our panel introduce themselves. Julie, could you tell us a little bit about yourself and your background in this topic?

Julie Carmichael: Sure. It’s nice to be here today. Thanks everybody for logging on. My name’s Julie Carmichael, I’m a healthcare consultant in Indianapolis. I have a consulting business that I started about six years ago. Prior to that, I was the chief strategy officer for Ascension St. Vincent in Indiana. And I had responsibility there for all of our real estate and design and construction. So I have a practical hands-on experience in this area. And then I work today with health systems and private physician practices and get involved in quite a bit of their real estates and medical office issues. So glad to be here.

Joel Swider: Yeah. Well, thanks for being here, Julie. Mark.

Mark Theine: Yeah. Joel, thanks to you and thanks to Hall Render for including us on the panel. I’m really privileged to be here, appreciate it. So again, my name is Mark Theine. I’m the EVP of asset management for Physicians Realty Trust. We are a publicly traded REIT under the ticker symbol DOC. D-O-C go by a lot of times. So our portfolio today is about five million in healthcare real estate investments located in 36 States across the country. About 15 million square feet. So it’s really been interesting managing our portfolio through the [inaudible 00:03:00] and then the care nationwide and watching into this, we’ve had different spikes in different regions. So hopefully can bring a little perspective to that, but day in and day out. My role as the lead in the operations team is release asset management, property management, leasing in capital construction.

Joel Swider: Great. Well, thanks again, Mark and Ryan.

Ryan Walters: Yeah, thanks for the invite. My name’s Ryan. I’m our senior real estate manager for Provenance in the Washington and Montana region. Less are a big Swedish portfolio over in Seattle. So we’re across seven States, each area is broken up with a different real estate manager.

Ryan Walters: So today I’ll talk about our portfolio across Washington, Montana. It’s about 275 properties, mostly MOBs, but we have office buildings, industrial, land, and all sorts of fun gifts that people have donated. So I’ll try to talk mostly about the MOB perspective. We have a team of property managers at CVRE and Kiemle Hagood that are really out, seeing what the differences and implementing all these new best practices for us. So try to talk to some of those and what our technicians are seeing. So before this, I was a property manager and broker at Kiemle Hagood in Spokane, I guess that’s me.

Joel Swider: Great. Well, thanks again to our panel and for your time and expertise, by the way if those of you listening today enjoy our discussion. We have three additional ways that you can connect with us and continue the discussion on healthcare real estate. First is to consider subscribing to our podcast, which is called the Health Care Real Estate Advisor. And you can find it on the Apple Podcast app or on our website.

Joel Swider:The second is we publish a monthly newsletter with news and insights related to healthcare real estate. And if you’d like to be added to that list, please reach out to me by email, jswider@hallrender.com.

Joel Swider: And third, I want to let the group know that we have another of these round table discussions similar to this happening on February 25th on healthcare real estate strategy consideration. So it’s sort of an offshoot of today’s discussion where we’ll be talking about the impact of COVID, recent regulatory updates and other trends on the broader strategy discussion.

Joel Swider: So I’m very excited to hear from our panelists. I want to give one or two quick backdrop notes from a legal perspective, because I think that we will find through this discussion that this is really more of a practical issue than a legal one.

Joel Swider: From a legal perspective, medical office space is really distinguishable from inpatient space in terms of the regulatory environment. So any certified provider or supplier that’s subject to survey by Medicare has to comply strict infection control protocols. Those require cohorting of positive or negative COVID patients. There’s a guidance level on surveys for social distancing and things along those lines. But outside of the inpatient setting and outside of the ASC setting, there’s not a licensure or accreditation requirement, in most States anyway, when it comes to medical office space.

Joel Swider: And so even though the guidance is there from CDC and CMS and [Ashe 00:06:25] and the World Health Organization and others, there’s no enforcement mechanism in this setting. So in some ways that’s a good thing because it means flexibility for landlords. In some ways it’s a difficult thing because it means it makes it more difficult to discern a reasonable approach when there’s no requirement.

Joel Swider: The last thing that I’ll say on the legal front is we did some research and found that the majority of States at this point have implemented or are advancing serious discussions around liability shield laws. And those generally protect a business owner from COVID liability so long as they act reasonably and are not negligent or grossly negligent.

Joel Swider: So what I’m hoping that we’ll come away with from today’s discussion is some sense of what is reasonable in this setting so that we can all serve our patients while also obviously avoiding liability.

Joel Swider: So with that as background, the first question that I want to pose to the group is, what are hospitals and other MOB operators actually doing from a facilities’ perspective to manage their medical office space? And maybe Ryan, if you could walk me through from the time somebody drives into the parking lot to receive medical care to the time that they leave what changes in protocols would that patient or visitor encounter?

Ryan Walters: Yeah, and I think my general response to this new normal, I think what we’re finding is if the buildings were professionally managed and following best practices pre-COVID, there’s really been minimal impact. I think there was a lot of unknown upfront of, “Oh no, what else are we going to have to do?” But I think we found our best practices have held true through this.

Ryan Walters: We obviously have more coordination, more PPE and some extra signage, but when a patient comes in, you’ll probably see some tents at some of our MOBs for testing facilities. So you might have to find a different parking spot. And I guess you’re used to. You’ll probably see some signage on the building entrance and maybe some directional signage on certain doors to enter or not enter. Please wear masks, social distance.

Ryan Walters: Often though when you walk into our lobby it’s the same friendly face. They’ll just have a mask on. You’ll probably see furniture spaced out a bit more in our waiting rooms. I think you’ll probably see less people in those waiting rooms. Trying to get patients back to an exam room as quick as possible. And we do have less people in our buildings. So it’s a much more coordinated effort. When vendors need to come onsite our technicians or property managers are meeting them at the front door, escorting them into the facility and getting out as efficient as they can. But other than that, for the most part, I think that’s what you’re going to expect to see.

Joel Swider: And Mark or Julie, I know when we talked earlier, you said there were some jurisdictional related items too, that you having a portfolio for example, Mark, that is in multiple States, you might see some variation in that. Any additional thoughts?

Mark Theine: Yeah, absolutely. Certainly. It’s going to be a customized approach based on the size of the building, location of the building geographically, climate, things like that. I guess even taking a step back it’s amazing that, I read an article this morning on [Axial Self Care 00:10:02], that one year ago today there were about 2000 confirmed cases of COVID and most of which started in China, of course. And there was just a handful in the US.

Mark Theine: So I mean what a ways we’ve come in just one year’s timeframe. And I’m really proud that within our company, we sent out our first communication to our healthcare partners around the country at the end of January of 2020, just about the importance of good hygiene. And if you’re feeling sick staying out of medical office buildings. And then obviously we got into March and pandemic started spreading a little bit faster and the awareness of what was coming at us increased.

Mark Theine: And within our team we formed our own COVID task force at that time. And we developed a 32 page building readiness manual for our property management workers around the country. So we could approach this with a customized and plan that we could implement all around the country.

Mark Theine: We also put together a tenant guide for all of our hospital partners with best practices and whatnot. And it outlined exactly what Ryan just said. All of those [inaudible 00:11:13] COVID crisis that we’re so used to seeing now with the importance of PPE, mask, ingress and egress of the building, and then your point about jurisdictional.

Mark Theine: And that was probably one of the biggest challenges that we addressed early on was about screening within buildings, medical office buildings. As patients were coming in, who was in charge of that screening? Was it the building owner? Was in the hospital system? And in the case of our portfolio, we partnered with the hospital system and entered into a license agreement to allow them to use common area space in a multi-tenant medical office building, or use a parking lot for screening or now the vaccine administration.

Mark Theine: But it definitely varied region by region. And we’ve worked with our revenue management teams across the country to implement those best practices that Ryan was outlining a minute ago.

Ryan Walters: And Mark that’s a good point too on who’s doing it. I think if you were to, I’m going to talk strictly from our real estate perspective. So our property managers and technicians, but really it’s our clinic managers that are in the buildings and the operations team that have taken on a bulk of the changes that need to be implemented. Because they’re there at the front door and taking on the temperature screening and those kinds of things.

Mark Theine: I would just say one additional thing we did this Summer was to partner with Julie and her company in a survey of health care consumers in five of our largest markets across the country.

Mark Theine: And we asked them just about their comfort level of coming back to medical office buildings, again, to your opening comments. They never really closed [inaudible 00:12:55] more people back and the volumes increased. But what would make them more comfortable coming back to medical office buildings?

Mark Theine: And one of the answers that didn’t surprise us, but one of the answers we heard loud and clear was, not just telling us the things that you’re doing in the buildings and you’re wearing PPE and you are cleaning, but physically seeing someone in the lobby, cleaning, cleaning the buildings, cleaning the common areas, elevator buttons, door handles, et cetera.

Mark Theine: So we’ll talk a little bit more about that survey, but yeah, those are the things that we’ve adjusted on our team to be very visible, very transparent in the communication and the efforts that we’re doing within our buildings.

Joel Swider: Yeah. I’d love to jump into that. Julie, how can we communicate to consumers that it’s safe to enter, and in some cases reenter, because a lot of people have put off care, right? So how do we get them comfortable?

Julie Carmichael: It’s a question that really puzzled me and why we started back in July with a survey in Indiana to see what consumers were feeling. I had heard a lot of anecdotal examples of patients not going to the hospital with heart attack symptoms. And I wanted to understand why that was and what it was going to take to get them feeling comfortable.

Julie Carmichael: So the results that we found in Indiana, and then when we did the survey for Docreit, really are similar across the country and we boiled it down to five key points. The first being consumers prefer strongly, 75% prefer to seek services not on a hospital campus. I think that’s important for us to think about from a strategic standpoint, especially as we’re trying bring patients back. If we have off-campus locations where medical office buildings and other facilities that are not on our main campus and we can ease people back into that setting. I think there’s an opportunity.

Julie Carmichael: As Mark mentioned consumers told us, “We want to see what you’re doing.” Show not tell. Just this need to visibly see that precautions are being taken and that we’re taking their safety very seriously. So I think that’s going to continue and will really contribute to getting people to come back.

Julie Carmichael: Consumers also want us to go above and beyond the requirements. Frankly, they look at what the CDC and others have said. And it’s great, but if you can do more than that, we would really prefer you to go further. And then when we’re communicating to patients, the last two points really get communication. One is physicians and nurses and clinical staff are the best way to communicate with patients that it’s safe to come back and what all you’re doing to keep them safe.

Julie Carmichael: We found, surprisingly, hospital CEOs were on the bottom of the list for folks that should be out in front and giving these messages. In fact, consumers told us they’d rather hear from their local legislators than hospital CEOs. Which I thought was very interesting. So think about who you’re putting out in front.

Julie Carmichael: And then the final point is, to the extent you can, one-to-one communication is appreciated. So rather than just putting out broad notices, broad marketing strategies, being able to send that email to your patient, kind of a one-on-one communication that, “Hey, these are the things we’re doing. This is what you’ll see. This is what you’ll experience when you come into the building.” I think consumers really like that knowing what they’re going to face, as Ryan discussed. What’s it going to be like when I come back to a health care facility?

Julie Carmichael: So that’s the study in a nutshell, and we can talk more about it and I’m happy to share if folks want to dive into that outside of today. Reach out and let me know. I think it’s helpful as you’re thinking about real estate strategy and just getting people to come back to your medical office buildings.

Joel Swider: Well, and that’s very interesting, Julie. I think one of the things that we’ve gotten some questions about is related to certifications and using that potentially as a way to say, maybe it’s a communication device, maybe it’s a sort of check the box item. I don’t know, but anybody on the panel have any experience with those sort of outside certifications that have come to the market recently? Is there any validity to those? Are they worthwhile or is your money better spent elsewhere? Any thoughts on that?

Ryan Walters: I can kick it off. We haven’t pursued any specific certifications. I mean, we have our employed infection preventionists and the relationship between that team and our real estate team is the strongest it’s ever been.

Ryan Walters: They are meeting with our janitorial vendors, looking at their scope and cleaning products, making sure they’re appropriate. And if there’s ever an issue they’ll run over to a building and meet the real estate team to look at the issue. Other than that, certification wise, we’ve definitely been doing more test adjust balance reports from certified vendors that are capable of doing those to make sure we have proper air flows.

Ryan Walters: But Mark or Julie, I don’t know if you’re seeing anything else on the certification front.

Mark Theine: I think you described it really well. Yeah, there’s a lot of groups obviously popping up now. Claiming to have the latest and greatest new certification and trying to monetize that.

Mark Theine: But back to Ryan’s initial point. I mean for groups that have already been operating their buildings to high level, we’ve already invested in the platforms to improve the patient and physician experience in the buildings. And what COVID’s really done, and managing through this right now, is improved the focus and communication of the operations teams.

Mark Theine: So to Ryan’s point again, we are communicating more and more frequently and sharing data in real time from our systems about what we’re doing for our work orders, for hours that people are in the building, screenings, tracking patient volumes. And these are systems that we had in place already pre-COVID, but the focus has really been on increased communication transparency around the efforts that we are doing. Both to our hospital partners and then ultimately to their patients.

Julie Carmichael: I would just add that our survey results really showed that consumers listened to the CDC more. The CDC and local health departments. So as these companies that do the building certifications have popped up, it’s really been after we’ve done the survey, but I go back to consumers have certain people that they view as experts. CDC, State Department of Health, your physicians. And then I think I’d spend my efforts making sure that what I’m doing is well communicated and visible and not necessarily putting a stamp on a building from an organization that consumers don’t know anything about.

Joel Swider: Yeah. That makes sense. And I guess we haven’t really gotten into, another question that we get a lot I’ve heard from you all so far today on communication and some of the protocols. Which to my mind don’t cost a lot or don’t have to cost a lot. Are there any capital outlays that have been necessitated in light of COVID that any of you have seen or recommend?

Mark Theine: Yeah, I can jump in and help here. So from a capital outlay perspective, certainly we’ve evaluated our entire portfolio form, mechanical systems, where we can improve, fresh air flow. We haven’t gone in, wholesale made changes to existing facilities. Where there’s new development facilities we can of course pick things as we’re in the projects, now with COVID implications in mind.

Mark Theine: But we haven’t gone back to retrofit an entire mechanical system or anything like that. But where we are investing our money now is in, when we’re doing common area renovations we’re putting in touchless sinks or automated doors. Sometimes elevators that you can have just one call button instead of pressing the button on every floor.

Mark Theine: So we’re looking at that. And then clearly on tenant improvements as we’re renewing leases and offering some capital to freshen up the space. We are looking sometimes at the design flow of how the office section lays out one way in and then a separate exit out. So it’s one way traffic.

Mark Theine: Some practices are considering not having as large a waiting room and taking patients straight back to the exam room and wait there, so that they’re separated. But then there’s other systems that want larger waiting rooms to separate everyone. So it’s customized by my practice there, but where we are investing our money, again, is more on the TI and the remodels as they’re coming up in our portfolio. But we haven’t gone back to wholesale [inaudible 00:22:51] yet.

Ryan Walters: Yeah, very similar opinion as Mark. We have design guidelines for our primary care and our specialty care clinics. So our architects have been revisiting those and having some conversations around some of the things that Mark mentioned.

Ryan Walters: So things we’re looking at are, should we have power and water hookups in our parking lots, or maybe a bigger plot of land? Should we need to use our parking lots to put up tents in the future? Should we have bigger entrance canopies if we have lines going out our front door? The automated door hardware and hands-free faucets for patients that Mark mentioned. What do we do in our exam rooms to increase our telehealth capabilities? Do we have some extra negative pressure exam rooms near a separate entrance? And where should the doctor’s workstations be for those telemedicine visits? Should they be in the clinic or elsewhere? Just some things we’re thinking about.

Joel Swider: Ryan, I want to follow up on one point you made. Talking about preparing the parking lot as another potential site of care. I suppose that’s easier when it’s owned real estate. I mean has that been successful on the tenant side as well and saying, “Hey, landlord, you’ve got to do something here.” Or it’s not really a TI issue as much as a facilities issue and amenity, if you will. Has anyone seen that on the tenant side?

Ryan Walters: Yeah, so we own about half our properties and lease about half. And I was just going to say, we do have tents set up. We are the single occupant in the MOB, which helps. But we’re very thankful to our landlords. It’s really come down to just a transparent conversation. Hey, who are the vendors? Show us some diagrams, how traffic flows going to work? What electrical systems are you going to tap? How are you going to restore it?

Mark Theine: Yeah, similar to me. Again it goes back to that collaboration with our hospital partners and how quickly can we help them set up something in the parking lots. Initially it was testing sites in the parking lots, but most recently in the last week or two, we’ve been having conversations about vaccine administration and drive-thru vaccine sites through larger tents.

Mark Theine: And some of the discussions get interesting and maybe you’ll appreciate this from a legal perspective is, some of those sites we own the buildings be simple, but in others we ground lease them. So the hospital may already own the land and we own the improvements of the building, but in those cases the hospital has decided on their campus to set up the tent and we just need to kind of over-communicate on where are we going to display some of that parking in those cars. Because a few of our leases do have minimum parking requirements in the leases.

Mark Theine: And it just creates some challenges operationally, in patient flow, and then again for our property managers to be able to communicate that to everyone. In the multi-tenant building those tenants that are not hospital tenants, so ground leases being reviewed a little bit more as we’ve set up testing sites and now vaccine locations.

Joel Swider: Yeah. I want to delve a little bit more into this idea of transparency. And Julie, you mentioned this earlier, Mark, you echoed it as well. Can we talk a little bit about how do we serve our customers, whether at patients or, Mark in your case, hospitals maybe by providing more transparent data. Have you seen that play out?

Julie Carmichael: Well, I think in a couple of the practices that I’ve worked with, I’m seeing the providers just be much more communicative. More regular communication, whether that’s newsletters, quick emails. That one office that’s done a great job putting out videos where the provider will talk about what’s the latest protocol in the office. What’s changed since the last time you were in.

Julie Carmichael: I think it’s just an extra attention to communicating things that we think that probably people already know. It’s that mindset of over-communicating. So that’s really what I’ve seen with most of the medical offices that I’ve worked with. I don’t know Mark, Ryan [crosstalk 00:27:49] seen something different.

Mark Theine: We’ve had employees before COVID, which really helped us excel in their customer service to the hospital partners during COVID. A work order management system platform, where we could track and measure and monitor all requests that we’re getting from our partners.

Mark Theine: So we could track how long until a work order is dispatched. How long until it’s completed? One of the most useful tools is at the end of the work order we can get a rating on how well we did. So thumbs up, thumbs sideways, thumbs down just like an Uber. You get a four star, five star Uber rating.

Mark Theine: We get real-time feedback on how well we’re doing on our work orders. And then in that system we can also track janitorial schedules, engineering hour schedules. And so we have all this data and we put together a [inaudible 00:28:40] report to our hospital systems.

Mark Theine: We share with them on a very routine basis all this data about here’s how we’re doing on work orders. Here’s our customer service to the physicians. They’re rating of our work order in our teams and then how quickly we’re responding to them. And then also showing them that we’re thinking about adjusting janitorial hours or engineering hours to take care of the team’s health, but yet also servicing the building. Those communication back and forth has just really gone long way to keep these buildings open and then ultimately keep the providers and patients safe in the buildings.

Joel Swider: Thanks one other, I want to switch gears a little bit, because one topic that we talked about on our prep calls was how taking the COVID response seriously when it comes to property management can actually enhance business. It could be an opportunity. And of course I don’t mean to be light of a very dire situation, but how can we, from a business perspective, enhanced business in our COVID response? Julie, I know you’ve talked about this before a little bit.

Julie Carmichael: it does feel somewhat awkward talking about trying to grow and expand market share in this environment. And at the same time, I think this is the kind of environment where there are opportunities to grow market share.

Julie Carmichael: Things that I think are important are looking at your portfolio. And if you’ve got assets that are not on campus, figuring out how to maybe drive more service there. I think consumers now like convenience, smaller offices, it’s just that big campus setting that I think people are a little bit leery of. So looking at where you’re providing services. If you can put services together in convenient locations and convenient packages so that people can do multiple things in one trip. I think that’s a good opportunity right now.

Julie Carmichael: And then just from a general standpoint, I think as you’re serving your competitive landscape there are a number of people that you’re probably competing with that are so focused on just responding to COVID because they’ve had to be. So if you’re not in that situation, or even if you are maybe pulling out a small group of people who you asked to focus on the future and think about where are the opportunities that we have.

Julie Carmichael: If everyone is thinking about today and no one’s thinking about tomorrow, I find that to be a bit dangerous from a strategic standpoint. So I like the idea of having at least a small team of people that are thinking about the future and where those growth opportunities are, because they are there.

Mark Theine: Yeah, I think that’s one of the trends that we’ve seen. Accelerated over the last year is the shift to the off campus buildings. I mean the reimbursement and technology and all those enhancements were already driving more and more care off campus. The COVID continued to accelerate that. As consumers didn’t want to go to the big box hospital where the COVID patients are being taken care of. They’d rather get their care closer to home in a clean and safe environment.

Mark Theine: So I think Julie’s spot on with her comments about shifting care to the off campus setting there. In fact 72% of new construction starts last year were in off campus buildings.

Mark Theine: And I think that historically healthcare has been very hospital centric and in the future, as Julie just said, it going to be very consumer centric. And it’s going to be more about the patients and their preferences. How to get care in a clean, safe, convenient way is the way to be thinking about healthcare in the future.

Ryan Walters: Which may or may not be in an exam room in a medical office building.

Joel Swider: Yeah. Ryan, could you elaborate on that? Because I think from the hospital perspective, I think, we just heard a lot of people are not wanting to come on campus or they’re not, obviously there are certain conditions where you have to, but for an office visit. Any thought from the hospital perspective in terms of how you’re responding or plan to respond in the year ahead?

Ryan Walters: Yeah. There’s lots of interesting conversations that I’m sure everyone’s asking throughout the industry, but with the care that’s being delivered in a car out in front of an MOB. What does it mean to look at a car as an exam room? What’s telemedicine do? And what’s an exam room look like if it’s in a patient’s home? Lots of interesting questions and conversations around that.

Joel Swider: Well, I’d like to wrap up our discussion with exploring the future horizon and what have we learned? What does this new normal look like? What will we keep and what will we discard? Obviously we can’t see the future. Any thoughts on that? On what we’ve learned and where we go from here.

Ryan Walters: I think, so big questions in my role, we oversee all of our leasing, buying, selling. Most of our office employees are remote today and plan to be through Summer.

Ryan Walters: I don’t know of many medical office buildings that have formally closed, at least not for very long, throughout this process. But we did close a lot of our office buildings. So we foresee a need for much less office space or a different type of office space. Where nobody has a reserved desk or cubicle. And we deploy a reservation system where you can reserve a cubicle or meeting room, depending on the type of work you need to do in the city that you’re currently located.

Ryan Walters: So we’re identifying which caregivers are fully remote moving forward. My VP recently told me I’m one of those. So I’m a guinea pig in this effort. And who needs to be in front of a desk five days per week can be assigned cubicle and who’s in between.

Ryan Walters: And then on the medical office side, it’s what is the impact of telemedicine? Does that allow us to see more patients and postpone the next new building a few years? Because we have some more capacity. Do we need a different type of space for telemedicine? Some of the questions we’re asking,

Julie Carmichael: I think it’s going to be a mix in some ways. I think a lot about the fact that people are pretty quick to forget things. And I wonder what the lasting impact on all of our psyches will be after living through a pandemic. Will it change our behavior forever, or will it change our behavior for a while?

Julie Carmichael: And I think there are probably some things that may change forever. I think telemedicine is something that has worked well in certain instances, but there are a number of practices and specialties. I think about obstetrics as an example, and a lot of women’s health where it’s just not practical to do a lot of that care via telehealth.

Julie Carmichael: So I think, to Ryan’s point, we’re going to have to live in both spaces. We’re going to have to figure out, maybe we can delay some additions that we thought we might need to do some expansions. And I also think it’s going to be interesting to watch what happens on the ambulatory surgery side. With changes to Medicare and other insurance companies being willing to pay more and cover more services in that setting. And providers, I think, starting to feel that the quality is comparable. I think we’re going to see a lot of activity in the ASE space going forward. But it’ll be interesting to see. I wish we knew for sure, but I think we’re all guessing.

Mark Theine: I love the optimistic question about thinking about what’s coming in the future, especially given how challenging this year has been. But the truth of the matter is that we are still in a crisis and there’s still a lot of COVID care being developed.

Mark Theine: And it’s really important for us to remain disciplined in our operations of the facilities today in what this new normal is that we’re talking about. It’s very easy to get COVID fatigue and not wear your mask or start settling into the new normal of your management hours and things like that. Your management tasks, but it’s really important to continue to stay disciplined for the very foreseeable future.

Mark Theine: And then further into the future to answer your question though. I, talking to a CFO yesterday of the hospital system, and one of the comments he made that really resonated with me is that they shifted more of their surgery procedures off campus, the AFCs.

Mark Theine: Again, the same capacity in the hospital system. And those procedures will probably now for a very long time continue to be located in that off campus surgery center. So there’s a lot of opportunities for certain off campus surgery centers, [inaudible 00:38:51] future. And procedures that have shifted away from the campus, off campus will continue to stay there in the future.

Joel Swider: Great. Well, that is the extent of my prepared questions here. Julie, Ryan, Mark, thank you so much for your insight and thank you to our audience for joining us.

Joel Swider: We will be sending out contact information to the extent that anybody has questions that didn’t get answered today and you’d like to continue the conversation. We have our strategy discussion coming up on February 25th, which I think will be an interesting follow-up to this one.