CEO of Avail Health, Joseph Harrison, NP-C

00:00] Michelle: My guest this week, Joseph Harrison, is a nurse practitioner who facilitates the creation of independent practices for other nurse practitioners through his company, Avail Health.

[00:13] Per his LinkedIn profile, Joseph states "Weaving together many threads to help realize the quintuple aim of healthcare."

[00:22] To be honest, I was unaware of this ambitious initiative before speaking with him, but he clearly and succinctly explained both our current successes and the areas where improvements can be made.

[00:36] I found it interesting to learn that before becoming a nurse practitioner, Joseph worked in the hospitality industry as a server and a teacher.

[00:46] Perhaps it's this background that enables him to be such an exceptional nurse practitioner.

[00:52] He forms personal connections with his patients, allowing them to take an active role in their care.

[00:59] I would also argue that this ability contributes to his success as an entrepreneur.

[01:05] Nurse practitioners often express a desire to provide excellent person centered care while also seeking time and financial freedom.

[01:15] Joseph truly listens to these needs and is working to make them a reality, one practice at a time. In the five-minute snippet: Barbarians, Rogues and Druids, oh my. Here is Joseph Harrison.

[01:44] Good afternoon Joseph. Welcome to the podcast.

[01:48] Joseph: Hi, good afternoon Michelle. Thank you so much for having me.

[01:53] Michelle: Well, I'm delighted. I know that during our conversation I'm going to learn a ton.

[02:00] So we kind of met each other on LinkedIn and I think you reached out to me and were very complimentary and you said that you really liked what I was doing and I always appreciate those kind words.

[02:13] So thank you again for that, and that if we would be a good fit that you would like to come on and we are a good fit. Any nurse that wants to talk about nursing and nurses and our mission is somebody that I want to talk to.

[02:30] So again, thank you for being here. When I saw your LinkedIn profile, one of the things that you say is that you are "Weaving together many threads to help realize the quintuple aim of healthcare."

[02:45] I was immediately intrigued because, full disclosure, I don't know anything about the quintuple aim of healthcare. That's why you're here today. So we're going to talk about that because I know through your company, Avail Health, that you work with nurses and nurse practitioners and that you yourself are a nurse practitioner.

[03:05] So before we get into that, I just want to hear your personal story of how you got involved in nursing and your journey to being a nurse practitioner.

[03:15] Joseph: Absolutely happy to talk about that. So, yeah, I've always identified as a nurse ever since I started my training.

[03:23] For me, a nurse practitioner, you know, is a nurse that practices, you know, nursing with a different scope of practice than a registered nurse, but essentially is still founding, you know, sort of still rooted in the foundational philosophy and worldview of nursing.

[03:42] I entered nursing in my 30s, so I had already had two careers.

[03:47] The first career was in hospitality. So think of it as, you know, service work. But, you know, service work, that's very transactional, right? People pay for food and drinks or entertainment or whatever.

[03:59] So that was, that was something that felt very natural and easy for me to do because I loved helping people. I'm, you know, one of those people that when you come into their home, they kind of, they're, they're like looking after you and wanting to make sure you're comfortable.

[04:13] And it, it's a family culture. It's very much a big part of who I was. So going into hospitality was easy for me. Went into, you know, into my 20s, I realized the lifestyle was hard, the, you know, income was not what it, what I needed.

[04:29] Um, so I went back to school and I became an educator. So I was this teacher and I ended up struggling actually financially as a teacher. But I mainly left teaching because some of the primary duties of a teacher, um, the, not the stuff in the classroom, but the stuff outside of the classroom I found very monotonous and frustrating.

[04:52] And I, I didn't want to give up on service work, but I just needed to find something else I could do that would be more engaging and, and that, you know, more of the job would be meaningful to me because I really love the classroom teaching part and the relationship with students and families.

[05:08] So when I was kind of regrouping and looking at my options, I found nursing. And when I was younger, man, I just want to name something here because I think it's important to name as a male nurse.

[05:19] When I was younger, I didn't even consider nursing. And I look back and I don't know. I don't want to rewrite history, but I think it was because I identified it as a female profession and I was, you know, young and more insecure, right.

[05:35] Not confident in myself and wanting to differentiate myself. And I don't say that because I'm proud of it. I think it was a mistake, but I was who I was and I think I just overlooked it.

[05:46] And so I went into teaching and found that I wasn't really satisfied in that role. And then I looked back at nursing and said, wait a second. Like I was a little bit older, I was more mature, I didn't care about that association.

[05:59] And I really cared about what nursing meant and what people do. And so as I started looking at and preparing to apply for nursing schools, I actually discovered nurse practitioning.

[06:13] And I was already in my 30s.

[06:16] The more I learned about it, the more compelling it was to me. And so I made a decision to apply for a program that would, you know, they're for 

[06:26] A program for professionals from other professions who want to become nurse practitioners. Where I actually trained in nursing, did all my, you know, all the prerequisites, I had to go back to school and do all that.

[06:38] And then I did all the nursing school stuff and all the rotations and then took the NCLEX and then immediately started training to be a nurse practitioner.

[06:48] And, and then after a couple more years, I finished that and passed my boards and went straight into clinical practice. I've worked my whole career in Medicare. So for the first 10 years I was in Medicare Advantage, you know, commercial Medicare plans.

[07:05] And, and I, I loved it. I worked for the health plan. I wasn't like a clinician from, from a practice that build the health plan for their care. I actually was employed by the health plan with a team of other clinicians, RNs, LVNs, social workers, licensed clinical social workers, therapists, physicians, clinical pharmacists, like a whole really cool mixture of professionals in the outpatient space taking care of frail and vulnerable seniors to help keep them as well as possible and out of the hospital as much as possible, or at least if they go to the hospital, help them get out as quickly as possible and not have to go back.

[07:49] And so that really was aligned with my values. I love doing it. And it was actually not in nursing or nurse practitioner school where I learned about the quintuple aim of healthcare.

[08:00] In fact, when I was in school, that term hadn't been coined yet. When I was in school, the term of the time was called the quadruple aim of healthcare. And what that aim is or aims, what those aims are, are improving patient experience, improving clinician experience, improving population health, and improving the financials of healthcare.

[08:33] In other words, like making it more cost effective because we have a system, you know, that keeps getting more and more expensive all the time.

[08:41] So you're, you're thinking, you know, like really broadly with the total cost of care and the population's health, and you're thinking much More specifically around individual patient experiences and also provider clinician experiences.

[08:55] Because we also have a big burnout problem in healthcare. Right. Like, people are working really hard and they're having a hard time sustaining it. Oh, that problem is very acute with nurses, for example, Right.

[09:06] Where we're losing hundreds of thousands of nurses to burnout.

[09:10] So that's the sort of origin. And then subsequent to my training, which is, you know, more than 15 years ago now, a new term was coined, and it was the quintuple aim.

[09:22] And so the additional aim, it's not, you know, replacing all four of those other four. Those four remain the same. The additional aim is adding in health equity.

[09:33] We're not just trying to produce, you know, improved health outcomes for individual patients and improve population health, but we're actually trying to make sure that, like, the population health increases benefit people regardless of their social status, regardless of their economic status, regardless of their, you know, their demographics, whether they're older or younger, whether they're white or person of color.

[10:00] Right. Whether they're straight or trans or you know, LGBTQ. You know, that like, regardless of those various factors, we're trying to actually improve health and make it more equitable generally.

[10:13] And I thought that was a

[10:14] wonderful addition to the quadruple aim. Cause I love all of the four aims. But that really resonates with me too, because having been in practice for. As a nurse practitioner for 13 years, more than 13 years now, I'm, like, very aware of how social drivers that, you know, really reflect inequalities can be a huge factor in health outcomes for people.

[10:43] So, um, a lot of what I've been doing, first in the Medicare Advantage health plan that I worked for and then in the last four companies that I've been building, are really about trying to minimize how social drivers impact health outcomes.

[11:01] In other words, trying to overcome those inequalities, disparities.

[11:07] To make sure that folks can do well and do better and stay, you know, where they want to live for as long as they want to, as long as they possibly can, regardless of their race or class or

[11:20] geography. Right. Like, another factor is rural versus urban. Right. Like I'm trying to help build a health system that serves people wherever they are, whoever they are, at whatever stage of life they're in, at whatever stage of the disease process they're in.

[11:40] Michelle: Well, thank you for that explanation. And first of all, I have to say that being in the hospitality industry and the education Industry, those are two, some of the toughest industries to be in, to make a living, to survive.

[12:03] They're crucial. Right. We need them, we need teachers, we need servers.

[12:08] But it's super, super tough out there. My daughter was a server for 10 years, so I got all the deets on everything that goes on in that industry. And then my late husband was a teacher for 30 years.

[12:23] My daughter is a teacher, my stepdaughter is a teacher. So lots of teachers. And man, you have all my respect, Joseph.

[12:32] Joseph: Oh, thank you. Well, you know, one other thing I'd say, Michelle, is yes, they are hard. And, you know, well, nursing is hard, but they are also, both of those careers that I had before nursing were actually, I didn't have to leave them entirely behind.

[12:47] Right. Because service and hospitality is a strength of good nurses. Right. Of course we need to have healthy boundaries. Of course we need to be able to, like, speak up if we're not being treated well or whatever, but have to be able to advocate for our patients.

[13:03] We have to be able to advocate for our peers. We have to be able to anticipate needs and meet them.

[13:10] And we also have to be able to teach. Right. We have to be able to educate our patients on their disease, their condition. We have to educate them on the treatment plan.

[13:19] We have to educate our peers. We have to train up the next generation of nurses. We have to teach the new, you know, new staff members across professions, whether they're, you know, intern to become physicians or residents or.

[13:33] Or new professionals in other categories. All those skills are really relevant. At least have been for me in my career as a nurse and a nurse practitioner.

[13:45] Michelle: Yeah, I can absolutely see that you took many of those skills and those tools in those jobs that you had before nursing and that they transferred very well.

[13:57] Joseph: Yeah.

[13:58] Michelle: So you went over the quintuple aims and we'll get into those a little bit more, but patient centered care, population health management, cost reduction.

[14:10] And I thought number four was very interesting, improving the life of the healthcare provider. And then number five, advancing health equity.

[14:19] As I said in the beginning, I'm being fully transparent. I wasn't familiar with the quintuple aim of healthcare.

[14:27] So I did what I usually do when I want to talk to the smartest person in the room. And I called my brother Chris

[14:35] Patty. He is a doctorally prepared nurse and he's just smart and he knows stuff about everything.

[14:44] So I called Chris and I said, Chris, I'm interviewing Joseph Harrison and I sent him your LinkedIn and of course, he came back with a very thoughtful question. So I'm going to propose it to you right now.

[15:02] And it's actually not a question, but I want to get your thoughts on it. What Chris said was if we had the first three aims, we wouldn't need the other two.

[15:13] So Joseph, what are your thoughts on that?

[15:16] Joseph: Let me make sure I have the right three. So you're saying if we had provider experience was addressed, population health was well managed and patient experience.

[15:28] Michelle: So the first three that I have is patient centered care, population health management, and reducing costs.

[15:37] And so he said if those were met, we wouldn't need improving the life of the healthcare provider and advancing health equity.

[15:48] Joseph: Oh, interesting.

[15:49] I don't know, I think what he's getting at there is, you know, it really depends on how you define those first three. Right? Because if you look at population health in this really broad brush and you say, oh, you know, we have the incidence of diabetes and the prevalence of diabetes in our, in the American population is this.

[16:10] And then you institute certain reforms, certain initiatives, programs, services to address that, and then you see the incidence and the prevalence going down, you say, hey, we're winning. But if you do that just like that, the folks who are more likely to be less served by those programs are not going to have the same incidence and prevalence as the general population.

[16:37] Right. So I would push back and say it really depends on how you do that. Right. And say, like I think, yes, the most thoughtful, complex approach to manage population health already weaves into it health equity.

[16:55] Right. And so you've got it woven in. You don't need this extra aim. If you define population health approaches from an equitable perspective. Right.

[17:06] The one that I think is harder for me to.

[17:10] Well, no, I guess if you take the financials, if you're approaching like cost management in health care in a very progressive way, we're looking at how only like 15% of all healthcare spend is on staffing costs, Right.

[17:28] The rest of it, a huge chunk of it, much bigger than 15%, is taken by middlemen. Right. You can actually lower the total cost of the healthcare pie and make sure that clinicians are paid more for their services.

[17:44] At the same time, you can do that by cutting out some of the middlemen, like pharmacy benefits management corporations, for example, that basically have this huge regulatory capture to grab and basically steal a bunch of money from the system and offer very, very little, you could say, in return for what they're taking.

[18:08] They tend to actually make things worse than better, but they take a Huge piece of the healthcare piece. You eliminate that and you replace it with like a well functioning system that is rational, then you're going to save a lot of money in the healthcare system and some of that could be redistributed to, to take care of clinicians, to reduce their workload.

[18:30] Right. To distribute the burden more evenly, to allow for services and benefits to clinicians that help it, help them, you know, make their career more sustainable. So yeah, I can totally go there on that.

[18:44] I can do that, I can play that game and kind of reimagine and I agree. I think it's where your brother's coming from is actually, I really like where he's coming from, which is saying like, we have to add these aims because the attempt to realize the first three hasn't been as well conceived as it should have been.

[19:03] Michelle: Yeah, thank you for that. And where do you think we are in achieving these aims and where do you think we need to go?

[19:14] Joseph: Well, from a very, very like long view, we've made a lot of progress because you know, to quote one of my favorite professors from my undergraduate degree, acknowledging a problem is actually two or three steps away from, you know, is, is an advancement.

[19:32] Just acknowledging the problem, like, right. The fact that our government recognizes there's inequities, the fact that most research organizations recognize that there are inequities, the fact that they're, most clinicians in the general public recognize like women's, women don't have the same benefits in our healthcare system as men do. Right.

[19:52] They pay more for insurance, they're less likely to be treated for pain. There's all these ways we can see that. But we know that now because we have research and it's published and it's repeated and it's validated and it's, and it's spoken about like by people like me, you know, on podcasts, by people, you know, that are hosted, people like you.

[20:11] So in that way, like there's progress, but there are huge disparities in our healthcare system. And so I like to focus on the positive and recognize that, you know, all the efforts that people have put in, in the generations before us have, have really borne fruit.

[20:28] On the other hand, there's a lot to be done. And then the other thing I would say too, Michelle, is it depends on where you are. Because if you're in rural Mississippi, healthcare doesn't like, you know, progress in healthcare doesn't look anywhere near the same as if you live near a University medical center in some population center of a state that has like robust, you know, safety net in place.

[20:52] Right. And so, so it does really matter where you are and it does matter who you are. But, but like I will say, like when I was in my training, you know, 17, 16 years ago as a nurse, and then, you know, 14, 15 years ago as a nurse practitioner, I was being educated about these issues back then.

[21:12] Right. Like, I was being trained to be aware of those things, to recognize, like you said, patient centered care means being open to learning what people's preferences are, being open to understanding that not everybody sees things the same way and that you can adjust as a, as a provider, as a healthcare provider, you can adjust to accommodate those things and that health outcomes tend to actually be better if you do that.

[21:40] Michelle: Yeah. And that's is a superpower that nurse practitioners have, I think. And a lot from personal experience, my provider has been a nurse practitioner.

[21:54] When I was going through breast cancer treatment, you know, I don't think, because we all, and we're nurses too, so I think we see the benefit.

[22:07] But we also live in a rural area. We live in the middle of the San Joaquin Valley in the middle of California.

[22:15] And you know, we live in a fairly small town of 160,000 people. We do have a big medical center here, but there are those deserts in healthcare. So I don't know if those are all factors that are leading to why we love our nurse practitioners so much, but we do.

[22:35] And I think that's definitely one of the superpowers that nurse practitioners hold.

[22:42] So you brought up schooling, and one of my questions had to do with that.

[22:49] So, Joseph, if you could dismantle one aspect of how nurse practitioners are currently trained or credentialed, what would it be and why would you dismantle it, if anything?

[23:06] Joseph: That's an interesting question.

[23:09] Very briefly, want to respond to your point about nurse practitioner superpowers. The California Healthcare foundation has published many reports on patient experience of care through nurse practitioners patient outcomes. And despite significant differences in preparation between nurse practitioners and physicians, there are many, many ways that nurse practitioners perform equally to physicians in the complex care of patients with chronic health conditions.

[23:40] And I think one of the reasons why that happens is it's kind of a subtle thing to say, but one of the reasons is that, you know, nurse practitioners are usually choosing to become nurse practitioners at a more mature age.

[23:55] They are, you know, either have already been nurses and decided to, you know, get retrained and take on new roles in their nursing identity or they're like me. They are professionals that have, like, seasoned, mature professionals who are changing careers midstream.

[24:13] And I think that matters a lot because we are like, fully internalizing what we're learning and we are fully committed to, to what we're doing. And then I think one other thing I'll say is that nurse practitioners are not trained to objectify patients.

[24:28] They're not trained to create the spaces between patient and provider. They're trained to partner with patients. They're trained to really sort of instead of it being, you know, the clinician facing the patient and the space between them, it's more like the image I like is the clinician sitting next to the patient.

[24:48] The analogy I always use when I'm talking to patients and introducing myself because I'm still practicing as a behavioral health, geriatric focused clinician, is I say, I am not in the business of telling people what to do.

[25:02] I am in the business of learning as much as I can and then reflecting back what I've learned, what my assessment is, what I think is going on, how I think we could approach addressing it to achieve the goals that the patient has.

[25:17] And then what are the potential upsides of that approach and what are the potential downsides? And I try to give them two choices at least, so that they feel like they can make a decision to move forward, but they have enough information to make that decision, and they're the ones making the decision.

[25:32] They're really in the driver's seat, right? They can speed up by pushing on the pedal. They can slow down by pushing on the pedal. They can change directions. Really what I am is a guy with a map who can help them figure out how to get where they're trying to go.

[25:45] Right? And that does tend to work for most people.

[25:50] Right now I'm going to segue into your question. Your question about reform nurse practitioner preparation.

[25:59] I think that nurse practitioners have no idea about the finance of the healthcare system. They don't know how the healthcare system finance works. They don't know very much at all about billing and coding.

[26:16] They don't know how to create and run a private practice.

[26:21] And the challenge we have, Michelle, like, if you just look at family nurse practitioners, which I think are the overwhelming majority of all nurse practitioners who are board certified are family nurse practitioners.

[26:34] And then think of that as like, that term really is like a primary care provider. That's what they're trained to be, but they're trained to be able to be a primary care provider across the lifespan, that is a huge endeavor, right?

[26:48] We're talking about from infancy to end of life, right? And so when you're trying to like add things into the bailiwick of the trainers, educators of family nurse practitioners, it's like, where's that time coming from?

[27:02] Right? There's like only so many hours. And how do you get everything they need to know to be prepared into their training in that same period of time without giving up things that then are, they're going to lack for.

[27:17] Right. And I honestly, it's a huge problem. Like I am clinical faculty at UCSF's family nurse practitioner program.

[27:25] And I've been actually up until end of last year, I just, just left my role there. But I was there for I think about six or seven years.

[27:34] And I felt like a huge missing piece in their preparation. Something I really wish would be different is behavioral health.

[27:45] Now this is also true for physicians. So I'm not, I don't want to like single out family nurse practitioners. You know, epidemiological studies, population health studies suggest that more than half of all primary care visits are behavioral health in nature.

[28:01] And yet our preparation for assessing behavioral health needs, for assessing readiness for change, for developing comprehensive, thoughtful and evidence based treatment plans for behavioral health needs are woefully inadequate.

[28:19] So my personal bias is, if I had to rewrite the training would be that first of all, we have to staff the educational community in a way that attracts. Well, how, how do I say that?

[28:33] Let me try to be really, really clear here. Nurse practitioner professors don't get paid enough.

[28:41] And so any, any faculty member in a, I did it as a volunteer. So I'm not complaining about my compensation. Like I'm talking about like full time faculty members, which any professional education requires, right?

[28:54] To their, you know, you want people who make a full time commitment who really get after it. You cannot live in California on what a nurse practitioner professor makes. You cannot live on it, right?

[29:06] So then what happens is nurse practitioner faculty, they, they leave now you've got a like replacement problem, right? You've got a lack of continuity because guess what? You get better at being a professor over time, right?

[29:21] And if your people are leaving because they can't sustain it because they can't afford to live on the income, that's a problem. The other one is that people are doing two things right, their faculty and their practicing, which there's nothing wrong with that except for the fact that the difference in comp between practice and, and, and being faculty is so significant, they're still might not be sustainable for them to work like a, you know, 75% time clinical job and then 25 or 50% time faculty job.

[29:53] They're still not making as if they were 100%. So unless we as a society make a decision to say we are going to pay nursing school and nurse practitioner school faculty what they, you know, something on par with what they would make in clinical practice, our education model is going to suffer.

[30:13] So how can you attract super accomplished, super expert, very well qualified clinical faculty and, you know, and, and other faculty in nurse practitioner schools that have the training, the experience, the knowledge, the brilliance to be able to comprehensively prepare nurse practitioners unless you pay them better?

[30:36] That is my biggest issue. The thing I think is most in need of reform. But how do you do that? Right. We have a system that has both public and private models, right?

[30:47] Well, you can invest more in public models. Are you going to be giving away money in large amounts to private entities that are for profit?

[30:56] That's really hard to do. Right. So I don't know if I have the answer. I know that is a big question and a big problem. I mean, some of the best clinicians I've worked with who've been faculty are no longer faculty because they just can't sustain it.

[31:11] Michelle: What's happening in academia is exactly what's happening at the bedside in many institutions, right? Nurses are leaving because they are being overworked and underpaid and underappreciated and you know, they're burnt out.

[31:30] And then that's continuing in academia. And I've talked to many nurses on this podcast. They're leaving nursing and they're becoming entrepreneurs. So they're doing what you've done, Joseph. You started businesses.

[31:49] And the one that I'd like to hear more about today is Avail Health.

[31:55] So talk about Avail Health and what you do there.

[31:58] Joseph: Thank you. That's a great segue. So I agree with you. You know, when I was doing the market research before I started Avail Health. Well, actually, first, let me just briefly introduce Avail Health.

[32:08] So Avail Health is a medical organization, a healthcare organization that delivers care to adults and older adults who are experiencing changes in their mental health or their cognitive health.

[32:25] And so we are essentially a behavioral health centered healthcare organization that serves Medicare, either traditional Medicare or the commercial Medicare plans, which we call Medicare Advantage Health plans. We also partner with other organizations like age technology companies, companies that are serving seniors, or with other healthcare organizations that are serving seniors that don't have behavioral health resources.

[32:51] Right. And what we do is we're closing big gaps.

[32:56] Now, unlike a lot of other healthcare companies that are started, I didn't want to do just a traditional employment model like a W2 model. And I want. That's for a few reasons.

[33:10] One of them is I'm an entrepreneur myself. I started my first practice in 2020.

[33:16] I wanted to start another practice, you know, at the beginning of last year. And I knew that the only way in California where I'm based that I could start a new practice and actually be able to take on patients and see them was if I was partnered with a medical group.

[33:32] Because you can't empanel your own patient. As a nurse practitioner in California, I don't want to bore you with all of the, you know, the regulatory stuff, but. So I knew I needed to, you know, do this through a medical group.

[33:44] But I'm lucky. I've been in practice for a long time and I have physician friends.

[33:48] So I reached out to some physician friends, I talked to a couple and I found one that wanted to do this with me. And. But what I explained to him is I don't want to just do this where we create this medical group and then I'm an employee of the medical group.

[34:01] I want to do this and I want my own practice that partners with the medical group. He was fine with that. And then I threw him another curveball. I said, actually I'm going to start an organization called Avail Health Incorporated.

[34:14] And Avail Health Incorporated is going to be an organization that creates new practices for nurses and nurse practitioners and brings them together with the medical group and with each other to provide team based, comprehensive care for persons with behavioral health needs in the Medicare space.

[34:33] And he said, I don't know how to do that, but I'm totally happy to do that with you because I think it makes a lot of sense. Right? As a physician, he's very aware, you know, when, when he started in, in his clinical practice, 6 more than 65% of all doctors were self employed.

[34:49] Just his career time. Now it's like 35 or 40%. Why is that? Because it's really hard to be a clinician and also a business owner and operator.

[35:01] But I had figured out through being in this entrepreneurial space in healthcare and in that sort of, you know, startup space, the innovation space, that you could create an organization that actually makes it a lot easier.

[35:16] So you, you don't even need to figure out how to start it yourself. You don't need to figure out how to do all the credentialing and all the compliance and all of the other things and all the insurances and all that stuff that burns clinicians out when they want to own their own practice.

[35:30] You don't have to figure it all out.

[35:33] Avail Health does it for you. But Avail Health also then runs your practice with you. So now you didn't just get help to start it, you don't. You get to focus on being a clinician, but you get the benefits of being a practice owner.

[35:50] And what are those?

[35:52] There's value in that entity that you own.

[35:56] The value you're getting isn't just based on your labor, right? The value you're getting is based on your ownership of an entity that has value, your own practice.

[36:08] Another thing is that when you are self employed, you don't get told told what your shifts are and how many hours you have to work and what type of patients you have to care for.

[36:20] You get to choose those things.

[36:23] So the appeal here for the registered nurse, because we have two primary personas in our model. One is the RN and one is the NP. Right now among RNs, we're attracting, you know, RNs that work bedside, you know, the ED, RNs, bedside RNs, MED Surg, ICU, RNs.

[36:43] We're also attracting home health RNs. We're attracting hospice RNs. We're attracting RNs that are, that are in a sort of transitional care management function, right? All different roles for RNs.

[36:56] They're all employed and they're interested in being self employed employed. So they get to decide, I don't want to start work until after the kids are in school, for example, and I want to be done before they get home.

[37:08] Well, it's hard to do as a registered nurse. You know what? Right? It's hard to like create that kind of schedule for yourself unless you own your own practice and you are your own boss, right?

[37:21] And so what is our medical group and our, and our management services organization?

[37:27] Do we partner with these practices? We help create them, we help manage them and we partner with them and we deliver the patients that need care to them. They take care of their patients.

[37:39] They bill. In our model, nurses normally can't bill for care out. So like in, in the hospital system, if you want to nerd out for a second, being a hospital nurse means that you're, you're actually a cost center for the hospital.

[37:55] You, the hospital doesn't get, they get paid a room rate, right? Your, the nurse is folded into that room rate.

[38:04] Nurses are doing most of the care in hospitals, but they're not submitting claims they're not billing. Physicians are billing for care, nurses aren't. Now NPS and PAS are billing. So that is a change that's happened in recent decades.

[38:17] Right. But RN still are not. Well, I find that to be a huge opportunity cost for our society. Why can nurses not bill for care? We desperately need nurses in the community.

[38:28] We need them not just in hospitals. We need them in our neighborhoods. Right. And so we've created a model where nurses can bill for care and get paid for it through their own practice.

[38:39] And the kind of care they're doing is preventing hospitalizations, is helping people stay where they want to be. And one of the additional benefits in our model, Michelle, is a nurse gets to have a longitudinal relationship with her patient.

[38:57] She doesn't. You know what it's like. Bedside nurses get to know patients who are the sickest because they keep coming back.

[39:04] Right. Yeah, I've seen her before. Right. Here she is again. Right. Well, in our model, they get to know them and they get to help them from, to prevent them from having to go back to the hospital again and again.

[39:19] And so there's this sort of reduction in burnout. Right. There's this job satisfaction. There's also, I just want you to know, you mentioned the pay issue. Do you know that?

[39:30] You probably know this. More than half of nurses in America make under $45 an hour.

[39:38] That is stunning when you think about what they're literally saving people's lives.

[39:44] Bartenders often make more.

[39:47] Yeah, right. And so what we do is our nurses in our California model, virtual nursing practices. So the nurse, as long as they're licensed in California, they can live anywhere in America.

[40:00] Okay. It's a virtual practice. They do it from home. They pick their hours and they make anywhere from 65 to $80 an hour into their practice.

[40:13] Now, they do have some costs associated with their practice. I don't want to misrepresent. There are some costs, but the, to the, the average, you know, what they pay in the costs of their practice is in the single digit dollars.

[40:26] Right. Per hour. And so they're literally, even after their costs are covered, they're still bringing in up to 50% more.

[40:36] Right. Than they would as a bedside nurse. And that's. We're not, we're not charging patients. That's literally through Medicare.

[40:44] Right. Like, we're not, we're not, you know, passing on the cost to patients. Patients are only paying their coinsurance or their co pay. And if they have a Medigap plan or they have medical or Medicaid backing Them up.

[40:56] They're not even paying anything, right? They're just getting care that is excellent. And they are. They're, you know, doing better, nurses are doing better. And we're trying to remove the middlemen, right?

[41:08] We're trying to remove people who are taking a bunch of profit and really not adding much to the system. And so the relationship is between the clinicians, the patients, and our entity, right?

[41:22] And our entity is founded and led by clinicians who are trying to make this possible for nurses. And then, of course, our society will do better on a population level as well.

[41:32] Right? Because when you provide care management services, when you provide navigation services, when you provide geriatric behavioral health, including psychiatry, psychotherapy, behavioral health care management, and you also have telemedicine to back it up, you're really covering most of the things that lead to preventable emergency room visits and admissions for the vulnerable, underserved populations.

[42:02] And our model brings it to people wherever they live. Right. Like, we're serving the entire of California.

[42:12] You can be in the mountains, you can be in the valley, you can be in the Northwoods, or you could be right in the center of Los Angeles where my patients right now are being traumatized.

[42:23] Right, because of, like, almost incomprehensible natural disaster.

[42:29] Michelle: Yeah, absolutely.

[42:33] Well, what you're providing through your company is what I talked to Tiffany Gibson about last year, and what she talked about was time freedom and financial freedom.

[42:46] And that's why nurses are leaving the bedside. That's why nurses are leaving institutions. You know, it's been said that there's not a nursing shortage. There's a shortage of nurses who want to work in that kind of environment for all the reasons that we just talked about.

[43:07] And one of the things you touched on that you would change about the education of nurse practitioners is really like business acumen.

[43:16] So you get new nurses, new nurse practitioners that want to have their own practice.

[43:24] Are they going through any special training? You know, do you have somebody come in? Like, how does that work?

[43:32] Joseph: We're turning on two new nursing practices next week. So they've been going through preparation, you know, for first, we helped them incorporate their practice. We credentialed them. You know, we got them their.

[43:47] Their LIA malpractice, liability insurance, and all those things that, like, it's just. I did it myself in 2020, and it was brutal. So we kind of really just streamline that for them.

[43:57] And then the other part that's essential is they don't have to figure out what the technology stack they're using for this is, that's all sorted out for them. And then the model of care, the model of care is already designed, right?

[44:11] So the contracts with the payers are already sorted out, the flows of patients are already figured out. And then what you just, what you just pointed out, which is what about the training piece?

[44:22] So there's like two primary parts of our training model.

[44:26] One is how do you use all the tools we have, you know, and what are the, you know, what do you, what do you do in this case, in that case?

[44:33] And what's the solution for these various issues that happen in a virtual or remote practice? And the other is what is our model of care? Like, how do you execute care in our model?

[44:44] And those are very related, right? Cause like, if you're using an electronic health record system, you're both using technology, but you're also executing care with it, right? So they're overlapping.

[44:54] So yeah, we're training them. Our clinical product and clinical education team is training them and they're getting ready to start. And then we already have patients waiting to come onto their panel.

[45:08] And so next week they'll start empaneling their patients. And I mean, technically, legally, it's not their panel, it belongs to the medical group. Just so you understand, right, that we need to do that for compliance and regulatory reasons.

[45:22] What I mean by their panel is like assigned to them to provide care management services. And so it's, you know, we're, we've trained them on like, this is your initial visit, this is the model.

[45:33] These are all the forms that are completed. This is how you review them, this is how you help. Like we've built it so that they're not typing a ton of stuff, right?

[45:42] Like it's mostly built for them. They're picking and clicking, right? So it's very easy to do. And then they have the communications tools they need, they have the documentation tools they need, and then they have access to the expert they need.

[45:59] So I always tell the nurses, like, you know, and we're really new, so we don't have tons and tons of practices, right? So we'll be iterating this and like, you know, improving it and redesigning it over time.

[46:11] But right now it's like you've got an internist physician, you've got a neurophysician's associate, you've got geriatric psychiatry, you've got geriatric medicine, right? You've got emergency room triage nurse. Like, you know, you've, you've got a licensed clinical social worker therapist.

[46:30] Like we're one team taking care of these patients. But the nurse is really that lead person that, that, that relationship, that point of contact for the patient and their loved ones to make sure that their needs are being met in their healthcare needs are being met.

[46:49] And even sometimes their social, right, social and socioeconomic needs are being addressed in a meaningful way to keep them more well and where they want to be.

[47:01] So you could even say, like the management services organization isn't just about creating and managing.

[47:08] It is actually about helping nurses enter a new phase of their career and knowing what they need to know to be able to do that. So we, we sometimes use the word academy in our team.

[47:21] We're not a university and we're also, by the way, we're not training them on all things like healthcare finance related and stuff. Right. We're, we have to operate as a business so we, we can't expect them to like study things for free.

[47:34] We can't, you know, deliver training and education that's already available out there. Right. We are doing the things that they need to do to be able to own and run their own practice with our support and then to be able to provide excellent specialty, specialty RN care.

[47:51] Michelle: That's fantastic. You're just removing all these blocks to make their experience so much easier and pleasurable, where they get to just really practice being a nurse and they don't have to worry about all that other stuff.

[48:08] Joseph: And man, that's the aspiration, you know. That is exactly the aspiration. And I did it. Remember I told you the beginning of this was Joe wants to be taking care of patients in California through his own practice.

[48:20] So I literally built the company. I needed to be able to do what I was doing and then very quickly realized this is, I'm already going through all the effort of building this.

[48:29] Why don't I make this for other nurse practitioners? And then literally a day later I was like, wait a minute. Registered nurses? There's 550,000 of them, thousand of them in California.

[48:42] And the American Hospital association says that 140,000 of them are going to leave hospitals by the end of 2027. Let me try to help some of them find an alternative career path.

[48:54] And in the meantime, tens of thousands and potentially hundreds of thousands of Medicare recipients are more. Well, and then the health and this, you know, then the Medicare, you know, system lasts longer.

[49:09] Right? So more of us can benefit from it. That's the broad, you know, very.

[49:15] Michelle: Hey, shoot for the stars, you know, I mean, you might as well, because really there's not a lot of other people doing it, Joseph. So thank God for you and Avail Health.

[49:28] And so I imagine that telemedicine is something that you use quite frequently in your practice, and also your nurses and other nurse practitioners use that. But just talk about some of the challenges of telemedicine for the providers and also for the patients.

[49:47] Joseph: I'll give you, happy to do that. I know that we're almost out of time, so I'll give you a great concrete example from today.

[49:56] Okay. So I have a patient visit. This is an established patient. I've got getting to know her well. She's helped to join visits by her adult daughter, you know, because she's, you know, needs some support in like, logging on.

[50:13] Even though we have a very streamlined, easy to easy to access system where they literally just click on a link that comes into their text or email, there's a couple of questions that they have to answer before the visit turns on.

[50:30] And so some, for some people, about 10, 12% of them, that's challenging for them and they need additional help. The good news is most of our patients have no problem accessing care through a telemedicine model anymore.

[50:44] Like, you know, seniors have gotten much better at it, let's put it that way. Right. It's been over four years here and they're, they're much more used to it.

[50:52] But. But this time it had nothing to do with the challenges on the other side. They came on, I heard them, they saw me, couldn't hear me, you know, and I wasn't muted.

[51:07] So it was a hardware problem. Right. So what? Because I've been doing this for a long time. I was actually doing telemedicine as early as 2015. Right. So.

[51:16] Michelle: Wow.

[51:17] Joseph: But it was then I was doing it through very special contracts.

[51:23] So when I was working for the health plan, like, they didn't have to bill for my care, right? They were the health plan. So they. The regulatory environment that allows telemedicine that didn't exist before the pandemic wasn't needed for certain scenarios back then.

[51:37] So I was doing it for certain scenarios anyway.

[51:41] So I knew this is a problem that I don't know how to solve other than I sent a message in the chat and said, I'm gonna log off and come back on.

[51:52] It'll take me about three minutes. And that should solve the problem.

[51:57] And so I literally rebooted my computer and, you know, the problem was solved. But then the visit got off to a little bit of a late start. And when you're back, you know, booked up, back to back, then that patient did get a little less time from me than she might have otherwise gotten.

[52:13] Right. I'm aware of that. But we know each other well. We had enough time to execute for me to assess what's going on, for me to provide feedback, for me to offer a new treatment plan, educate the patient and get her consent to make that treatment plan.

[52:30] So it didn't prevent care, and it also didn't prevent, in my opinion, care would care. But it was a challenge, like you were asking about. Right.

[52:39] And then I had a patient last week whose phone was acting up, basically their smart device. And that's where they, you know, like, probably four out of five visits. That's 

[52:52] The device they use for the visit.

[52:54] And that particular issue we weren't able to overcome.

[52:58] You know, so we offered a telephonic visit as an interim visit.

[53:04] And then that patient's scheduled for a virtual visit this week. And we're collaborating with the patient's family to make sure that, you know, he has a good working phone, a smart phone to.

[53:16] Because he's actually getting not just his care virtually, not just from us, but actually from another provider as well. That's not in our model. So it's really important for him to get it.

[53:28] So there are challenges. But I'm happy to say that generally speaking, we feel very bullish about deploying virtual care, even in the geriatric Medicare population.

[53:41] It works. In the pandemic, I'll say one last thing. Cause I know we're about to wrap. But in the pandemic, when it kicked off, I went from.

[53:48] Because, again, I work for the health plan. So I just pivoted and I took all of my patients on telephone.

[53:54] And then about three weeks in, I already had, like, the health plan I worked for already had the functionality of virtual visits in place. So, like, we didn't have to go out and shop for technology and contract and then train everybody on it.

[54:08] It was already there. We just weren't using it very much. And so over a period of about 12 weeks, I transitioned 87% of my panel of, like, 440 patients onto fully virtual visits.

[54:24] Wow.

[54:26] With the help of a fantastic medical assistant, I will say. But you know, where there's a will, there's a way.

[54:34] Michelle: Yep, there absolutely is a way. And it sounds like you've really had to navigate your way around all of these barriers and four years of using telemedicine virtual health system, I imagine you've gotten really good at figuring out, troubleshooting these problems with technology that seem to plague us, no matter, you know, how much we try to learn about.

[55:00] So, man, you're doing great things there, Joseph. You're a trailblazer.

[55:07] Joseph: Oh, yeah, I appreciate it and I really appreciate the opportunity to speak with you and you know, to join your long list of interviewees and you know, I love to stay in touch and I welcome the chance, you know, to stay in touch and to update you.

[55:24] I mean, you know, this year is going to be a huge year. Health. It's our first full year in operation.

[55:31] We have a lot of contracts and a lot of opportunity to grow robustly. We, we anticipate that we'll have, you know, 10 independent nurse practitioner practices operating by the end of the year.

[55:42] And then 2026, we actually, we feel really confident that we'll probably quadruple that number in 2026 because every, every payer in the Medicare space we talk to is like, yes.

[55:57] You know, how do we, how do we turn this on? Because there's nobody out there trying to do what we're doing there. Nobody out there that's bringing all the combination of services and the personas that we have in our model to the patients wherever they are.

[56:12] Right. And it's one of the big reasons, like the average patient, dementia patient in Medicare costs 300%.

[56:22] The average Medicare patient, that difference is literally like 12 or $13,000 a year.

[56:32] And for $2,000 a year, we can eviscerate that difference.

[56:38] Right. So when you think about it, it's like sometimes you got to spend money to save money.

[56:43] Well, the entities in the Medicare space, they get that, they understand that services in the outpatient setting are far cheaper than services in the inpatient setting. If you can deploy outpatient services correctly in an evidence based way with the right resources, you can actually save many times what you spend on those services.

[57:07] And so that's our appeal and they get it. So we're looking forward to growing it and then just spreading the opportunity to more and more nurses and nurse practitioners who want to go down this route.

[57:18] Michelle: Yeah, I really love it and I love the focus being on preventative care and trying to keep people out of the hospital.

[57:27] I think if that were done in a more robust way, our healthcare system would just be so much better and our providers would be so much happier and our patients.

[57:40] Right, our patients would be so much happier with their care, with their lives.

[57:46] And we could definitely meet the quintuple aim of healthcare.

[57:53] Joseph: Yeah, I think it's within reach for us. It's a big, like you said, big ambitious goal. There's nothing wrong with that. I look forward to, you know, spending the rest of my career, at least in that, on that mission.

[58:05] Michelle: Yeah, it's a worthy one. Joseph, thank you so much for joining me today and for talking about your passion and what you love to do. It's certainly come through the airwaves today and I will ask you what I ask all my guests now.

[58:19] Is there someone you recommend as a guest on this podcast?

[58:24] It's a good question and you can think about it. I know it's always a spur of the moment question.

[58:30] Joseph: I think what I'd like to do is I'd like to introduce you to one of the nurse practice owners in my model.

[58:37] Michelle: Okay.

[58:38] Joseph: And so since we're turning on a couple of new practices next week, I'll make an introduction probably in February or whatever. And once they've been in the model for a couple months, you know, they can speak for themselves.

[58:49] Right. You know, like what they're doing and how it's working and what are the pros and cons.

[58:55] Michelle: I love it. I'm totally open to that. So, yeah, introduce us and where can we find you, Joseph?

[59:03] Joseph: So our website, Avail Health's website is availhealthcare.co.

[59:13] and, and then my, I'm, you know, if you look up Joseph Harrison, NP on LinkedIn, you can find me there and look forward to meeting any new folks who are interested in connecting.

[59:27] Michelle: Yes. And I have all those links and I will put them in the show notes for anybody that wants to contact you.

[59:33] And again, thank you so much, Joseph.

[59:36] I absolutely love what you're doing. It was a great fit that you came on today and there's so much more to talk about. So I can foresee you being one of my repeat guests.

[59:49] Joseph: Oh, I'd be happy to do it. And I'll, you know, I mean, there's, like you said, there's so much to talk about. We'll see what happens in the next 12 months with CMS, you know, with Medicare and Medicaid.

[01:00:00] We're actually opening up a couple of different service lines in 25 that go beyond Medicare and, and so we'll learn more, you know, about what those look like as we deploy them.

[01:00:11] But yeah, I look forward to it.

[01:00:13] Michelle: All right, Joseph. Well, we have reached the end, which means it's time for five minutes of fun. We're going to play the five minute snippet. So are you ready for that?

[01:00:25] Joseph: I'm looking forward to it.

[01:00:28] Michelle: Okay, that sounds tentative, but let's go.

[01:01:13] Convince me to live in Ithaca, New York.

[01:01:17] Joseph: Oh, easy.

[01:01:19] So there's this kind of playful motto or advertising campaign for Ithaca. It's "Ithaca is gorgeous."

[01:01:28] Ithaca is a very unique topography. It is sitting adjacent to a beautiful lake, one of New York's finger lakes, Cayuga Lake. But a lot of the people who live in Ithaca live up on the watershed.

[01:01:44] So there are these gorges that are formed by water flowing downhill to the lake for, you know, millennia or eons. Right. And so these, these gorges are so amazing. They're so beautiful.

[01:01:57] They create these natural waterfalls, 150, 200ft tall. The area is full of New York state parks and it is just really beautiful. And then if, if nature's not your cup of tea.

[01:02:11] Ithaca has two universities surrounding it. One, a very old, you know, famous Ivy League school, Cornell University, and another, less famous university called Ithaca College. And it has a very high density of students as compared to the local population.

[01:02:27] So there are as many students as there are people who live permanently in the area. What that does is it's a boon to the local economy. So there's beautiful places to dine, there's great entertainment.

[01:02:40] But it's really spacious place, sparsely populated. So you have this density and you have the diversity that the universities bring. And then you've surrounded by this robust and plentiful and beautiful nature.

[01:02:55] Michelle: Oh my gosh, it sounds amazing. I had no idea. Okay, this is finish the sentence. The snow makes me feel like...

[01:03:07] Joseph: Everything is clean and fresh.

[01:03:09] Michelle: You know, that's how I picture it, Joseph. I've never lived in the snow. Of course I visited the snow. And it's always just so beautiful and peaceful and calm. I think if I had to live in it and drive in it and do all those things like scrape it and blow it and I, I don't know if I would want to do it.

[01:03:28] Joseph: I'm only one winter in, but I've thoroughly enjoyed it. I love waking up in the morning and there's snow on the ground and when you get a fresh snow like we did two days ago, and everything is just renewed, you know, and it's white and in the darker places, having white snow, you know, ubiquitous, it feels like,

[01:03:49] It feels less dark and it's really good for I think, your spirit and your mood.

[01:03:54] Michelle: Yeah, I would think it really helps with seasonal affective disorder in a way. Right?

[01:03:59] Joseph: Yeah, that's what I think because I suffered from that when I lived in Seattle, Washington.

[01:04:05] I had really hard winters there, like struggled. And this is my first winter in Ithaca and I have just not felt that.

[01:04:14] Michelle: That's fantastic.

[01:04:15] Joseph: I do use a full spectrum light about five mornings a week too, so that helps.

[01:04:21] Michelle: Got it. Yes. That is super helpful. I have had problems with SAD as well so that light is really helpful.

[01:04:29] Okay. Did you have a favorite childhood game?

[01:04:33] Joseph: Like a game that you'd play at home or a sport? Which one do you mean?

[01:04:38] Michelle: Yeah, like a board game.

[01:04:40] Joseph: Oh yeah. What would I say. So I was a, I was like a role playing game junkie when I was a kid. So myself and

[01:04:51] three of my very close friends formed like a group of four. One of them was our like dungeon master that led us on our journeys and the other three of us, you know, created these characters depending on the game.

[01:05:05] We played Dungeons and Dragons, that's the most famous one. But we played probably 10 other role playing games through our throughout our childhood. And I mean, I'm talking about an investment of thousands of hours in my childhood.

[01:05:20] I don't play it anymore. But I'm still a dyed in the wool sci fi fantasy lover and my imagination is just lit up by those like new worlds.

[01:05:30] I still read epic fantasy books for fun.

[01:05:34] I mean I probably read seven, you know, thousand page books in the last year because I just love them.

[01:05:41] Michelle: Wow, that's amazing. I love it. Love that story. Okay, this is fill in the blank. People often misunderstand________

[01:05:56] Joseph: Weakness.

[01:05:59] I think people often misunderstand what weakness is.

[01:06:04] I think that our culture sends us all of these signals about what is strength and what is weakness.

[01:06:11] And some of those signals are very, very old and very dated.

[01:06:16] And people still believe them.

[01:06:19] And that belief in, like, what represents strength and what represents weakness causes all kinds of suffering for people that is actually preventable.

[01:06:32] Michelle: Wow. 

[01:06:34] That's really profound and so true. And I love the way that you explained it.

[01:06:41] Okay, we're in your home, and there's a picture on the wall of your favorite travel destination.

[01:06:48] Where is it and who is in the picture?

[01:06:52] Joseph: That's a great question.

[01:06:54] Let's say my favorite travel destination 

[01:07:01] me standing on the top of a pass, a mountain pass.

[01:07:06] There are no roads. There's no cars. There's just humans. My wife, my two children, and myself standing on a pass. Our backpacks are on the ground. We've got snacks out.

[01:07:21] We're trying to keep the marmots away from eating our food.

[01:07:25] And we're just, like, deeply appreciating, being completely immersed in nature. With no easy in, no easy out. We're relying on our own bodies and each other and our preparations to get us where we're going.

[01:07:43] Michelle: So serene and so necessary to just unplug. Right?

[01:07:50] Joseph: Yeah. When you do it that way, too, Michelle, you can't plug back in. There's no cell signal. You know, you have to have a GPS beacon, emergency beacon, in case something goes wrong like that.

[01:08:04] You're really like. They're just. There's no. You're not relying on your discipline. You just have no choice but to be present, you know?

[01:08:13] Michelle: Yeah. And sometimes we just need those choices, like, removed from us, that we don't have to make a choice. We just get to be, so that's cool.

[01:08:24] Okay, last question.

[01:08:26] The first thing I do when I reach my travel destination is...

[01:08:34] Make camp? You gotta live somewhere, right? And sleep somewhere. Yeah, Right.

[01:08:41] Joseph: We, my wife and I have, we have our system. We have our jobs.

[01:08:48] Michelle: Yep.

[01:08:50] Love it. Reminds me of my husband and I RV'ing. And once we would get there, you know, it's like, he did this and I did that, and pretty soon everything was put together, and then we could just start relaxing.

[01:09:04] Joseph: That's right. Yeah. And I mean, I think my other answer to that question is, you know, get undressed and jump in the glacial lake that we're camping next to. Because that's something that's like a ritual for me, is I'm, like, tired and my muscles are sore and I'm probably hot, you know, And I just.

[01:09:24] I'm kind of like, oh, I don't want to really, like, make camp right now. And so I. I just. My wife will not go in that lake.

[01:09:33] I get my. I get all my stuff, all my gear off. There's nobody around, Right. And I jump in the lake and call to my ancestors for help to survive the shock.

[01:09:44] And then, you know, I'm in there for 2 minutes, 3 minutes, and I'm back out. And I feel like brand new, you know?

[01:09:51] Michelle: Yeah. Refreshed. The best cold plunge ever.

[01:09:55] Joseph: Exactly. Exactly. And you earn it, you know?

[01:09:58] Michelle: Yeah. So cool.

[01:10:00] Well, Joseph, you did amazing in the five-minute snippet. I really appreciate it, and I just appreciate everything that you've brought to this conversation today.

[01:10:10] And I look forward to more conversations with you.

[01:10:14] Joseph: Me too. I look forward to staying in touch. And this is going to be a really big year for Avail Health and myself as a founder. And I'm just looking forward to, you know, moving from strength to strength and helping more and more patients and clinicians.

[01:10:31] Michelle: Yeah. I love what's in store for you. So thank you, Joseph. You have a great day.

[01:10:36] Joseph: Thank you. And have a good year.