Critical Point Episode 27: Telehealth in the time of COVID

Transcript

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Lesley Pink: Hello and welcome to Critical Point, brought to you by Milliman. I'm Lesley Pink and I'll be your host today. In this episode of Critical Point, we're going to be talking about the rise of telehealth in the wake of the COVID-19 pandemic, and what that could mean for the future of healthcare in the United States. Joining us today, virtually of course, are Mei Kwong, executive director of the Center for Connected Health Policy, and Susan Philip, a senior healthcare consultant at Milliman with over 20 years of experience in healthcare policy, finance, and research. Hello to you both.

Susan Philip: Hi, Lesley.

Mei Kwong: Hi, Lesley.

Lesley Pink: Mei, you're a nationally recognized leader on telehealth policy, leading the center's work on public policy issues as they affect telehealth on both the state and federal levels. Susan, this is actually your second go round on Critical Point. You joined me way back in 2018 for a podcast on telehealth, but a lot has changed since then, especially in the past six months. I'm curious, what are the biggest changes you've both seen when it comes to telehealth in light of COVID?

Susan Philip: Sure, I'll jump in. Lesley, yeah, you're right. A lot has changed since I was on the podcast in 2018. Back then, I'm not sure that most people even knew what telehealth was. Now, I think a lot of people have had some either direct experience with telehealth. Maybe in the last couple of months, they've had a remote visit with their doctor, or maybe they know someone who has. So I think the expression I'm hearing a lot these days is that the genie is out of the bottle when it comes to telehealth, and the COVID-19 pandemic really has been a singular reason for the dramatic increase in use. I would say before COVID-19, we saw telehealth use for some urgent care, maybe some behavioral health visits, and it really was a way to increase access to rural communities. But in the last few months, there's been a really big increase in the use, in the early months of the pandemic, many states have asked hospitals and practices to really halt all elective procedures. So given the need to preserve protective-- personal protective equipment for healthcare workers, it was really important to limit in-person visits to those folks who really needed that visit to be in person. Patients are still looking for ways to get the healthcare they need without fear of exposure to the virus. Doctors are trying to find a way to provide that care without exposure. So I think that's really the big change that's happened in the last couple of months. Mei, what do you see as the biggest changes?

Mei Kwong: Well, Susan's absolutely right. The profile of telehealth has increased dramatically. Consumers, before COVID-19, they really were not aware of telehealth or understood what it was. I've been doing this for 10 years, and before COVID, I'd still had family and friends who were confused as to what I did for a living. I like the analogy of, before COVID-19, telehealth was kind of like that unknown actor who'd gotten a few roles over the years, but was not really known to the general public, suddenly being cast in the next Marvel franchise movie series. Suddenly everybody knows who this person is and are trying to see what he or she will be able to do. So that's kind of like the experience with telehealth. As Susan pointed out, given the highly infectious nature of COVID-19 and the orders that came out for people to isolate or shelter in place, stay at home, there was that need to still allow people to be able to access health services. So the unique qualities of telehealth which is, for those who may not be as familiar with it, is the use of technology to provide services when a patient and a provider are not in the same location. Those unique qualities were able to really be applicable here during COVID, in that you can still be sheltering in place at home, but still get the healthcare services that you need. So where we've seen dramatic changes though, on the policy level, was that the pre-COVID-19 policy landscape didn't necessarily allow for that to happen very easily. So that's why you saw so many policymakers, both on the state and federal level, making so many changes over the first couple of weeks of COVID, in order to allow those greater flexibilities for telehealth to be used on a more widespread scale.

Lesley Pink: And what are some of those regulatory changes that we've seen at the beginning of the pandemic and as we move along and this goes on for months and months and months?

Mei Kwong: So most of those changes really have to do with reimbursement because before COVID started, a lot of the established policies that you had, both on the federal and the state level, really centered around what would get paid, if you used telehealth. There are other laws around it, such as licensing laws or how you prescribe if you use technology. But a lot of the established sort of policies were around reimbursement, and those were the ones that needed to be adjusted during COVID. Now the major ones that we saw, that were played out both on the federal and on the state level, were policies that limited where telehealth could take place, like the location of where the patient was receiving the services when it was done via telehealth. What we saw on a wide scale common type of policy change was allowing the patient to be in the home, which was very logical again because of orders to shelter in place. Another sort of major thing that we saw that was very interesting, because before COVID-19 it really wasn't regarded as telehealth, and that was the use of allowing audio only phone to be a way of delivering a service. So before COVID, on the federal and the state level, a lot of people, when they define telehealth, did not include audio only within it. I mean, there are states that actually have a specific definition for telehealth or telemedicine, depending on what term they use in statute or within their policies that explicitly exclude audio phone. However, policymakers recognize, because of the fact that some people may not have adequate connectivity or the equipment on their end in order to use telehealth, such as a smartphone or a laptop with a camera or something, that this may be the only way in which they would be able to receive some type of services and that's through the phone. So those were the two sort of major types of widespread changes that we saw taking place. Then there were other things, such as allowing certain types of providers also to be able to use telehealth. A lot of times, the policies might be narrowed to just some types of healthcare professionals, such as doctors or nurses or a dietician or a social worker, expanding that pool of who could deliver services, and the types of services that would be covered.

Lesley Pink: OK.

Susan Philip: Mei, are you seeing states continue to expand the parity rule? That is, that the payment for telehealth happens to be at the same level as in person?

Mei Kwong: Are we seeing more states do that? Not at this point. If they're introducing legislation, because that would have to be-- if it's on commercial payers, they'll have to do that through legislation. What we're seeing with the legislation, a lot of the legislation is in reaction to COVID. So they're just looking at, well, what were the things that we did in reaction to COVID? Should we make them permanent now? That's sort of what the majority of states' policymakers are focusing on. So they're not necessarily focusing on that particular question, a parity of payment for commercial payers.

Susan Philip: There are certain health plans that have said that they are going to be reimbursing and are reimbursing telehealth at the same levels as in-person. It was very specific that it would occur during the pandemic. So it will be interesting to see whether commercial players, who have flexibility in terms of what they do with their policies, whether they continue to voluntarily extend that going forward, or whether that will end at some point. I imagine that that might end at some point, barring any state rules or other state or federal rules. And I think one other prior limitation, and of course privacy is always a concern, and the rules under HIPAA limited use of certain types of platforms. I think the federal flexibility to expand the number of platforms that could actually provide telehealth also gave providers that flexibility and confidence saying, "Okay, well, now I can actually use FaceTime and Skype, and this is going to be okay, and I'm not going to get in trouble for using that." Would you say that that was also a factor that drove some increase in use?

Mei Kwong: I think so. Part of that, the reason they did that, I believe, is that there was this rush of like, they needed to stand up these telehealth programs really quickly. And there were certain rules, not only around privacy issues, but also for those who may have heard about, there are things called Stark or anti-kickback laws, which basically say things such as, you have to do certain things in order to make sure you're not trying to game the system in Medicare or Medicaid, in receiving services, when you do a relationship with another healthcare professional. Like relaxing some of those because you were responding to this emergency situation. I think that did have a lot of influence as well for people who were really starting from zero in starting a telehealth program in reaction to COVID-19. That was less of an issue for organizations that, of course, already had a telehealth program in place.

Lesley Pink: What are some of the differences that you've seen between Medicaid, Medicare, and commercial health plans, in the use of telehealth during this time?

Susan Philip: So under Medicare, I think there's been a pretty dramatic increase-- actually, across the board, there's been increases. As Mei said, the federal flexibility allowed for increase in use, and let's look back in 2016. Back then, there were about 300,000 telehealth visits for that year for Medicare fee- for-service beneficiaries, and that was for the whole year. We saw, at the end of March, from Centers for Medicare and Medicaid (CMS) services analysis, that that had gone up to about 300,000 visits per week. So that's a pretty dramatic increase in the amount of services that were actually being provided under Medicare. Under commercial, I'd say pre-COVID, we're talking about maybe less than 1% of all visits being delivered by telehealth, maybe a little bit more in some parts of the country. But in March and April, when we take a look at all visits that were being delivered, we saw about half being delivered through telehealth. So it's a pretty dramatic increase. Obviously, again, March, April, May, those were months that the shelter in place orders were in full effect and things are beginning to open up. Even in the first couple of weeks of June, we're seeing a little bit of a dropoff there. But I do think that the increase, now that everyone has had some kind of experience with it, there will continue to be an increase. A couple of examples for some specific plans. I do know that based on the public reports, Blue Cross Blue Shield of Massachusetts, for example, they changed their policy to expand coverage for telephone and virtual visits and reimburse them at the same rate as an in-person visit during the COVID-19 state of emergency. They saw, in March, a 3600% increase over February-- so pretty dramatic increase. If you look at the same time period of 2019, they saw a 5100% increase. So pretty big increases. I know that's also similar, Blue Cross Blue Shield of Arizona. Based on their reports, they also said that they saw a 3200% increase in March and April. So again, pretty big increases.

Lesley Pink: Right, so it's not just a single digit increase. We're seeing increases in the three digits or four digits.

Susan Philip: Yeah. I think the term here is orders of magnitude. It's definitely pretty substantial.

Lesley Pink: How does reimbursement work with telehealth rather than an in-person visit? What are payers saying about telehealth?

Mei Kwong: So in a lot of cases, definitely when you're talking about Medicare and a lot of the Medicaid programs, practically all of the Medicaid programs, a telehealth visit is paid the same amount as an in-person visit. Now, but keep in mind though, usually it doesn't mean all visits that Medicare and Medicaid will cover in person, you can also use telehealth for. So there are limits in that way. But for those services that are covered, that they say you can use telehealth for, they pay the same amount. Commercial payers, it varies. I think Susan just cited a couple examples where they said that they would pay the same amount during COVID-19, but it can vary across payers and in states. So what actually the majority of states have, at this point, it's like 42 states and the District of Columbia, they have in their statutes laws that actually apply to commercial payers and how they treat telehealth. Those laws range from everything from a state saying commercial payers, you can cover telehealth if you wish to, all the way to a state that will say commercial payers, you shall cover telehealth services the same way you would have if the service is delivered in person, and by the way, you will pay the same amount. Then all other states kind of fall in between there. There's actually less states, though, that have that explicitness in their laws saying you pay the same amount. So that's why you get this variability of what the commercial payers do and what they will pay.

Lesley Pink: Do you think that the uptake in usage is here to stay, or do you think it will peter out a little bit, as you had mentioned before, as things get a little better on the COVID front?

Mei Kwong: I think there is the possibility that it's probably not going to run as hot as it has been in the first couple of months of COVID. So I do think what we're seeing now, when some of the shelter in place orders were lifted, we saw the dip. I think that will be logical to see, what we'll continue to see. The thing is that COVID, we're not going to go back to normal of what we had pre-COVID within the next couple of months. At least, that's my opinion.

Lesley Pink: Right.

Mei Kwong: So I still think that we'll still see the use of telehealth, at least definitely through the end of the year, maybe even a year or two beyond that. But there will probably be at some point where it kind of levels off, but it will definitely be at a higher level than what it was pre-COVID-19 because you do have that added factor of some of the policies being more expansive, more broad, and more providers who have put up or instituted telehealth programs, still continuing those, and a big factor of patients having received telehealth services. There are going to be some who didn't like it, but I think there's also going to be a good portion who did like it, who are going to say, "This was really great. I was able to go visit my doctor from home. I didn't have to go to the waiting room," and they're going to want to keep that. So I think it will be natural for it to obviously not be at that furious pace that it was in the early days of COVID, but it's definitely something, as both Susan and I have said during this talk, something that's here to say.

Susan Philip: Yeah, and I'd just say that I think there's a few different factors that would drive whether telehealth persists, and one that Mei touched on, of course, is payment. That's a big factor. Having that regulatory flexibility in payment policy will help drive some kind of sustained use of telehealth. I agree-- it won't be at the same levels as during the peak of the pandemic, but certainly more than in prior years. The other factor is doctors’, physicians’, providers' adoption. So I think physicians are now adopting it as well. They needed to because they weren't seeing any patients and they wanted to find out how their patients were doing, make sure that there was continuity of care, especially for individuals who are older, who had chronic conditions. They needed to set up that infrastructure in place. So it really was a demand that we saw and the physicians really did want to say, "Okay, how can I continue to see my patients without jeopardizing their health and exposing them to the virus?" One physician leader of a large health system, I heard admit that it was embarrassing that it took a pandemic to finally adopt telehealth, right? It was on their roadmap and they were planning to do it, but the pandemic really made it happen faster and created an urgency there that wasn't there before. I saw a recent survey, a physician survey, where they found that the use of telehealth has rapidly been accelerated by the COVID-19 pandemic. Almost half of doctors, based on that survey, is now using telehealth to treat patients. And as Mei said, the consumers and patients, before there wasn't necessarily a groundswell demand, but now there is a convenience factor by being at home and not having to go in and see your doctor in person. So I do think that that is going to be a factor in driving consumer demand.

Lesley Pink: So what have you both been hearing about telehealth from the provider perspective, from the patient perspective? Is there anything that stands out to you that is especially noteworthy?

Susan Philip: So sure, I'll share a report from Mount Sinai. Of course, they're based in New York. They were at the epicenter of the pandemic a few months ago. They had a telehealth capability. They were doing video visits, especially for urgent care, and they were reporting, back in late February, early March, maybe about 10 to 50 video visits per day. Then when they moved into April and May, they were seeing about 3,000 visits per day, so a really big jump. Of course, they had put in those capabilities in place because they wanted to make sure that they were continuing to serve their patients and keeping them out of the hospital. In early June, we did see reports from Mount Sinai, saying that the number of video visits did trend down recently, but it's still fairly high. It is still a modality that they are using to reach out to their patients. But they also said that it's not like they've done a lot of advertising, or really done a lot of outreach, saying that they have virtual care visits. So they do plan to advertise the fact that they have virtual care services, and that this is a new way that they want to keep in touch with their patients and ensure the patients have the care they need post-discharge, and also for urgent care services. So that's the experience of Mount Sinai that I've heard.

Mei Kwong: Yeah, I'm hearing similar things, too, from other hospitals and clinics. Almost exactly like the Mount Sinai example was the Children's Hospital here in California, which already had an established telehealth program that was seeing probably, they estimated, about 100 telehealth visits a week. When COVID hit, it went up to like 1,000 a week. Then as the weeks went by, it fell slightly to about 600 a week and held steady. There's another clinic that did not have a telehealth program and literally, over the weekend, they had to launch and stand up a program, because they were saying, "Nobody was coming into our doors, through our doors. We're just not seeing anyone, so we needed to do this in order to survive." So over basically a weekend, they managed to get a telehealth program up and running and they saw-- they didn't see 100% volume return of what they were seeing pre-COVID, but they definitely saw a significant amount of people coming in. They estimated probably about 50 - 60% and it was all telehealth. On the consumer side, I'll just relay a personal example. My mother is actually one of those people who are in the most vulnerable populations to COVID, with some chronic conditions, some health issues. She's elderly, she's a senior. She had her first telehealth interaction during COVID-19 and she basically, at the end of it, turned to me and said, "That was it? That was so easy?" She goes, "Why was I going to the doctor's office so many times? We could have done it that way." So it was kind of funny because she was one of those people who were confused what I did for a living. I said, "This is what I do for a living, Ma." But yeah, you know, it's sort of like that-- it's not for everybody, but it is for a lot of consumers their first exposure. They're just like, "Well, wow. This is great to have. I wish I had it earlier."

Lesley Pink: What are you hearing doctors and nurses saying about how they're treating patients via telehealth rather than in person? Have you heard any anecdotes from that group?

Susan Philip: Yeah, what I've heard anecdotally is that physicians that I've spoken to who are new to it do like it in the sense that they feel like the visit is a little bit more relaxed. They get to spend more face to face time with the patient. Sometimes an in-person visit can feel very rushed. There's something about the video visit, maybe because both parties are sitting in their home, but there's something about it that does feel more relaxed, which seems like a plus. On the minus side, the physicians say that they are spending quite a lot of time, especially depending on the specialty, in just coaching the patient through some parts of the visit. So, for example, an ophthalmologist might need to tell the patient, "Okay, can you position yourself in front of the camera in this way?" and then kind of coach the patient through those sorts of things that are just needed during the visit, that the physician might normally do during an in-person visit, but now they need to kind of help the patient through. So that's been interesting because now the physician has to spend some time actually training the patient on how to really optimize that telehealth visit, and that way the physician can get all the information that they need to make a call. And of course, if the physician doesn't feel comfortable that they really have gotten all the information they need during that visit, well then, they're going to ask the patient to come in. The physician needs to have the clinical guidelines, so you have best practices. They need to have guidance to say, okay, when do I really make that call of saying, all right, I've gotten the information I need, I can make a clinical decision or, you know what, this is not sufficient, I'm going to need the patient to come in? So I know quite a few specialties are working on guidelines right now, on supporting the physician on various workflow changes, on clinical decision making through the use of telehealth. So all of that is actually under development now, and so that, I think, will really help physicians increase their comfort level and potentially increase adoption.

Lesley Pink: On that note, there are, I'm guessing, certain areas of medicine where telehealth works better or certain populations where that works better. You had mentioned an elderly population-- the coronavirus poses more of a threat to them. So do you think it's going to be used more among an elderly population? Also I had read that people with substance use disorders were not getting-- might not be getting the care that they needed and there was some opening up of telehealth for that population. So are there certain populations, certain areas of medicine, where you think the uptake might be a bit greater than others?

Mei Kwong: I definitely think at least a certain type of condition, or a certain part of medicine where you definitely will see a big uptake, is where telehealth was actually very popular, where it was utilized the most, a specialty where it was utilized the most before COVID-19 and that's with mental and behavioral health. I mean, especially now during COVID, people have seen an increased need for the services. We already have that, even before COVID. It's just been more of a larger increase of demand for it and need for it. And that also relates to, Lesley, what you had mentioned about substance use disorder because part of the treatment for substance use disorder does involve counseling and behavioral therapy. So that's a big area, I think, where you'll see probably even more use of telehealth to supply the services. As for certain populations, obviously it works well for those who would be in rural or underserved areas, who just have access issues in general, even before COVID, of reaching healthcare providers and health services, just simply that there may not be a lot of people that they need to see around them. So that was one reason telehealth was utilized a lot in rural areas before COVID-19. I don't see that need going away, but now that they've opened up the policies to allow it to take place in more areas, I think you'll see people in urban settings who also had those same problems of trying to reach a certain type of specialist, also using telehealth. There are parts of LA where it can take you hours to reach the type of specialist that you may need to see.

Susan Philip: Yeah, absolutely. I definitely think that telehealth lends itself better in some specialties rather than others. So take for example, COVID-19-related care. Telehealth has been used, for example, to screen patients who might have symptoms and then refer them as appropriate. So telehealth is very useful for screening patients and then triaging them to determine whether they really have COVID-related symptoms and whether they need to come in or whether they can be treated remotely. Another use case for telehealth that’s really interesting to me is related to pregnancy and prenatal care. I imagine if you’re pregnant right now it's a very challenging time, if you need prenatal care and need to be using a hospital during a pandemic. And a recent survey by the Blue Cross Blue Shield Association said that we found that about 61% of the women in their survey, their doctors had very limited office hours, and that 48% had their prenatal appointments shifted to virtual visits. So half their visits were shifted to virtual. So prenatal care, especially if you have a non-complicated pregnancy, telehealth could be a good option for prenatal care. Although one concerning finding from that survey is that there were about a quarter of all women surveyed who actually missed a prenatal appointment at the start of the pandemic. So that's also a concern, just the effects of COVID-19, and people just not getting the care they need, but hopefully with telehealth, they could get some of that back. Another specialty which I thought was interesting is oncology care treatment. I know that Kaiser, in northern California, for example in San Francisco, they have a breast cancer oncology unit and they had to limit in-person visits really to patients that required the physical breast examination. But other discussions that include say, a multidisciplinary visit, an oncology visit might include your oncologist, your radiation oncologist, social workers, genetic testing, etc. So those types of visits, they are able to successfully shift to telehealth. So I think that's an example where you have certain specialties, and depending on what services are being provided, can be successfully shifted to telehealth.

Lesley Pink: One thing in this country that can sometimes be an issue is what's referred to as the digital divide, that some people in this country have access to internet. Others do not. How is that affecting things in the telehealth world?

Mei Kwong: It's a significant issue. I mean, without that connectivity, telehealth simply doesn't work. There has been a lot of discussion of it because as we move towards looking at what to make more permanent from these temporary waivers, there is the concern of leaving some people behind. Not only on the issue of connectivity, but also on, do people have access to the equipment on their end? Do they have a smartphone? Do they have a laptop with a camera, etc.? So there have been discussions about that and some actions by the FCC to try to at least address the broadband issue. But it is a concern. It's like, what do you do in order to make sure there aren't large segments of the population who aren't able to access this type of service or this type of technology in order to get those needed services.

Lesley Pink: On that, aren't there a lot of people who might not speak English as a first language who might also be sidelined because of it? Because I'm assuming for the most part that telehealth is being provided in English?

Mei Kwong: Yeah. It's not only a cultural issue as well, with like, language barriers, which can be addressed. You can have translators-- I'm not sure if all the states have. I do definitely know California, there's a core remit of having translators available. That still applies to telehealth. You do not avoid that requirement because you're using telehealth. But not only people from different cultures, how comfortable they are with telehealth, which by the way, is a rather understudied area, but you're also talking about maybe people with a disability, maybe people who are vision impaired or hearing impaired. Are their needs and their specific circumstances being addressed when you're using the technology as well? These were things that I have to say were talked about a little bit before COVID in the telehealth world, but they were not large scale discussions in a lot of sectors. But COVID has really elevated a lot of these conversations and saying, more people are using this. This is becoming more widespread, but have we not paid enough attention to these particular populations and their specific requirements?

Susan Philip: Yeah, I would just add that we do know that not all households have a desktop or a laptop that have a camera. You know, seeing that more than one in three households where the household is headed by someone who’s over age 65 or older, they just don't have a desktop or a laptop, or might not have that smartphone device with a camera. One thing we don't want to do with the use of telehealth is really exacerbate issues of healthcare disparities. We need to think about how we're applying these technologies very deliberately.

Lesley Pink: As we're starting to understand and see statistics regarding the cost of deferred care during the pandemic, how is telehealth offsetting that or affecting that?

Susan Philip: Yeah, so Milliman research has shown that the COVID-19 pandemic has really had an impact on healthcare use overall. There's been deferred care. There might be care that will not come back, so eliminated care, and we're seeing quite a lot of decrease in healthcare use overall during the pandemic months, that will likely be sustained through the end of 2020 and maybe even the early months of 2021. Telehealth has had some impact in increasing healthcare use or basically offsetting some of that deferment. So for example, we've seen some clinics who've had to essentially shut down services. The way they have been able to offset some of that decrease is by providing telehealth services. So if they, in the early months of March and April, they might have seen a 60% decrease, 70% decrease in total healthcare use, but then as they implemented telehealth, they were able to get about a quarter to 30% of that care, of their healthcare services back, and able to provide some of those services. So telehealth has offset some of that deferred services. It doesn't make up for the total deferred services, of course, since there are still surgeries and other services that absolutely can't be provided, of course, through telehealth. But some of the outpatient and physician office visits have decreased, and those services have been offset by telehealth.

Mei Kwong: That's like one of the other effects that we've touched upon here, that COVID has had, is that it has had this enormous impact on just health institutions, healthcare providers, and their livelihood. As a telehealth resource center, we do get a lot-- definitely during the early weeks of COVID, we were getting a lot of questions from providers, of "How do I start this? What do I do? I've never used telehealth before." A lot of those enquiries that came in were from solo practitioners or small practices, who were devastated by all this. Large hospital systems, even a clinic, they were able to figure it out, probably a lot quicker than that small practice of two or three doctors, or just even a solo practitioner, like a therapist, trying to sort out what they would do in this time.

Lesley Pink: That's actually really interesting. I was thinking about things in terms of hospitals, but I wasn't thinking of a doctor who has a little shop just on his own, and him having to figure everything out and how to implement things. Yeah, that's a really interesting point.

Mei Kwong: Yeah. Got a lot of calls from that therapist who just had a client list and suddenly the clients weren't coming in.

Susan Philip: Yeah, and I think this also sheds a light on our payment system in general, the fact that practices were being paid on a fee-for-service basis then means that they're not providing the services. That means we're not getting paid. I think this is actually going to be a way of thinking about just our entire payment system and how we move to more value-based payment systems, and that includes telehealth as well. So that way, physicians and practices and hospitals have the right incentives to pay for value and outcomes and not necessarily just based on pure volume and the number of services that they're providing. So I think that's going to be another outcome of the pandemic. That's a whole other podcast, though.

Lesley Pink: Susan, Mei, thank you for joining us. You've been listening to Critical Point, presented by Milliman. To listen to other episodes of our podcast, visit us at milliman.com. You can also find us on iTunes, Google Play, Spotify, and Stitcher. See you next time.