BrightSpring Health Services, Inc. (BTSG) Earnings Call Transcript & Summary

All right. Good morning, everyone. Welcome to the Goldman Sachs Healthcare Conference. I'm Jamie Perse, the providers analyst. Our next session is with BrightSpring Health, and we have President and CEO, Jon Rousseau. Thank you for joining.

Yes. Thank you, Jamie.

Maybe just to start, coming off the recent IPO, I think a lot of people are still getting up to speed on the company. Can you start with just a brief overview of the platform? And what's unique, what's differentiated?

Sure. Good afternoon, everybody. Good morning. Yes, at BrightSpring, we are serving -- we are a home and community health services provider. On the Pharmacy side and on the Provider side of our company, serving people in home and community end markets, going to where they are with very highly valuable services. So we're serving very large markets with essential services and doing that with very high quality and coordinated care as well. What we've been able to do fundamentally in these markets is drive outsized market growth on top of attractive end market growth rates. We've been able to do that through our operational excellence and our focus on sales and marketing. And then really third, we've seen the benefits of our scale in many ways, whether that's on the procurement side, leveraging our fixed OpEx as we grow, whether that's through acquisition synergies or payer diversification. So think of our company is being within the Pharmacy side. We focus on 3 key end markets in the home and community versus retail. There's retail and then there's us in the home and community side, serving people where they are with specialty programs. On the Provider side of our company, we have nurses, therapists and doctors and NPs every day that are going into people's homes in the home and community setting. And that's us. You've got hospitals and doctors' offices and then you've got us on the home and community side. So complementary home and community health provider and really been able to leverage the breadth and the scale of our platform over the last 7 years to drive growth rates which have outpaced the markets we're in.

One question I've gotten repeatedly throughout the last few months, I'm sure you've gotten it as well. How do you address the question of just when you're asked, why do all these businesses fit together? I mean, there are some obvious ones that do. But there's some where the synergies and the complementary nature that you spoke of aren't as obvious. So how do you answer that question of why this collection of businesses fits together?

Yes. Fundamentally, we are providing really strong quality, good coordinated care and operational execution in a culture of continuous improvement in our organization. I think that's one of the things that's really differentiating about us, is we work within these home and community settings specifically. Every one of the patients that we're serving with our essential services requires multiple services. Everybody needs their pharmacy and most people need provider services as well. So through our platform, offering better integrated care, which is more proximal, it's more timely, it's more preventative. We're able to do things for patients that are fundamentally better in these lower-cost settings. And then these are all very related service lines that benefit from the best practices that we have within our portfolio and our platform. They benefit from our contract and capability and our scale as well. And so we want to be there wherever the service need is in the home and community. We're better able to drive integrated care for the multiple services people require. And then we get significant benefits with our platform in driving best practices and efficiencies.

Can you just lay out the strategy over the next couple of years? And where you're spending your time? What are you focused on in terms of executing the strategy?

Sure, sure. Thanks, Jamie. Our playbook, which has been successful really now for over the last 7 years, has been to drive volume growth, operational excellence and then accretive acquisitions. On the volume side, we participate in very large, growing markets. And so we like to focus on markets on the Provider side that are growing at 6% to 8%. And on the Pharmacy side, several growing in the double digits. And so riding the market growth, obviously advocating for our services from a rate perspective, but then driving volume through our operational capabilities and sales and marketing team to drive volume in those markets above the market growth rate. So volume has been a focus for us, reaching as many people as we can to drive more impact. Number two, we've been able to leverage our platform to drive operational efficiencies. And then number three, we've been executing on accretive acquisitions, given our platform as well. I think as we look forward, we're going to continue executing against the three strategies of volume growth, operational efficiency and accretive acquisitions. I think that's a winning formula within health care. It's even a more winning formula as you look forward into the future of health care. And really a fourth growth strategy and that we can layer on to this now is our ability to provide value-based care into the future. Our third pillar that we've built out in the last year, 1.5 years is home-based primary care. We have pharmacy, now provider services and home-based primary care. We are seeing about 400,000 people a day between our pharmacy and home health patients. And that is just a tremendous amount of access of patients that are available to us. If we can serve them under our primary care and serve them in a more attractive payer model, that's a potentially really unique opportunity that we have into the future as well.

You touched on market growth. Can we talk about the drivers of growing above the market? So just through the lens of your commercial go-to-market strategy. And then I know you have specific investments in the clinical nursing hub and Continue Rx. These are programs to try to drive above-market growth and differentiate the patient experience. Can you talk about those and other initiatives to kind of execute on the commercial side to grow above market?

Sure. Sure. First and foremost, we really are very thoughtful about what market we're participating in. Again, on the Pharmacy side, we focus on home and community pharmacy, which is totally different and really the opposite of retail. So we really focus on going to the patient with specialty conditions and service needs and focusing on markets where you can really deliver significant differentiation and a bunch of value-add that's durable over time. Multiple of those markets are growing into the double digits, and we see that continuing through the long term. On the Provider side of our business, too, we really focus on services that have a tremendous ROI and save the health system money while they produce better outcomes for patients. Growth rates in our target markets going forward of largely 6% to 8% on the Provider side. So within those markets, we try to deliver really good quality. If we can deliver great quality and differentiated programs for our customers and our patients, that can drive added access to patients and referrals. And then we invest in sales and marketing. So we try to drive quality and operational excellence. We'll do 40 million scripts a year on the Pharmacy side. We're serving 400,000 people a day. I mean, that's obviously a very large organization. It takes a tremendous amount of operational focus to be able to do that well every day. And then with that operational capability, we invest in sales and marketing. I had the benefit of being in devices and pharma for about 10 years of my career. That's an area where sales and marketing along with R&D innovation is just critical. And so I've really tried to bring that focus to every organization we have. How are you different? How are you reaching patients, whether through your people or other vehicles, to communicate with them through? So we make a big investment in sales and marketing as well. And then ultimately, we're pursuing de novos as well to open up new geographies. We do accretive acquisitions given our platform and the relationships that we have out in the market and our access to transactions. So it all starts with picking the right markets, having a quality and operational focus, investing in sales and marketing and then continuing to try to grow and deepen geographically through de novos and tuck-ins.

Over the last, I don't know, probably 2, 2.5 years, being able to attract and retain employees has been a big differentiator for companies. You guys just did all-employee stock grant. Talk about your focus on people as a differentiator and how that's factoring into the strategy.

We certainly try to focus on people in everything we do. I mean, those are the right words, Jamie. We treat it as hopefully a competitive differentiator. I think our equity grant that we announced at the time of the IPO and just recently executed on is a good example of that, the $100 million equity grant. And just trying to create and drive more and more of an ownership culture. People really want to work in a place where they feel like management cares and where there's a focus on quality and [indiscernible]. And that's what we just try to drive throughout our whole organization. We have something that we've called our [indiscernible] that serves for a bunch of good words. But fundamentally, how do you leave something better than you found it? [indiscernible] our patients every day and just try to help them live a better life, whatever that [indiscernible]. So culture and employee programs has [indiscernible] organization. I would say also on the labor side, with Pharmacy, that's a much more scalable labor model. We have a revenue per FTE of about $1 million on Pharmacy. So that really is a business that can scale from a labor perspective. We really like that. And then on the Provider side and across the whole company, we've seen our turnover and retention improve every single year that I've been here. And we're just going to continue to try to invest in our people as much as we can. We've rolled out more and more 401(k). We're very focused on training throughout the organization, the most efficient onboarding process. So it gets a lot of attention in our organization.

I want to get to some of the business details in a minute, but just even at a very high level and simplifying the kind of story for a second. The building blocks you've talked about getting to 8% organic EBITDA growth and 10% with M&A. Why is 8% the right number in the context of what the recent history has looked like? I mean, you've been much faster than that in many of your markets. What are you contemplating in that guidance? Why is that the right kind of long-term outlook?

Sure. Sure. Historically now for the past 6 years, our CAGR has been in the double-digit range, both on revenue and EBITDA approaching the mid-teens levels. Our organic growth rate on both revenue and EBITDA has been right around 9%, 10%. So we certainly hope to continue to be able to execute on those growth levels. Particularly for a company of our size, north of $500 million, I do think that is a pretty differentiated growth rate for a company of our size. But you look at the Provider side first -- and one of the things I'll say is that the growth in our organization has been very broad-based. As I mentioned before, we're very thoughtful about the markets that we try to focus on. We're very strategic on a quarterly basis, where do we want to deepen, what do we want to do, in what market. And so we try to think about our markets very thoughtfully. And we see broad-based growth within our organization across service lines, and that's been very helpful. On the Provider side, we have some steadier businesses that are more Medicaid-funded. Think about those as 3% to 4% to 5% to 6% growth markets, depending. But extremely reliable businesses that have grown their revenue for 30 years in a row just given the front of the line population [indiscernible] provide the payers in that part of our [indiscernible] on the Provider side of our company. home health and hospice, rehab, primary care, we see those markets growing 6% to 8%. And hopefully, in all these markets, through what I said before, we can continue to grow at rates above the market. On the Pharmacy side, I think we'd expect a little bit higher growth rates than that. You start with specialty pharmacy business, which really focuses on oncology, so some rare [ and orphan conditions ]. We really think those are [Audio Gap]. And really where we've created just a tremendous franchise over the past decade in oncology. That's a market that is growing at 15% within specialty. It's a business for us that's been growing well north of 20% for quite a long time. So you just got an oncology market, which is one characterized by a tremendous amount of innovation, where I think there's $90 billion of incremental new drug revenue in oncology estimated to be at the FDA in various stages to be coming out over the next 7 to 8 years. So we're operating in just a high-growth market of oncology with very strong position as one of the biggest independent pharmacies in the space and really strong quality results. Infusion is a market growth rate depending on acute versus chronic therapies and sub-therapies they're in. That's growing at about 6% to 8%. And then home and community pharmacy is, if you look at our end markets of assisted living, skilled nursing, hospitals, behavioral, home health and hospice, those are markets that on average grow at 4% to 7%. Most recently, that business for us has been growing at between 10% to 15%. So as we step back and look at the aggregate an average of all of our service lines, we think it averages out to right around sort of that 8% to 10% range. And we're going to continue to focus on as much differentiation as we can internally to do our best to grow beyond that by reaching more patients disproportionately.

And then the M&A side has obviously been a huge part of the story. I mean, the company has really been built through M&A. Approaching 60 deals, I think, over the last 5 years or so. Talk about your approach to M&A, how you have differentiated access to and execution of deals. And just how we should think about your target of $100 million deployed to M&A getting out into 2025. I think you have free cash flow in the $275 million range. So there would seem to be room to be more aggressive there. Just talk to us about how you're thinking about M&A.

Sure. Sure. So if you break down that historical CAGR of 14% or so over a long period of time, about 9%, 10% of that is coming organic. And then you've got about 4% to 5% from the M&A. Yes, we are proud of about 60 deals at this point. We just did some small tuck-ins here most recently, which were very characteristic of the type of transactions that we've done for the last 5 years. But really, almost all of these acquisitions have performed for us over time. They're largely characterized by tuck-ins. We did do one more significant acquisition a few years back, 3.5 years back in home health and hospice to get some critical mass there with a unique asset. Other than that, it's really been mostly tuck-ins. If you look at the vast majority of our acquisitions, the average EBITDA that we've acquired has been about $750,000. The average pro forma EBITDA multiple on a run rate basis is about 4x at this point. So we're really able, first and foremost, to be very thoughtful and pick carefully about doing the right transactions. Most of our acquisitions have been proprietary. We have people out in the field deeply across all of our service lines. We tend to see a lot of transactions. We tend to be a company that a lot of local owners want to sell to for the long term and be a part of our story for the long term. So a lot of our deals are proprietary. And then we bring our operational prowess and our scale and our synergies to bear. And we've typically been able to cut our acquisition multiple by about 50% to 100%. We usually get things onboarded within about 30 days, and the synergies come very quickly. So it has been a purpose-built platform that we have here over time. And as we look forward, we operate in very, very large and fragmented markets. And with our platform, scale and our proven capability in this area, I mean, there is almost an endless opportunity to do accretive M&A in our markets. And so -- but we've got to be very thoughtful. [indiscernible] and we have a long-term leverage target of 3x, obviously. So balancing our [indiscernible] and highly accretive M&A is something that we want to continue to do into the future.

Is there any appetite for larger deals? Or what's the flexibility on the $100 million? And then just to throw something out there, you can comment on it or not, but United is obviously shopping a larger portfolio of home health and hospice facilities. Is something like that feasible given your strategy and capital position?

Yes, I think you're going to largely see us continue to focus on our historical bread and butter of accretive tuck-ins where we can really bring a lot of our operational prowess and acquisition synergies given our scale to bear. That's going to be, without a doubt, the predominant strategy for the organization. We like to structure deals the right way creatively to make sure it works for us optimally. I think if there were to be anything a little bit larger than a historical tuck-in, it would have to come for extremely strategic reasons at a very attractive multiple that would be very favorable to shareholders and our perceived equity value creation. But the default mode for the foreseeable future certainly is going to be to continue to execute on tuck-ins that are highly accretive. Our acquisition strategy is to achieve really three objectives. Number one, to deepen and expand geographically. A good example would be on the Provider side, there's some CON states where you can't participate in a state without a certificate of need. And so ability to access the geography, number one. Number two, continuing to have the mix of our complementary services in each market and having those integrated care capabilities. And then number three, just continuing to drive broad-based growth in the organization. And there's so much fragmentation in our markets. And we can leverage our scale to a great extent by really focusing on small transactions that fit those three criteria.

I guess last one on this. Is there at all your Provider versus Pharmacy focus, either internal focus or just based on what's available in the market?

Yes. We've been very balanced historically, and I would expect to see that same sort of capital deployment on the acquisition side play out into the future. A nice mix, pretty evenly split between the Pharmacy and Provider side.

Okay. I guess going in detail on the businesses, starting with Pharmacy and specialty in particular, you're coming off a 40-plus percent growth quarter in Q1. How should we think about the -- what elements of that are sustainable? Obviously, I don't think we expect 40% growth every quarter. But how much of that is sustainable? How much of that is cyclical, sort of onetime tailwinds that will abate? How should we think about growth in specialty?

Yes. I think that Q1 growth rate was really just a reflection of just the ongoing execution in the business and the pieces that we've put in place over the past 5 to 10 years. Oncology, as mentioned before, is a very attractive market with a lot of innovation at FDA where new products keep coming out. Infusion is a very attractive market. We have about 117 limited distribution drugs that we service and support on the oncology side today. We see about 18 to 20 of those -- more of those limited distribution drug launches over the next 18 months between our existing base of LDD drugs, new LDD drugs launching and then continued conversion of brands to generics over time, those are three growth drivers for the organization that we continue to see playing out for the long term.

I asked you this question in the context of the whole company, but it's most obvious in this segment where the track record has been here -- the last 3 years have been growing much faster than how you framed the forward outlook. I think CAGR is north of 30% in this business. And you've been -- you're talking about 8% to 9% Pharmacy growth going forward. Are there specific headwinds you're contemplating? And again, just why is that kind of the right long-term expectation?

Yes. I think we do not see anything that would necessarily abate our growth in these markets. As I said, there's a ton of innovation at the FDA, brands that go generic over time. Those are very positive events as well. There's 11 big brands over the next 6 or 7 years that will be going generic. Our success in specialty has been built around a focus on the patient and our manufacturing partners upstream and having extremely high quality levels in that business which has facilitated very constructive relationships with manufacturers. And then we've really invested in the largest sales force in oncology that is out in 3,500 oncologists and doctors' offices every day working to pull through those prescriptions. And so it's a business that has been built around quality relationships upstream and then a sales force for the past decade. That's created a really nice franchise position for us. And then you've got an oncology market that just continues to grow. I think 8% to 9% is certainly our goal for the overall organization. But we would certainly hope and expect that, in Pharmacy, we would continue to grow into the double digits.

And I guess on the home and community pharmacy side, this is largely the legacy PharMerica business which many people will have some history with. What's different about the business today versus the old PharMerica? And I guess just most recently, you've been talking about contract win rates and just coming off a very strong quarter in 1Q. What's driving that? Is that sustainable going forward?

Great, great question. Yes, if you were to look back to the old PharMerica that existed 7, 8 years ago, really apples to oranges versus today. That business 7, 8 years ago was 90% serving skilled nursing facilities as a pharmacy, which is a nice end market. We're growing in that market. Today, that looks more like 10%. And so we've deepened tremendously in specialty oncology and infusion and in all these other myriad of channels where people need their medications every day outside of retail, which is where we play. That's skilled nursing facilities, but also assisted living facilities, behavioral providers, hospitals, hospice providers, home health providers, addiction treatment centers. There's a lot of growth end markets within Pharmacy, and we've really tried to penetrate a lot of those leveraging the scale and the operational platform that we have. Again, we'll do about 40 million scripts this year. I often talk about this business is it's like UPS with a clinical overlay. I mean, there is a very significant logistics and operational element of this business. That is a big barrier to entry. Scale is just paramount in pharmacy from a procurement perspective and from an operational execution perspective. And so -- and these businesses are hard. We lean into challenging businesses where, in home and community pharmacy, you've got to be anywhere in the United States for us within 3 hours with the medication delivery. And we're able to do that anywhere in the United States within 3 hours. And so that pharmacy network and that scale and that machine has been built up over the last 25, 30 years. And again, very different from retail. We go to the customer. They have higher acuity needs. They have very specialized needs. So all of those end markets, we have very customized programs for our customers and our patients that we execute on for them. And ultimately, really high levels of service. And we're able to win contracts with customers because of our service levels and our scale and some of what that affords us on the pricing side, too. So scaled business where we've tried to leverage that platform into a lot of different settings out there in the home and community which need a higher level of pharmacy support and service.

Let's go to the Provider side. There's about half of profit within the business, but probably gets less focus just given the growth rates on the Pharmacy side. You mentioned a couple of times in the conversation 6% to 8% growth in those markets. On hospice, yes, that makes sense. Home health is probably dilutive to that. IDD, almost certainly dilutive to that. So how are you getting to 6% to 8%? And I guess what stage is the home-based primary care in? And how much is that contributing to your market outlook?

Yes. So it's going to vary a little bit by these end markets within the home and community. But broad-based growth in our organization serving pharmacy and provider markets. On the provider side, there is a lot of demand for these services, just given the ROI in the front of the line populations that we're serving every day in the home who need these services. Otherwise, they're going to be going to the hospital and to the ER much, much more. 6% to 8% is how we would view growth in these markets. And the demand more for the skilled clinical services of hospice, rehab. Rehab that we see is growing about 8% to 10% in our areas. And then home health and primary care. I would say the more supportive care services of community living and personal care, the Medicaid businesses, those are just very steady, growing more at the 3% to 4% in terms of demand and population growth. Home-based primary care and value-based care, I think, is the third pillar that we've been focused on in the last year, 1.5 years, which presents really interesting upside for the future. We're very much focused on our core and driving volume growth and efficiency. But as we look towards the future, if we can build out home-based primary care to leverage the 400,000 people we're seeing every day. If they can come under our home-based primary care, think house calls, we see a 50% reduction in hospitalizations where we have home-based primary care. Where we've rolled out our Continue CareRx program, med management in the home, we've seen a 73% reduction in hospitalization as written up in JAMDA in November. So these are just very profound quality results that we're getting. If we can serve more and more of our population under our own home-based primary care and then serve them in an ACO or a more attractive managed care model, that's very interesting for the future. That's what we've been building towards. I would say we're in the second inning of that. And -- but very excited about where that could lead to in the future. Our goal is to serve 100,000, 200,000 people under our own home primary care in the next 3, 4, 5 years.

We started the conversation with where these businesses are complementary. You just mentioned the 350,000 patients that are discharged from facilities you serve on the pharmacy side that are opportunities for you. Is that the biggest kind of cross-sell synergy opportunity? Are there others? And then really, how do you get after that and execute on converting [ on that today ]?

Yes, on the Provider side of our company, we're serving the vast majority of those individuals with our Pharmacy Services to better integrate their care and drive their outcomes. One of the bigger opportunities we have is skilled nursing facilities, where we're the pharmacy provider. Those buildings are discharging 300,000 people a year back to the home. Every one of those people should have home-based primary care. Every one of those people should stay on our Continue Care med management program in the home for the best outcomes. And 30% of those folks will go on to home health or rehab or palliative and hospice. So it's a big opportunity if we can better coordinate the care. That's why we've been investing in home-based primary care, to try to drive outcomes and better coordination and holistic care for patients. And we've really also started building out internal care management teams to work within those facilities and out in the communities to better navigate and coordinate those services.

Can you just give us an update on the rehab business? I think this sometimes gets a little lost. You've highlighted on some recent calls, you brought it up in this conversation as just a really strong growth business. But it's not as prominent, it's not a reportable segment. So just what's going on in rehab and driving the strong results there?

Rehab is really focused for us on more of a neuro population, similar to kind of the behavioral populations we serve. But think ABI, TBI, stroke populations. A very, very clinically high level of clinical care to people where they are in their home and intensive day programs, really changing the trajectory of their functional capability over 6 to 12 months. We get people who 5% of the time can't be left alone for an hour. And after 6 to 12 months, 85% of them can be independent for up to 12 hours a day. Just phenomenal outcomes with what we're able to do for these neuro populations. I think looking forward, we see the opportunity to offer more Part B rehab to the seniors in assisted living facilities and in the home, for example. Extremely synergistic with home health and home-based primary care. I think that will be an added growth driver for us in rehab in the future.

Okay. Last few minutes here. I want to touch on the outlook for the year and some other financial topics. So maybe first, just on the longer-term margin outlook, that's one area, I guess, I struggle with the math of how do we get to 6% or so long-term operating margin? You're at, I think, 5.1% in the first quarter. Given the strong growth in some of your lower-margin businesses, how should we think about realistically the cadence of margin growth? Is 6% a realistic target in the next few years? And how much of that is business mix versus G&A leverage and that type of thing?

Yes. Yes. I mean, first and foremost, we really focus on GP dollars and EBITDA dollar growth. That's -- we grew 13% in Q1. That's where we've had a double-digit CAGR over a long period of time. That said, we're obviously also focused on being as efficient as we can in what we do. The company's margin outside of specialty grew year-over-year in Q1. Any margin impact that we had in Q1 was largely driven by explosive growth in our specialty pharmacy business and just mix and then a little bit of product mix as well within that business. I mean, over time, we expect that continued conversion of drugs from brand to generics to be additive to margin. We think that our infusion and home and community pharmacy business has some efficiency opportunity in it. And then more broadly, as we just continue to drive volume at double-digit growth rates, that should be additive to our margin, leveraging our fixed costs. And we're always working from a -- working hard from a lean perspective on operational initiatives in the organization. That's really kind of been a hallmark for us. And so we're always focused on trying to figure out the best ways, from an IT and from a process perspective, to deliver our services as efficiently as possible. And the culmination of all those together makes us feel good about, adjusted for mix of the businesses, the margin continuing to trend in the right direction.

Okay. Just on the outlook for the year, you guys have already raised guidance coming off a very strong first quarter. Included in that, you took out $16 million from the Quality Incentive Payment. Just talk to us about your confidence in the balance of the year. And then how should we think about range of outcomes on the QIP? I think we're pretty close to knowing if that's coming or not. How should we think about that contributing?

Yes. Adjusted for that Quality Incentive Payment, i.e., either it's in both years, last year and this year, or it's not, we're forecasting about 9% to 12% organic growth for the year. We did take up our guidance up about $21 million already since the IPO, adjusted for that QIP. As we just continue to focus on volume growth in our markets and drive operational excellence and our operational initiatives, we feel good about that number for this year and our continued growth. On the QIP itself, it's an incredibly high bar that you have to meet to achieve this payment. We should find out in the coming weeks by the end of Q2. We did decide to strip that out of our guidance and make it exceedingly clear, our numbers with and without the QIP, is that will be at this point in time onetime in nature.

Okay. You guys are 4.3x levered. We talked about some of the M&A capital allocation priorities and cash flow. I guess just what are you hearing in conversations with investors on what you should be doing with the balance sheet? How is -- has anything changed in terms of how you're thinking about the deleveraging strategy that you've laid out?

Yes. Our goal is to get to 3x leverage within the coming, call it, 2 to 2.5 years. We can do that through both direct debt paydown as well as investments in very accretive M&A. The math would tell you that, even if we grew at 6% and all our cash went to debt paydown, we'd get to 3x in about 2 or 2.5 years. So we're going to continue to be very thoughtful about how we get to that target and balance very accretive M&A that's strategic for us. And now as a public company, we have the ability to use our acquisition currency and our stock as well in select situations, which could accelerate that deleveraging path, too.

And I'll close with this. I think there's still a lot of discovery value that -- in terms of market getting up to speed on pricing. What's the one thing you think is just totally being overlooked at this point in terms of the company or what you guys are building towards?

Yes. Look, we're, I think, very well positioned, serving very attractive markets in the home and community. And our differentiation, what we're trying to drive there is really through operational performance and execution and volume growth. I think it's the platform that we have and the complementary nature of our services and the scale that we've been able to build which has been the reason that we've been successful, and it's why we have multiple growth levers in the future as we look out. I think that scale and that mix is only going to be more important for the future of health care.

Great. Well, with that, thank you, Jon. Thank you to everyone in the room.

Thank you, Jamie. Thanks.