Speakers: Stoddard Davenport, Anna Morgan, Amanda Burkhardt

Moderator: Ryan Hart

In our What’s Trending in Benefits? services, Milliman consultants take a closer look at meaningful and informative topics in benefits that employers are facing. In this conversation, we looked at the results from our May 2023 pulse survey conducted on mental health benefits. For results from this survey, as well as other What’s Trending in Benefits? pulse surveys, visit https://www.milliman.com/pulse-survey.

Transcript

Ryan Hart: And welcome to our What's Trending in Benefits? live webinar where Milliman consultants take a closer look at meaningful and informative topics and benefits that employers are facing. The topics for these conversations are taken from the results of our various ongoing pulse surveys that we run throughout the year. If you'd like to see the results of these surveys, they can be found on the link shown here on the screen at https://milliman.com/pulse-survey.

My name is Ryan Hart and I'm on the Health and Group Benefits team here at Milliman. And I'll be your host for today. Before we get too far, I'd like to remind everyone that our webinar is intended for educational purposes and presents information of a general nature and is not intended to guide or determine any specific individual situation. Any person should consult qualified professionals before taking specific action. The views expressed in this webinar are those of the speakers and not those of Milliman.

So in May 2023, What's Trending in Benefits? looked at mental health benefits, which is always good timing because May is Mental Health Awareness Month each and every year. And joining me to discuss the results of this pulse survey on mental health benefits are three of my Milliman colleagues. I have Stoddard Davenport, Health Management Consultant; Anna Morgan, Consulting Actuary; and Amanda Burkhart, Communications Consultant. A huge welcome to the three of you and thank you so much for joining us today and sharing your thoughts on the results of this survey.

So what we've done, we've preloaded a bunch of questions. We're not necessarily going to have time for live Q&A today, but if you have any questions in viewing this webinar, certainly feel free to e-mail us at [email protected] and we'll be sure to get back to you with any answers that you may have.

We ran a similar pulse survey in May of 2022, which was timed at the tail end of the COVID-19 pandemic. Now that we've had a little bit of time to adjust to this "new normal" since then, have you seen any interesting changes over the past year? And maybe, Anna, you can start off with sharing a few of those thoughts.

Anna Morgan: Sure. Thank you, Ryan. Yes, in fact, we did see a few interesting changes from last year's study to this study. I would say first, we saw a decline of about 11 percentage points in the number of participants offering mental health resources through the medical vendor, meaning it was more prevalent to embed the behavioral health program in the medical plan in last year's study than we're seeing today.

And just to back up a moment, I do want to mention that there is some ambiguity in the term mental health. It may include items such as subclinical maintenance, stress management, counseling, therapy programs just as an example.

So the survey showed that there was more migration towards offering the mental health benefits through a third party or even through a specialized point solution. In fact, it was actually an increase of about 11 points specifically in offering these areas, including stress management and counseling therapy.

I do want to mention that data does drive a lot of decisions. We'll talk a little about a little more about this further on, but I do want to comment. Please review your data to understand what the employees need before implementing any new behavioral health programs if you do it through a third party or solution partner.

Another item is that we did see an increase in the number of participants that are offering these benefits not only to the employee, but to the family members and the dependents.

And finally, this year's actual survey included a number of detailed questions around engagement and communications due to the importance of having these as part of your program. In the past, or last year rather, we asked more high level questions in this area. Amanda will comment on the specifics as to what we did see in communications and engagement later in our presentation.

Stoddard Davenport: Yeah, and just to add a little commentary to what stuck out to me. I think it's as Anna mentioned, we're continuing to see a really strong increase in the role that the digital behavioral health market is playing and in providing benefits to employers. Historically, a lot of the first way in the door for those folks is through the EAP. Some are hitting a stage of later maturity, where they're also trying to plug in through the major medical benefit. That trend has been continuing and we'll talk a little bit more about that side of the market coming up.

The other thing that I thought was an interesting piece that we're highlighting newly this year is that really what motivates different employers that respond to the survey to try and improve their mental health benefits. And it really, as much as we talk about things like finances and ROI and things like that, it really came out that wellness. The happiness and well-being of employees really is the top driver here. And we'll get into that in a little bit more later too.

Amanda Burkhart: Yeah, and when we talk about that employee wellness, the one most important thing is to make sure employees know what they have access to and how to use it. And as Anna was saying, we're seeing so many more people using these point-source solutions. And Stoddard kind of mentioned how it used to be, people would come in through the EAP or maybe they would just have access to counseling through their medical benefit. Now they might have EAP, the medical benefit, and then a whole host of point-source solutions. We had one client who had somewhere in the neighborhood of a couple dozen different point-source solutions through one of their vendors that was in the behavioral mental health/stress reduction kind of world. And for an employee, for a person on the plan, trying to navigate that can be really, really complex. They can look at it and say, "I have stress, where do I go? Which one of these helps me with stress?" Or "I am depressed. I have clinical depression. Which one of these things is for me?"

So we'll talk about it more later, but just really making sure there is a place where employees can go to see what options they have, what kinds of services those options offer, and where it's going to help them. And contact information as well, is so, so important. Making sure you take that barrier out of an employee having to ask anyone for that information because it that privacy in the mental health arena is so important.

Ryan Hart: Great, thank you. Let's shift gears a little bit and kind of talk about the utilization of these mental health resources. 62% of the respondents in our survey said that they saw an increase in mental health related claims from last year. Now we all know that mental health resources were highly engaged during the pandemic, but now the pandemic is winding down and many of our employers, or many employers, are seeing the workforce return to the office. So what is continuing to drive this demand? I mean, should we be expecting to see this percent increase in claims go down at some point?

Stoddard Davenport: Yeah, that’s a great question, Ryan. So really, in the behavioral health space we're dealing with longer-term trends and shifts in how we deliver behavioral healthcare that have been going on well before the pandemic. The pandemic shined a light on a lot of the cracks in our behavioral health delivery system in a big way since the need for help with mental health was so acute during that time. But I think we have longer term headwinds that are likely to continue driving increasing utilization and behavioral health for some time to go.

And maybe this might be more of a history deep dive than most folks need to dive into, but behavioral healthcare in the 70s/80s really relied, probably more so than was appropriate, on institutionalizing patients. And there was a big push in the 90s to really move back towards managed behavioral health, where we had really large systems come in with the specialty in managing behavioral healthcare and really pulled inappropriate institutionalizations down. And a lot of other behavioral health utilization came down during that same time.

And we've since kind of turned the corner of understanding. Maybe the pendulum swung too far and really we need to make sure that access is easy for folks to have and that we're kind of dealing with underutilization chronically. I mean, if you look at national sources, such as the National Survey and Drug Use and Health, they're consistently reporting that only half of people with mental health conditions that could use help, actually access any kind of services. And for those with substance use disorders, the gap in treatment is more like 90%. And so we've got rising trends in the number of people that have conditions like depression. We've got increasing epidemics of substance use. We've got all these trends that are really part of a longer arc that are going to likely continue to increase, even though we don't necessarily have the kind of acute phase of the pandemic shining as much of a spotlight on it.

So really not a huge surprise probably for those of you that have been deeply involved in behavioral healthcare delivery to see that spike happen. And if it's not so intuitive to see that continuing, hopefully that helps give some context for why that may yet continue to trend upward for some time to come.

Ryan Hart: And you know that’s a…I’m sorry, Anna. Go ahead.

Anna Morgan: Sorry. I was just going to add, one part of behavioral health that we saw a big change in due to the pandemic was telemedicine. That was a big increase that we saw. And once we COVID started winding down, we're seeing a pretty big decrease in the usage of telemedicine, particularly behavioral health. We do want employers to continue to promote the telemedicine and let employees know where it is and what's there to offer, so that they continue with any virtual care that they may need, including EAP calls too.

Ryan Hart: I wanted to continue that thought on provider access. W are hearing over and over again, this underutilization that Stoddard mentioned about provider access or lack thereof. And to be honest, given all of the different motivations that people have for offering mental health resources, was anyone at all surprised to see that only 69% of respondents indicated that the availability of a mental health provider was the most important consideration?

Stoddard Davenport: Yeah, I’m happy to jump in here. I'll say that was surprising to me a little bit, but perhaps in a kind of a positive light. I've probably got sort of a biased sample here because of the nature of the work that we do, but I work a lot on the economics of behavioral health issues. And so many of the conversations that I see revolve around financing and reimbursement and return on investment. Conversations about investing more resources and mental health offerings for employees and their dependents.

And really, the findings here show me that the underlying motivator for most organizations is trying to help their employees wellbeing, right? There are a lot of other financial and systems issues to resolve, but this kind of highlighted for me, again, that those are all really means to an end. That folks really are looking to try to improve the health and wellbeing of their employees and dependents, first and foremost. Issues like "getting access" figured out, and being able to hopefully reduce absenteeism, or having good financial return – those are the nuts and bolts and housekeeping items that we need to take care of. But that really the driver is looking after folks’ wellbeing. That was kind of a refreshing highlight for me from this part of the survey.

Anna Morgan: And I think that third item there - the provider access and availability - I can look at it two ways. I think in terms of provider access, for some of the EAPs or other virtual care, it was a shock when we went into COVID in how many people now wanted to access their EAP. And it was nothing against any of the providers, but they were not staffed. They were not ready for that big increase.

So I think a lot of the providers have done a good job of trying to fix that issue that I think that they were, you know, many of them were aware of. So I think continued access is very important and now I think that that's on the top of mind.

When I look at also, when we talk about like the social determinants of health, can we instruct the providers to make sure that one individual, you know, if they're male, they talk to a male. If they're female, they talk to females. If they are in the LGBTQ+ community, that’s basically a provider they want to talk to. We are getting a lot more requests for that. It hasn’t been easy for the provider because they really haven’t, sometimes like in certain areas, they just don’t staff that way. But I do see that that will be a continued trend going forward.

Ryan Hart: Really good insight. I mean, let’s take a look at sort of what resources we are talking about. We asked the question from last year in 2022 versus this year versus what we're looking for in 2024. And most of the responses that we got in this survey, I felt were fairly consistent. Although the jump that I saw was looking ahead to 2024. It seems that the third-party solutions, point solutions, are definitely growing in popularity. Can maybe, Anna, could you comment on sort of what may be causing this?

Anna Morgan: Yeah, I sort of touched on that in the earlier, so maybe I got ahead a little bit. Basically talking about that shift of moving from the embedded medical programs to these third party or these point solutions.

One thing I want to point out, I mean there are many layers of mental health/behavioral health, you know, such as on the slide it says “stress management”, “sleep disorders”, for example. Many medical carriers have these programs. They have a number of different programs whether you opt in or it's just part of their bundled solution. But now there are third-party vendors or point solutions that specifically focus on different areas. So really based on the data and the cost drivers, or what your employee needs, you can really kind of look at these third parties to determine this is all they do. There may be one vendor that focuses on stress management and that's all they do. We tend to see that piece of it for the migration, because maybe you don't need to focus on all the aspects of mental health, but like focus on specific programs.

You touched on it just a minute ago. The number of new, small healthcare businesses is growing exponentially. Every day it seems like there's a new specialty, point-solution vendor coming to market. As an example there, there's a company that provides some comfort through certain apps, you know, such as music/podcasts to help people sleep. That's their focus basically to maintain a level of calmness.

I would say, and Amanda will touch on this again, but communications is key when implementing a new third-party vendor. Employees are used to it being under the medical care and now you're introducing a new a new point solution, so you just need to make sure that that's communicated well. But at this point, I would say, and we have clients that have as Amanda mentioned, a dozen point solutions that focus in all different areas, so I see that really being part of the trend towards a third party.

Amanda Burkhart: Yes, and I would say absolutely correct, Anna. If you're bringing in a new vendor that may be reaching out to participants, they may see a trigger that comes from medical data and give them a call. You want to make sure your participants know who that is. We're all so trained these days to avoid the scam calls, not give people our personal information, and kind of be a little distrusting of calls that we get and emails that we get. So making sure through your official channels that are trusted, you say, "Hey, we have this new vendor. This is what they're called. They may be reaching out to you. And here is why we really encourage you to take advantage of this because it's got all of these benefits.”

The other thing that we've seen from kind of a communication standpoint is some of these point-source solutions that are in, what you may consider sort of the lower end of the spectrum, like sleep, better sleep, stress management. On the higher end, you'd have sort of institutional or much more therapeutic kind of treatment. That lower end is a great place to maybe get to people to say, “Hey, do you want to sleep better? Everybody wants to sleep better, right?” Or “Are your kids not sleeping well enough? We have a solution that might help them with that” That may make them feel comfortable taking the next step to try. You know, “Hey, we have this stress management program that you could be part of.” “Oh, I’ll try stress management.” And you might step somebody who would never quite feel comfortable just jumping into therapy or calling the EAP…you might be able to step them into more of these resources, so it’s kind of a great door to open there as well.

Stoddard Davenport: The other thing that I’ll throw out there too, just to kind of understand some broader trends in the behavioral health industry, is that really there has been a pretty significant mismatch in supply and demand for behavioral healthcare providers for a very long time. And there've been a lot of different attempts to try to reconcile that issue over time. And this growth in the digital behavioral health space that's happened over the last few years really comes out of a confluence of that sort of longer term missed balance of supply and demand, coupled with really cheap capital during a low interest rate environment in 2020 and 2021, plus this huge impetus for providing more flexible ways to access care during COVID. I mean the amount of funding flowing into the digital health space in 2020 and 2021 was just exponentially higher than what we've seen in prior years and behavioral health point solutions were kind of top of the pack in where those resources were going. Just this massive influx across the market of new entrants into that space, so it makes sense that these folks are working hard to get in with employers and others throughout the healthcare space to deliver their services.

But the one thing, I think, that we're seeing now that interest rates are going up and capital's not so cheap and easy to come by, a lot of those folks are now moving to the phase where, you know, maybe the initial enthusiasm for novel approaches to delivering care is waning enough that they're really being expected to demonstrate results and efficacy and financial outcomes and things like that. I think we're going to start seeing a little bit of a winnowing of the fields here for folks in that space coming up, where really the ones that are providing high quality, highly effective services are probably going to be able to figure out business models that let them stick around, while some of the others may turn out to just kind of been a flash-in-the-pan that benefited from a unique moment in time to be able to pop up. That's something for organizations to keep an eye out for too.

Don't hesitate to set high expectations with the point-solution vendors that you interact with for them to really be able to kind of demonstrate good outcomes for how they're planning to help your employees independence.

Ryan Hart: Yeah, you know on that note, let's talk about sort of that availability with the wide increase in the number of resources that are available out there, the number of solutions out there, and the need to basically provide that sort of data. Overall for me, another surprise was from the survey how little data that employers apparently have surrounding their mental health benefits. According to what we saw from the results, mental health related claims expense, and in terms of utilization, 26%, nearly one in four of the survey respondents indicated that they didn't even know whether their benefit utilization or claims expense had gone up or down or not. Why do you think this is? Anna, maybe you can comment?

Anna Morgan: Yeah. So as an actuary, this is very important to me. We need data to make decisions. Basically, we don’t want to be putting in programs where there’s not an issue. And so if the mental health benefits are carved in with the medical care, there should be no excuse for the medical care to not provide this information at a minimum annually.

I think for medical carriers, they're so focused on the top spend – the MSK, the cancer –basically what are driving healthcare costs and that's been traditionally a big problem that we we're trying to solve. But the mental health benefits are so close to members. It's so important to the members. I don't think the medical carriers may be aligning exactly with the target of employers of how to reach the members. So if you're not getting that data, if the medical carriers are focused more on the large expenses, please ask for it. I think this is going to be something that we're going to need to look at on an ongoing basis.

When transitioning to a third-party or a point-solution vendor, there is a time where basically there's a non-credible period as a program ramps up. Some companies require about 18 months of data before seeing how the program is even running. In that case, don't be shy to ask for participation results. How many people participating? Maybe you don't have the actual data on the utilization and the cost just yet, but you know how many people are participating. You can start asking those questions.

I mean, if the data is available, you'll want to compare the old data (with the medical care) to the new data to determine the level of savings and basically understand the level of member satisfaction. There could be surveys that could come out about these programs too when you don't have the data.

Some third-party vendors or point solutions will determine success of the program based on an ROI. We do recommend in these situations that you consult with your actuary or your consultant to review their savings methodology before coming to any preliminary conclusions of your program.

Ryan Hart: Yeah, along those notes, the next slide that I have too, was pretty much the same thought, right? There is a level of understanding of benefits out there that's fairly consistent from last year and a few more organizations seem to be getting some data. Clearly, the majority of people indicated that the data they received was… that they were getting some data, but it was minimal and generally insufficient. Not nearly as much very useful data than what we'd like to see. Stoddard, do you have any recommendations on data for employers?

Stoddard Davenport: Yeah, and I think some background here on what's going on again in the digital behavioral health space is probably helpful to understand the data gaps. I mean really a lot of the new digital behavioral startups that have been coming out in the past several years are started by folks that come from outside the traditional healthcare delivery world. And so you've got folks that are coming in with a business innovation mindset, where they're looking to be a disruptor and solve long-term issues in behavioral healthcare by bringing in new and outside perspectives.

And while that sort of injection of fresh and innovative thinking is really helpful in this space, it comes with the side effect of a lot of these organizations maybe not having a real good understanding of what folks need or want in terms of data reporting and what level of information might typically be shared back to a sponsoring employer. And so that really, kind of because some of these folks are coming into the healthcare delivery space as somewhat new to that world, it kind of puts the onus on the sponsoring organization, the customer, the employer, to make sure to be really explicit and asking for what you need. Don't sort of go into a new relationship with the vendor with assumptions about what you think you're going to get or what kind of reporting you have access to. These are conversations to have upfront. If you're already engaged with somebody, these are conversations to bring up now, and it's really a matter of making sure that you communicate really clearly what you need. And if you're working with other kinds of benefit advisors or consultants or brokers or anything like that to help you set up access to these kinds of vendors, its good to make sure that they’re on their game too in terms of how they help you manage those relationships to make sure that you are keeping an eye out for setting up good expectations going in for what kind of information sharing would be in place if you get underway.

Anna Morgan: Yeah, and Stoddard, you made a good point. I think that when we're rolling out third-party carriers, we do need to be innovative in what type of data reporting we want. The carrier may have a standard, but I think that if we want to compare from last year to this year, we can create it. I mean, the partners have been pretty good about accepting new data reporting if we have specifics that we want to trace. I just wanted to mention that real quick.

Ryan Hart: Yeah, I mean, data obviously is super important, but if no one is engaging with those resources, there's not going to be much data there for us to measure. Two-thirds of our survey respondents said that they didn't reach out to their employees in order to gauge their satisfaction with mental health resources. Nearly 40% didn't know if their employees were satisfied or dissatisfied with the benefits. Amanda, do you think employers are missing an opportunity here? It’s like the most underhanded pitch I can give you.

Amanda Burkhart: Yes. Yes, definitely. I do like to see that 33% said they were planning to in the coming year. That is very encouraging. But absolutely, just like you want really high-quality data from your vendors, you certainly want to know what your employees think of these programs you’re putting out. We saw earlier on that a full, more than 90% said their goal with these kinds of programs was employee wellbeing and one of the best ways to measure whether employees are happy or not is to ask them.

And we know that there's a lot of hesitancy, because if we ask employees, then we may feel like we have to do something with that information. And that's true to some extent. You do have to be careful in what kind of questions you ask and how you ask them. But it just is a good way to make employees feel heard, to make them feel like they're part of the process, so there is a lot of goodwill that comes from just asking the questions.

And also, it's a great way to make sure that the kinds of resources you're providing meet up with what employees want to see. If you've got all of these programs and you think everything's so wonderful, but then you find out you actually have a huge amount of employees with kids who need resources for parenting and resources for their children that they're not really seeing – the way to find that out if by asking them.

And this kind of also goes back to what we were talking about earlier with availability and sort of meeting employees, (i.e.) LGBTQ communities and different kinds of employees, with the resources that they need. We really recommend asking those questions. “Are you getting the resources? Are they meeting your needs? Are they coming to you where you need to see them?” The other kinds of questions you can ask when you do reach out to employees is, “If you do use the resource, how did you hear about it?” We have a client that with their EAP, the number one way people were accessing the EAP, or finding out about the EAP and bothering to pick up the phone or go on the website, was through posters.

Because when it comes to mental health, the privacy part is so, so important. And I said this before, you want to make sure they know about these programs, but you want to make sure they don't have to ask anyone. Don't put any barriers between an employee having problems, like stress or depression or anxiety, and then getting access to those resources. Put these things out there where everyone can see them: posters around the office; on the intranet; on the internet that is accessible to the folks at home. If you have an EAP that’s accessible to the dependents and spouses, you want to make sure those folks can see it too. Send things home. Send postcards. Send it in newsletters that go physically to the home so that that information is there when they need it and really meets them where they're at.

Anna Morgan: And Amanda, I like what you just said about sending materials home. I know that there is some hesitancy with a lot of employers that say that maybe they don't have that information or they don't want to send something to the house. But with a lot of plans, you need to make sure that the spouse has access to these benefits too. Sometimes the employee won’t share that information, but if it goes to the house, maybe the spouse is at home. They can read about it as well.

Amanda Burkhart: Yeah, and it can be something as simple as a little insert that goes in something that you’re mailing already. It can just kind of sneak in there. Or, like I said, postcards are very economical and they also get to the spouse because the spouse doesn't have to open anything to see what's on that postcard – so that can be handy. And a lot of times, it’s your spouse saying, “Hey honey, did you see this? You should call this.” Or “We should call this for a kiddo” or whatever it is.

And back to the privacy issue, if you do some kind of outreach, if you do ask these questions of employees, we really recommend you do it in a very anonymous way. Anonymous SurveyMonkey-type surveys where they can put in information and they know that they're not being necessarily connected to what they say, because privacy is utmost importance when it comes to mental health.

Ryan Hart: And to close our thoughts today, we identified another potential opportunity in the survey results. We think it's pretty universally well known that the most successful adoption of benefits happens when leadership and management are directly involved from the top. But only 51% of the respondents said that they were leveraging leadership to send messages to employees on these benefits.

I'm just going to go ahead and move to the next slide too.

We asked to see the difference between who is “engaged” versus “visibly engaged” in supporting the importance of mental health and found that less leadership was ”visibly engaged” or “somewhat visibly engaged.” Throughout the pandemic, we've heard again and again about the importance of mental health. What kind of effect, Amanda, does this have with when leadership not being visibly engaged?

Amanda Burkhart: Yeah, as you said Ryan, in any benefit, when you have sort of that top-down support, that's going to have a huge impact on its adoption. When it comes to mental health and the stigma behind having a mental health issue or getting care or support for mental health issues, that's still a huge problem. We're seeing more and more where employees expect their employer to be supportive of their mental health, to give them resources, to be out there kind of at the front line helping out with that stuff.

But that really does start with the top down. It would like a leader being very open about their own mental health journey, or resources they’ve tried, or their families have used. If someone is comfortable doing that, that can make a huge difference in an organization.

It can also mean making sure those leaders are equipped with how to talk about mental health in the workplace. It can be a scary thing, and maybe they don’t know. They have an employee who’s struggling and they see it, and they know it’s happening, but they are not sure if it’s their place. They're not 100% confident on what to talk about or what resources to try and connect that person to. Making sure there's training for the leadership and the management, those people leaders, on when it's time for them to step in, even the exact words they can use to step in. “Hey, it seems like you’re having a hard time lately. Is there something that we can do to help you there?” Or “Here are some resources I can connect you to if you’re interested. I’m just going to leave them here for you to look at.” Really giving them the language and the tools and the direction of how to step in and have those conversations.

And also, really holding your vendors accountable, making sure they know that a lot of those vendors have resources specifically for management. I'm mostly talking about the EAP here, but a lot of EAP programs that folks are putting a lot of resources into have management specific tools. They have trainings for the stuff that I was just talking about. They also have, if there's been a major stressor in your workplace, if there's been a death or an accident, something like that, they have people who can come in and have a session with your folks or be there for them. Make sure you're utilizing the resources that are there for management and giving them the tools to talk to their folks.

Anna Morgan: Yeah, and I would say with mental health, we work with a lot of CFO's when we're making decisions for the next year, and the cost of mental health may not show up in the radar, so for senior management, sometimes they don't see that as being a real big issue. But I think there's other areas you can measure that in: productivity, absenteeism, and people going out on STD.

And then there's other areas that really need a little bit more support and knowledge, and have the senior leadership really understand that impact. I also had a client that actually an employee committed suicide at the actual client site. Then senior leadership said, “How did we not stop this? What happened?” So letting them know, again, maybe this is a smaller piece of the pie, but there's a lot of implications involved that may not just be straight healthcare costs.

Ryan Hart: Great. Well, with that, thank you again all three of you – Stoddard, Anna, and Amanda – for sharing your thoughts today. While we don't have time for live Q&A on our webinar today, I invite you to send any questions that you have to [email protected].

Just a quick reminder as well, you can see the full results of all of our pulse surveys in our “What's Trending in Benefits?” series by going to https://milliman.com/pulse-survey. You can also sign up to have your say on future pulse surveys. We’d love to hear your input.

And with that, until our next conversation. Thanks again and by for now.