Webinar: Beyond the Clinic Walls
How Telehealth is Breaking Barriers
With “Beyond the Clinic Walls: How Telehealth Is Breaking Barriers,” our Doctors Innovate Fund team explores the transformative power of telehealth and its future trajectory in our comprehensive webinar. As part of this webinar, Senior Principal Meera Oak hosts a conversation with two esteemed healthtech CEOs: Christina LaMontagne of Clarity Pediatrics and Joan Zhang of Arise.
See below for an edited transcript and an on-demand recording.
ON-DEMAND WEBINAR
Beyond the Clinic Walls: How Telehealth is Breaking Barriers
Meera Oak
My name is Meera Oak and I’m on the investment team at Alumni Ventures. Today I’m so excited to dive into the meaty topic of telemedicine with two seasoned experts and CEOs from our portfolio, Joan Zhang of Arise Health and Christina LaMontagne of Clarity Pediatrics.
I want to kick things off maybe with some introductions. I’d love for each of you to introduce yourselves as I could never do your backgrounds justice and share a bit more about yourself, but also what you’re building.
Joan Zhang
My name’s Joan Zhang. I’m based in Houston, Texas. I’m the co-founder and CEO at Arise, where we’re providing more accessible eating disorder support. That’s done all virtually. I really come to this work out of my own personal lived experience with an eating disorder that was actually diagnosed when I was in college. And I experienced the barriers firsthand of trying to get care from the financial barrier of appointments. IT costs hundreds of dollars even with really great health insurance, and there are a lot of the just cultural and systemic barriers. I didn’t have any providers of color on my care team and ultimately because of the shortages, no one followed up at the end of the semester. And so I ended up really just struggling with the eating disorder for more than a decade, ending up in ERs constantly.
And so Arise really came out of my own recovery journey and also the experiences and journeys of the millions of people out there. A lot of the stories that we heard firsthand about how just inaccessible care really is 9% of the global population has an eating disorder. 30 million Americans in their lifetime yet 90% won’t have access to care. And so really we’re focused on how do we solve that problem. My background is in product, so I am excited to dig into some of the tech side and how do we really innovate and expand access from a technological standpoint.
Christina LaMontagne
I’m the CEO and Co-founder of Clarity Pediatrics. I started my career working in HIV and AIDS clinics and really wanting to help underserved populations and carrying that through to my job just before Clarity where I was working at a large women’s health contraceptive access telehealth provider. And I’ve always been really motivated by solving for underserved populations and improving the experience of healthcare. And unfortunately, kids are a really vulnerable population within our healthcare ecosystem. There’s about 75 million kids in the us. Each one of them has family members that are impacted or their health is in relation to each other, and yet pediatrics is often quite overlooked by the people who pay for healthcare, whether it be the payers or the employers. And I really wanted to do something about this.
I’d looked at pediatrics in quite analytic way and I saw that common chronic conditions like A DHD, obesity, asthma, allergies, the prevalence had about quadrupled since the time I was a kid. But as a parent, the healthcare system still functions almost exactly the same. So who is taking care of the kids and where is the availability of care and who’s paying for it? Were questions I was really wrestling with. And so I just wanted to dive into those problems and that was the genesis of clarity. And so we are serving families with kids who have chronic conditions via our telehealth platform. We’re live now in California, but we’re expanding and our first indication is A DHD where similar to eating disorders, millions of people experience A DHD. About 80% of kids do not have access to the standard of care, but we can make that available through our platform now.
Meera Oak
We have a lot to cover here to start telemedicine or the use of technology to really provide access to remote healthcare services, much like Arise and Clarity are doing. They’ve been around for several decades. I think we, we’ve sort of seen it, but I think it truly emerged as this game changer in healthcare in 2020. And I think that was in part driven by the COVID-19 pandemic pre pandemic. It was almost hard to imagine how this sort of relatively nascent industry could emerge as this hundred plus billion dollar industry today. And that’s only growing. Moreover, I think it was really tough to imagine how patients and providers would respond to telemedicine, how the quality of care would be maintained, how the regulatory landscape would respond and how technology would factor in. But yet here we all are, right? It’s 2024 and it’s quite an exciting road ahead. And so I’d love for you both to maybe take me back to that 2020 era as builders in the space. What did you observe during that period and how did you think about or leverage the adoption that you were seeing?
Joan Zhang
I remember pre-2020 at least, there was so much skepticism around whether you could do eating disorder treatment, virtually providers, I think from everyone around and I think 20, 24 us to really try it out and to experiment. And I think what we had seen is it actually made care a lot more accessible to more people. I remember when I was going through treatment, one of the big barriers was actually I had to go to a campus hospital every single day. I had to sit in a public waiting room where all of my peers could potentially figure out that I had an eating disorder. And so that was a huge barrier to actually continuing with care. And so I had always thought for many years telehealth would’ve been such a great solution for that. What was really beautiful about this transformation over into telehealth is we see more people getting access to care, especially our vulnerable populations like pregnant moms who aren’t able to really take time away from work or from their families to really go to in-person care.
There’s more convenience for Medicaid populations where maybe, again, they don’t have the time to really go to a physical location for an appointment and it’s easier for them to maybe from the convenience of their home be able to attend their appointment. So I think we’ve seen expanded access and I think we’ve also seen that the clinical outcomes, we can still demonstrate really strong outcomes. We actually, in the eating disorder space, there was a report by Fair Health that was a spotlight on eating disorder claims. And they saw that the telehealth utilization from 2018 to 2022 increased by over 10000%, and telehealth is actually the most commonplace of service for eating disorder treatment in 2022. So I think it’s, I’m really optimistic by the adoption of virtual eating disorder treatment and I think it’s done a lot of good for this space.
Christina LaMontagne
Just as Joan is saying in her population, telehealth has been dominant in the last three or four years. I think that’s really true in pediatrics as well, where that convenience factor for parents is a parent or two need to get out of work, take their kids from school to go to routine appointments. It’s just too much for this population and it leads actually to lower outcomes because it’s just so hard to follow through with care. So I know that the data suggests that telehealth adoption is uneven and in some areas it’s waning since the pandemic, but when you’re really focused as a founder on a particular population and their problems, there are these amazing pockets where telehealth is just game changing and I think we really should not go back.
Meera Oak
You both touched on such strong adoption, especially within your respective patient population. So I kind of want to stay in that space for a second and just understand how you prioritize patient engagement and satisfaction across your platforms, your founders. You’re juggling a whole slew of different elements of company growth, but obviously the patient engagement and satisfaction is key. And so I’m trying to understand what strategies have you found to be most effective in building that patient trust and loyalty?
Christina LaMontagne
We have an approach that really starts with clinical credibility where no matter who your stakeholder is in healthcare, a payer, a referring provider, a parent, the patient themselves, everyone wants to be in the right place with the access to a great provider or a great clinic. And so that’s how we really think about starting that journey. And we’ve even turned this into one of our company values where we have to earn trust from everyone. That’s something that we hold ourselves to day in, day out. So that’s certainly part of it. I think in our space, time to care offering a very scarce part of the care ecosystem has been a big part of it as well as outcomes. But really time to care, access to care has enabled us to run a lot faster, I think, than if we didn’t have that.
And then I’ll just say we work in pediatrics, which means that a lot of the trust and patient experience that we’re able to attribute is actually through the parents’ eyes. And so we need to think about multiple stakeholders and to generalize that because of course not everyone is in pediatrics. I do think that in healthcare it is often complex. Yes, the patient’s point of view is essential as the cornerstone, but there are stakeholders and people that you also need to keep very happy in most business models. So not forgetting that yes, you need an exceptional user journey with a great defensible product and a killer business model and a great team and all those things, but I think the best founders are thinking more holistically about all the stakeholders within healthcare and whom to prioritize at what times, in what ways to give themselves that extra edge.
Joan Zhang
I love that you referenced your company’s values. Actually, one of the first things that came up for me is one of our values is listen to lead. And so what that means from a leadership level at our company is listening to our team, but it also has been about listening to our members and their perspectives and our model of care. We call person-centered care. And what that really means is rather than some traditional eating disorder programs that really focus on maybe one modality of care, which might not really be what everyone needs, we actually take the time to listen to each individual’s experiences, their co-occurring conditions, their identities, their past treatment experiences, and really consolidate all of that to really determine the right combination of different types of modalities and therapeutic approaches. Ultimately, that allows us to deliver better outcomes. And what we see is that it also really helps members to feel like the care is designed for them, and it’s not like they’re just being fit into this protocol that really often really doesn’t account for their needs.
I think a really important second piece is we have this role on our team called the Care Advocate. Fundamentally for us community care is a huge part of our model, really about how do we give folks the tools to really carry forward their healing longer term? And so this Care Advocate is someone with lived experience with an eating disorder who’s been in recovery for several years and has had the training to provide the support. And their whole goal is to really build trust with the member, to really develop empathy with a member and understand what are the social determinants of health that might be at play here so that we can really better inform our clinical team and staff on how do we make sure that this treatment plan is working for the individual. And ultimately we see that because of that care advocate members will stay engaged for much longer because when they have concerns, maybe they lost their job and they’re worried about copays or maybe just the therapist isn’t the right fit, they have a person that they can really share that information with and they feel heard, and then we can really adapt with the member.
Meera Oak
I kind of feel like that sort of segues us nicely into the other side of the equation, which is of course the providers, the care advocates, the care team. And I guess on the same side of the coin here, what strategies are you guys thinking about employing to encourage healthcare providers as they embrace telemedicine and how they incorporate it into their practice?
Joan Zhang
We’ve actually had a lot of providers who are really receptive to telemedicine, and I think being able to work remotely is a huge sell for a lot of providers. I think one of the things that we really do is take a balanced approach where we allow providers to do maybe it’s 30 hours with us and 10 hours they can run their own private practice. And I think having that split really allows providers to have the benefits of working on a team, but also be able to continue their own goals. So we have a split W2 and 10 99 model just depending on our needs, depending on the provider’s needs. And I think that flexibility has been really a sell to our providers. And I think the other piece is really fostering collaboration and comradery on the team. For us, one of the biggest selling points is you’re getting to work with cross-disciplinary team of registered dieticians, therapists, psychiatrists, primary care doctors and peer supporters. And so when you’re working in private practice, it’s often just you as a therapist and you often then have to take on the load of maybe some of the nutrition questions that your client is coming to you with and you’re not trained in that. And so being able to work on a team and problem solve together can be a huge benefit when done correctly and done with the right culture in place
Christina LaMontagne
I couldn’t agree more about that clinical comradery and support aspect. I think in a startup environment for many people they can find more of that sense than they found in a more traditional healthcare environment. So we go out of our way to bring in experts and to support professional development and to get people trained and the cutting edge new treatment modalities. And I think people enjoy that. We as employers are investing in them in that kind of growth mindset kind of way. A little bit different than other clinics. We have fewer part-time people. It sounds like that’s something very interesting that Joan has been able to put together for her team. But what we have done is really ensure that when a clinician comes to us, they become a bonafide A DHD expert. And so what we try to articulate to candidates is that this is a chance to go really deep in an area that you already care a lot about.
You already seeing the need and when any of us gain mastery, but especially in medicine, higher volumes means better quality of care that you’re going to feel this satisfaction because you’re just so good and you’re always honing that craft over and over and over again every day. And that makes you valuable to the families, but that makes you valuable in your career as well. And so that again, plus the professional development and the access to other experts think has been enticing. The final thing I’ll say is that many, many providers are burned out. We all know this. Telehealth companies I think have an advantage in that there’s very little crisis and there’s very little call, everybody does their share, but you can offer often a different work style that takes away some of what’s been soul crushing to providers in the last five years, but again, gives them the expertise and the professional confidence and skillset that comes with a more focused clinical role.
Meera Oak
I think you guys sort of framed sort of how you’ve been able to engage, again, both sides of this ecosystem, and I think quality of care really rang true through even when you were talking about the origin stories of your companies. So I kind of want to spend a little bit of time there, which is sort of understanding, of course, telemedicine’s lauded for the potential for increased patient engagement and experience. And clearly you guys are finding that within your respective companies, but I just want to understand how do you maintain and monitor that quality of care when it’s delivered through telemedicine? And are there metrics, are there benchmarks that they’re using to assess effectiveness in these services?
Christina LaMontagne
All the metrics you stated do matter. I’ll add time to care, and then short and long-term clinical outcomes as well. But there’s many things that are important and quality, not just one measure. I’ve been very fortunate as the business co-founder to team up with a clinical co-founder and have very strong clinicians across my team, and I really credit them in understanding how to set up safety, quality control, compliance. We also had great legal input, but as a team that really built the policies, it makes it happen every day. So we do carve out time in different schedules for safety and compliance as well as quality control. And it’s just a daily devotion. It’s back to values and culture. It just has to be part and parcel of what you do top to bottom and bottom to top. Every patient has to matter. And so again, for us, I think there’s lots of frameworks and best practices I could articulate, but it really was the DNA of my co-founder and early clinical experts that I think has led to a best in class quality and compliance system. And then just never stopping. New things are going to come up all the time. You’re going to expand your clinical program, and the risk is obviously huge when you’re in healthcare. So we take that really seriously and I think I’ve had enough experience in my career to know that things can and will go wrong, and it’s really scary when those things happen. So you feel very intrinsically motivated to avoid every risk you can.
Joan Zhang
Christina, I love that you have such a strong clinical leadership team, and I think that’s one of the things that I really want to just highlight is there are so many startups out there that clinical leadership is really not at the forefront and it’s really showing, and it’s really I think a stain. I think a lot of our reputations when that happens. So I think it’s been so important for us as well to really center clinical leadership and experience. And I think what’s really important is finding a clinical leader who is values aligned and also has a little bit more flexibility. I think all clinicians are not the same, some are a lot more protocolized and a little bit more rigid and see some of the gaps in their existing treatment models and see the opportunity to really innovate.
And so our chief medical officer, Dr. Erica Taylor is truly incredible in that way. And I remember we had just have conversations around how she’s always done things, but there’s opportunity to improve on that because we’ve seen that if 90% of people are not getting care, that’s an issue. And so for us, it really comes back again to person-centered care. And so what we really do is we have defined eating disorder measures that we’re certainly looking at, like the E-D-E-Q-S is a main measure. We also look at mental health benchmarks like the PHQ nine, GAD seven. We look at quality of life as well as time to care. And for us, what’s important too is our ability to prevent escalation into hospitalization again. So those are all really important, but longer term for us, what’s really important is that a member understands what these metrics are and what these benchmarks are, so that way longer term they can really carry forward that healing for themselves.
So what we really try to do is from the very beginning as we’re developing that treatment plan, we will tell them, here’s what an E-D-E-Q-S is. It’s the eating disorder examination questionnaire. It’s a 12 question questionnaire that really goes through eating disorder, symptom frequency and severity. And we will kind of check in every appointment on how you’re progressing. And we show them a chart on how things are trending, and that way they have that knowledge of, okay, this is why you’re asking me all these questions every time. And I can use this longer term as a check-in just for myself to see how I’m doing with the eating disorder and the progression. I think one of the most exciting moments was when a member of ours mentioned to their care advocate during appointment, Hey, they asked the member, what was the highlight of your week?
And the member said, well, I saw that my E-D-E-Q-S score dropped significantly over the past few months, and I just really am so proud of myself for that. And I think that that seeing that progress is so key, I think in the mental health space where oftentimes it just feels like things are often feeling like they get worse before they get better. And so having something to really benchmark your progress and to see the progress that you’re making is so, so important. I think with physical health, we see, let’s say A1C levels or glucose levels, you see the trends moving in the right direction, and I think we need something like that in the mental health field and especially for eating disorders for people to feel a sense of progress. To continue,
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Meera Oak
I want to turn the page a little bit and think about expansion with telehealth services. And of course, what goes hand in hand with telehealth expansion is always regulation and regulatory hurdles. And so I am sure each of you can sort of touch on this, but I would love to understand what are the most significant regulatory challenges for telemedicine or for your specific companies as you think about expanding into different regions and how did you navigate those complexities?
Joan Zhang
We’re currently in Texas and North Carolina about to expand to New York and Florida. And this has been just the standard challenge from every single digital health company that I’ve been at is our ability to expand to new states because it feels like honestly, we’re dealing with 50 different countries and there are some little pieces here and there that make it a little easier, like the medical compacts, the spac, but at the same time, it still just is such a significant challenge to really get ready in every state to get your providers. And it’s also really expensive. And so we’ve taken more of the approach of go really deep in markets, go really local and really become part of the community and get to know some of the referring providers, know the referring community organizations. And I think we will continue to really take that, but at the same time, we get hundreds of people reaching out and saying, Hey, do you have services in this state?
And it’s like, well, we will be soon. But right now from a regulatory standpoint, we really just can’t. Our providers legally cannot. And so if I had a magic wand, it would really just be to standardize this process. And I want to say too, it’s not even just, oh, all 50 states have different rules and regulations. It’s also different rules and regulations for every single different type of specialty. So for us, it’s like even within just the category of therapist LPCs versus LCSW versus societies, it’s all different. There’s a whole team that you have to have in place to just really know what you’re getting yourself into. You have to forecast almost like a year out sometimes for some states you’re going to launch next year, and it’s just becomes really an operational nightmare. And I think the second piece on regulatory is I think there’s a lot of opportunity to innovate with Medicaid, and I think I’m most excited about ways that we can start to expedite that process. It takes a long time to get providers enrolled and credentialed, and I think there’s opportunity for us to speed up that process so we can get these much needed resources to these communities.
Christina LaMontagne
I think Joan brought up so many good points that I just want to, plus one across the board, maybe I’ll start where she left off. We have secured Medicaid contracts now for several counties in California, and it took a long time. And back to all the things we’ve been talking about, you’re trying to scale great access to high quality care, and it often feels like the system is just working against you. It’s just very hard to make the moves that you think your patients deserve. Not to mention the costs and the operational headaches and the forecasting challenge as a one and a half year old company that you just articulated.
I would say on top of that, and on top of being a founder, I’m also an angel or an advisor to about a dozen other companies in this space. Everybody’s got a problem for risk that they’re taking somewhere or other, whether it be prescribing risk or async versus sync visits. And different states have different rules, reimbursement risk, CMS risk. We are working in a disease where the standard of care requires a controlled substance, and there are different ways of course, that those substances need to be managed. But again, there’s federal ambiguity on multiple levels about how these drugs will be managed in the future and not to mention all the ambiguity that comes on different levels at state state. So I just see across the board that it can feel really hard to expand access quickly. And to your point about magic wand, nobody enters, nobody takes on the risks and throws himself into being a founder to hit legal roadblocks to do the thing that every doctor is telling them should be done.
And you used a great word, how do we expedite? How can we do things faster? There’s always hope, but I just wish that there were more systematic ways of doing that at times. I’ll also just add that depending on your business model, you may feel these pressures more or less. There are many business models where being in 50 states is really important right off the bat because your business model is direct to employer or whatever it might be. And there are workarounds for that. But even then you’re taking on a different type of risk maybe than what Jones and my business looks like, where we’re going deep in particular markets. So there are now tried and true ways of working through the complexity, which is great. We don’t have to make it up as we go and the way that our peers 10 years ago did. But it still feels hard.
Meera Oak
I feel like this sort of lends itself nicely into the next area I wanted to talk about, which is accessibility and I think at times expansion, this sort of promise of telehealth sort of its ability to reduce cost to break these geographical barriers. There’s so much promise here, but I think that there are still challenges when it comes to accessibility, and that’s the question I posed to both of you. How do you think about ensuring equitable access to telehealth services, right? Because it’s sort of breaking down one barrier, but are there many to go?
Christina LaMontagne
What comes immediately to mind is something near and dear to my heart. So my co-founder is a Guatemalan immigrant, and it’s just been very important to us from day one, especially in a place like California that we offer culturally sensitive, multi-language care to different populations. I think what’s really hard though, as an early stage company is you’re trying to evolve and change and iterate on so many things at once so quickly, and then to also be making the time and the intention to interpret, or better yet the things you learn in serving some populations like you bring back to other populations. But it’s just that things are moving quickly. You’re iterating quickly and trying to figure out how to keep up across all the dimensions that you care about. We just started in Medicaid, we just started in Spanish, but then there are other forms of equity for us.
Again, we really encourage two parents to attend care on behalf of their children, but sometimes that’s not possible. Or there’s a non-traditional family structure, and we think a lot about what does equity mean when what’s best for the child is both parents and care people are there, but again, the traditional system isn’t quite set up for that. So how do we cross the chasm from an equity point of view? So again, I think every business is a little bit different, but understanding your user and what matters most to them is a good place to start.
Joan Zhang
Christina, I’m really just glad that you brought that point up, because I actually have a dear family member who was not able to get treatment for A DHD or even get the diagnosis because there was a lot of stigma in their family around mental health and just denial that there was anything wrong. And it wasn’t until that they were an adult that they were finally able to even start that process for themselves. And even then it required that they get their parents to give them kind of a report on what they were growing up. And they’re like, I can’t do that. And so thankfully I was able to step in and provide some of that background and history. But I think to your point, I think we need to be thinking about some of these just access barriers that people will have. I think for us on the eating disorder side, and if you think there are two really big categories, one is still financial barriers.
I mean, there are a ton of programs who’ve moved into the virtual space, but they’ve effectively just taken their care model that they had that was already inaccessible and just made it virtual at the same price point or barely a discounted price point. Sometimes for eating disorder treatments, it’s like $15,000 out of pocket for people for a couple months of care, which I know I couldn’t afford. And so I think first of all, it’s really thinking financially about how do we make this care still work from a cost perspective for a business, but then also be more accessible to the people who need it the most. And so for us, similarly, we’ve really prioritized getting our providers enrolled with Medicaid and really focusing on Medicaid populations. So that is one piece is how do we really partner with health plans to really be able to pay for these services and make it more affordable?
But then on the flip side, to Christina’s point on the cultural side and some of the other access barriers, just because it’s affordable doesn’t mean the care model also has to work. And so to your point, I think a lot of eating disorder treatment, especially when it’s for young teens and children, there’s a common model FBT family-based treatment, and it requires, again that you have a parent or caregiver who can really monitor your entire treatment. It requires a significant amount of time. And so when you think about Medicaid populations where maybe the parent isn’t even involved, maybe this is a kid in the foster care system, or maybe that parent is working a handful of jobs and doesn’t have the time, or even I talked to someone who’s in the VC space who had a kid with an eating disorder and just doesn’t have the time. And so we need to really be thinking about alternatives where we provide more flexibility. And it doesn’t have to be maybe the 15 hours a week of required clinical time. If someone only has two hours to give, let’s not just turn them away, let’s try to get them the most important care that they need to really prevent them from getting worse. And I think for us, that flexibility has been so critical to really make sure that people can just start the care process with us.
Meera Oak
I feel like we could drill into so many more topics on this call, and this is amazing, but I want to maybe end on a bit more of a forward looking question. We’re in this era of every single day there’s a new technological innovation, ai, IOMT 5G, there’s so many new technologies emerging, and I’m just curious to hear sort of where are some of the most exciting technologies you are seeing in your space particularly, and then are you doing any work to incorporate them or plan for them as you look out over the next five years or so?
Joan Zhang
My background’s in product and tech, and this is what I really love doing. And I was previously at Headspace, so just love the consumer kind of tech side of everything. For me, I think one of the most important pieces is how do we actually use data to better personalize care and actually get closer to developing more N of one care models where what I mean by that is rather than every single person following the same treatment protocol, how do we use more of our predictive abilities to say, Hey, the right dosage, so to speak, of care appointments, is this the right provider match? Is this person the right Therapeutic approaches are combination of these pieces, so that way we really think that we’re optimizing for each individual’s prognosis and treatment success rather than just kind of trying to fit everyone in the same model.
And so what we’re trying to do now is as we’re really building up our patient cohort, really start to learn what are some of the patterns that we’re seeing, the correlations that are leading to better outcomes and start to build models to really better predict that. I think the other piece that I’m really excited about is creating more consolidation and just connectivity between systems and starting to work towards some, even just digital biomarkers for eating disorder care where we can better sense like, oh, based on some of these factors that we’re seeing, maybe if it’s just your activity level has changed or your sleeping patterns have changed or things like that, we can actually determine, Hey, maybe it’s time to go, just check in with your therapist briefly. Things like that where it doesn’t require the member to have to self-report something that we can gauge in their day-to-day.
Christina LaMontagne
In a phrase, we think about how we can bring precision medicine to what is today more of a behavioral health realm. So some of the things that you might do in cardiology, what my co-founder does to ensure great outcomes, how do we use some of those same types of analytics and measurement across healthcare more generally? So it’s things like user journey, things like matching, but then also not everyone learns or absorbs like medical information in the same way. And then fundamentally, if the basis of our business is there’s not enough supply of pediatric specialists, how do we do everything from reorganize their day to really enable much more automation in the way that care is delivered in the right way for the right person? And so that it feels very much more like precision in terms of who the person is, as Joan was saying, and also in terms of being able to predict what the outcome would be from that very precise intervention.
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