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Local Health Care Agencies Brace for Cuts

Local Health Care Agencies Brace for Cuts
As the governor and legislature struggle to close the state's $24 billion budget gap, local health care providers worry about the impacts of cuts on San Diego County's poor.

This is a rush transcript created by a contractor for KPBS to improve accessibility for the deaf and hard-of-hearing. Please refer to the media file as the formal record of this interview. Opinions expressed by guests during interviews reflect the guest’s individual views and do not necessarily represent those of KPBS staff, members or its sponsors.

DOUG MYRLAND (Guest Host): I'm Doug Myrland, sitting in for Maureen Cavanaugh, and you're listening to These Days on KPBS. As the governor and legislature struggle to close the state's $24 billion budget gap, local health care providers have to worry about the impacts of cuts on San Diego County's poor. In this part of the program, we'll talk about some possible effects of reduced payments to the County on public health. Our guests, all in the studio, are Dale Fleming, Director of Strategic Planning and Operational Support for the San Diego County Health & Human Services Agency. Dale, welcome.

DALE FLEMING (Director of Strategic Planning and Operational Support, San Diego County Health & Human Services Agency): Thank you, Doug.

MYRLAND: Gary Rotto. He's the Health Policy Director for the Council of Community Clinics. Gary, glad you could be with us.

GARY ROTTO (Health Policy Director, Council of Community Clinics): Good morning, Doug.

MYRLAND: And we also welcome Dr. Davis Cracroft, who's the Medical Director of Scripps Mercy, and emergency room physician. Good morning, Dr. Cracroft.

DR. CRACROFT (Medical Director, Scripps Mercy): Good morning, Doug.

MYRLAND: Dale, I want to start with you as the strategic analyst here…


MYRLAND: …and the person who has to have a lot of the aspects of the problem in your mind. I want to just start with some money questions. First of all, what's the county's Health & Human Service Agency's annual budget altogether?

FLEMING: About $1.8 billion.

MYRLAND: And then how much of that goes toward healthcare programs?

FLEMING: Percentage-wise, I'm not sure. I know that we get, excuse me, we get about 80% combination of state and federal revenue to run state mandated programs, and a good portion of those are health, public health, mental health and Medi-Cal enrollment programs.

MYRLAND: And then the other part of human services would be welfare.

FLEMING: Right, social services, child welfare services, public assistance programs that issue cash benefits to families.

MYRLAND: Now how does the county provide these healthcare services typically? Do you use vendors? Do you use other agencies?

FLEMING: Absolutely. We have a very strong public-private partnership where we work with local health plans and community clinics, with the local hospitals, UCSD, and the other private hospitals here, to create what we call a safety net for healthcare in this region for uninsured and underinsured folks.

MYRLAND: Would it be accurate to say that, by and large, the county doesn't really directly provide any of these services out of your own offices, it's a – the county kind of administers the programs?

FLEMING: For the most part, we do administer the programs through other vendors, through other providers. There are a few instances where we might provide immunizations or mental health services but, by and large, we rely a lot on our community providers.

MYRLAND: Now I want to move over to Gary Rotto, who is the Health Policy Director for the Council of Community Clinics. And your clinics who are in your council are some of the recipients of these dollars and mandates from the county, right?

ROTTO: From the county and from the state. It's a variety of partnerships, some directly with the state, some that flow through the – from the state through the county, and some direct work with the county also.

MYRLAND: So just give us a couple of examples of what kind of county programs that some of your clinics would provide.

ROTTO: Well, we work with the county, for example, on the Mental Health Services Act, Prop 63 as many people know, and the provision of mental health services. The county contracts with the Council and then the Council, in turn, works with not only our members but other members, other community clinics in the region, to provide these services. The OHI program, Oral Health Initiative, which comes through the local First 5, very similar situation. That was Prop 10 funds that the public set aside that they wanted spent for care for children zero through five years of age. And the local First 5 Commission thought that it was very important to provide dental care for children in that age range. So again, another contract, another working strategic partnership working together.

MYRLAND: Now, Dale, I've seen all kinds of different figures about how many people are receiving services. Do you have a ballpark figure for all the recipients of county health services?

FLEMING: Well, for county medical services, we have a population of about 16,000. Those are indigent adults who are uninsured. And in the Medi-Cal program, which is a state and federal program that we enroll people in and the community clinics and hospitals actually provide the service, we have about – just under 300,000 people enrolled and that includes 165,000 kids.

MYRLAND: So, and Gary, clinics would serve the majority of those services?

ROTTO: A wide variety of services. I mean, when you look at what the clinics do, our particular group, which has 16 partners, 16 private, nonprofit entities, 102 sites throughout the region, San Diego, Imperial, a portion of Riverside County, serve about, oh, 540,000 people, 1.5 million visits a year, a variety of medical, dental, mental health visits.

MYRLAND: Okay, now there's a logic to the way we've structured our guests today, believe it or not, because now we go to Dr. Davis Cracroft, who's the emergency room physician and the Medical Director of Scripps Mercy. And you're sort of the end of the line, so to speak. When folks, for one reason or another, filter through this system in a different way they end up in the emergency room sort of as a health provider of last resort, would that be fair to say?

DR. CRACROFT: Yeah, we are sort of the last link in the safety net, if you will, and we're happy to provide that service. Unfortunately, at times we become – oftentimes we become overwhelmed.

MYRLAND: Now you, just in Scripps Mercy alone, see about how many people a year in your emergency room?

DR. CRACROFT: We see 55,000 patients, about 150 to 160 a day.

MYRLAND: And then just in general terms, in a more perfect world how many of those folks really probably should have received service somewhere else? So they didn't just break their leg or get in a car accident or cut themselves with their band saw, they're coming there for some healthcare service that, again, in a more perfect world would've been provided someplace else.

DR. CRACROFT: Yeah, at my hospital, I would estimate somewhere in the range of 30 to 40% of patients could get care in a urgent care doctor's office, some other alternative site. We have a very high acuity population and admit about 25% of all patients who come into our emergency department, which is quite high. Most hospitals and most ERs would admit around 14, 15% of the patients. So we have a high acuity population and pay attention to those that are the most sick. We have to triage and oftentimes those that have minor complaints or can't get care elsewhere have to wait a longer period of time.

MYRLAND: Okay, so we've kind of set the stage of the various stakeholders here in the room. And I want to go back to you, Dale. There have been all kinds of proposals kind of floated out there about what might be cut, what might not be. We all know that the state budget is still a matter of debate at the legislature. What are some of the things you're most worried about as the person who has to do this strategic planning for the county Health & Human Services?

FLEMING: Well, we're most worried about the cuts that are going to affect kids and some of them are directly in medical programs and some of them are social services that will eventually have a health impact. So, for instance, the governor had on the table the elimination of the CalWORKS program, which is cash assistance, food help and medical help for families with kids, 54,000 kids. Now so far we're hearing that the legislature doesn't agree with that but he hasn't taken it off the table, so that's a concern. A concern for about 8,000 child welfare kids and the concern for 78,000 kids that receive Healthy Families, that's a publicly funded health insurance coverage program. And then we're worried about the extremely ill, mentally ill or the moderately mentally ill that will be pushed out of the managed care service as a result of cuts to the mental healthcare program. So those are our concerns for people, really, who can't take care of themselves, the kids. And it seems that, ironically, CalWORKS, for instance, is the California Work Opportunity and Responsibility to Kids Program, it seems like the responsibility to kids is maybe being shifted or an attempt to shift or step away from it, and that's really a big concern for us.

MYRLAND: And in your strategic planning, do you look at the services that are provided by the federal government other than the ones that you're directly responsible for? Do you sort of coordinate and figure out, well, maybe the feds will pick up some of the slack, or are you able to do that?

FLEMING: This is – We're talking about 27,000 families and a program that issues $180 million in benefits each year and it has an administrative cost of about another $100 million. There is no one who can step into that breach and fill that gap, so the burden will then fall on the local social service and healthcare safety nets and none of us has the capacity or the ability to sustain that kind of assistance. So it is very concerning.

MYRLAND: And Gary Rotto, that comes back to you then and your clinics. What's the capacity there to provide expanded services if you have reduced funding level from the county?

ROTTO: It makes it very difficult, not only the county but the state, because it's hand-in-hand as we're looking at the budget because so much of the county budget is dependent upon what's going on at the state level in the state budget. So when you have cutbacks, it really depends how deep. You have cutbacks, and the clinics are very efficient in what they do. We have some very talented CEOs at – in our network and running the individual clinic operations. Run very lean operations, one, two percent margins maybe. So when you start to have cutbacks of, let's say that we're looking at 30% at some programs, the other day the legislature had decided rather than outright elimination of things like early access to primary care and some rural health programs. You're looking at potential cutback in hours and, therefore, you have an access barrier for people that are working or people who have kids in school. You're looking at maybe cutback in staff, which runs counter to what the Obama administration was doing with some of the Recovery Act funds that were flowing to the clinics to try to increase services because of the increased demand with the downturn in the economy, more unemployed individuals. Potential closures, in the worst case scenario, of sites or of cutback in particular services.

MYRLAND: That's Gary Rotto. He's the Health Policy Director for the Council of Community Clinics. Also joining us, Dale Fleming. She's the Director of Strategic Planning and Operational Support for the San Diego County Health & Human Services Agency. And Dr. Davis Cracroft, Medical Director of Scripps Mercy and emergency room physician. And, Dr. Cracroft, since you're the physician in the room, I want to ask you what some of the implications longer term are if people aren't getting some of these kind of preventative care, dental care, some of the things that we're talking about cutting. I'm jumping to the conclusion that you anticipate then that increases visits to your emergency room down the road.

DR. CRACROFT: Absolutely. For those who neglect routine care, they come in with more advanced disease processes, may require hospitalization or referral to specialists out of our ER. And those that are excluded from the clinics will come in with routine matters that have to be dealt with, and right now we're relying more and more on the community clinics as our safety net to get those patients with less severe illness out of our hospital, out of our emergency department, and into a medical home where they can get routine care and avoid the use, misuse, if you will, of our emergency department and services that we have to be good stewards of and maintain for those that are critically ill or injured.

MYRLAND: Now you're only one of several emergency rooms in the area but you seem to get more than your share of the business. Is that because of your location?

DR. CRACROFT: Yeah, we're in a central city location and, you know, you can get to our hospital by walking or easy other means of transportation, by public transportation. Some hospitals are geographically advantaged in that respect that it's more difficult to get to the hospital. So we have the center city population that we care for, along with UCSD.

MYRLAND: I want to stick on this thought about accessibility barriers for a few minutes because San Diego's a big county and I'm wondering, Dale, how you sort of address serving the entire population with some of these programs, especially when you're looking at deep cuts.

FLEMING: Well, we have an organization that – where we convene health plans, providers, consumer advocates. It's called Healthy San Diego, and they try to look for just that sort of thing strategically for Medi-Cal and Healthy Families. For the County Medical Services program, we use the community clinic, 43, I think, community clinics in their system, to contract out for primary care services for indigent adults. And then we offer contracts to all hospitals and all clinics who are willing to work with the safety net population so that we can manage that coverage. The other thing that we're looking at is some more modern ways to reach out to folks: online instead of in line. And we have been piloting things like telepsychiatry for remote locations so that a primary care physician can get access to mental health consultation without them having to move the patient or move the consultant there. And Gary knows a little bit a project called Safety Net Connect where, as Davis was speaking to the connection between the ED and the community clinic for follow-up. This is an online connection where the ED can schedule appointments in the community clinic to make sure that there's appropriate aftercare. So we are trying to narrow the holes in the safety net, so to speak. It's going to be much more difficult with this very – this evolving situation in Sacramento.

MYRLAND: Well, I want to continue this conversation in a couple of minutes and I also specifically want to talk a little bit more about some of the particular services that are offered in the community clinics so our listeners can have an idea of exactly what kinds of healthcare is being delivered, what sorts of services. And I also want to invite our listeners to join the discussion. If you have a question or you have a concern about cuts in healthcare, or a story to tell, 1-888-895-5727 is the number to call. That's 1-888-895-KPBS. And we'll be back with more discussion on what possible state budget cuts' effect will have on healthcare delivery in San Diego County right after this quick break.

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MYRLAND: I'm Doug Myrland, sitting in for Maureen Cavanaugh on These Days. We are talking about the state budget or the budget gap, once again. And today the specific topic is about possible effects of reduced payments to the county on public health. Three guests in the studio: Dale Fleming. She's the Director of Strategic Planning and Operational Support for the San Diego County Health & Human Services Agency. Gary Rotto is the Health Policy Director for the Council of Community Clinics, and Dr. Davis Cracroft, who's the Medical Director of Scripps Mercy and an emergency room physician. And we put the call out to ask you to join the conversation as well at 1-888-895-5727. And we have Bella in La Mesa on the line. Bella, welcome to the program.

BELLA (Caller, La Mesa): Thank you very much. I just wanted to make a mention, as you were talking about community clinics, I'm a nurse practitioner and I went for an interview for a position through UCSD for psychiatric nurse practitioner. And during the interview, the way the job was described to me was that I would be seeing people without insurance, which was great, but that I could only prescribe prescriptions for medications that were in the sample closet, which means the closet that every clinic has that the pharmaceutical representatives bring their samples. And if the medication that I felt was appropriate wasn't in the sample closet then I had to give them an older medicine, you know, a 20 or 30 year old older medicine that was cheaper. And I felt that that was such poor care and such discriminatory care for people without insurance that I felt that it was shocking, and I just needed to tell the story.

MYRLAND: Well, Bella, I really appreciate you setting the stage, and that's exactly the kind of real world example that I think is germane to our conversation. Gary?

ROTTO: Yeah, I'm surprised by that. I don't know that particular clinic. I know from the clinics that are involved in our network, many of them have pharmacies, pharmacy programs, and look to try to get patients, whether they're in a particular program, whether they're on a sliding fee scale, you know, or with a private insurer, get them what they need. Now, of course, as with any managed care program—and a lot of Medi-Cal these days is through managed care, managed care partners—they may have a formulary. And I…

MYRLAND: But usually the formulary isn't just the samples.

ROTTO: No, absolutely not. It doesn't – You know, that's something that is ancillary.

MYRLAND: That's an interesting…

ROTTO: I mean, we're talking…

MYRLAND: That's an interesting new definition…

ROTTO: Yeah.

MYRLAND: …for the formulary.

ROTTO: Yeah, no, no, no. That's not in our formulary, I know…


ROTTO: …I know that.

MYRLAND: But I think it's helpful to understand the kind of stresses that some places are undergoing. I want to hear from another caller. Bart is in Encinitas. Bart, welcome to the program.

BART (Caller, Encinitas): Good morning. Yeah, you know, I think everybody's under stress in government and so forth right now and the important thing is to see the demonstration of efforts like the Recession Help Expo on June 28th, downtown at the Holiday Inn where there's 150 agencies going to be there to reach out for people. You know, that's exactly the demonstration of what we need.

MYRLAND: And your point is about public-private partnerships?

BART: Yeah, you know, basically there's probably 50 or 60 agencies that are already taking up the slack of helping to sign people up for different medical programs and food stamps and housing assistance and everything else. We're already seeing that trend on a large scale. And I know this is a benchmark event, the Recession Help Expo on June 28th at the Holiday Inn. I mean, there's going to be 10,000 people are going to show up to get the help that they need because the county is just – they can't deliver, you know, they're constrained, they're overworked and, you know, so now people are stepping forward and they're saying, hey, you know, let's connect, let's put it together.

MYRLAND: Well, we…


MYRLAND: We appreciate that information and it's sort of an optimistic note for us here. Gary, I want to get your reaction onto (sic) that because you're already participating in a public-private partnership. Are all the clinics in your network nonprofit clinics?

ROTTO: Yes, all are private, nonprofit.

MYRLAND: And in a short couple of sentences, can you talk about what advantages it is to be a nonprofit healthcare provider as opposed to a for-profit?

ROTTO: More than being a nonprofit, I mean, what the caller described is very much how the clinics started. They're community-based, community-rooted. When you look at the history of any of these clinics, maybe it's San Ysidro Health Center, maybe it's North County Health Services, and you see how they grew from a group of volunteers to the institution that they are today and still maintain those roots because their board is comprised not just of community members but also actual patients, users, that are actively involved in helping to guide the program and guide and understand the needs in the community so that the clinics can continue to meet those needs.

MYRLAND: Dale, is that congruent with your strategic objectives, and that is to keep things as much at a community level as you can in terms of providing – of delivering healthcare services?

FLEMING: Absolutely. I mean, they do have the connectivity and the history in those communities. They are strongly linked and connected and the community themselves see them as a partner and a help, so, absolutely, we couldn't do what we do without them.

MYRLAND: Dr. Cracroft, I want to ask you about a specific cut that's been floated several times and that's Denti-Cal. And even though, you know, you're a physician and not a dentist, I wonder if you could talk a little bit about the implications of great numbers of people no longer receiving that regular dental care and if there are larger public health implications than just, you know, uncomfortable teeth.

DR. CRACROFT: Absolutely, yeah. We do see a number of dental patients in our ER. Offices are often nine to five or, you know, regular daylight hours for dental care. So after hours, if they've got an abscess or severe infection, they'll seek treatment in our emergency department. And up to now, I think we've had adequate community resources to get emergent treatment for these patients. If they're severe, we admit them to our hospital and – but most of them can be referred out, and our community clinics have adequately, I think, cared for these patients. Without that safety net and that degree of coverage, I think we'll see more and more advanced cases of severe dental infections and other problems, and it's not something that is trivial. It can lead to huge abscesses, osteomyelitis, bone infections, other serious problems that are not only – they're disfiguring and disabling to the patients.

MYRLAND: Gary, is this an issue for your clinics as well?

ROTTO: Oh, absolutely, especially with pregnant women. I think the doctor will tell you, dental health is so important because any type of infection or serious medical situation can be passed on from the pregnant mother to the fetus.

MYRLAND: And I want to talk about just a couple of other examples of the kinds of medical care that we're talking about that your community clinics deliver. You know, I think all of us have our own experiences with our own physicians and our own HMOs and whatever but I think many of our listeners may not have had occasion to visit a community clinic or receive their healthcare delivered through the county services. So what are some of the things that you help people with?

ROTTO: Well, basic medical services, your ambulatory and primary care for adults, infants, children, well child check-ups, other check-ups for individuals, for adults. When you have a situation and you don't know what it is that you have, you want to – you've had some flu-like symptoms for a number of days and it's not going away, you're not getting better and you want to be seen, you want to know what's happening, you can come into a community clinic. OB-GYN, we talked a little bit about dental programs, immunizations for children and adults, pharmacy services, radiological services. So many of the clinics now have on premises the ability to take x-rays or other types of scans, and laboratory services.

MYRLAND: Dale, I know that there's been some discussion about Healthy Families and whether or not that's going to be cut. Maybe you can talk a little bit about that because I think it's along the same lines of these kind of basic preventive activities.

FLEMING: Right. Healthy Families is a healthcare coverage program, an insurance program, and they include in-patient services. They offer diagnostic procedures for kids—all for kids that are up to 17. They have mental health services, vision, dental care, so it's a full gamut, a full range of services that you might receive in your typical health plan.

MYRLAND: And about how many children in San Diego County are currently benefiting from this?

FLEMING: We're projecting about 78,000 by year end.

MYRLAND: So that's a lot of kids.

FLEMING: That's a lot of kids, it is. And if that program were to be eliminated, we're thinking at least half of them might attempt to get onto the Medi-Cal program. We're not certain if they would be eligible or not.

MYRLAND: Now I want to ask a more political question of all of you and that is that, you know, everybody who is a guest today is, in one way or another, involved in some form of advocacy in trying to make sure that these issues are known and that – and, Dale, I don't know what the restrictions on you as far as actually lobbying the legislature may be as a county employee but I – there's plenty of lobbying going on even if you're not the person that's allowed to do it. What are the kinds of messages that you try to send to Sacramento to say, look, this is really important. You really need to look elsewhere to save money. What are the messages that you're trying to send that says your need is actually a priority and ought to be considered that way? Dr. Cracroft.

DR. CRACROFT: Well, you know, one of the things that I think we need to realize is that this is perhaps a short term cost avoidance but a long term increased cost in caring for patients that are excluded from the system because of lack of funding and that it will later on catch up to us in that we are perhaps, you know, looking too close to immediacy and not to long range planning in this. And I think we can easily make the case that those patients that are excluded will end up costing more in the long run and to the detriment to our society, too. I think there are bigger issues that we're facing of health and happiness here.

ROTTO: For the average patient that comes to a clinic, Doug, a year of care runs about $450, $460, so that's what, one-twentieth of a emergency room visit. So the efficiency of having these programs and of having care provided in a clinic setting is great value not only in society but in particular to the taxpayer.

MYRLAND: It's a tough argument to make, though, because of human nature. I mean, we all have preventive maintenance that we should have done on our house but instead of cleaning the gutters, we end up having to replace the roof. How do you keep driving that message home? I mean, when you put it in the economic terms and you say, well, $460 dollars to visit a community clinic or, you know, ten times that much to go to the emergency room, it's kind of clear. But human nature is to put off things until they have to be dealt with.

ROTTO: And some people have chronic care situations—it may be diabetes maintenance, it may be a child with asthma, it may be hypertension—that need regular counseling, regular education or they have to be seen on a periodic basis in the clinic. Whereas if somebody doesn't have that coverage and they put that off, it's not very far down the line, if I'm correct, Doctor, that they end up in the emergency room.

DR. CRACROFT: Sure, and I think the consequences of uncontrolled diabetes with heart disease and visual problems, vascular problems, are well recognized. Similarly, for hypertension, you end up with a stroke or congestive heart failure where if it's well treated and well maintained, you can avoid these issues. And it's not only, you know, as I said, it's not only the cost of care that escalates, it's also the patient's wellbeing and, you know, state of fitness, mentally and physically.

MYRLAND: That's Dr. Davis Cracroft. He's the Medical Director of Scripps Mercy and an emergency room physician. We also heard from Gary Rotto. He's the Health Policy Director for the Council of Community Clinics. And Dale Fleming's with us. She's the Director of Strategic Planning and Operational Support for the San Diego County Health & Human Services Agency. It must be quite a challenge to do strategic planning in this kind of an environment. I mean, when you don't know how much money you're going to have to work with, you don't know where the pressure points are going to be but still you've got to do it. So how are you approaching looking ahead at allocating resources in the immediate future? How do you – what's on your desk as to what you can predict and deal with right now?

FLEMING: Right. Things are changing minute by minute and they're – nothing is firm. And what we operate under in the county is under a general management system where we try to plan, lay out scenarios and continue to update and change those scenarios for what-ifs. You know, what would we do if…, and be prepared and proactive. And, you know, in terms of advocacy, if there's anything that we could get the state legislature to do it's to practice that same kind of fiscal discipline and make strategic cuts rather than wholesale elimination of programs that have long term negative effects on communities. But we continue to update ourselves, keep ourselves updated and do scenario planning, try to figure out the best use of the resources that we have. We do have many resources coming, federal, state and Mental Health Services Act, for instance, from the ballot initiatives, and it's a matter of putting the right funding in the right place to leverage as much as possible and continue to maintain the safety net as much as possible.

ROTTO: One of the key things that the county does is public health. And we're partners with the county on so many levels, especially in protecting the public's health. So I think when Dale talks about scenarios and talks about don't wholesale eliminate certain structures, we need the structures in place so when there is another swine flu outbreak, H1N1, or there's another health emergency in the community that we have the structure in place to be able to respond, to be able to continue to work together.

MYRLAND: We're having a national discussion about healthcare right now and we know that how we all receive healthcare is going to change in some way or another depending on what ends up going through congress. What do you do to put this more immediate budget issue in context with this larger healthcare discussion? And I guess what I'm getting at is, is it – is there a danger here that people will say, well, this is a problem now but it's all going to be fixed later anyway so we have to just get through this for a while and then this new healthcare provision from the federal government is going to take care of a lot of these problems.

ROTTO: Well, what many people look at as far as healthcare reform and some of the models out there, whether it was with Mr. Daschle or currently with Senator Baucus, Senate Finance Committee, who has a major program out and white paper. So many of them look at – some of the models we're working with here in San Diego County today, the model of Medical Home, the model of working together between emergency rooms, clinics and public health, and if we have that in place it helps to bring healthcare reform more seamlessly into the community and into our lives so you don't have a great change. You can still feel comfortable in how you're receiving your services but they're done in a much better and more efficient setting, delivery of services as well as increasing access.

MYRLAND: Well, I want to thank all three of you for being here. We've been trying during this program over the last few weeks to really get our listeners' minds around all the budget issues in the state and this one's a very challenging one because there are so many moving parts, but I really appreciate you all helping us clarify that and really get the discussion down to more understandable terms. Our guests have been Dale Fleming, Director of Strategic Planning and Operational Support for the San Diego County Health and Human Services Agency, Gary Rotto, Health Policy Director for the Council of Community Clinics, and Dr. Davis Cracroft, Medical Director of Scripps Mercy and emergency room physician. Thanks for listening. We will be back with lots more These Days right after this quick break.