In the history of America’s healthcare system, there has perhaps been no bigger disruptor to hospital finances than COVID-19, which has strained resources and shut down service lines. Telehealth reimbursement waivers have provided a fiscal lifeline for struggling organizations, but for some, more is needed. That’s where examining and re-thinking labor costs come into play.

In a way, looking at labor costs is an obvious consideration for hospitals, as such costs typically represent the largest category of health system expense. But with labor cost information generally siloed from an organization’s other data, a modern solution requires some form of automation technology to truly give hospitals and health systems a sense of how they can shift resources in an effective and efficient manner. If the goal is to avoid furloughing or laying off workers, these capabilities are essential.

Nebraska Medical Center realized this. Leadership knew it wanted budget, cost accounting and patient data all in one place, and got the ball rolling in January with new data capabilities and some training and education to get physicians, nurses and hospital leadership on board. As the worst of the coronavirus’ first wave has played out, the hospital has yet to furlough an employee, and hopes to keep it that way.

“When we were in pandemic mode here, we thought, ‘Let’s not panic and furlough people, because we’re going to need them back,'” said Kristi Atkinson, budget and cost accounting manager at Nebraska Medical. “Let’s use the data so we’re not playing favorites, and we can look at the data and say, ‘Whose productivity is down because they don’t see patients anymore? Whose productivity is too high?’ We used it as a way to determine where we have resources, who’s up and who’s down.”

In that way, Nebraska medical was able to shift around some staff to maximize their available resources. Clinicians who are otherwise unoccupied are helping in the access department, assisting overwhelmed staff in performing check-in processes. Surgical nurses who find themselves in limbo after the cancellation of elective surgeries are plugging in those gaps and escorting patients to various spots in the facility during check-in, taking some of the pressure off regular access department employees.

At the same time, management created a flex pool so managers could see where there’s a need for more bodies and who’s available to help. The hospital pays these employees based on flex codes.

Some hospital employees had trepidation about shifting their roles, but a thorough training program convinced them that shifting resources, and stepping out of their comfort zones, was the best move for the stability of the business.

Liz Kirk, senior vice president of strategic services at Strata Decision Technology, Nebraska Medical’s tech partner, said the move is a preferred alternative to paying out overtime to overworked employees. It’s all about challenging conventional wisdom, she said.

“Challenging conventional wisdom is sometimes hard to do,” said Kirk. “But in this time, when there’s such a need for financial recovery after COVID, as well as the level of attention organizations have from senior leaders, and the mountains people have moved over the last couple of months, this is the time to challenge that conventional wisdom.”


Typically, the data Nebraska Medical needs would exist in two different systems: The billing and cost accounting systems. Now, all of the data is in one place and staff can easily blend together payroll data, volume data, and statistics on cost, revenue and margin. With all of this information in one central repository, various teams across the hospital can get a full picture and understand the financial impact of each move they make.

“If we didn’t have productivity set up on a daily basis, and hadn’t validated the data and gotten statistics in there, we would be pulling from multiple systems on the fly,” said Atkinson. Now, the team can drill down by cost center and be more nimble when deciding which staff members can fill a need in another department. It’s quicker and more user-friendly than using the payroll system.

In addition to allowing for a better handle on its financials, the hospital noticed that the move has mitigated feelings of stress and burnout among clinicians — which has been a growing problem in healthcare for years, only made worse by the pandemic.

With the reduction in surgeries, Nebraska Medical was able to shift some of its pulmonary and sleep study staff to more active departments, for example. And with respiratory capabilities set up in the anesthesiology department, anesthesiologists can now be tapped to help out with respiratory aid for COVID patients.

“With elective surgeries resumed, we’re in the crunch and bringing on some contracted labor,” said Atkinson. “But our COVID patients are higher now than they’ve ever been. Nursing leaders are trying to make sure we get the right people on the right units, and adjusting the ratios a little bit. Same with the emergency department — we can’t be as efficient as we used to be, but we have nursing leaders looking into that.”

The results have been dramatic: By the second week of May, Nebraska Medical saw an 80% drop in overtime pay. That’s ticking back up slightly at the moment due to a challenging market, but the hospital still hasn’t furloughed any staff, which is a top consideration given that a main goal is to prevent people from losing their jobs.

“The difference between organizations that can predictably improve costs and margins and those that can’t is having strong governance and accountability processes in place,” said Atkinson. “To do that well you have to be able to keep track of all these different initiatives. For recovery, health systems will be doing hundreds of initiatives, but to keep track of them and keep track of the financial benefits of that, the only way you can do that is through automation. Organizations will drive themselves crazy trying to do it in Excel.”

  • The concept of a finance center of excellence is gaining traction as a way to help health systems tackle daunting financial challenges.
  • Finance centers of excellence have improved the budgeting process and interactions between financial analysts and operational leaders.
  • A finance center of excellence can smooth a health system’s transition to value-based care.

Bringing together experts to collaborate and share best patient-care practices in a clinical center of excellence is a common practice. Faced with the challenges of shrinking margins and demands for greater affordability, many progressive health systems are applying a similar approach to create finance centers of excellence.

Unlike their clinical equivalent, finance centers of excellence are not necessarily physical locations but rather a collection of the right people, tools and practices to help organizations achieve better financial performance. Below, we share some lessons from two health systems that have laid the foundation for such ecosystems.

Deploying expertise in the field

For some organizations, building a finance center of excellence begins with rethinking the structure and location of the finance team so analysts can support operational leaders in implementing processes that create better financial performance.

In 2014, OSF HealthCare in Peoria, Illinois, completely revamped its finance and accounting functions by centralizing its corporate finance team and deploying 60 financial analysts across the system’s 13 entities. These analysts have a “get-out-of-the-back-office mindset” and work “elbow to elbow” with operational leaders to help them reach their targets, which are based on a long-term financial plan, said Mike Allen, FHFMA, CPA, the health system’s CFO and the 2019-20 Chair of HFMA.

Making financial planning more efficient

Another critical step to building a finance center of excellence is refocusing leaders’ efforts. That aspect may involve doing away with a labor-intensive annual budgeting process that produces little return.

OSF HealthCare eliminated its arduous annual budgeting process at the end of FY18. Instead of producing a detailed budget annually, OSF HealthCare implemented a more agile planning process that uses rolling forecasts paired with intuitive performance management to drive accountability. The new, simpler approach creates financial targets for operational leaders based on prior periods, with a focus on driving ongoing and sustainable improvement — eliminating the laborious work of developing an annual department-level budget.

Having streamlined the planning process and deployed analysts to the different entities within the system, finance leaders at OSF HealthCare can work with operational leaders to analyze the bottom-line impact of their decisions and refine strategies to close performance gaps, Allen said.

Developing a structure to partner with operations

Another vital step to building a finance center of excellence is establishing regular operating reviews, which may occur quarterly or monthly, depending on the organization. At Wellforce, a $2.2 billion healthcare system in Burlington, Massachusetts., leaders chose a monthly approach.

In 2015, Tufts Medical Center, which formed Wellforce through an alliance with Circle Health, was facing financial challenges due to Medicaid expansion, heightened competition in its market, unprecedented snowfalls and the Ebola crisis, all of which had a negative impact on income, said Michael Wagner, MD, Tufts Medical Center’s former CEO.

Wagner met with the CFO, Kristine Hanscom, and determined that they needed to fundamentally change course. In January 2016, senior executives invited the top physician, nurse and administrative executives from each of the organization’s eight product lines to present a financial report. The product line leaders were asked to focus on two areas:

  • How they could drive their top-line revenue
  • How to improve their contribution margin

“It was probably the most enlightening eight hours that the senior team had had,” Wagner said.

That was the genesis of what has become a monthly financial reporting process for all service lines. The monthly reports have helped guide new investments designed to improve both financial performance and quality and outcomes at Tufts Medical Center.

Investments in surgery, cardiovascular care, neurosurgery care, pharmacy and other areas helped the system grow its top-line annual revenue from $850 million to $1.1 billion over a four-year period, said Wagner, who has moved to the system level as chief physician executive and served as interim system CEO in 2019.

Lessons learned about building a finance CoE

The C-suite leaders offer the following advice for other organizations that want to build a finance center of excellence and implement best practices for financial planning, analytics and performance.

Start by gaining support from the board and C-suite. For organizations aiming to roll out metrics and tools to drive accountability for nonfinance stakeholders, engaging the COO, CMO, CNO and other operational leaders is a crucial first step. Without their sponsorship, it is difficult to create buy-in throughout the organization, said OSF HealthCare’s Allen.

Recognize that doing away with the annual budgeting process will be uncomfortable. “As finance people, we tend to go with what we know and what we’re comfortable with,” Allen said. Leaders can reduce their team’s uneasiness by establishing that it is OK to get out of comfort zones and by deploying a robust communications plan to prepare stakeholders.

Be specific when setting financial targets. At Tufts Medical Center, senior executives provided product line leaders with dollar figures representing specific contribution-margin targets that they would be expected to hit. Using dollars is more concrete than using a percentage, Wagner said. Educating end-users is also a critical change-readiness step as organizations roll out new approaches to planning and accountability.

Make cost data transparent. “One of the biggest ‘a-has’ out of this entire process was that we needed to give our managers much more information so they could engage in a dialogue with their clinical lead, whether it was the division chief or the nurse manager on a floor or in the clinic,” Wagner said.

Don’t expect a technical solution to do all the work. Both OSF HealthCare and Tufts Medical Center implemented a management-reporting platform to support their finance center of excellence. But leaders concede that it takes more than sophisticated software to create change — it takes a commitment from leadership and deliberate change management efforts to drive adoption and avoid lapsing into old habits.

Preparing to thrive in a value-based care environment

Best practices like implementing rolling forecasting and continuous performance management can help organizations understand their cost structure so they can transition to value-based payment. In a value-based world, both health plans and physicians want to be assured that the cost structure of a hospital is rational and reasonable, Wagner said.

At OSF HealthCare, building a finance center of excellence has allowed leaders to move toward continuous performance management as they prepare for payment changes ahead, Allen said. Instead of focusing on “putting numbers in boxes” as they had with the old budget process, executives in finance, strategic planning and operations work together on solutions to reach their revenue and cost targets.

Such collaborative work can be rewarding for finance leaders. “The fun work is driving the change,” Allen said.

About the Authors

Frank Stevens is vice president of solution engineering & planning at Strata Decision Technology ([email protected]).

Alina Henderson is senior director of professional services at Strata Decision Technology ([email protected]).

This article was based on the executive leadership roundtable at Strata’s LIFT19 Summit.

Health systems’ volumes have dropped drastically during the COVID-19 pandemic — even in “hot spots” overwhelmed with COVID-19 patients.

In these hard-hit areas, overall visits are down 54.5 percent, inpatient volumes are down 41 percent and emergency room volumes are down 60 percent, according a new report from Strata Decision Technology analyzing over two million patient visits and procedures from 51 healthcare delivery systems using the company’s financial planning, analytics and performance platform, StrataJazz®.

These across-the-board low volumes translate into revenue losses and fiscal hardship for health systems throughout the U.S. During a May 15 webinar sponsored by Strata Decision Technology and hosted by Becker’s Hospital Review, Strata’s John Baker, senior director of continuous improvement, and Liz Kirk, senior vice president of strategic services, outlined five key steps to financial recovery:

1. Establish leadership and ownership. Every financial recovery program needs an executive champion to set the tone for improvement, as well as a designated “recovery program owner” to coordinate the entire program, Mr. Baker said. The involvement of C-suite executives creates urgency and ensures accountability while helping to remove barriers and avoid indecision.

“Having an executive around the table, fully engaged, is going to make things move faster,” Mr. Baker said.

2. Set a reasonable, clear target. Although the months ahead are uncertain, health systems can calculate financial improvement targets using core principals, Ms. Kirk said. That starts with determining how much cash on hand will be needed at the end of the recovery period, then subtracting financial gains such as estimated federal relief or current cash balance of unrestricted assets. From there, systems should create projections as to what cash flow is expected to look like when volumes return to somewhat normal levels.

“That gives you the target you need to activate your organization around to find savings,” Ms. Kirk said.

3. Establish guiding principles. Financial recovery shouldn’t come at the expense of quality outcomes or physician and employee satisfaction, said Mr. Baker. Organizations can help employees rally around financial targets by showing them the thought and reasoning behind targets, while instilling confidence about efforts to maintain a high-performing culture.

4. Stay on top of governance and accountability. First, identify opportunities for financial improvement and test whether initiatives in those areas can be backed by analytics. Data-supported initiatives can be implemented and moved to the performance management and tracking stage. From there, health systems need to ensure they’re able to track how well hundreds of simultaneous initiatives deliver on results — and that they can course-correct as needed, with a strong accountability structure in place.

5. Break down the messaging. Communicate financial goals in a way that makes sense to front-line providers and senior leadership alike, Ms. Kirk advised. Telling a physician that the health system needs to find $100 million to recover from COVID-19, for instance, won’t be productive. Instead, frame the project in terms of cost reduction per inpatient case or operating room cases per day — metrics that seem far more manageable and will therefore drive crucial engagement.

  • Study finds cardiology visits down 57%; breast health visits fall 55%
  • Elective procedures plunge; uninsured hospital patients increase

U.S. hospitals are losing an estimated $60.1 billion a month and facing a 113% increase in uninsured patients during the Covid-19 pandemic, according to a new study.

The heavy losses reflect a 54% drop in patient visits due mainly to the cancellation of non-emergency and elective procedures, according to data from 2 million patient encounters across 40 states compiled by Strata Decision Technology, which provides financial analytics for the health-care industry.

The data, derived from a two-week period between March and April, saw revenue for 51 health systems fall by an estimated $1.35 billion when compared with the same period in 2019. Projecting the findings nationwide suggests an overall revenue loss of $60.1 billion per month for the nation’s hospitals.

The losses occurred as the share of uninsured patients rose from 7% in January to 15% in early May as millions of Americans lost job-based coverage.

The findings released Monday are the latest to show the financial impact of the Covid-19 health emergency on the nation’s hospitals. On May 5 the American Hospital Association released a report that estimates hospitals will see $202 billion in losses between March and June of this year. That averages out to more than $50 billion in monthly losses.

At Yale New Haven Hospital in Connecticut, revenue is down roughly $1.5 million a week, Keith Churchwell, the facility’s executive vice president and chief operating officer, said in an interiew.

The 1,541-bed hospital is likely to receive some stimulus funding, but Churchwell, who’s a cardiologist, doesn’t know when or how much.

Whatever the amount, it “will not make up for our overall deficit by the end of our business year,” Churchwell said. “We’re in the hundreds of millions of dollars in terms of our overall deficit.”

In the Strata study, clinical service lines that saw sharp declines over the two-week study period included cardiology encounters, down 57%; breast health visits, a decline of 55%; and cancer encounters, down 37%. Patient volume also fell for cataract care, down 97%; coronary heart disease, down 75%; hypertension, down 74%; and diabetes, down 67%.

Those canceled visits helped fuel the loss of 1.4 million health-care jobs lost last month “simply because the patients aren’t coming though,” said Dan Michelson, CEO of Strata Decision Technology.

Ten inpatient procedures account for about 50% of hospital revenue, Michelson said.

“So when hip and knee surgeries go down by 79 and 99%, when spinal fusions are down by 80%, when stents are down by 44%, that has an enormous impact” on hospital employment and revenue, Michelson said in an interview.

Even if hospitals restored half of their lost volume over the next six months, the industry would still require hundreds of billions in additional government funding to bring them back to pre-pandemic levels, Michelson said. “The ability to weather this storm is super challenging,” he said.

‘A Wave of Demand’

As the Covid-19 threat lessens and more facilities resume elective procedures, millions of patients who put off non-emergency care will likely “flood hospitals and physician offices seeking care,” the study said. “Many facilities will likely be hard-pressed to handle the surge while simultaneously maintaining capacity for Covid-19 patients.”

“You’ve got a wave of demand that hasn’t been taken care of,” Steve Lefar, executive director of the data science division at Strata Decision Technology, said in an interview.

“You’re seeing urgent care and important care being delayed and it’s being called ‘elective,’” Lefar said. But “it’s not really elective once it gets out two or three months from when that stuff was scheduled.”

Churchwell said he’s concerned that patients who put off care during the pandemic, “in many cases, went through their acute medical issues at home, leading to significant adverse events,” including possible deaths.


The COVID-19 pandemic has had an unprecedented impact on hospital visits, driving volumes to record lows. But patient volumes could be on the upswing as elective procedures resume, TransUnion Healthcare recently reported.

An analysis of over 500 hospitals across the nation found that hospital visit volumes further declined between the weeks of March 1st through the 7th and April 12th through the 18th. Volumes fell between 33 and 62 percent after already sliding throughout the month of March. TransUnion Healthcare previously reported that hospital visit volumes fell between 32 and 60 percent in March alone.

The updated analysis showed that hospital visits may have reached their lowest levels, but recent trends also indicated early signs of improvements.

For example, the analysis showed that outpatient hospital visits saw a record one-week 64 percent decline during the week of April 5th, as compared to pre-coronavirus volumes. However, outpatient hospital visit volumes started to rise by about 4 percent between the weeks of April 5th and April 12th, marking the first increase in hospital visit volumes since COVID-19 was deemed a pandemic, TransUnion Healthcare reported.

“Our research suggests that as hospital providers look to re-engage patients and resume elective procedures, the slight rise in outpatient visits may indicate very early stages of patient volume recovery,” said David Wojczynski, president of TransUnion Healthcare.

More than half the states have started to reopen according to the Trump administration’s plan for bolstering the economy, The New York Times reported Saturday.

The plan requires states, among other criteria, to have a decline in either documented COVID-19 cases or positive tests. But the number of coronavirus patients continues to rise nationwide, with over 4 million confirmed cases in the US, data from Johns Hopkins University showed at the time of publication.

The growing number of confirmed COVID-19 cases prompted lawmakers and healthcare providers to stop elective procedures and other non-emergent services to reduce exposure to the highly contagious virus. That number also prevented patients from seeking hospital services.

About 55 percent fewer Americans sought hospital care in March and April due to COVID-19, a new report from Strata Decision found.

The sharpest declines were services for life-threatening illnesses, such as a 57 percent decrease in cardiology, and a 55 percent decrease in breast health with a 37 percent decline in cancer care overall. Inpatient procedures and surgeries that normally drive hospital revenue – accounting for over 50 percent of total payments made to hospitals – also fell dramatically, with significant decreases in hip (-79 percent) and knee (-99 percent) replacement surgeries, as well as in spinal fusions (-81 percent) and repair of fractures (-38 percent).

“Hospitals across the country are eager to open their doors to elective procedures so they can serve their community, care for their patients, and survive economically but how they get there is literally a hundred-billion-dollar question,” said Dan Michelson, CEO of Strata Decision Technology. “Many facilities will likely be hard-pressed to handle the surge while simultaneously maintaining capacity for COVID-19 patients.”

Re-engagement of patients will be key to handling increasing hospital visit volumes, stated Jonathan Wiik, principal of healthcare strategy at TransUnion Healthcare.

“As providers approach patients, one consideration will be to check-in with those who may have delayed necessary care the most, then engage those who would like to reschedule as soon as possible,” Wiik explained.

Younger patients were also more eager to reschedule delayed or canceled services, TransUnion Healthcare found in a separate survey. Meanwhile, older patients part of the Baby Boomer and Silent Generation groups demonstrated the largest declines in hospital visits by nearly 60 percent each, the recent analysis found.

Having visibility into patient volumes across service lines to critical to the re-engagement strategy, Michelson added. Tracking hospital visit volume will allow organizations to “safely engage patients while balancing the clinical, operational and financial complexity and pressures imposed by COVID-19,” he said.

Across all service lines, COVID-19 pushed the number of unique patients who sought hospital care down by an average of 54.5 percent, according to a year-over-year analysis from Strata Decision Technology.

For the analysis, data scientists examined more than 2 million patient visits and procedures from 51 healthcare delivery systems in 40 states. The 228 hospitals represented in the study had varying rates of COVID-19 cases.

Here are the estimated volume losses for 30 service lines for a two-week period in late March-April 2020 compared to the same period a year prior:

Ophthalmology: 81 percent
Spine: 76 percent
Gynecology: 75 percent
Orthopedics: 74 percent
Ear, nose and throat: 72 percent
Endocrine: 68 percent
Dermatology: 67 percent
Gastroenterology: 67 percent
Rheumatology: 66 percent
Neurosciences: 66 percent
General medicine: 64 percent
Urology: 62 percent
Genetics: 60 percent
Vascular: 59 percent
Hepatology: 58 percent
Cardiology: 57 percent
Pulmonology: 56 percent
Breast health: 55 percent
General surgery: 54 percent
Nephrology: 52 percent
Hematology: 49 percent
Allergy and immunology: 48 percent
Behavioral health: 45 percent
Burns and wounds: 44 percent
Cancer: 37 percent
Obstetrics: 30 percent
Infectious disease: 23 percent
Neonatology: 20 percent
Not assigned: 4 percent
Normal newborn: 2 percent

View the full report here.

More than 3,000 surgeries have been put off at Yale New Haven Health since mid-March, which accounts for about 80% of its total surgeries.

That scenario mirrors health systems across the country that have had to delay procedures deemed less urgent as they focus on the COVID-19 pandemic. At Yale, overall outpatient services have declined by about 50%, said Dr. Keith Churchwell, the system’s chief operating officer.

“The numbers are staggering,” he said, noting that the 3,000 doesn’t factor in diagnostics and imaging. “The impact has been significant and going forward, we have to plan how to restart that.”

Restarting deferred surgeries pose a series of series of hurdles related to operations, finances, testing, staffing, supplies and patient safety, among others. One of them is how treatment will be prioritized.

The significant drop off in the number of patients receiving emergency care related to heart attacks and stroke is a major concern, Churchwell said.

“This patient population hasn’t gone away,” said Churchwell, adding that fear has likely kept them at home. “We are concerned that there has been a missed opportunity to give appropriate care and that we will be seeing patients down the road who will be sicker and more complicated, unfortunately.”

Nearly 55% fewer Americans sought hospital care over the past two months, resulting in a $60.1 billion average monthly revenue loss across all U.S. hospitals, according to a new Strata Decision Technology analysis of more than 2 million visits from 228 hospitals. Those losses represent about a fifth of the healthcare industry’s monthly output.

A decrease in procedures for life-threatening illnesses was particularly alarming, researchers said, noting a 57% decrease in services related to cardiology, 55% decline to breast health and 37% decrease to oncology.

“When you see things like heart attacks down 50% to 60% and the number of necessary procedures like stenting down 45%, it is really remarkable,” said Steve Lefar, executive director of Strata Decision Technology’s StrataSphere line of business. “This tells the story of the secondary implications of all this care deferral.”

About 40% of inpatient admissions at Edward-Elmhurst Health are non-urgent procedures. The health system in the west Chicago suburbs saw significant declines in cardiology, orthopedics and cancer care, said Denise Chamberlain, chief financial officer at Edward-Elmhurst.

“Procedures that were considered elective have now become urgent,” she said.

Treatment related to chronic conditions like hypertension and diabetes fell 37% and 67%, respectively, according to Strata data. Preventive wellness visits, gynecologic wellness and screenings, and gastrointestinal benign neoplasms and polyps all saw volumes drop by more than 75%.

That pent-up demand threatens to overwhelm providers. Edward-Elmhurst continues to reconfigure its workforce, ramp up testing, reorganize its facilities to improve social distancing and add to its personal protective equipment supply, which has been one of the biggest obstacles, Chamberlain said.

Eisenhower Health has had a similar problem, said Ken Wheat, chief financial officer at the Palm Springs, Calif.-based system.

“The biggest challenge from the planning and prioritization standpoint is PPE,” said Wheat, adding that the organization incrementally restarted elective surgeries about a week and a half ago. “But we are a long way from having enough PPE to open up the gates.”

As for the financial impacts, inpatient surgeries and procedures typically account for the majority of hospitals’ revenue. Some of the biggest impacts stemmed from a 99% decline in knee replacement surgeries, 81% decline in spinal infusions, 79% drop in hip replacements and 38% decrease in fracture repairs.

Meanwhile, the number of self-pay patients has increased by 114% in just 90 days as millions have lost their employer-sponsored insurance. In January, 7% of all patients lacked health insurance. By April that figure had risen to 11%, and early results from May indicate 15% of all patients are uninsured, Strata found.

“This is the equivalent of the banking crisis of 2008,” said Dan Michelson, CEO of Strata Decision Technology. “We’re on the verge of a financial collapse in healthcare.”

The $3.6 trillion healthcare economy makes up around 18% of the country’s gross domestic product, he noted.

Going forward, relying on the fee-for-service system is not sustainable, Chamberlain said.

“We have to get off the model where we get paid the most for patients being in the hospital—I don’t think that model works in the future,” said Chamberlain, expecting more of a capitated model. But that will require convincing self-insured employers that approach will lower costs and improve outcomes, Chamberlain said.

“I don’t think healthcare will go back to the way it was.”