NIC Chats Podcast with Bob Kramer: Six Key Drivers Shaping the Senior Living Industry

Beth Mace (00:04):
Hello, and welcome to the NIC Chats podcast. My name is Beth Mace, and I am NIC's chief economist. Thank you for joining us today. The focus of the NIC Chats podcast is talking to interesting people have ideas that I think you'd really like to hear about. As you listen today. I hope that you'll find some humor, insights, inspiration, and hopefully what I call an "aha moment" when something pithy or insightful is said, and a light bulb may go off for you. Now, today's structure is a bit different than my typical podcast. Today we are going to dig into factors that will shape the seniors housing and care environment over the next decade. To frame that for us, I am pleased that Bob Kramer is joining me today. Bob is NIC's co-founder and currently strategic advisor. He's also the founder and fellow at Nexus Insights. Nexus Insights is a think tank and its mission is to advance the wellbeing of older adults through innovative models of housing, community, and health care.

Beth Mace (01:06):
For the past year or so, Bob has been developing a thesis on the influencing factors that will shape the seniors housing and care industry through 2032. These are categorized into six drivers. The first is the COVID-19 pandemic. The second is the staffing crisis. Third is a new customer, and how that mixes with longevity of the aging adults today. Fourth is reframing health in health care. Five is a increasing importance of data in analytics. And the last driving factor is really moving from a siloed to a seamless environment in health care. So before we start, first, Bob, thank you for coming here. Welcome.

Bob Kramer (01:52):
Thanks, Beth. I'm delighted to be with you today and thanks for hosting this series.

Beth Mace (01:56):
Absolutly. Before we into specific of the six drivers, I was just wondering what was genesis of thought process that you used to create the ideas and what influencing factors have shaped your thoughts?

Bob Kramer (02:09):
Well, first and foremost, as a member of NIC's board, and we were starting to engage on developing a strategic plan. So that was kind of the first thing of how could I be helpful into that process? And I was struck, this was back in April of 2020, in the very beginning, early days of the pandemic, Henry Kissinger wrote an op-ed piece in the Wall Street Journal, and he was talking about lessons learned from the end of World War II in terms of applied to the COVID-19 pandemic crisis. And he said at that time that the historic challenge for leaders is to manage the crisis while building the future. And I was really struck by that quote. He drew the analogy to all the planning in the last year, World War II for NATO and for post World War Europe. But I was struck for that in terms of what it meant for IC and our strategic plan and our industry.

Bob Kramer (03:10):
What did it mean to build the future? And to build the future, you gotta be looking out and saying, What does that future going to look like? And I've been fortunate, and I would say just really blessed that NIC, the board and Brian have enabled me to have this role where I spend a lot of my time doing, thinking about that, reading widely and engaging with people outside of seniors housing and care. And so whether it's a scout ice cutter or ambassador or agent Provocateur, different roles that the board has given me. I'm given the freedom of doing this reading and engaging widely outside the sector. So it was taking that, then taking this challenge really from Kissinger of what does it mean to build the future? And that's what caused me to really develop all of this. Plus just having this being encouraged and really supported by NIC to do this exploration.

Beth Mace (04:11):
That's terrific. Thanks. So the first driver is COVID-19 pandemic. So how is that helping us shape the future of senior housing and care?

Bob Kramer (04:21):
Well, I would say that with many trends going on, they didn't suddenly appear because of COVID, but COVID accelerated and brought into our consciousness trends that would've happened anyway. It sort of put a dramatic emphasis point on them. I'll give a few examples one was that because of COVID had a loss of consumer trust in our setting. A fear of the setting. I don't mean people wanting to avoid having to be in assisted living because of what that represented and then mean more the sense of a fear that it could be dangerous to me at there.

Beth Mace (05:05):
Because of a COVID infection.

Bob Kramer (05:05):
Yes. Because of infections. And just as people were afraid of being in hospitals, they're also afraid of being in congragate care communities. And so I think what that put then was if you're going to rebuild trust to get trust, you've gotta have credibility.

Bob Kramer (05:21):
And that relates to transparency. And so I think a move already in a more consumer driven environment and culture, which the boomers represent, to more transparency really got accelerated because of COVID. Secondly, we came, as I like to put it, kicking and screaming because of COVID in the 21st century world of digital in so many areas; for communication with staff, with residents, with families, in care delivery. We couldn't ship people out for health care. And so that meant figuring out ways and a lot of it was digital to be able to monitor folks and deliver care, meaning such things as telehealth and telemedicine. Thirdly, for engagement, our van was sitting empty and still. We couldn't take people out in vans for engagement, and our multipurpose activity room was closed down. So we had to think more creatively about engagement and how we used the digital world to create engagement. Lastly, sales and marketing. We couldn't do live tours anymore. We had to think completely differently about sales and marketing. All of these areas, I would say as tough as they were, we made huge strides forward in learning that we could do things and we could be flexible and we could adapt in ways we never realized as an industry.

Beth Mace (06:50):
So I think I've heard you talk in this conversation here area about COVID, about sort of a moat around our building and how that's collapsed. Can you comment a little bit more on that?

Bob Kramer (06:59):
Yeah. Basically until March, 2020, private pay senior living, basically said proudly we have a moat around our building. No health care happens inside our buildings. All of a sudden, starting in late March, we're up on Capitol Hill saying, "Hey, we are not only part of the health care system, we're the front lines of defense against this pandemic." And the only way your ICUs and your ERs are not going to get overwhelmed is if you provide us the ability to provide better care, testing, PPE, later on vaccinations for the residents in our building. So that moat that said, we don't do health care, we dropped all pretense of that as of April, 2020. And that was huge because there's no going back on that for the industry.

Beth Mace (07:54):
So has that affected you think the perception of sort of real estate investors in senior housing?

Bob Kramer (08:00):
I don't think it's accident coming out of this that there's a huge interest in active adult and in areas of senior housing that have the least staff. It's the staffing, really staffing crisis and the least health care least regulation least danger of reimbursement vagaries and so forth. So yes, and I think a couple other things I would say about COVID. One, it brought mental and behavioral health issues sort of emerge from the shadows and they won't return. Just yesterday, a new company was launched with Chris Enscof as the CEO with major private equity backing led by both Arch Ventures and General Catalyst to a specifically addressed issues of mental health and behavioral health amongst seniors and I think infection control and prevention, they're new table stakes.

Bob Kramer (09:02):
They're not the thing that's going to enable you to attract people into your communities. It's not sufficient, but it's necessary. If you are not doing the latest in terms of infection control and prevention people won't move into your communities. And the last thing I'd say about COVID is that it punctuated the end of what I would call the first generation of private pay seniors housing and the second generation more broadly of housing and care for the elderly in the United States.

Beth Mace (09:38):
That was like the board and facility.

Bob Kramer (09:40):
Yeah. The first generation was boarding care and the CCRC, the launching of faith based CCRCs. Second generation then was the explosion of private pay senior living, independent living, memory care, assisted living. And now the third generation I think is really going to be very much driven initially by how do we reach people in their seventies and eighties? Because the more highly educated residents who can afford private pay senior living, those folks aren't going to need care driven senior living for the most part until their late eighties or nineties. So they're still 10, 12 years away from being our customers, but how are we going to serve them? Now a lot of folks are very interested in that.

Beth Mace (10:30):
So that gets into your third point. But let's go there then. So the new customer. And who the new customer is and longevity that fits into the drivers.

Bob Kramer (10:42):
What I like to talk about it, Beth, is that a new customer is arriving now with a very different take on longevity. What I mean by that, the best example I like to use is my father-in-law, Sam. And he was a World War II army veteran. At 89 he said to me when we were visiting the Churchill Museum and the war rooms in London, he said, "Bob, can you believe it? I'm still alive." And he'd retired at 62 after a heart attack and here he was at 89. He ended up passing away at 93. He had what I call, and the greatest generation had what I call accidental longevity. They'd never expected to live this long. And they were just grateful to have survived. Their children coming along behind them, who are going to be our new customer, they're not going to have accidental longevity. They know they're likely to live a long time. They want purposeful longevity. Purposeful longevity means it's not enough to live longer. You want to live better. You want a better quality of life. And that put simply means you want not just years added to your life, in fact, that if it's poor quality of life is a drag, what you want is more life in those years.

Beth Mace (12:10):
I think I've heard you say thrive, not just survive

Bob Kramer (12:11):
Yeah. You're determined to thrive. It's not acceptable to just survive. And that's going to change the expectations for our product. So I think put simply, I would say that our society still today is built for people to retire and die in their sixties and seventies. And it hasn't adjusted to the reality that many people are living not just to their eighties, but to their nineties and a hundred and beyond. And that has enormous implications. But key for the boomers, this new customer is they want what Lynne Katzmann has has called "well span." They want their health span to, as nearly as possible, match their lifespan. And for many boomers, that means they want a lifestyle and aesthetic that is as much as possible, not only going to enable them to have well span, but as much as possible going to enable them to avoid care driven senior living for as long as possible, if not completely.

Beth Mace (13:12):
And can you mention comment a little bit on what Stanford has done with their map of life?

Bob Kramer (13:16):
Yeah. This is revolutionary though. It's meaning it greatest. And this is what I love about the field of aging and longevity. This has the greatest implications for our children and their children. But what the for new map of life is, it's a map for the hundred year life. And it's recognizing what I talked about before. Most people aren't retiring and dying in their sixties and seventies. When they released last November, they pointed out that in the United States, demographers predict that as many as half of today's five year olds can expect to live to the age of a hundred. Oh my gosh. And if you look at our customers who tend to more likely than not to have more education, the likelihood of living to a hundred even goes up beyond 50%. So then that looks at the implications.

Bob Kramer (14:14):
People have a career, they'll have careers. They won't have one time of preparation for what they're going to do. They may have multiple times. So Harvard, Stanford, Notre Dame, University of Minnesota now all have what you could title encore career programs to help you find and train for and prepare for an encore career. You could say that when I launched Nexus Insights, that was an encore career for me. My wife trembles to think what might be next after that. But it's recognition that we have enormous economic power, we have enormous brain power, we have enormous wisdom and experience, and we need to harness this and use this in society.

Beth Mace (15:02):
So can that help? I know one of your other key drivers is the staffing crisis. So in the example you just provided of a second career, after you retired doing something, is that a possible solution for some staffing crises that everybody is facing a staffing crisis, but especially in the skilled nursing center.

Bob Kramer (15:20):
We're going to have to think younger, think older, and think differently. So what does that mean? Think younger, I'm seeing now more and more internship programs starting with kids when they're 16 and also courses to introduce them. Cause it's not just thinking about a career in aging or a career in senior care. It's thinking differently about aging and those that are aged. That's critical. We will never ultimately solve that workforce challenge without addressing that issue. But also it's thinking older in Japan that doesn't have the positive immigration that we have and that has an even more anemic birth rate than ours. There it's much more now the standard social expectation that those 60 to 80 years of age will be involved in the care of those 80 to 110.

Beth Mace (16:20):
The old taking care of the older and the older taking care of the oldest.

Bob Kramer (16:21):
Absolutely. So they've also focused much of their technology to offset the physical limitations of the 72 year old. Exoskeletons and robots and so on and so forth. So I think, yes, I believe there's going to be an increasing role for people in their sixties and seventies to be involved in the care and housing and services for those older than them. And I also think that's going to mean an increasing role for volunteers in senior living settings. Also as a way of potentially in a sense deferring <laugh> or, or, or, or reducing overall costs, overall cost of the community, overall costs of the resident. You will, in a sense pay it forward, and you see that in the village movement concept. But you are also starting to see that like two Life Communities in Boston, their opus model. Where there's a requirement and which in the focus...

Beth Mace (17:22):
People like it. People like that.

Bob Kramer (17:24):
As you know, Beth, because we've talked about this, the perspective residents were given four options and they chose the option for the highest number of required hours of volunteerism. Because they said they wanted their fellow residents similarly invested in the community because they recognize that creates community too. So going younger, going older, the role of immigration is going to be key. We still have far too many barriers and too many of our exceptions are only quote for highly skilled workers. And we need to create a pathway for low skilled, unskilled workers, particularly who come from cultures who value older adults and elders and value service to come into our country.

Beth Mace (18:11):
So that's interesting. So I've been talking to some operators about this lately that we spend a lot of time, or some operators spend time teaching their staff about the residents and the music that they like when they were growing up in the forties and the fifties. But I'm increasingly thinking that we need to teach our residents about the staff and have the two way communication, two way understanding both ways. And especially if you're going to be calling upon a staff that maybe different than who the residents are in terms of different just back backgrounds and experiences in their life.

Bob Kramer (18:46):
The growing income inequality in our country has honestly led to less and less empathy, let alone understanding of the frontline or what we now have come term because of COVID to call the essential worker. One of the ways we're going to change or address the workforce challenge is to realize our employees are our employees, not just from the time they clock in to clock out, but we have to show understanding empathy. And we can't solve all the issues they leave at home when they come to work. But we've gotta show that we're partnering with them in addressing some of those very challenges. When we do that, we'll be the employer of choice. When we do that we'll have employees who are committed to us and committed to our residents.

Beth Mace (19:37):
Ok. So we talked about three drivers, the COVID-19 pandemic, the new customer in longevity and how that merges with each other and now the staffing crisis. So a fourth one is reframing health and health care. So talk about that a little bit.

Bob Kramer (19:51):
Yeah. Reframing health and health care is realizing that we're moving. And the way I would put this deliberately, Beth, is we're moving slowly but surely. So many people anticipated this would happen overnight. It's not, but is it going to happen or is this just a fat, it's going to happen? Why? Because of the concerns about uncontrollable cost for governments of health care. And the only way that on top of this is to move ultimately from a sick care model to a well care model. A sick care model is curative and focused. It's reactive, waits till you get sick or have an accident and it's passive. There's very little role for the consumer, whereas a WellCare model is preventative, it's predictive, it's trying to anticipate when you may have a health issue and it's participatory. There's a key role for the customer.

Beth Mace (20:48):
Does that relate to fee for service and value based?

Bob Kramer (20:51):
It, it does in that the move to a well care model is people realize because we've always had a sick care model. And the only way we're really effectively shifting in that is to no longer pay based on volume of services, but based rather on the value in terms of the outcomes and the total cost of those services. And so to incentivize, in other words, health care providers to be able to reduce unnecessary hospitalizations to start particularly with our residents, what I would call the, the destructive cycle, which is you go to the hospital for a flare up for chronic condition, you come back out and then everyone waits till it flares up again, and then you go back again. Each time your health has suffered and your quality of life has suffered. It's very expensive. It provides a crappy quality of life for the resident, and they're on a roller coaster that usually over two to three years ends up taking their life.

Beth Mace (21:58):
The systems aren't necessarily talking with each other.

Bob Kramer (22:00):
Not at all. And that gets to another one of our drivers that we'll get to. But yes, we have all these disconnects. Right now, we have silos. Each silo has been incentivized to hold onto its customer for as long as possible and maximize everything they can charge during that period of time, because it's all based on value. And what that means is a lot of unnecessary call to care. And so we have the wrong care at the wrong time and the wrong place. Rather than the right time care and the right place at the right time. This is a, I would say a 10 to 20 year shift, which also was kind of interrupted because of COVID when all focus had to be on the pandemic. So we're in the still in the early days of this shift. But it is going to happen. And as an industry, we need to realize our residents are some of the keys. Why? Because in memory care, in assisted living, and in particular skilled nursing and more and more in independent living, they're the highest risk, highest cost individuals. So they're the ones where you're going to have the greatest gains in terms of reducing health care costs by starting to move to a preventative predictive system.

Beth Mace (23:22):
Let's talk about that a little bit more. A lot of our listeners will be those who are involved in the senior housing industry. So how does senior housing fit into this? Do there have to be shifts in how we are serving our residents?

Bob Kramer (23:36):
There do need to be shifts. Absolutly. But let me put it this way, I think first of all, it's important. The operator, the owner, the investor have got to understand how this is going to change the fundamental nature of what happens in our buildings and with our residents. That said, does that mean the senior living operator has to become a health care provider? No. There are a lot of choices about how you choose to address these needs of your residents or have them addressed. Doesn't mean you've gotta do it. What would be an example of that? Well, an example of that would be, for instance, partnering with a health care provider who is focused on value based care, who is focused on reducing unnecessary hospitalizations and who either themselves or whoever is paying them is taking what is known as the health care dollar risk for that person.

Bob Kramer (24:35):
But I think what's key to that, in other words we can partner, we don't have to do it ourselves. That said, whatever you decide to do, you can't make good business decisions, good partnership decisions, good strategy decisions without data and analytics. And that's my fifth driver. Because without them, you can't customize the data. Now, and this is really exciting, I'm literally in the midst of writing this right now, this week in my next blog post because data analytics enables us to customize and personalize, and that's what the customer wants in the future. And when it comes to health care, we need to have customized, if you want, journeys or paths. And it's data that allows that. Now does that mean that the senior loving operator has got to be actually mapping out that journey? No, but you can't partner with someone as a real partnership unless you know, the data about the residents in your building now wasn't available even a year ago.

Bob Kramer (25:45):
But now, thanks to work between NIC MAP Vision and NORC at the University of Chicago, we now have data that that shows us based on Medicare claims data and using the nine digit zip code locator of senior living communities. We know the average health care spend, the average spend on hospitals, the average spend on home health, the average spend on hospice. We also know, for instance, who are the top 10 providers coming into your building providing health care services. They may not be coming in, but who are the 10 docs that provide the most services to the people that live in your buildings?

Beth Mace (26:29):
What are you gotta do with that?

Bob Kramer (26:31):
What you're going to do with that is understand. For instance, we now know and can look at the prevalence of the 10 most expensive chronic diseases. And so we see that, for instance, Miami compared to Cincinnati, Miami has more than four times the rate of Alzheimer's disease than does Cincinnati. This is going to change all market feasibility studies for the future. Just as years ago, we shifted from only looking at older adults to looking at their adult children. And this health care data is going to have to be a fundamental part of any feasibility study in the future down.

Beth Mace (27:13):
Absolutly. I used do feasibility studies, quite a lot, and we used a plot number 12% when you try to figure out the incidence of memory care. And now what you're saying is that I know that the higher incidences in Miami, so I'm going to use a different factor in figuring out my demand.

Bob Kramer (27:28):
And you're also going to be able if you own some buildings in there or operate, you're going to be able to look at those buildings and see what is the actual incidence in those buildings. And it might cause you to compare it to that MSA or to that county. What I'm saying is for strategic planning, for partnering, for market, anyone that is not incorporating this data into market feasibility studies is not basically in the new era of senior living.

Beth Mace (27:59):
Well, and they might miss the mark too, and they might lose a lot of money.

Bob Kramer (28:01):
Very much so. Because otherwise you're going to be making your example 12% generalized assumptions that may be flat out wrong. The market may be one quarter what you think, or it may be four times what you think That's a pretty big difference. So the whole point is that this data is available to you as an owner or as an operator. You have to have it, you have to understand it, but it doesn't mean you have to be the one that goes out and provides all these health care services. I would actually argue too that because data ultimately is more than just medical spend and chronic disease data. This is where our industry has a real opportunity, but we've been historically weak. We are real experts on data, on functional needs, activities of daily living, instrumental activities of data and living, prescription drugs, over the counter drugs, and especially ability to pay, but no one's identity is defined by that. And so now we're starting to see data sets that are, for instance, one company calls it an electronic life record. And that's capturing what matters to the individual, what to them gives them a sense of purpose, belonging, connection. And that enables you to, for instance, think totally differently about things like engagement programs. Again, rather than having one size fits all, it's only with using this kind of data that you can personalize and customize programs without having to have a hundred staff members do engagement programs for a hundred residents.

Beth Mace (29:40):
So as you're getting more specialized in medicine or in the engagement, is that going to be cost effective or is that going to raise the overall cost in the bigger overarching theme?

Bob Kramer (29:50):
Well, great question that leads to our last driver from which I call from siloed to seamless. Right now in our highly specialized silo driven healthcare system, we basically have experts in each silo. And what happens is, with these silos, three things happen. First of all for the individual, their journey is a series of silos with nobody there to help them in between. And the gaps in the silos. And the more specializations means rather there being four silos, now there's eight and in the gaps, A, the individual gets lost. Absolutely. B, their data gets lost. C providers who really care about the resident or patient get frustrated because they're just seeing this person bounce back and not get better. And if they actually have a relationship with the patient and care about them, it's unbelievably frustrating. And so from silo to seamless is this move that is just starting to happen.

Bob Kramer (31:00):
But where we think about, first of all, the customer experience, and again, this is part of consumerism. Again, I spent a lot of time looking at retail and because retail is so much further along. Hospitality, just think of all the different brands, for the different niches. That's in our future, but we're not there yet because we don't have the data and wee haven't known how to use it. Basically this means you're going to have a seamless experience for the customer. Their data will flow seamlessly. And most importantly, even if there are different providers, they're going to be looking at the same set of data. And it's not just health outcomes. The most important question to every older adult, particularly in our industry, where many folks other than entrance via CRCs, they're moving in for what is usually the last three to five years of their lives.

Bob Kramer (32:08):
So the most important question is, what matters to you? What experiences do you want to have in the next three to five years? What would signify a sense of joy or accomplishment or just something that would be really rewarding to you in these remaining years of our lives? And those are actually the questions we need to be capturing the answers to. And it's only then with machine learning and artificial intelligence, as I said, to ask those questions. Now, without algorithms, machine learning and AI, we'd have to have these huge engagement staffs and it would never happen. It's too expensive, except for the super wealthy. So this moving from siloed to seamless is firstly for the experience of the customer, the consumer. Secondly is their data. Thirdly is all the people that engage with them, which includes the family caregivers who get incredibly burned out and frustrated.

Beth Mace (33:08):
That's for sure. All right. So the six drive was just to review them again, would be the COVID-19 pandemic, the staffing crisis, the new customer, and sort of the merger of that with the longevity that we're seeing in aging, a reframing of health and health care, the increasing importance of data analytics, and then moving from siloed to seamless. So that's, so I know, I just want to let our listeners know that they're interested in hearing more on this. We have a series of blogs written by Bob on the NIC Notes blog that I think the first four are up right now, and you can go and listen to them further. So, Bob, now that you've been thinking about this for a long time have these six drivers at all sort of affected your own personal view, and we're all getting older? So has this affected your view on aging and lifestyle.

Bob Kramer (33:55):
Absolutely. In two ways. First of all, my wife and I have both just turned 73. And so we're thinking for us, every time I go look at a community or hear about a new idea or a new trend, I put it through the filter of what would appeal to us. And I'd be lying if I didn't say, I'm not doing that and we're planners. You know, thinking about, well, if something happened to one of us, what would we do if we lost mobility, got a diagnosis of Alzheimer's or something like that. But also thinking about right now with our lifestyle, what would we want? But the second thing I would say, the way it's impacted me is I hadn't realized the extent that ageism influences all aspects of our society. And as I alluded to earlier, what I've realized is my efforts in that area, many of them through what I'm doing at Nexus Insights are ultimately for my grandchildren because they have the most at stake. It's too late to be blunt, to change societal attitudes about retirement and old people for me and for my wife. But knowing that my grandchildren have a very high likelihood of living to a hundred or beyond, I don't want them to spend a third of their life consigned to cultural, economic, and social irrelevancy because they're over the hill, they've lost utility. That's my passion and motivation for teaching in universities. I really want to reach Gen Z and work with Millennials around this issue. So those are two key ways in which it's really very much impacted me.

Beth Mace (35:47):
That's great. All right. So I only have a few minutes left here, and I always love your stories. I've known you a long time and every time I'm with you, you tell me something else I just love hearing about. So see if you can find one you haven't told me yet about, about your life that you'd like to share with our audience about a life lesson or fantastic experience you've had.

Bob Kramer (36:07):
Well, I guess I would say, and I'll apply this in a second, I would say it's read wisely, read deeply. And I say that in a time when there's not a lot of reading going on. Sure. The internet... Short takes on everything so forth. But my reason for saying this is this, I feel, again, as I think I have shared with you, my father had an enormous influence on me. But one of the things he taught me by pushing back every time I would... I've never been into a loss for words or opinions. I know that'll be a shock to all the listeners. Starting, literally when I was 10 or 11 years old, I would expressed an opinion. My father would always take the other side. And what he taught me by this was that in essence, if you don't understand other points of view to your own and you don't understand the reasoning behind them and why people hold them, then to be blunt, you're not wise, you're not educated, and frankly you're not informed on the issue.

Bob Kramer (37:15):
And that was made an indelible impact upon me. And then when I kind of think about right now, I guess I'm going to close with something I just heard in a podcast that I listened to and the statement was made and it was from someone that I view as a leader, but he made the comment, he said, As a leader, if you're not managing change, you are just presiding not leading. And I thought, wow, in this disruptive moment that we're in as a society in terms of democracy, so many things also in terms of senior living with all the changes that we've just been talking about. And you know, I thought that was incredibly insightful. As a leader, if you're not managing change, change is a reality because if you're not managing change, all you're doing is presiding over something you think is the greatest thing since slice bread, nobody can move us off our pedestal. And we all know many examples in business and in life where that's proven. Once you have that perspective, you're usually at risk of being disrupted right out of business. And so I thought this was a great quote to close with. We're in a time of change. And so leaders have got to manage change. And going back to the Kissinger quote, that means managing the crisis. It was COVID, now it's workforce, but while building the future and what does that look like? So that's what we've been talking about.

Beth Mace (38:56):
That's great. So at the beginning I mentioned that I'm hoping that you walk away with an "aha moment" here from something that Bob said and certainly one that I'm going to walk away with is I'm going to go home and have an argue with my husband tonight, and we'll take two sides so you can see both side points of view. So that's really helpful. So thanks so much and as I said, you can hear more about the drivers. Go to the nic.org. Look at the NIC Notes blog series. Thank you Bob, as always.

Bob Kramer (39:23):
Thanks Beth. Great to be with you.