Thomas R. Rice - Senior Vice President of Investor Relations
Kelvin A. Baggett - Chief Medical Officer and Senior Vice President
Joshua R. Raskin - Barclays Capital, Research Division
Tenet Healthcare Corporation (THC) Clinical Operations Webcast December 10, 2012 3:30 PM ET
Good day, ladies and gentlemen, and welcome to the Tenet Investor Webinar Clinical Operations Conference Call. I would now like to turn the conference over to your host for today, Mr. Thomas Rice, Senior VP, Investor Relations. Please proceed.
Thomas R. Rice
Thank you, operator. Good afternoon, everyone, and welcome to the seventh in Tenet's 2012 webinar series. As the operator mentioned, today's webinar will focus on clinical operations. Our speaker is Dr. Kelvin Baggett, Senior Vice President, Clinical Operation and Tenet's Chief Medical Officer. Dr. Baggett is responsible for the efforts to improve clinical outcomes and the efficiency associated with achieving those outcomes in all Tenet inpatient and outpatient settings. Dr. Baggett reports directly to Trevor Fetter, Tenet's President and CEO.
Dr. Baggett completed his training in internal medicine at Yale Medical School and completed dual scholarships as a general internal medical fellow at Duke Medical school and as a Robert Wood Johnson Clinical Scholar at the Johns Hopkins University School of Medicine. His fellowship work focused on improving the quality, safety and efficiency of medical care.
To the extent that there are forward-looking statements made on this call, those statements are subject to the cautionary statements included in our SEC filings.
Dr. Baggett, the floor is yours.
Kelvin A. Baggett
Thank you, Tom, and good afternoon. The presentation should be seen in a PDF format. So what I will do is make reference to the slide number occasionally, just to keep us on track. But of course, that means I will not be advancing any slides.
Just to give an overview, today, we'll talk about some of the things that are going on in the macro environment of health care and how it's impacting and influencing some of the things that we're focused on here from a clinical operational perspective. We'll talk about our internal focus and part of that is our strategy, which you've heard in many other calls similar to this. And we'll go back and revisit Tenet's position on clinical quality and the way that it really formalize that, and we worked to formalize that in 2003 with our Commitment to Quality, and talk about how we've continued to advance that commitment and the associated results.
Next, we'll move to our clinical quality agenda 2.0 and compare and contrast a little bit the difference between the way that we worked and viewed it in 2003 as compared to the way that we're working on and doing it today. Well, of course, in each of those highlight the results that we've been able to achieve, and then talk a little bit about what's on the horizon and how we're continuing to demonstrate leadership in those areas as well.
So as we all know, the environment of health care is changing, and what we're hearing a lot about and what we're talking a lot about here at Tenet is value. And as we progress through this, I'll get to a slide that specifically defines value for us and how we think about it, how we create strategies around it and how we work to improve it. But what we do know is that both from a commercial payer perspective with value-based insurance design, federal payers such as Medicare and their value-based purchasing initiative that this is continuing to be at the forefront of the changing reimbursement model and also incorporate some of that increased risk sharing that also has been introduced into the marketplace.
The second trend that we continue to see more of and hear more about is safety and the actions that can be reasonably taken to present potential harm to patients while they are under a hospital care or under care in any other clinical environment. And there are a lot of emerging external reporting of that, be it at the state level or be it with other organizations, public and private, to create increased transparency, awareness and action around that. And we're doing a lot of work in that area, and we're achieving a lot of results. Obviously, like every other institution, our goal on each day is to continue to improve, and safety is one of those areas where we continue to focus and strive for greater improvement as well.
The third piece is around the alignment of providers of care and the clinical settings in which that care is being provided. And so we're seeing this, if you look at some of the bundling things that are taking place, those initiatives from Medicare and others, if you'll look at accountable care organizations both in the federal payer domain as well as in the public payer domain, there is that shared risk in the management of populations as well.
On Slide #6, we've highlighted 6 key elements of the Tenet strategy. And I've checked 3, and those 3 are most closely related to the work that we do day-in and day-out in clinical operations. We are committed to helping to differentiate our hospitals and other clinical care environments based on superior quality and service, and we're also committed to driving and providing greater value to our customers. Secondly, we are seeking to align with our physicians across our facilities to improve quality and efficiency, which gets to increasing that value proposition as well.
Third component of our strategy is to drive efficiency and cost effectiveness through our Medicare performance initiative. And that is an area where clinical operations works very closely with our leaders and MPI to look at care variability, to actually identify opportunities, to actually reduce and eliminate that variability, recognizing that it does not create improvements in the quality of care and in some scenarios, it actually may increase the potential for harm. And then the other 3 are unchecked because while we help to support those things, those aren't things that from a clinical operations perspective that we are involved in on a day-in and day-out basis. Those are, as you know, acquiring acute care hospitals to strengthen the portfolio, growing Conifer Health Solutions and growing our outpatient footprint to create a greater representation of services along that care continuum.
On Slide #7, we outlined some of the key aspects of our initial activities to improve quality through our commitment to quality. This was something that was established preceding my joining Tenet in late 2009. So Tenet started on the commitment to quality in 2003. And if you'll go back and think through what was going on at that time, while there was a recognition through some of the Institution of Medicine reports and others that there was care variability, that there was an opportunity to improve the quality and safety of care, this was still not at the forefront of discussions. And at that time, Tenet recognized, leaders here, colleagues across the company, recognized that there was both a need to do it, and that there were certain things coming into the public domain that would help us to really look at quality in a different way. And one of those was what was taking place in terms of CMS and the joint commission and core measures performance.
So Tenet looked very closely at those processes of care, looking at the 4 areas that were being covered in that: surgical care improvement; pneumonia; heart failure care; and care for patients who had received heart attacks, and began to design tools and tactics and construct processes to increase the performance against those evidence-based metrics. And what you'll see when we get to the next slide is how that helped to elevate the care in those areas for us and also how it helped to advance the care in those areas for the rest of the nation as well.
The second component of our commitment to quality starting in 2003 was around getting external recognition primarily through commercial payers' designations for centers of excellence: those elements of care, those processes of care, those settings of care that had really distinguished themselves based upon what they were able to provide in terms of overall quality as well as the associated patient outcomes.
And third was our commitment to measuring patient and physician satisfaction. At that time, you didn't have the external benchmarking that we have today with the hospital-consumer assessment of health care providers and systems. What you did have was an internal commitment to assess it and also to be able to get comments around that to identify opportunities for improvement and then to go forward and to address those as well.
So as I've said, when we committed in 2003 to core measures improvement, it was still at a very nascent stage. The graph on Slide 8 shows how we have progressed over the last 8 years. So as you can see, starting the beginning of 2005, we had around 80% compliance to those evidence-based standards that are part of core measures. If you look at where we're performing as of the first quarter of this year, we are at 98.5%. So 98.5% of the time, patients are receiving evidence-based care that is congruent with the core measures, processes of care.
What you will also see is that since 2005, we have been above the national average of performance. As of today, we are 100 basis points above the national average for care in this area. We continue to work very diligently, refining the processes we have so that we can make improvements in this area as well as gaining ground in some of the things that I'm going to talk to you -- talk with you about for our Commitment to Quality 2.0 agenda.
On Slide #9, as I mentioned, we have set as an expectation that we will continue to demonstrate leadership, differentiate ourselves on superior quality and service. And this demonstrates how managed care payers in the commercial realm have also recognized that, awarding us over 300 designations in these clinical care areas, including bariatrics, cardiac care, orthopedic surgery and stroke care. And as we look to this increasing value-based design, what we're also expecting is that more payers will begin to narrow the options and begin to help to influence beneficiary to go to those settings where there has been recognized superior differentiation on these areas of care and others. Therefore, we continue to not only look at these, but also as we look at our own data, to seek opportunities where we can continue to establish and demonstrate that leadership recognizing that in the future, this will account more than it even does today.
Slide 10. We sought to lay out how we think about our quality agenda 2.0, and as you can see from the very title, it is very focused on outcomes. When we, like our peers, started on this work in the very early 2000, we had structural components to evaluate: do you have technology; do you have certain mix in your hospitals, and some of those things. We had some process measures to evaluate, which we highlighted here in the core measures, process measures that we just spoke about. But what we didn't have was a way to really look at and evaluate outcomes. While that is still growing, what we are in an environment now is where there is a greater discussion around outcomes, and there's an expectation that we have insight to outcomes, especially in certain key areas such as heart attacks, heart failure and pneumonia, and the associated outcomes there are primarily 30-day mortality.
We refresh the commitment, and so we started with safety being our foundation. And so we focused on how do we reduce health care-associated infections, how do we reduce potential harm events, and then how beyond that do we look at the evidence generated externally. But also because we have a system, we are geographically dispersed, we treat a large volume of patients, we're able to generate internal evidence and also look at best practices and what we call next or leading practices, things that we believe that have not surfaced publicly yet that will help us to both improve the care in that setting but also are replicable to other environments in which we're delivering care to similar populations.
The third component is really around standards and standardizations. We talk a lot about clinical care variability and variability in waste, where it's redundancy that is not creating additional value for our patients and for our customers, and then how do we work with various resources around the company. And in this area, one of the ones that cyclical operations works most closely with is our Medicare performance initiatives to look at our DRGs, to look across our population, to identify conditions where we have high volumes. And we recognize there's an opportunity to either address a supply, another utilization pattern, or some other components of the care that add no value and can present additional cost and potential harm or complication and then drive that out.
We also are working externally to harmonize metrics. And so to try to promote alignment so there is less confusion to the consumer regarding what really defines quality in a certain area and what should define a safe environment to improve care as well to be a part of that national dialogue so that we can reach a level of consensus that causes us all to be aware of it, to communicate more effectively with the consumer base and also to be able to then focus on driving improvements in those areas, moving past the point of debate around what that metric should be.
The third component for the new quality agenda is really partnering with the business leaders within the company as well and identifying things that can help us in our managed care negotiations, can help us in our discussions with large employers to be able to articulate what we're doing, the kind of results that we're achieving and how that would be a benefit to them as well.
Slide 11 lays out how we talk about value. When we discuss value, we talk about it in terms of outcomes achieved and then for the denominator, it's the cost to deliver those outcomes. And so the focus is either on delivering better outcomes at a same or reduced costs or continuing to deliver the same outcomes in those areas where we have superior performance while also driving that cost down.
If you move -- if you look at the bottom of the slide, we lay out clearly some of the things that we put in terms of outcomes. Safety, we're first committed to reducing harm in the organization. Care variability, making sure that its evidence-based and scientifically sound. Service, and we talk about service in terms of person-centered care: how do we make sure that every person's individual needs and their wishes are expressed, that they are communicated with, with dignity and respect, and that they have the engagement and involvement of their patients and their families as they wish that to be.
In the denominator, when we talk about cost, we want to make sure that it's the right care being delivered in the right environment in the right way. We talk about the resources that are being consumed and how we can more judiciously or appropriately manage those resources to achieve that outcome. We are, of course, have been and continue to do work in cycle times in our throughput and our turnaround times. And of course, our continued efforts to drive down the malpractice claims that are associated with care, and we continue to demonstrate the leadership that we have in terms of our overall compliance.
Slide 12 is intended to articulate the 4 components that we really lay out when we're putting work together and defining where things should fall. First, we start with what is our purpose from a clinical operation perspective. We want Tenet to be the safest, highest quality, most efficient provider of health care services, and then we go to the 4 components. We want to be the safest provider of care. We want to continue to reduce and eliminate clinical variability, especially in those areas where it then results in the same or improved quality of care.
We want to be a leader provider of service to our patients, to our communities, to our physicians and to our partners and our employees and colleagues across the country. We also then want to focus on driving operational efficiency and this is, again, is an area where we work most closely with our Medicare Performance Initiatives, how do we improve throughput, how do we look at supply utilization, create standardization across the various formularies. We're hearing a lot now around imaging and imaging efficiency. So how do we do that? How do we make sure that the clinical workflow is also appropriate?
I'll go back to each of the columns to the left just quickly. In safety, we're continuing to focus on eliminating our never events. We've had efforts to reduce patient falls, which have been successful, and I'll go to some of the numbers there in terms of the results we've been able to achieve. Over the last 2 years, we worked with our colleagues across the company to make sure that we're appropriately using blood products for those patients in our hospital settings. And we've been able to continue to drive this down and meet savings goals and targets for that, exceeding well over $14 million over the just the last 1.5 years in savings there. Preventable readmissions. Obviously, there's a lot of discussion on the national level regarding readmissions and where readmissions are excessive or where they could have potentially been unavoidable. And so we've had efforts that I'll give you some more color around momentarily to really address that in a very methodical, systematic way that we believe is sustainable as well.
Clinical variability. We are looking at how we manage populations who are ventilated in our intensive care units, both getting them on, managing that vent appropriately, and then having weaning protocols to actually remove them from the vent appropriately as well. We continue to work on core measures, as I've mentioned, and that's expanding. And we demonstrated the leadership that I mentioned earlier there. Our perinatal care and what we're doing in terms of the elective deliveries prior to 39 weeks that are not clinically indicated, we've been driving this in efforts that preceded my joining and more intensely over the last 1.5 years.
And then service, both in providing the service as well as recruiting and retaining star performance to the team, recognizing that we have a need to attract them, to then make them a part of the team and to continue to educate and develop them as well.
Slide 13 speaks to the ways that we lay out how we work in the system to increase the overall value: the appropriate reporting of publicly required data, and there's a lot in the public domain, as you know, and that's continued to grow; participating in external registries, such as the National Cardiovascular Database Registry. Really looking closely at our data, and we are, as you would expect, a data-intense organization, using that data to inform decision-making, to inform our actions and really integrating data that's clinical, operational and financial so that we can see what taken action in a critical area might do financially and also taking an action clinically, what we might need to do or just operationally to make it sustainable.
We are advocates of best practice sharing and have mechanisms to both identify through our data, to identify through other forms that we have, people who are demonstrating best and leading practices within Tenet and then to be able to quickly bring that into a system and structure that allows us to capture it, to have conversations with them, to figure out exactly what is working. Sometimes there are things that are hidden, that are not as well known, to drill down on that, to be able to package it in a way that is easily understandable and digestible and then to disseminate it quickly, which, again, is another benefit of the system that we have and the scale and scope of our services.
Also looking at establishing internal collaboratives. We do this. We continue to expand upon this. We do high-performer calls, high-performer webinars, where we're bringing those people who are demonstrating great work within the system, bringing those leaders in. They're sharing that with their colleagues so that they can get a direct understanding of it and work across to do it.
Also, we do internal collaboratives around problems. And so if we have a problem at an academic medical center, to bring another academic medical centers so they can talk about some of the things that may be unique to their environments and then can work towards solutions together, would be one example of that. And of course, we continue to have strong subject matter experts, performance improvement experts, clinical experts to make sure that the things that we're putting in place are sustainable so that then that allows us to focus on other things and continue to make progress.
In Slide #14, we lay out one of the things that we do to improve our overall safety in the care that we provide. And what you'll see is that when an event happens within Tenet, it is reported to us. We have an electronic system where the facility leaders will enter in that information. We quickly work with the patient safety and clinical risk teams here to determine if that is something that might be a risk elsewhere. So while we are solving a problem in one setting, we're also quickly putting together some things to communicate if it is a problem elsewhere, and to put together solutions that we believe will be effective to prevent it from happening elsewhere.
We have news flashes that we put out, that are one-pagers. If we hear about something, then that allows us to pull information together quickly to alert our colleagues, send it out so they can see it, take action around that. And we also have more in-depth patient safety communications that we'll send out as additional information services as well. That really helps us to make sure that if it happens in one environment, that we're doing everything that we can to reduce the likelihood that it will happen in another.
Slide 15 is a communication around how we work effectively across the organization in response to the New England Compounding Center meningitis outbreak that occurred earlier this year. What you'll see is we have a photo of some members of the team. We came together in an Incident Command Center structure. We had experts from risk, from our business continuity team and our disaster preparedness team. We had patient safety and clinical experts. We had nursing experts. A lot of people came into the room representing various stakeholders, so that we could immediately determine where we had some potential exposure and then work through how we help to manage and address the issue.
As you know, about 29 people died as a result of that. Multiple hospitals and states were impacted by it. And what we were able to do was to identify environments where we might have some products. We were fortunate where we didn't have any steroids that had been provided to us that were associated with the outbreak. But we did have, like our other peers, we did have some products from them. We immediately sequestered them ahead of the FDA's notification to do so, days before that occurred. We worked with our supplier to -- our GPO to work with our suppliers to help us to identify other contracts for sourcing.
And to put that in motion, we established a call center, working with Conifer Health Solutions to provide a line for patients who had potential symptoms to call in, to get a response, and then to be instructed as to whether they needed to go and to also inform us if they felt they needed to go and receive some follow-up care and evaluation as well. We had ongoing lines of communication with the FDA.
And so this was another area where it was quickly convening the appropriate members of the team in various parts of the organization to respond to and address what was a concerning issue with a potential rate of mortality for patients in a way that was very well constructed, that was executed in a manner that helped us to reduce the chaos or confusion, to clearly communicate with those patients who had trusted us with their care regarding any potential concerns they might have, and also to set up the appropriate procedures within each of our hospitals for those patients who would be presenting and returning to one of our hospitals.
As I mentioned before, we've made progress in our safety efforts, and Slide #16 shows some of the areas where we have continued to make those advancements. We've reduced ventilator-associated pneumonias in the last year by 46%; retained foreign objects by 57%; catheter-associated urinary tract infections by 31%; our catheter-associated bloodstream infection by 64%; our pressure ulcer stage III and IV, which are never events, by 36%; and our falls with injury by 41%.
And if you're wondering, we said we talk about things in terms of really how do we do the right thing while also reducing cost of care and improving the overall quality. If you're wondering what these improvements have contributed to our overall financial performance, if you look at something, with falls with injury, each fall that we avoid saves us about $12,000. And if you'll -- in some of these other areas, they can be as high as $40,000 to $44,000 for a patient if we're able to avoid that occurring while they're under our care.
Slide 17, we lay out the actions that we took beginning in 2009 to address the prevention of avoidable readmissions. As you know, the Center for Medicare and Medicaid Services instituted a Readmission Reduction Program starting in October of this year. The maximum penalty for this year was 1% of total base operating DRG. And it focused on the excess of readmissions for 3 conditions: heart attacks, heart failure and pneumonia. We only had 2 of our hospitals that received a maximum penalty of 1%. Most of our hospitals were somewhere on average in around the 23% to 29% penalty range -- I'm sorry, in the -- not the 23% to 29%, but they were at 0.23% or 0.29% penalty range. So a minimum penalty there.
We attribute that to the work that we did earlier on, bringing together a task force to work on it that included our hospital teams and others who are engaged in providing the care, working with those vendors who could provide us some predictive tools so that we could look at those patients who were most at risk for being readmissions, readmitted, and to take specific action in terms of managing their care, managing their discharge and follow-up process to make sure that those things that we believe and the literature supports are most likely to increase a readmission have been addressed prior to the time of discharge. And as we look going forward at hospital-wide, unplanned readmissions expanding to other conditions, we have a framework that already helps us to identify some of the things that we've done well, to refine those for those populations in addition to looking at how those patient populations are being managed.
Slide 18 talks to our Health Care Information Technology efforts and what we've been able to do with IMPACT, our program around improving patient care through technology. We have, as of today, completed the rollout of our IMPACT core clinical systems at most of our hospitals and have advanced CPOE in over 26 of our hospitals. We will add 14 additional hospitals before the end of the year. This has already helped us in the things we've introduced in terms of bar-coded medication administration, CPOE, clinical documentation and clinical decision support to reduce duplicate ordering of tests that will come at a cost to us, a duplicate radiology test to reduce our medication administration events by over $100,000. And also, to reduce the potential for adverse drug events, we've identified over 2,000 situations where a patient may have received a medication without these systems that would have been contraindicated and might have posed an additional risk to them. So this is a core enabling technology as we look at how we both understand and continue to refine the clinical delivery of care.
On Slide 19, we just laid out 3 of the areas that are new measures that are coming, just to show again where we're taking on leadership roles to address these for the patient population and also how that will be beneficial to our overall performance going forward.
Stroke. We had an academic medical center, Saint Louis University Hospital, created and leads the MidAmerica Stroke Network, which includes over 45 regional hospitals. We have 90% of our hospitals are participating in the American Heart Association Get With the Guidelines program for venous thromboembolism, which impacts about 1 million people a year, with about 30% of those being fatal. We also recognize that it's the second most common cause of excess length of stay due to complications after surgery. So we've been working on that.
And as you can see, we created a bundle, which has best demonstrated practices, and we have 96% compliance today with those policies and practices. And of course, like all things, are continuing to sustain it at those hospitals where it's being done well consistently; and in those environments where it needs to be improved, we have teams that are working with them to identify some of the unique circumstances or scenarios that may be impacting their inability to adhere to it as consistently as some others.
As I mentioned, we've had success in our efforts to reduce excess of readmissions for heart attack, heart failure and pneumonia. And we've also been working over the last year to look at other areas, some that were introduced by CMS hospital wide, unplanned readmission, total knee and total hip. And so that data has been publicly reported. We are looking at the process we've had in place for the other readmissions and how they apply. We're incorporating things such as the venous thromboembolism management, DVT prevention, so that we can also continue to make sure that they don't develop those complications. And working with our post acute care partners to ensure that the things that are supposed to be done for them, once they are discharged from our environment, are being done and completed as well.
Well, with that, we will move on to questions and answers. Tom?
Thomas R. Rice
Thank you, Dr. Baggett. Operator, could you assemble the queue for the question-and-answer portion of the call?
[Operator Instructions] Your first question comes from the line of Josh Raskin with Barclays.
Joshua R. Raskin - Barclays Capital, Research Division
Dr. Baggett, I guess a couple of quick questions for you. One, I was wondering, are there any specific set of payers that you think are more focused on what you're calling value-based reimbursement? Is it more in the Medicare advantaged side, or is it more on the commercial side? It's the first question. And then is there anything they're doing that shows you definitive proof that they're moving volumes, that these payers are actually moving volumes to what they're considering to be their high-value providers?
Kelvin A. Baggett
Thank you for the question, Josh. So I am actually working with Clint Hailey in our -- who is our Chief Managed Care Officer, around this area. And so in my experience, what I've seen is the commercial payers are the ones who are looking at ways to incorporate value-based purchasing. As you know, they started initially along the pay-for-performance realm. And now they are looking at specific areas where they believe there's an opportunity to drive a cost reduction and to also meet their quality objectives. In terms of volume being directed, let's say that I'm seeing less of it than I expected at this point. But as I mentioned earlier, I think that it's going to pick up. We're seeing providers introduce these narrow networks, and they're using that as a tool to really look at those who have that efficiency component as well as that quality component as well. If you look at some of the things they've already done in terms of some of the surgical procedures and the ways that they're actually trying to bring that into the realm, if you look at what CMS did earlier on with bariatric care and the managed care providers and their requirements for having designations to do that, we just anticipate that in efforts to continue to reduce the overall cost of care while also preserving the element of the quality of care that more people are going to use this as a measuring stick. And some of the conversations, and I won't mention those specific managed care providers, but in some of the conversations that I've had over the last few months, I've heard them clearly articulate that, that is a strategy that they want to do more of, and the question will be in what areas and what pace.
Joshua R. Raskin - Barclays Capital, Research Division
Got you. So that's helpful. And then I guess the other question is just around CMS measurement, and I know you mentioned there's only 2 hospitals that are getting the full 1%. But I guess from your perspective, do you think CMS is actually measuring quality correctly? Do you think they're looking at the right metrics? Or are you guys talking to them in terms of, "Here is what we think is a better set of value-creating or quality metrics that we think are more important"?
Kelvin A. Baggett
I think that if you look at the effort, one is to put some metrics out there that have been in the public domain. In these cases, typically for at least 1 year to actually create some transparency around it and some associated accountability. I think that that's a commitment they've had and that they continue to promote. Obviously, to then say that performance in those areas alone is indicative of everything that you do in your environment would be the wrong position to take. But we do believe that the things that they've introduced in terms of surgical care, heart attack, heart failure, pneumonia, are areas that have a strong basis that are supported by societies, that have been supported by the National Quality Forum as well. And therefore, they have a basis, but we also want to make sure that both them and our other payers are aware that there are other things that should determine quality, and they should also be put into the appropriate context. And we should be both evaluated and rewarded for performing well in those areas, too.
[Operator Instructions] I will now turn the call back over to Mr. Thomas Rice.
Thomas R. Rice
Thank you, operator, and thank you, everyone. Since we have no more questions, we'll conclude today's program. We do have additional webinars planned for 2013, and we'll be announcing those dates and topics shortly. Thanks, again, for joining us.
Ladies and gentlemen, that concludes today's conference. Thank you for your participation. You may now disconnect. Have a great day.
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