Bonus Episode: This Policy Would Have a Catastrophic Impact on Alzheimer’s Disease Research

Show Notes

In this special bonus episode, Alliance President and CEO Sue Peschin discusses how implementing international reference pricing in the U.S. would decimate the clinical development of therapies for Alzheimer’s disease and related dementias with Vital Transformation’s Managing Director Duane Schulthess.

Episode Transcript

Sue Peschin:

Hello everyone, and welcome to This Is Growing Old, a podcast from the Alliance For Aging Research. My name is Sue Peschin, and I’m the President and CEO of the Alliance for Aging Research.

Sue Peschin:

International reference pricing proposals currently under consideration by the US Congress and proposed in the previous Congress under Title 1 of HR 3 would allow the federal government use of foreign price controls, in direct negotiations with pharmaceutical companies, for the cost of 250 prescription medications in Medicare Part B and Part D. It also extended the negotiated price to insurers and the commercial market at large, so for those under 65.

Sue Peschin:

Given the risks of investing in medical breakthroughs for neurological conditions, companies need successful products to underwrite and subsidize the investment into new areas of research. So a new analysis by our organizations, Vital Transformation and the Alliance for Aging Research, shows that implementing international reference pricing in the US would decimate clinical development of therapies for Alzheimer’s disease and related dementias, and drastically reduce the revenue that helps support this critical research.

Sue Peschin:

So here with me to discuss this analysis is the author, Vital Transformations managing director, Duane Schulthess. Duane, thank you so much for joining us today.

Duane Schulthess:

It’s a pleasure, Sue, thank you much for the opportunity.

Sue Peschin:

So Duane, tell us what international reference pricing is and what your previous research on this policy found.

Duane Schulthess:

Well, that’s a big subject. So the international reference pricing proposal that came out, it was initially rolled out by Secretary Azar, of the former administration, the Trump administration. He’d mentioned it at a presentation he gave at the Brookings Institute. And the idea was, the US, as we know, pays way more than other countries for our drugs, and this is becoming a political issue. So the idea was that for the government run programs, Medicare Part D and B, in particular, and Secretary Azar and Trump were specifically looking at Part B at the time. We were going to base our U.S. Pricing off the prices that were done and off a basket of countries, sort of an average weighted price of all the other countries that buy our drugs and get our drugs internationally. And that would become an international average that we would only pay that price, no higher, in the United States.

Duane Schulthess:

So that’s basically how international reference pricing worked. And then, with the initial rollout of Medicare Part B, you had sort of this race to the bottom, where then, basically, you had the US Congress saying, “Hey, we can do more than that. And so then we’ll do 150 drugs, and we’ll do 250 drugs.” And so you’ve had this sort of acceleration of everybody racing to the bottom to try and bring in more drugs to bring to the reference as it is. And more of drugs to reference price, and the basket gotten bigger and bigger. It’s more like a steamer trunk now, I wouldn’t really call it a basket. It’s basically everything we got, and then some.

Duane Schulthess:

And the current bill, just a one thing about the bill, I think a lot of people… it’s somewhat tortuously written, the HR 3 bill that’s currently floating around the halls of Congress. Well, what’s intriguing about the bill, if you read it, and it is quite tortured, the language, you have to really sort through it, but it doesn’t just limit itself to Medicare. It does say any other drugs. So it’s, basically, 125 Medicare part D, and then 125 catch as catch can, whatever you want. So that could be some of the most innovative drugs like our CAR T drugs or our CRISPR or any sort of procedure, and it’s really not defined.

Duane Schulthess:

So essentially in a nutshell, then that’s sort of a long winded description of what’s been going on politically, but the basic idea is we will base our price on the price of drugs and the average price of drugs in these other markets that would then be rolled out in the United States.

Sue Peschin:

Yeah, so it sounds really attractive, I think, from a consumer perspective that other countries are paying a lot less than we pay in the United States. Why is that? It does sort of feel like we’re shouldering this big burden. Can you talk a little bit about the dynamic there?

Duane Schulthess:

From a red meat, political perspective, it’s brilliant. It really is brilliant. It’s a classic political move. It’s a very short couple, two or three bullet points. And it’s like, yeah, and it gets everyone upset, and foaming at the mouth and jumping up and down and threatening to eat worms. And I get it. I totally get it. But there’s a huge amount of economic reality behind this that’s come out from decades and decades of US policy versus European policy.

Duane Schulthess:

Again, this idea that it’s “free” healthcare. I always love this idea that its healthcare is free. The reality is there is no free healthcare. And even in Europe, yes, they control and they really ration healthcare and they control pricing and they limit who gets it. And that’s how Europe has a different pricing structure. It’s because it’s a different approach.

Duane Schulthess:

Whereas in the US, we made a decision, decades ago, particularly around the Medicare Reform bill of 2003. The US government was going to subsidize new, innovative, personalized, and more stratified, and orphan drugs and things like that. As a society, we were going to focus on those things. And we were going to put in a subsidy from the federal government around the Medicare and Medicaid programs to facilitate the development of those drugs.

Duane Schulthess:

That’s not happened in Europe. In fact, what you’ve seen is an enormous transfer of the pharmaceutical industry, which was 60, 70% European in the 1980s to, now, it’s 60, 70% American. I mean, these are the economic realities, so I can understand why it great on paper, and I think from a frothing political melting brew that we have right now, that’s really quite aggressive. I think it just makes a lot of sense, politically, to position yourself against your opponents, but it’s really quite destructive.

Sue Peschin:

So in reality, what is going to end up happening? If you talk about the broader analysis that you did, and then more specifically about the one that you did for us on Alzheimer’s disease, what’s the effect of all of this? If you put this in place and say, “Okay, now, we’re going to average the price at all these countries that pay a lot less, and bring that here to the United States.” According to the congressional budget office, everything’s going to go smoothly. We’re going to save a ton of money in the Medicare program. What does your research find is actually going to happen?

Duane Schulthess:

Not that. It will not go smoothly. Essentially, here’s the situation, what we’ve had internationally is an enormous transfer of innovative capacity from Europe to the United States. And if you look at it from a real nuts and bolts perspective, we did a huge deep dive on how innovation is actually done. Now, 30 years ago, 40 years ago, you had these huge, big, huge monstrous buildings that would sit in the suburbs of outside Philadelphia and outside London, England, Sandwich, England. Pfizer had this gigantic thing that you could see from space, and all of the R&D was done internally, like GE making the light bulbs. Everything was done internally.

Duane Schulthess:

And what you’ve had now is a huge shift in the way innovation is done. And this goes to the heart of research that was done by professor Henry Chesbrough at University of Berkeley, formerly of Harvard, and it’s called open innovation. And essentially, what it is, is you can try and do everything yourself, but the fact is, the ecosystem is so much larger… And this goes to perfect market theory, and a lot of things that came out of University of Chicago, the fact is, not every one person has all of the knowledge that’s currently available. And you can have a 100 really, really smart people in a room, but that’s not going to equal the intelligence that’s out there with tens and hundreds of thousands of people working in the sector, globally.

Duane Schulthess:

So the idea is you can actually diversify your research dollars by doing external partnerships with universities or with small biotechs or emerging technologies. And you can cast a much wider net, that’s far more efficient, much lower cost to you, and then you can develop these things in partnership. And that’s really how the system has worked.

Duane Schulthess:

And what you find when you look at how these partnership agreements have evolved, particularly over the last two decades over the last 20 years, and in particular, since the passing of the Medicare Reform bill of 2003, what you see is, for example, over the last 10 years, if you just look at the companies who are going to be impacted by HR 3, this bill reference pricing, the 37 companies who would be touched by this, the regulation that would actually hit their portfolio of products, what you find is if you look at the amount of activity they’ve done in open innovation, they’ve made 250 investments globally, into small emerging biotech companies with new breakthrough technologies. And a lot of the stuff that we have now has come from, if you look at the Hepatitis C drugs that came from Pharmasset, which was a New Jersey biotech company that was acquired by Gilead, that’s just one example of how this has worked.

Duane Schulthess:

There have been over 250 partnerships that have been signed over the last 10 years for about $450 billion, half a trillion dollars, 80%, 85% of that is US-based. So the vast majority of these deals are being cut in the United States. And this doesn’t mean that it’s just American companies, either Roche, GSK, GlaxoSmithKline, AstraZeneca, they’re all cutting these deals in the US too. So they’re coming here and they’re working with US innovation. That’s inward direct investment, foreign direct investment, FDI, that’s really good for the economy. We want that. That’s what the US needs. That’s that helps us be more innovative and more competitive. And you’ve seen an enormous transfer of these assets and that comes from free cash flow.

Duane Schulthess:

So basically, what that means is, when the company is at the end of the year, they have what’s called an earnings before income tax, EBIT, that’s a quick way to say it, that’s the bottom line as it were. And they take that free cashflow and they, they do these deals. What will happen is we will decimate. We will decimate that ecosystem. That ecosystem will get eviscerated. And what you’ll see is that whole cashflow for the ecosystem is going to go away. Now, the taxpayers and some of the cynical folks, which I completely understand, and this is a viable argument, “Well, it’s US taxpayers anyway. It’s our money, and we’re tired of paying the high prices. So why should we subsidize this?”

Duane Schulthess:

And I totally get that. I can completely understand that argument. That’s a decision we have to make, but we need to look at the reality of this. The US is dominating this space completely. And if we cut that off right at the feet, if we just chop that off at the bottom, and we cut that revenue by 40 50%, we will not get 40 or 50% less drugs. We’re going to get 70, 80% less drugs, because it completely decimates the ecosystem. And I think a lot of people don’t understand that. And dare I say, and I’ve presented at the congressional budget office, I think they missed the boat on this too a little bit.

Sue Peschin:

And then what about in terms of access, do you think it’s going to have an impact at the patient level? Even if it cuts costs in Medicare, like the CBO is claiming, so what you’re basically saying is we’re going to have a few less drugs and the CBO report does acknowledge that, I think they say something like eight to 10. Do you think that that’s accurate? And then what kind of an impact is this, ultimately… Aside from like the patients won’t get new drugs, any other impacts at the patient level?

Duane Schulthess:

Well, first off, it’s going to be way more than eight to 10 less drugs. I mean, maybe eight to 10 less drugs a year. If you look at this over a decade, you’re probably looking at 60 or 70 less drugs. But the problem is, what drugs are? It’s where do these things fall? And what you find is that, over time, the US innovative ecosystem has moved more and more to orphan drugs, rare diseases, targeted stratified therapies. If you look at, say, you take a random selection of 12 drugs that came out last year, you’d find that four of them would be blockbusters, give or take, between a billion and $4 billion a year of revenue, which is great, fantastic. You’d find there’d be about eight in the middle, and right around the mean, that would be sort of break even, maybe, probably losing money. And then you got four that are complete write off, absolute write off.

Duane Schulthess:

And these are drugs that came to market. They were approved. They had good clinical research, but the fact is, there’s just not a market for them. A lot of those are orphan drugs and rare diseases. The average revenue for an orphan or rare disease, from research we’ve done is about 70 to $80 million a year. Now it takes $2.2 billion, $2.6 billion on average to bring a drug to market. So those things are… No one’s making money on that. So the fact is it’s really these blockbusters that are what are subsidizing all of this other stuff, with the hope that maybe one or two of these things will come up, and they’ll maybe find another indication, and then, oops, we’ll, Hey, maybe there’s another thing we can do with this. And then there’ll become blockbusters too.

Duane Schulthess:

And it does happen. It’s rare, but, shall we say, it’s not the mean, it’s not what’s average. It’s sort of, that’s the exception, not the rule. So what’ll happen is we’re not going to get a small, 10 less drugs. We’re going to get way less drugs. There’s going to be far less innovation. And fundamentally, the problem that we’re seeing now is the way the Medicare bill was written in 2003, five percent goes out of pocket, once you pass the donut hole, once you’re passed this sort of gap in the middle, where you do have to pay quite a bit of money, it’s up to about $5,000, depending on which Medicare you’re on. Then it goes into the catastrophic phase, and then you’re on five percent.

Duane Schulthess:

Now, five percent, when the average price of a drug 20, 30 years ago, when we were dealing with big market drugs like Lipitor, that was a 10, $15,000 drug, that’s 500 bucks a year. Okay, it’s 500 bucks, but okay, that’s 500 bucks. Most people can probably cobble together 50 bucks a month. If it’s going to save their life. Now, again, people on limited budget, that’s tough, but that was the way the bill was written. We’re into a totally different kettle of fish now, if you’re dealing with an orphan drug that’s $150,000 a year, or CAR T that’s $400,000 a year. That 5% becomes a real big problem for a lot of these drugs.

Duane Schulthess:

And again, this was a strategy we wanted to go. We wanted to go after these orphan drugs, these targeted indications. This is something we really wanted to do. And we’re dominating the technology. This is the way the science is leading. We’re going to stratified medicines. We’re going to targeted therapies. This is the reality. So the fact is, is it really the problem for the individual, the way the law was written 30 years ago, that now they’re on the hook for these things that we’ve basically been subsidizing?

Duane Schulthess:

Maybe we want to keep the science and keep the science going, and maybe look at this out-of-pocket cost side. Maybe that’s the way we want to go. Maybe look at things around this five percent in the catastrophic phase, softening that a little bit. Maybe there are things we could do that’s more strategic that wouldn’t necessarily put the onus on the individual. I think that’s the problem. I think the bill was designed for a technology era that no longer exists or we have evolved beyond it. And I think we need to go back and look at that as opposed to basically saying, “Well, scorched earth, we’re just going to kill all the technology. And we’re just going to cut everything by 60, 70%,” which to me seems ridiculous.

Sue Peschin:

Yeah, that’s really helpful, I think, to understand for our listeners is, it’s not really a regulatory approach, it doesn’t get at the core structural issues with the program itself, in a way to lessen burden on patients and on the Medicare program over time, but really just tries to sort of, like you said, like with price setting, as you’ve said before, a little bit like a rent control type of structure. And it’s squeezing on one end, so it’s going to hurt on the other side and not necessarily get at the root of the problem. Talk to us about, I mean, what we’re hoping, where the science goes, in one of the areas anyway, is Alzheimer’s disease. What were the findings of the additional analysis that you did when you just looked at Alzheimer’s neurological?

Duane Schulthess:

Yeah, Alzheimer’s is really tough, and all the neurological disorders are really, really challenging, just let’s say that straight up. This has been a graveyard of R&D investments, brutally difficult. And it’s not for a lack of trying. The fact is there was a thesis called Amyloid beta, which was a plaque. And if you talk to the imaging technologists and the people who work in neurological disorders, you can go to the conferences and you see them put the slides up of the brain scans of pre-Amyloid beta plaque buildup and post-Amyloid beta plaque buildup, in my word, you sit there and you think, this has got to be it. You just kick yourself. You look at the imaging and you’re just like, “That’s the cause of Alzheimer’s. It has to be.” It’s like clogged the plumbing in your brain. And you look at the imaging and it correlates perfectly with the onset of Alzheimer’s.

Duane Schulthess:

And so we’ve had this thesis called the amyloid thesis that we’ve been working on for 30 years, that by removing these plaques or stopping the up of these plaques, we would then turn back Alzheimer’s. And when you look at it, it just has to make sense, when you look at the imaging and when you look at the data, but the fact is it hasn’t worked. It has not worked. It’s 25 years of a cul-de-sac that we’ve ended up in, and all of the research has basically shown that this is not going to be the right way to go. So we have to find a new direction. And so basically, you’ve had companies spending billions and billions and billions of dollars. There have been 300 clinical trials in Alzheimer’s that have been failures, now, in a row, and counting. We have two drugs that are… they treat some of the symptoms that have also been repurposed.

Duane Schulthess:

So you’ve essentially had 340 clinical trials, and you’ve got four drugs that are, essentially, two repurposed drugs. So your failure rates about 98.5%, depending on how you count this. That’s with current economics. The reality is, if you look since 2010, most of the companies and the large work has been pulled out, it’s been really put into very niche, boutique companies who were doing the work. We had a 50% reduction in clinical research budgets around neurological disorders, specifically around Alzheimer’s. And this was before we get to HR 3. If we start reducing revenues by 40, 50%, and we start reducing drug entries by 60, 70%, 70% of 98, 99.5% gets you pretty close to a 100%, as far as failure rates and the ability of people to do work. Nobody is going to take that risk on, essentially, we’re going to see a complete dearth of neurological disorder research, if we move in this direction.

Duane Schulthess:

There’s just no economic argument you can make to take on that risk level. If we’re going to, basically, decimate revenue potential of the sector, which is what we’re talking about. And I think people don’t get this. It’s like, well, this is an area where we still need drugs. It’s like, yeah, but you also need to get a return on investment. And someone’s got to pay for the clinical research. Nothing that we’ve been talking about, related to HR 3, these international reference pricing proposals, or whether it was what was proposed by Secretary Azar, and the most-favored-nation’s bill that Trump passed in the last days of his administration. None of these things talk about regulatory reform. We’re only talking about pricing. It’s a pricing stick with no carrot. And that, fundamentally, is the problem. All you will do is remove the incentives for people to take on risk, to go into these very risky, very challenging areas where there’s been, basically, nothing but failure.

Sue Peschin:

It’s interesting, since the NIH funding for Alzheimer’s disease has gone up exponentially in the last 10 years, so why do you need that private investment into R&D?

Duane Schulthess:

Well, this may not be popular to some of your listeners, but there is a reality around NIH funding. We’ve looked at 24,000 grants of the NIH from the year 2000, and we’ve looked at what happens with those grants, with their ability to produce investible intellectual property. And then from that intellectual property to actually become a product. And it’s not bad data. I mean, the NIH does a very good job. And since the Bayh-Dole legislation, which, Bob Dole, it was a patent legislation that allowed the government to transfer the intellectual property to the investigator who created it and then create a business, basically. It became a vector and a vehicle for us to commercialize public funded research, which is something that Europe doesn’t necessarily have. And again, it’s a huge competitive advantage to the United States.

Duane Schulthess:

What you see is, from those 24,000 NIH grants we researched from the year 2000, you have about 8,000 patents. Those 8,000 patents are linked in some capacity, some are direct related to the actual molecule, but the most aren’t. Most are imaging technology that facilitate the asset. I mean, there’s a huge amount of patents that go into any product. If you look at a product patent portfolio, you’re seeing hundreds of hundreds of patents. So there’s always some peripheral thing that may lead to something else. And their pathway is very circuitous and not very clear. But the fact is, we could identify, from these 8,000 patents, about 41 products that came to market over 20 years. What’s intriguing is when it’s only NIH funding, when the private market isn’t there, we built a statistical regression model, and essentially, the probability of coming to market without private investment is statistically zero.

Duane Schulthess:

And what you find is as the larger percentage of money becomes the private sector, so as the private funding increases to where it’s 90, 95, 98% of the funding mix, in other words, where the industry is come in very, very large, or the private investors who come in very large on an asset, at that point, the probability of that becoming a product that’s approved is 60%, when you get above 98%. So essentially, there’s a direct correlation between the amount of… It’s not even a correlation, it’s a statistical regression, it’s a really high certainty P value, that says, when you have private market interest in an NIH asset, that asset has a much, much higher likelihood of coming to market. And when the private market does not pick up an NIH asset, it doesn’t go to market period.

Duane Schulthess:

And there’s also a belief, I think, if you look at NCATS and a lot of the programs that have been started out of the National Institutes of Health, there were all of these sort of [onceler 00:22:57] little things left detritus, left all over the place, these little things that we’ve just been ignoring, because, oh, we don’t want those. Those can’t make money. That’s not what we found. We found that the vast majority of the assets have some level of venture capital or some level of punting on them. Someone’s taking a shot at something. And very few of these assets are overlooked.

Duane Schulthess:

So I think the conventional wisdom is not terribly wise nor conventional. The reality is everyone’s trying to figure out if this stuff works or not. And then when something does have the possibility, you do see money coming in for size. And of the 41 assets that came into clinical research ,18 were approved, which is quite a high success rate of that port. Now, there was one group that was an epidermal patch, that was a technology that went across multiple products, so it was sort of an anomaly in the way the patent portfolio worked. But the fact is, 24,000 to 18 approved products is what we found, and overwhelmingly, this statistical driver of that was the private market. That’s the nuts and bolts of it.

Sue Peschin:

So for Alzheimer’s, given what you were talking about with the Amyloid theory and all that, even with all that extra NIH investment, do you think it’s still going to be worth, in the years to come, the federal and private investment searching for effective treatment and cure for Alzheimer’s disease?

Duane Schulthess:

The NIH pipeline to the private market has been hugely, hugely successful. I mean, I cannot understate or overstate this. I mean, the reality is, this has been an enormous win for American innovation. And the fact that we have harnessed really groundbreaking innovation at the university level, which then leads to commercially viable products, and a whole combination, hundreds and hundreds of these patents need to be combined to get a product. The fact is, this has worked. This has worked. Now, someone has got to take that early risk. Someone’s got to do the innovative breakthroughs, but that doesn’t get us to a product. That’s a long, long way for our product. In fact, it takes, from the first NIH grant to coming to market’s about 25 years. That’s the amount of time.

Duane Schulthess:

And what’s been the triggering is there is general research that says it takes about 20 years from a published breakthrough to actually lead to something clinically viable. And that’s what we also found in our research, we validated that theory. It does take 20, 25 years to get something from the first NIH grant, first publication to market. Something has to do that. Amyloid beta didn’t work. Someone’s going to need to figure out what it is that will work. Now, we’re talking about stratified therapies. Now we’re talking about, Alzheimer’s, it’s not going to be what Alzheimer’s, it’s going to be several Alzheimer’s and a stratified approach.

Duane Schulthess:

Dare I say, the mRNA vaccines are a vector to deliver genetic material. There was, always has been talk of mRNA vaccines as a way to go against some of these diseases, which may or may not have a pathogen related to a virus. We don’t know. There’ve been several correlations around viral stems in the spine related to Lou Gehrig’s disease and other diseases that, well, wait a minute, maybe there’s a vaccine vector for this.

Duane Schulthess:

This is all new science. We’re not there yet. Someone’s going to have to take a look at that stuff. And now we have a new vector to play with where we can deliver synthetically derived genetic material right into a virus or whatever, and change it or into a cluster of cells that have gone bad. Who knows? I don’t know, but that’s not my job. My job is to tell people what it’s worth and what we should be investing in and what we shouldn’t be investing in. So I’ll look at the value, when we start getting some.

Sue Peschin:

Right. Well, NIH just had their big, every few year Alzheimer’s disease summit, and they’re going to be putting together their recommendation soon. And there is a lot of innovative targets that they’re looking at beyond the Amyloid hypothesis, so I’m hopeful. But it’s good to hear, from your perspective, that it is worth the investment. It just takes time. Congress needs to be consistent and sustain the funding and continue to be supportive as researchers make their way to finding an effective treatment and cure. So here’s a question that we ask all our guests, when you were a kid, what did you imagine growing older would be like?

Duane Schulthess:

I don’t know. I probably thought it would be a fireman or something like that, like everybody, I guess. Well, if you would’ve talked to me when I was 12 years old, and said, “You’d now be a health economist working up in the Hill and dealing with issues around new cancer technologies,” I would have said “What?” Again, I had no idea I would end up here, honestly. If you would’ve told me I’d be doing what I’m doing now, I think I would have said you were nuts. I spent 20 years as a professional musician.

Duane Schulthess:

I’ve had a long and wide and circuitous path to get here. I was always pretty good in math and computer science, I guess. And anyway, I got sick of playing in orchestras and ended up following my way to healthcare. So I love what I do. There’s no question about that. And certainly there’s a need for it. I do think the fact that I didn’t come from the medical profession as it were, I came from this obliquely from a rather tangent approach. I do think that gives our firm a somewhat unique perspective on a lot of these issues. I think we have a tendency to be far more data-driven than other firms, and we have a rather agnostic approach to things that aren’t necessarily driven by politics.

Sue Peschin:

That’s great. No, we hear that a lot. I think a varied background and flexibility and openness is a recurring theme for a lot of people. So what do you enjoy most about growing older now?

Duane Schulthess:

Oh, I think the world has changed so incredibly much. I mean, in the ’80s, when I was in high school, the idea that just even international travel, I mean, just going places internationally was so cost-prohibitive, and just logistically prohibitive and just trying to find plane tickets. People have no idea how hard it was to get plane tickets. You’d have to go downtown to a travel office and sit there and take a number like at a butcher shop, and then have to negotiate with someone who was trying to take… all they were trying to do was extract money from you. And it was really difficult. Just the world was so much bigger. It was so much bigger and access to data, the availability to find data now and information in general, the flow of information and knowledge is so much greater now.

Sue Peschin:

Duane, thank you so much for joining us today.

Duane Schulthess:

Oh, it’s my pleasure. Thank you Sue.

Sue Peschin:

Thank you so much for listening to This is Growing Old today. Our theme song is City Sunshine by Kevin MacLeod. Props to Kevin MacLeod for City Sunshine. Please stay tuned for new episodes every other Wednesday, and please rate and review us, if you’re enjoying the show. Thanks for listening to This is Growing Old and have a great day.