Can Kindred Help Humana Bend the Cost Curve?
In December 2017, national health insurer Humana and two private equity firms, TPG Capital and Welsh, Carson, Anderson & Stowe (WCAS), announced the $4 billion acquisition of Kindred Healthcare, a national provider of post-acute services. This was not terribly surprising as it was rumored back in April that Kindred Healthcare was exploring sale options, with Humana and private equity firms as interested buyers.
This deal marks yet another sign of increasing convergence between payers and providers. Vertical integration continues to be a key strategy, as evidenced by UnitedHealth’s deal with DaVita and the pending Aetna and CVS merger.
In evaluating potential home health partners, Humana sought a platform that has the capability to move beyond Medicare FFS home care to robust data collection and sharing, as well as anticipatory actions that will “bend trend” for MA members.
Humana Acquiring Kindred at Home
This transaction involved three parties: Humana, TPG Capital, and WCAS.
Humana sought more than just cost-lowering levers for seniors in its 3.3 million member Medicare Advantage (MA) business. Instead, it was looking to actually purchase home health and hospice providers with a national presence for a few key reasons:
In evaluating potential home health partners/targets, Humana sought a platform that has the capability (systems, culture, training) to move beyond Medicare FFS home care to robust data collection and sharing, as well as anticipatory actions that will “bend trend” for MA members. The model needs to be clinically focused, proactively looking for other opportunities while in the home.
Humana reportedly evaluated a number of other larger home health companies with a nationwide presence, including Amedisys Inc., LHC Group Inc., and Encompass Health Corporation. Humana reportedly came close to acquiring Almost Family, Inc., but Humana wanted more sophisticated clinical capabilities that could be used to identify and act on care opportunities. Subsequently, Almost Family merged with LHC Group in November 2017 instead.
There are five key reasons why Humana purchased Kindred:
This merger created a few interesting trends we are watching:
Integrated care as a core component of Humana’s strategy. Humana is attempting to bring together primary care, home-based care, behavioral health, and the drug benefit around members to manage their whole health and disease progression. The question is whether this investment, and others recent investments in clinical capabilities, will lead to a lower medical loss ratio and higher quality scores that generate values to its members and helps to build additional MA membership.
Netsmart taking aim at interoperability. Netsmart has aggressively expanded its post-acute capabilities over the past two years and supposedly has had talks with Kindred about wiring them into Netsmart’s national HIE network. With Netsmart’s extensive install base in the behavioral health market, it presents a very interesting strategy to build a coordinated communication system at a national scale with a large number of post-acute and behavioral health providers.
More acquisition of post-acute providers. This deal sets up a strong likelihood that other mid- and large-sized post-acute providers will be acquired over the next 12-18 months. Will it be other Medicare Advantage payers who are trying to replicate what Humana is doing? Will it be a new entrant with other significant non-hospital provider assets — even though Kindred ‘Integrated Care Markets’ strategy failed for several reasons (including debt burden and fiscal pressure on post-acute payers due to reimbursement?
Humana remains a likely acquisition target. After the failed proposed merger of Aetna and Humana last February, it was speculated that Humana was going to be acquired by another behemoth such as Wal-Mart, Walgreens, or Anthem. Despite some speculation that this Kindred acquisition makes an acquisition less likely in the interim, Humana still represents an attractive takeover target, especially for a firm that wants to aggressively enter the Medicare Advantage market to compete with United Healthcare on a national scale. Only a handful of companies, though, could possibly afford the M&A price.
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HIMSS’15 Pilgrimage: Impressions and Takeaways
Another year, another HIMSS conference. While I often may gripe about this event; the seemingly endless parroting of buzzword(s) de jour, the countless press releases that really are much ado about nothing and highly questionable surveys and research results, that have little founding in reality, there is a silver lining to all of this…
HIMSS affords me the opportunity to meet with so many people I’ve come to know in this sector. Some are my mentors, others clients or partners and all have become friends. That friendship extends from a shared desire and dedication to improve healthcare delivery through the effective adoption and use of IT.
While HIMSS is utterly exhausting it is also incredibly invigorating – kind of a Yin/Yang thing. I always return from the event with a ton of ideas as to where Chilmark can further assist this industry, because frankly, finding good objective research and insights in this sector sure seems tough to come by.
The “Big Data” hype cools to a simmer. Thankfully, the number of companies quoting, referencing or inferring how they address big data has subsided. This sector needs to get the little data right before it can step-up in any meaningful way to big data.
PHM is a too vague a term. The challenge with population health management (PHM), as a term, is that it is so broad. This results in virtually any vendor laying claim to it – though they may only be solving a very small piece of the PHM puzzle. No vendor at HIMSS’15 has a solution that can fully enable a PHM strategy. Met with many a CIO who has come to same conclusion, but every CIO struggled with same problem: Where best to start and with who?
Everyone does Care Management. In his post prior to HIMSS, our analyst Matt predicted that care management/care coordination would be the new buzzword term de jour. He was spot on. Countless vendors had banners promoting their ability to address care management processes. Unfortunately for users, when one takes a deeper look at these care management apps, one typically finds a glorified spreadsheet. Surely we can do better than this!
Clinical analytics is cool, but financial and clinical analytics together insures long-term survival. Saw plenty of vendors promoting their latest analytic wares and virtually all the demos focused on clinical analytics. Only a few vendors have taken the next step and are co-mingling clinical and financial analytics – which will be absolutely critical for HCOs. Unfortunately, most of these solutions make it far too difficult to perform such a simple task as: At the patient level, identify the most costly patients, what is driving the high costs of care for these patient(s) (visits to specialists, procedures, labs, meds, etc.) in order to determine what may be done to reign in costs.
A couple of companies I spoke with, Arcadia and Health Catalyst, did talk about the co-mingling of clinical and financial data, but as mentioned previously, they were in the minority.
ICW was back after a five year hiatus from HIMSS. They’ve gone through a major restructuring to refocus their development efforts on HIE and care management. They’ve always had some pretty decent technology under the hood – their challenge has been channel(s) to market. Not easy for a company from abroad.
Humana announced Transcend Insights (combo of Certify Data Systems, Anvita and nliven), yet another payer-led solution suite. They’ll be challenged to compete with Aetna’s Healthagen and UHG’s Optum. Humana’s deep expertise in Medicare may be key differentiator.
Caradigm looks to be finally gaining some traction and their booth was very busy. They are beginning to get some wins for their Care Management suite, which they co-developed with Geisinger Health.
Orion Health has the most visionary architecture for CNM that I have witnessed to date. Now they have to execute on that vision.
RelayHealth now has both performance analytics (HBOC) and MedVentive under its wing. They will be combining RelayHealth’s data aggregation capabilities, these analytics solutions and hosting in Microsoft’s Azure Cloud. Going beta this summer at ten sites and G.A., by end of summer.
Apervita was one of the more interesting briefings, as they are a company trying to create a marketplace for analytic algorithms that an HCO can source and apply to their EDW. Recently landed Series A round – one to watch.
Aetna’s Healthagen is targeting self-insured employers as well. In North Carolina, the PHM program Healthagen rolled-out across the 680K state employees realized a savings to the state of some $450M over three years. Not sure how those savings were calculated, but a number even half that is impressive.
Kryptiq, which recently spun-out from Surescripts, is taking to market Care Manager, an app originally developed at Providence Health in Portland. Solution automates many of the tasks required for CCM reimbursement under Medicare.
The EHR bubble is over but big question is: Will bolt-on sales of PHM-enabling modules be enough to sustain this market? Cerner is seeing very good traction for its Healthe Registries product, but a contract sale of that product likely pales in comparison to a Millennium sale.
The EHR vendors with the biggest, most elaborate booths are also the ones that are struggling the most in today’s increasingly competitive market.
Athenahealth had by far some of the best marketing booth panels I’ve ever seen at HIMSS.
InterSystems is jumping into the patient portal business. We’ve never been fans of EHR-tethered portals and Intersystems’ move is welcomed.
Health Catalyst continues its momentum, both in raising funds and landing new clients. They are moving fast knowing that the likes of Epic, Cerner and other best of breed vendors are in pursuit.
Lumira, management buy-out of Wellogic from Alere, is building out a solution suite combining engagement, data exchange, biometrics and analytics. Lumira sees itself as a becoming an “Outcomes Company”. How that differs from a traditional MCO is hard to gauge right now.
Everyone wanted to know the implications of IBM’s big announcements at HIMSS. Certainly thought provoking, but IBM has a ways to go to convince the market, especially providers, of what value they can deliver.
The record winning CCD file that Medicity has seen fly over its network was 100MB – that’s HUGE! By way of comparison, one of our 100+pg market trends reports averages about 1.3MB. Is it any wonder that this industry struggles with interoperability.
Plenty of talk and wringing of hands over issue of interoperability, but saw nothing at HIMSS that gave me hope that this issue will be solved across the country in the next 12-18months. Think 3-5yrs at best.
Box had a small booth at HIMSS and unbeknownst to me, acquired a start-up that has a pretty slick DICOM image viewing and medical grade mark-up application that now resides on Box.
BluePrint Healthcare IT’s Care Navigator is a nicely packaged app for care coordination. Children’s Specialized Hospital in NJ have been able to derive some high value from its use in caring for its pediatrics patients.
Of course, with 42K+ attendees, some 1.2K+ exhibitors there is no way any one person can take it all in. One needs a plan and a highly targeted one at that to be able to really get any value out of this event. As they say, practice makes perfect and this being my eighth or so HIMSS, I am getting a little more practiced at how to navigate this event. Never easy, always exhausting, at times depressing, but also never boring. See you in Las Vegas – the site of next year’s HIMSS.
Wellness Market: Too Many Chasing Too Little
Having taken a hiatus from last year’s Health 2.0 event, was looking forward to this year’s event to see what may be new and upcoming among those looking to disrupt the status quo. Unfortunately, surprisingly little.
Health 2.0 a couple of weeks back had your usually cheery crowd of those who are looking to transform healthcare. As with past Health 2.0 events we have attended, hype was far out in front of market reality but that does not seem to deter the cheerleaders, which were again present with abundance among the some 1,700+ attendees.
Show Me Your Big Data – That’s what I thought, not so big after all
There was plenty (i.e., too much) talk about Big Data when in reality, presentations focused on relatively small datasets with little thematic similarity in any one session. For example, the Risk Assessment & Big Data session had Dell talking about genomics, Sutter Health talking predictive analytics for CHF, another about mashing up claims and clinical data and the last looking at risk assessment. At the conclusion of this session, nary a question was asked – audience confused. Another session on Big Data tools for Population Health Management (PHM) was cut short, thankfully, when the power died. Hard to say if it is the industry drinking the hype, this particular event (though experienced similar at HIMSS’13), or what but this silliness has to stop – we really need clarity, not smoke n’mirrors =- and don’t even get me started on PHM…
Track Me – Track You and no, I probably don’t want your data, at least not yet
In addition to riding the Big Data hype, the event also jumped on the hype surrounding the rapid proliferation of self-tracking, biometric devices now entering the market and all the great things that will come as a result of consumer adoption and use of such devices to monitor health. Not all are jumping on this band-wagon and for good reasons. There is no doubt that in time, such devices will be used by clinicians and patients together which will be the focus of a forthcoming Insight Report from Chilmark but our early research points to a number of challenges in the adoption and use of such devices in the context healthcare delivery.
There was again a plethora of solutions for price transparency. Some odd partnerships that are more opportunistic, for the partners, than providing value for the end users, e.g., the Dr Chrono-Box.net demo was so laborious I can’t imagine any clinician actually doing it. On the patient engagement front, plenty of new solutions on display and was particularly impressed with what Mana Health had build for the NYeHC patient portal contest. Simple, clean, straight-forward and intuitive to use refreshing.
Of course no Health 2.0 event would be complete without one of the large commercial payers taking the stage to announce their latest and greatest member outreach initiative. Two years ago it was Aetna with CarePass. This year it looked like it would be Humana until they were a no show – but Cigna was there with GO YOU Hub. First impressions of GO YOU: a fairly shallow pool in the health & wellness domain with lots of catchy phrases and colors – something your pre-pubescent daughter may like – but this adult quickly lost interest after four clicks
Health & Wellness Redux, Redux, Redux
And again, no Health 2.0 event would be complete without a gaggle of health & wellness solutions, the majority of which won’t be around by 2016.
There are now far more health and wellness solutions in the market than what the market can absorb. This situation is not likely to get better anytime soon as the numerous incubator/start-up accelerators continue to spew more of these solutions into the market every year. The only thing I can think of is that the barriers to entry must be exceedingly low, yet few of these companies realize that the barriers to adoption are exceedingly high and the market is on the verge of contraction.
The Big Squeeze
We are now projecting a significant level of contraction in the health and wellness arena as the broader market comes to grips with a shift in risk from payers to providers with providers ill prepared to accept that responsibility and the migration of many employees off of their employer plans and onto Health Insurance Exchanges (HIX).
This will create two challenges:
Providers are not accustomed to providing such solutions to their patients. While risk may shift to providers, provider adoption and use of such solutions to manage their patient populations is limited. When one adds in self-tracking devices, well…
…providers are struggling with the data dumps from their recently install EHR. The last thing they are seeking is another data source. Healthrageous is one example. A self-tracking wellness solution that was developed by provider Partners Healthcare, adopted in pilots by some big providers, failed to gain traction and was quietly sold to Humana. Not a pleasant outcome. If a provider organization can’t make a go of it through a spin-out, to the multitude of these health & wellness solutions think they can?
Second, we are at the very beginning of a massive shift of employers directing employees to HIX. Despite a fitful start, the use of HIX will grow overtime as a wide range of employers, but especially those in the retail and hospitality industries, direct their employees to these exchanges. Shifting employees to HIX reduces employer exposure (risk shifting) and will lead to decreasing interest and adoption of health and wellness solutions by employers.
Yet despite these challenges, the cheerleading at all Health 2.0 events and a questionable future, one thing that comes through every year is that there are a significant number of people that truly want to do something good, something meaningful to improve the sorry state that is our dysfunctional healthcare system, which we all struggle with at times. These are the people that attend Health 2.0, the ones willing to talk about the “Unmentionables”, the ones to project a vision of a better future for us all, the ones willing to take a risk. For that they should be applauded. But be wary as most will not be around three years hence.
But next time, can we actually have some front line providers in greater abundance to give us their take on all of this. Unfortunately, this event was sorely lacking in such, though it did have its fair share of various healthcare representatives – they just weren’t the ones from the front lines which is who we all need to be hearing from today.
Special thanks to Graham Watson for the image. Graham is easily the best cycling photographer in the world today.
And an extra special thanks to Cora who was there with me and provided a few tidbits of her own to this post.
At the Intersection of Obesity and HIT
We Americans are on a very terrifying path, health-wise, based on the latest obesity projections from RWJF.
Medical “innovations” around the obesity epidemic are unsettling, to say the least. Most recently, Dean Kamen (of Segway fame) filed a patent for a self-serve Stomach-Pumping Machine.
Disturbing medical devices aside, what does the obesity crisis mean to healthcare IT (HIT)? Yes, increasing obesity rates means more metabolic syndrome, more intervention, more biometric data,more data stored in EHRs, more HIE to share that data, more clinical analytics and care coordination software, …
Does this sound interesting to you? In my research I am more focused on how technological innovation can function as a solution to the obesity crisis. First let’s consider the payers — the large, innovative ones who continue to rally for behavior change.
Payer-sponsored behavior change programs have never sustained results in the long term, but this doesn’t stop the early adopters from soldiering on. For our 2012 Payer Benchmark Report, we profiled several large, innovative payers working to engage their members and the public through low-cost consumer technologies.
Some interesting new developments in this space include:
If payer apps can’t motivate widespread weight loss, then maybe the consumer space can? Consumer companies are currently busy developing software and testing out motivational models on the fly. This is not exactly the scientific method but it works for small agile environments…and is definitely something that large payers are less adept at.
There is a belief among many of the quantified-self set that just the act of presenting health data to the consumer affects behavior change. I seriously doubt this, and believe that consumer health startups have played a miniscule role in affecting real behavior change. So far, they have provided diet and exercise fanatics better tools to fuel their obsession.
In order to reach the ‘bottom of the pyramid’, must we then dole out dollars for weight loss? I recently spoke with Gregory Coleman, one of the founders of nExercise, which offers a gamified “rewards program” where users randomly accumulate points, similar to a lottery, which can be applied towards real world discounts.
(nExercise is also the driving force behind the recently formed FITco, or ‘Founders In Technology Combating Obesity’. FITco functions as a place for founders to form data sharing/interoperability partnerships, and aggregate marketing dollars).
Talking with Gregory, I found myself better understanding the challenges these consumer companies are up against as they seek to move beyond their core base. In offering financial incentives, they must spark interest without destroying intrinsic motivation. Framing financial incentives in term of ‘rewards’ and ‘discounts’ helps, but the real goal is to wean users off of them.
Several academic studies have shown that a combination of financial incentives, social support, and coaching from a trusted ally, produced significant behavior change, at least in the short term.
I can imagine a day when I seamlessly upload exercise and diet related data into a CarePass-type platform, where:
Hmmm, what is that distant feeling of unease, the feeling like I am a pawn in someone else’s Grand Plan? It might have something to do with the complete loss of privacy around my data. However, if those premium discounts are steep enough, I can live with that.
Whether we get people sharing their health data or tempt them with financial incentives for weight loss, the systematic nature of the obesity problem remains a force to contend with. In the end it will be up to all of us to push back against the institutions that make us fat. Seeking out motivational consumer solutions is a low cost place to start.
Humana Jumps into HIE Market, Claims Analytics Turn Sights of Clinical, Med Adherence
November saw the acquisition of yet another HIE vendor by a payer (Humana). An in-depth analysis of this acquisition and its implications was provided to Chilmark Advisory Service (CAS) clients at the end of November. Following are abstracts of the three research notes in our latest Monthly Update.
Humana Leaps Into the HIE Market
The health insurance industry is undergoing massive upheaval. Payers don’t need a crystal ball to see that in the near future, providers will sell services directly to employers, and that insurers need to get creative in order to stay competitive. With its acquisition of HIE vendor, Certify Data Systems, Humana joined two other payers in the HIE market: Aetna and UnitedHealth Group. Yet Humana’s strategy sets it apart from the other payers. On a single day in November, Humana announced not one but three acquisitions: Certify plus two Florida-based managed care service organizations. Humana has clearly articulated its plan to become the preferred Integrated Delivery Provider to Medicare Advantage members and dual eligibles. By adding Certify’s strong HIE capabilities to its bag of tricks, along with the ability to deliver primary care directly to a large Medicare population, Humana has positioned itself to do just that. (more…)
Another HIE Purchase by a Payer
Today, national health insurer, Humana, announced that it has acquired Certify Data Systems (CDS). This marks the third HIE vendor (UHG acquired Axolotl & Aetna acquired Medicity) that has been acquired by a payer in the last couple of years. Not that surprising when one looks at how aggressively payers are moving into the accountable care arena and seeking to form tighter links with physicians in their network, particularly those in the ambulatory sector, where CDS has done particularly well.
A key part of CDS’s success in the market was through its partnership with Cerner where it provided the technology stack for connecting ambulatory practices. The Certify HealthLogix is a well architected platform that has seen strong adoption. While terms of the deal were not disclosed, it is our guess that Humana paid a pretty penny for CDS, likely all cash deal at about 6-8x estimated 2012 sales.
While it is good to see that CDS leadership will stay in place, at least for now – serial entrepreneurs, such as CDS founder Marc Willard, typically do not last too long in large corporate entities such as Humana- we do have some concerns with Humana’s ability to actually manage a software company. This is way outside their core competency and hopefully they know well enough to provide CDS the resources to scale but also the wisdom to let CDS call most of the shots.
We will be providing Chilmark Advisory Service (CAS) clients with a more detailed breakdown of this deal later in the week after we have had a chance to speak with some key contacts/stakeholders of this acquisition. This will be pushed to subscribers via an Alert.
Benchmarking Payers Adoption of Consumer Tech
Awhile back, a large health insurer (payer) commissioned Chilmark Research to do a market scan on how payers across the country were using emerging consumer technologies to engage their members. We found this project to be quite interesting and rather than have much of that research sit on the shelves forevermore, we decided to build upon it.
Today we are releasing the results of that effort.
Our latest report: Benchmark Report: Payer Adoption of Emerging Consumer Technologies takes a close look at over 40 payer (health insurers) initiatives that are using a wide variety of consumer technologies (apps, social media, games, etc.) for member engagement. Here’s the PR announcing the report’s release.
Now it is well-known that payers have had a very mixed record in engaging their members. Part of the problem has been trust as members are justified in taking a cautious approach when sharing their health information with payers for fear of future denials. Secondly, many payer initiatives have been half-baked wherein payers have not been fully engaged themselves in the concept of member engagement.
But as we pointed out in a post earlier this summer, this is all beginning to change. Numerous market forces are now pressing down upon payers and payers are increasingly coming to the realization that they need to deploy member engagement solutions that work. Payers are now going to where consumers already are seeking to engage their members via a variety of consumer-based technologies. This report is our initial effort to gain a greater understanding of what payers are doing today and provide some guidance as to how their efforts will evolve overtime.
One thing we have learned in the course of our research is that despite all the talk, the majority of these efforts are in their infancy and that the vast majority of payers have not even begun to venture down this path. Therefore, we intend to update this report on a periodic basis to benchmark payer adoption of consumer tech in support of member engagement and gain an even deeper understanding of what works and just as importantly, what does not.
Thanks to the many that we have interviewed over the course of the last several months to compile this report as your inputs have been invaluable.
Payers Take Another Stab at Engagement with Consumer-based Tools
It is now nail-biting time, as we here at Chilmark Research brace ourselves for the upcoming Supreme Court decision on the legitimacy of the Affordable Care Act. We as a nation are indeed living in very interesting times and I am again reminded why I find healthcare markets endlessly fascinating (and perplexing). (Editor’s note: This post was written by senior analyst Cora Sharma and highlights some of her latest research that looks at payer strategies for patient/member engagement.)
Of interest is just how many of the ~30 million uninsured US citizens will land on insurers’ doorsteps in 2014. Even if the Individual Mandate is upheld, it is still uncertain just how many of these uninsured individuals will opt to pay penalties rather than purchase health insurance.
For my patient engagement research, I have spent the past several months speaking with executives at large payers about their consumer-focused strategies. Just how are payers planning on using relevant consumer technologies to keep new individual customers engaged and healthy? After such a dismal track record over the years around health/wellness/DM initiatives, is it worth another go-around? (Cora’s research will culminate in a forthcoming report to be released within the next couple of weeks.)
Payer Initiatives in Consumer Technologies
Kaiser Permanente and Humana actually began experimenting in this area circa 2008, creating flash-based, online health games for children. In 2010, UHG released the first version of the OptumizeMe social game App, Anthem released its Grocery Guide App (now EOL), and Aetna partnered with OneRecovery.com to provide a social network for members in recovery.
Now all of the major payers have ongoing products, partnerships, and pilots around consumer-focused health and wellness and disease management — though with varying respective strategies (the upcoming report explores these 35 ongoing payer initiatives in detail).
The figure below shows an interesting slice of data around social games, in that the majority of these initiatives are becoming social and ‘gamified’:
Note: Data point positions do not represent degree of gamification/ social-ification. These are just meant to illustrate number of initiatives in each category
Another trend our research has found is the willingness of payers to look beyond health and wellness and towards the complex FDA-regulated space of chronic disease management solutions (partnering with Healthrageous and Welldoc), as well as seeking to improve member ‘Wellbeing’. Aetna’s partnership with Mindbloom to offer members the premium version of the Life Game™ is one of the few efforts we found among payers that looks to engage the full spectrum of health of a member with a focus on Wellbeing.
Growing market in payers that can transition to a post-FFS world.
In the future, we predict that this market will continue growing along two distinct tracks:
As many readers may know, the health insurance industry is going through a period of rapid transformation. Payers with the means and the wherewithal to innovate their business models are purchasing providers, as well as partnering with them for data-sharing agreements and ACO-like payment contracts. Some large payers are also getting into the ACO-enablement business through acquisition of software companies.
Insurers who do not innovate their business models towards a post-FFS (fee for service) world (be they pure insurance providers or mostly claims processors) will find little incentive to experiment heavily with emerging consumer technologies. The crux of the matter is that they will never have the long-term incentives (nor the culture) to shift gears away from their actuarial focus and will remain low margin businesses, if they manage to survive at all.
Affecting behavior change towards health and wellness has proven incredibly difficult over the long haul. There is scant evidence that these new payer initiatives that seek to adopt common consumer engagement technologies and strategies are meeting objectives. As the entire healthcare industry pivots towards new bundled care reimbursement models though, there may be a glimmer of hope. I remain cautiously optimistic to see payers experimenting with and adopting emerging consumer technologies, knowing that there is still a long road to travel.