Coordinated Care and Beyond: Coverage and Chronic Care

8:00 – 8:45 a.m. Registration and Light Breakfast

8:45 – 9:00 a.m. Welcome and Introductions

• Sarah Dash
  Alliance for Health Policy

9:00 – 10:00 a.m. Future Trends in Chronic Care

• Peter Fise
  Bipartisan Policy Center
• Clay Marsh
  West Virginia University
• Sue Nelson
  American Heart Association
• John Romley
  USC Schaeffer Center for Health Policy and Economics
• Sarah Dash, moderator
  Alliance for Health Policy

10:00 – 10:15 a.m. Break

10:15 – 11:15 a.m. Coverage and Chronic Care

• Mark Fendrick
  University of Michigan School of Public Health
• Rebecca Kirch
  National Patient Advocate Foundation
• Kathleen Nolan
  Health Management Associates
• Hon. Allyson Y. Schwartz
  Better Medicare Alliance
• Julie Appleby, moderator
  Kaiser Health News

11:15 a.m.-12:15 p.m. The Future of Integrated Care for Complex Chronic Conditions: What’s Working, What’s Not

• Bart Asner
  Monarch Healthcare
• Larry Atkins
  Long-Term Quality Alliance
• Sandra Wilkniss
  National Governors Association
• Susan Dentzer, moderator
  Network for Excellence in Health Innovation

12:15 – 12:30 p.m. Closing Remarks

PLEASE NOTE: This is an unedited transcript. Please refer to the video of this event to confirm exact quotes. SARAH DASH: Alright, we’re going to go ahead and get started with the next panel. Thank you all. Once again, thank you for being here, and in our introductory panel, one of the issues that came up, of course, was access to care and to coverage, and so that is what we’re going to talk about in this panel. And we are really thrilled to have with us some fantastic experts on this, and Julie Appleby, who is a Senior Correspondent with Kaiser Health News is going to be moderating this panel, so without further ado, I’m going to hand it over to Julie to introduce the panel and get it started. Thanks. JULIE APPLEBY: So as we’ve heard from the last panel, the number of people with chronic conditions and multiple chronic conditions is only going to get larger, and I think one person said the scale of the challenge is very, very large, and there’s no question that insurers, both commercial plans and government programs and other payers, are going to play a huge role. How they design their benefits can help people with chronic conditions or cause them to pay a whole lot more in out of pocket costs. How they pay their doctors, their hospitals, and their other providers can either incentivize coordinated care or encourage excess spending. In this panel, now, we’re going to talk about the world that payers: Medicare, Medicaid, commercial health plans, as well as the role consumers play in preventing chronic conditions, encouraging prevention, shaping the nation’s response to the growing number of people with such conditions. And, luckily, we have this excellent panel here today to help walk us through this. They’re each going to chat for four or five minutes, sort of on an opening question I’m going to give them, then we’re going to have a discussion among ourselves and I’m leaving plenty of time for questions for the audience, so if you have something, jot it down, think about it. We’re going to have some microphones and people are going to be able to ask questions. So without further ado I’m going to introduce the panel. We have Mark Fendrick, who is a physician and a Director of the University of Michigan Center for Value Based Insurance Design; we have Congresswoman Allyson Schwartz, who is President and CDO of the Better Medicare Alliance; we have Kathleen Nolan, Managing Principal at Health Management Associates; and we have Rebecca Kirch, Executive Vice President for Healthcare Quality and Value at the National Patient Advocate Foundation. So, Congresswoman, I want you to briefly describe the role that Medicare plays in financing care for people with chronic conditions. Folks with disabilities, folks with end stage renal disease, if you could chat a little bit about what does Medicare do now? ALLYSON SCHWARTZ: Well, whatever Medicare does, not only for the beneficiaries under Medicare, it matters to the entire healthcare system. It really sets the stage, often in what it reimburses, what it doesn’t reimburse, and of course, there’s, well, funds a good bit of the healthcare – government funds half of healthcare, right, in this country anyway, so when people say where’s government – why is government involved in our healthcare you have to say, well, it funds 50%, it sort of has a little bit of a say about what it funds. But it also means that it has a great opportunity to really address the issues that are facing seniors and those with disabilities who are on Medicare – Medicaid also, and we’ll talk more about that – going forward. And what we know is, of course, there are already 55 million people on Medicare between 40 plus million who are seniors and others who are eligible because of disabilities and the 10,000 new eligible people on Medicare every day. So we’re going to almost double the number of people covered by Medicare in the next decade so the numbers are huge. Anyone who says we can find sort of enough money in Medicare, even though we do think we can do a better job of cost effective care, and we’ll talk more about that, it’s still a lot of people to cover – over 80 million people. So it’s going to be 20% of the population and, of course, what we know about seniors today is that, half of – 50% of adults, have a chronic condition, more than one chronic condition. In Medicare, what we also know is that the number of seniors who have six or more chronic conditions is growing, and the interesting thing about that is that more and more seniors are living with serious multiple chronic conditions than ever before. It’s kind of good news for us, right? So we all hope to be able to achieve is maybe not to get those conditions but, if so, to live with them and live with them as comfortably as we possibly can. So what’s important about Medicare is, of course, it was set up as a fee for service system, and it was set up to basically, in the beginning, pay for catastrophic cost, hospitalizations in particular. That does matter still. You can have serious conditions. You can have episodes that are really costly. But the fact is, that the high cost now to Medicare are the beneficiaries who have multiple chronic conditions and need attention and use most of the resources. So you’re talking about 10% to 15% of beneficiaries, the cost is 50% to 60% of the cost Medicare is spent on 10% to 15% of the people on Medicare. That’s a big deal. It means we should be doing several things. We should be doing what Medicare Advantage does, which is focus on the beneficiaries who need it the most, be able to offer, because of the capitated system rather than a fee for service system, change the incentives for providers, change the incentives for through the home care delivery system, to move from episodes of care that are high cost to how do you actually lower cost, be cost effective, and be able to use dollars effectively for people with chronic conditions. It’s a very different mindset. It’s a very different delivery system. And that’s what’s exciting that is happening right now. Medicare Advantage covers about 19 million people. It’s a third of Medicare, so it’s not like a little program over there, it is a very important part of Medicare and it is changing the service delivery for seniors from attention to fee for service episodic care, to one that actually looks at the patient and the patient’s needs over time. And can rule out, to a certain extent, the dollars available – we’ll talk more about how to do that – the dollars available in a capitated system. So when you change the incentive to incentivize outcomes and not just what you do to people it really changes care for seniors with chronic conditions. It already is showing reduced hospitalizations, reduced lengths of stay, more care in the home, and more attention to a broader definition of healthcare. I understand you talked about that a little bit this morning. It isn’t just about the clinical needs, although getting more integration across specialties is a good thing for people with chronic conditions, but understanding that your primary care physician, your specialist can tell you to do something, but if you really don’t have the capacity to do any of those things you’re not going to get better. And so having clinicians, care teams, including non physicians, including care in the home, look at what patients want and need is really important to both more cost effective and improving the outcomes for these seniors. So I think there’s a lot of important work going on in Medicare that is, I think, potentially changing, voicing the effect in fee for service, changing the way seniors and people with disabilities get care. So it’s good news in a mix of moment where we are like all anxiously disagreeing with each other on just about everything in healthcare, so what’s exciting is that there actually is a lot of important work, innovations in care delivery. Like about VBID. You’ll hear about telemedicine. You’ll hear about care in the home. You’ll hear about involvement of different practitioners and different styles of care. Talk about risk stratification. All these things are changing healthcare for the better for our seniors and potentially for everyone else. JULIE APPLEBY: Kathleen, Medicaid is also playing a huge role and refresh our memory. There’s something like 70 million people on Medicaid right now, and some of them are young people, some of them are children, some of them are women, a lot of them are elderly in nursing homes. Talk a little bit about how Medicaid handles chronic conditions and what they’re doing to care for folks? KATHLEEN NOLAN: I mean, like Medicare, Medicaid has basically an outsized role when it comes to chronic conditions because we do cover disadvantaged populations. Most of those disadvantaged populations are disadvantaged by income, but they’re also disadvantaged by disease and by disability and so there are some real issues that have caused, for many years, a focus on how we handle chronic conditions in complex populations in the Medicaid program. So I think that’s really the point. I think you mentioned it, too. It’s not just older folks. We have a very diverse population and a very diverse set of needs in chronic care when it comes to the Medicaid population. We have children with special healthcare needs who have chronic conditions that are lifelong, and we’re managing them now. We could be managing them 30, 40, 50 years from now, so the arc of that is really challenging Medicaid to be responsive and to have those models of care that you need to deal with all of the issues that folks with chronic conditions really manage. You know, I think one of the things that has really brought Medicaid, in some ways to the forefront, is we’ve been dealing with these issues for a long time, and a lot of the conversations that we talk about now are about care coordination. They are about bringing the clinical world together to better manage chronic conditions, but we’ve also been talking for a long time about what we’ll call support systems and support services. We do this a lot in the long term care world where we provide personal care attendance, we provide transportation for individuals to get to the doctor when they need to. We provide a lot of support services. We even are getting into the field of dealing with housing. When individuals have a chronic condition and they don’t have anywhere to live, managing that chronic condition is practically impossible. So looking at this very holistic, very broad definition of care for individuals is exactly where chronic care is and where it needs to go. I think one of the biggest challenges, though, that we face in that space is those are the most formidable services when it comes to hard physical times. Those are the challenging pieces of hanging onto those support services and to that care coordination. When you come to brass tacks in a budget crisis, you look to go to your core essential services. You make sure that you can cover the hospital and the doctor and you call it quits. So really keeping that focus over difficult dynamic times in Medicaid is going to be a real challenge but really important. We are also seeing a lot more, I don’t want to call it mainstreaming of Medicaid, but we have this issue where we’re using a lot more of the managed care systems in order to get access for Medicaid people. That’s actually got an upside because we aren’t cordoning off Medicaid populations into just bare providers, just their systems. We’re getting more of the access to the kinds of tools and mechanisms and supports that managed care brings: care support, case managers, and other kinds of things. But we also still need to provide the supports in that environment. We’re not going to simply turn it into a regular managed care program that we would provide to everybody because Medicaid populations are different. So that’s one of the things that I wanted to mention and we can talk some more about is what does that relationship look like with managed care and Medicaid. But one other thing I wanted to mention, too, is in the last few years of Medicaid expansion and what I would call I’m less worried about the expansion part of it than basically we have populations for longer. We have less turn off of Medicaid and what does that do for our ability to do prevention and chronic care when we don’t have individuals who are rolling on and off of Medicaid? And so what does that say for us and how do we take that conversation forward as we think about managing these populations over the years? So I think in a lot of ways, Medicaid’s doing a great job. It is doing an exemplary job in thinking about how to manage chronic conditions and even prevent chronic conditions, but I think there’s a lot of challenges that remain and we really have to have a focus in this time that we don’t recede from the progress we’ve made when the fiscal times get difficult. JULIE APPLEBY: Okay. Thanks. And so let’s talk a little bit about benefit design. Mark, what are payers doing around benefit design and chronic conditions? MARK FENDRICK: So, first I’d like to thank Sarah and the Alliance for inviting me to bring the only Y chromosome to this panel, and the opportunity to talk about a common sense bipartisan reform idea as we enter a new dawn of healthcare transformation in this country. I find it very interesting as a practicing primary care physician, like my colleague over here, that the principle focus of healthcare reform in this town is cutting costs. I did not go to medical school to learn how to save people money. My nurse colleagues, my pharmacist colleagues—everyone in the healthcare system is kind of intrigued by the fact that health is no longer in this healthcare cost debate and, particularly, if I were to ask any of you about what we think we should be spending our trillions of dollars of healthcare dollars on we’re under-using all of them, whether it be prevention, whether it be diagnostic tests, whether it be management of chronic diseases—all of the things that are determined to be the quality metrics, the things that we should be buying, we’re actually underutilizing which makes it very unusual to come in this town to say we should be spending more on certain things as opposed to less with this pressure to do less of everything and lower prices on everything. And this comes at a very interesting time in the fact that the innovation that’s coming upon us, the opportunities that I have, and my colleagues, to improve individual and population health is truly enormous and is going to come at a great cost. And I think the difference between the Star Wars science, which I hope to be able to practice in a year or two, and the Flintstones delivery system in which I practice, is actually getting further away as opposed to closer, given the issues that were discussed by both Kathleen and Congresswoman Schwartz. So this, on top of the fact that the most common and popular health policy lever in this town now is cost sharing and making my patients, and making all of you, pay more for everything, right, whether it’s the high value services or the low value services and this comes, of course, at a time where there’s great consternation about healthcare costs which we cannot deny. I think a very important point is that Americans do not care about healthcare costs. They care about what it costs them. And I think this is why I have devoted over 20 years to the issue of consumer cost sharing and benefit designs and, you know, imagine the fact that we have done studies to show that these blunt cost sharing instruments that make everything cost more, people buy less of the low value services, which is why you have cost sharing, but people stop buying the things I beg them to do. They stop buying the things that I am benchmarked on. They stop buying the things that which my shared savings bonus in a capitated system is based on. So it makes no sense to me at all. And it shouldn’t come as any surprise is that the folks that are most impacted by raising cost sharing are those who are financially vulnerable and those who have multiple chronic conditions. So, I support consumer cost sharing. I support high co-payments and deductibles on the services that we should not be buying in the first place. Fortunately for us, but really unfortunately for us, that’s $500 billion in services that are not making any American any healthier. So it gives us kind of like a little wiggle room. So where do we come in here to support cost sharing, but most importantly, to drive better outcomes for my patients, which motivates me and most clinicians, is a smarter healthcare system of which we have something called clinically nuanced cost sharing. Let’s put cost sharing low or no amount for those services that make Americans healthier. Let’s put high levels of cost sharing on those services that don’t make us healthier, and that is implemented in something called Value Based Insurance Design, or VBID as Congresswoman mentioned. VBID very simply lowers cost sharing for the things that are important and raises them that aren’t. And it’s one of these things, and doing this for 20 years, my kids will never know what it is to sound like a broken record, but I think, Congresswoman, you know what that is. I’ve been promoting this idea of nuanced cost sharing for a very long time in 49 states and in this town for which it’s been accepted by multiple stakeholders, many of them here, and has the very, very rare designation as having bipartisan political support. One of the most popular aspects of the Affordable Care Act that Sue Nelson mentioned, which is 2713, which makes evidence based preventive services no cost to patients, that is the VBID aspect of the ACA. Republicans and Democrats support that. We have a Medicare Advantage Value Based Insurance Design demonstration test in seven states now, 10 states next year, bipartisan, bicameral legislation to expand this demonstration to lower cost sharing for evidence based services for people with specific chronic conditions to all 50 states. A bipartisan supported demonstration in the TRICARE program for the Armed Forces will be launched this January 1st, and there is bipartisan support to reform health savings accounts, to remove the crushing deductibles on evidence based services that both Democrats and Republicans are facing as millions of Americans are rolling in these high deductible health plans. Bipartisan legislation there as well as a draft and Executive Order that actually may move this idea that has been pushed by multiple stakeholders to make these plans smarter. So I’m hopeful that we will see a change in benefit design to make those services that are evidenced based, that the clinicians really know are important, more accessible but also focus on the waste in the system by making those services less so. JULIE APPLEBY: But, Rebecca, what do consumers with chronic conditions need from their coverage, and also we’re hearing a lot about co-pays and that kind of thing. I’m wondering, what’s your thoughts on putting that burden on consumers as well, to decide what’s high value and what’s low value, where are they going to spend their money? So what do they need and what are some of these choices that they’re facing? REBECCA KIRCH: That’s such a critical question. I think value based cased holds such promise if we focus it on what people want. And we first ask them, call me crazy, but you start with the consumer and what they want and in the context of healthcare, it’s a little bit of a hard frame for me to still grasp that people are consumers because usually it’s in the context of some sort of crisis and that’s not the time that you can make, go out and be a shoppable consumer. What people ultimately want is treatment that supports them as a person beyond their disease and what I’m encouraged by with the themes of today is that quality of life and functioning were high on the radar of this move and certainly out there in different care models that are being tested and innovations in delivery that focus on the person beyond the disease. And I think one of the opportunities we have, I think it’s a mistake when we think that cost shifting and sharing with patients is going to help make them better consumers because they’re in this vulnerable place where they really can’t be out making informed decisions. But, the health system can help support what we mean by value based care. And I think one of the fundamental foundations that we haven’t spent enough time thinking about, and I’d like to see policy around, is the communication skills that are really a learned aspect of good medical care, person centered communication skills that focus on the principles of palliative care that came up this morning. What’s important to you in the context of what’s happening to you? How can we help make you feel better while you’re working to get better? Our system is so oriented toward disease-focused care and specifically specialty care that focuses on one disease so that we’re talking about coordinated care is really important, but it’s much more than a buzz word in terms of what people need. So I think the opportunity to think about accreditation standards and training and payment incentives that focus on the skills training that clinicians need, to focus on the person beyond the disease, but also to equip patients and families with prioritizing – they already do in their own minds, their quality of life. My mother was diagnosed with ALS a few years ago. There were no treatment options, it was all about staying ahead of the game for her. So palliative care was her best friend to make sure that she could enjoy every moment, relish every moment, and was a short term but chronic illness, and that’s what most people want. They want to stay ahead of the game and be equipped with services in their community. That’s another theme I’ve been hearing this morning already. Community based care instead of hospital oriented care. Whole person care instead of disease centric care. That’s where I think value based care can help get us there and communication skills and emphasizing those as much as we do disease specialty treatment I think will make a big difference. JULIE APPLEBY: So a lot of talk about cost shifting and consumers paying more and having to pay higher co-pays and deductibles with the idea that hey, you know what, if you’ve got a bigger cost to go to the emergency room, maybe you won’t go there if you just have a sore throat, you’ll go to the urgent care center, etcetera, etcetera. So those kinds of things are in place, but can that work in a Medicaid program and are they trying it, and what are the specific challenges in Medicaid, given if it’s a fairly low income population? Are we seeing these attempts at cost shifting? Do they work? Is it fair in that population? I wonder if you could talk just a little bit about that. KATHLEEN NOLAN: Yes, we are trying it in the sense that on sort of a – not the kind of granular level that Mark is talking about. It is more of a big picture thing. Emergency rooms is one of the things that has been identified as the hope of a way of getting people to behave differently. It’s not a punishment, it’s supposed to be a behavioral shaping tool, right. It’s not a very – we don’t have a lot of evidence that this is going to be the way that we’re going to reshape the system. I think much more of the focus is on the idea of doing value at the provider level and at the insurance level than at the consumer level. I think that that’s part of the package often, that maybe a state is considering doing something like a co-pay, but it’s not the only thing we’re looking at and I do think that given the limited dollars that exist in most of these Medicaid populations it’s not going to be the tool that’s going to reshape the system. It might get rid of a very targeted problem. The value conversation is much less about the co-pays in the Medicaid space. It’s much more about how, as a purchaser, and you said this, I mean, we’ve got a lot of people in the Medicaid program. We’ve got 70 million people in the Medicaid program, that is huge purchasing power. And so one of, I think a much more critical focus in the chronic care environment is how do we use that purchasing power to do better with chronic condition management, and chronic condition prevention, and I think those are the kinds of conversations that are not the headline, they’re not making the headline, that’s what making the headline is the co-pay on emergency rooms, but the hard work of negotiating with managed care plans, of working with providers to get to that value equation is what’s going on in every state because it is the real winning opportunity is to get to the kinds of nuances that Mark is talking about. That is a very nuanced conversation. That is not an easy conversation. You can group all of these over here and everything over there and you go. It’s a real change. So how do states use that purchasing power in Medicaid to leverage a system that’s value oriented? Consumers should be part of that, but it’s the providers, it’s the managed care plans, it’s the state itself. JULIE APPLEBY: And, Allyson, are you seeing that? ALLYSON SCHWARTZ: I was going to say there is also an overlay of the dual eligibles, you know, there are 11 million people who are eligible for Medicare and Medicaid. And, yes, they’re low income by the nature of Medicaid so that itself adds some additional components to think about it in the healthcare system, or medical system should. But it is a real opportunity and we’re seeing a little shift in a number of ways of looking at how you provide care for people who are dually eligible, and they often do have multiple chronic conditions. They may not have had good care for many years. They might have, they may not have, and obviously there’s some other social determinants, other issues that they have that affect their ability to actually use the healthcare system the way they might. But then there’s special needs plans within the Medicare Advantage which is geared specifically for dual eligibles, low income, or people with very serious chronic conditions, or who are already eligible for institutionalized care. And to your point, people want to stay home, okay, how do you do that if you are poor and have multiple chronic conditions and ready to go in a nursing home, or almost, how can you do that? How can you stay in the home? Where are the providers? How do make the connection? JULIE APPLEBY: Are these special needs programs available in traditional Medicare as well as Medicare Advantage? ALLYSON SCHWARTZ: No, they’re specific to Medicare Advantage. JULIE APPLEBY: And so what additional services do people get if they’re in one of these plans and how does that help? ALLYSON SCHWARTZ: That actually is a really good point. Actually they don’t get additional services. It’s about organizing the services that they have access to, so it actually isn’t paid more than somebody in traditional Medicare Advantage, it’s paid the same, but they are giving the authority to the little more leeway on how they organize it and they’re actually required to have an approved model of care that points to do you have care coordination? Are there care managers? Are there tailored benefits? Do you specialize and have an individualized care plan for beneficiaries? So the idea is to really focus on those who are duals or have chronic conditions, or as I say … And what’s interesting is what the 2.4 million people in special needs plans. That’s a lot of people. It’s grown pretty quickly. But it shows how, also, if you can really parlay some of the benefits of Medicaid that don’t exist in Medicaid, and there are, and really coordinate those, then you can get the person to the doctor’s office and they don’t call 911 a month later being sicker. They may not even go to the urgent care center because there’s a co-pay there. And they may be not in their neighborhoods. We sort of forget about that. Who has access to care also depends on what’s available to you, but actually they can, in some cases, they want to be able to provide transportation. In some cases they do it. In fact, there’s a bill that just got voted out of Ways and Means that reauthorizes SIPs, which has to be done before the end of the year otherwise they go away, and there’s really good strong bipartisan support to do that, but also adds that there actually will be greater flexibility given to Medicare Advantage plans in the use of their supplemental benefits because they’re finding that the definition is too narrow. If they want to offer transportation, they can’t. If they want to – well, you’ll talk more about this – they’ll co-pay for medication. You know, that inhaler maybe costs a $30 co-pay, or $50. You don’t have that you end up in the ER about once a month and probably hospitalized if you’re COPD. So we know this. We know it’s a cheaper way to go and we like to be able to have that flexibility JULIE APPLEBY: They can’t always do it. ALLYSON SCHWARTZ: Exactly. So I think that kind of notion. Again, this is very individual – looking at the individual, what do they need. To your point, it also says you’ve got to engage the patient and you’ve got to engage the caregivers in this conversation about what does the patient want, you know, what do they expect, what do they have the capacity to do, what kind of help do they need to get it. And that discussion is, in some ways, I feel like the one that always circles around healthcare but now we’re saying, okay, you know what, it makes sense for us to pay for some of these things. Wish there were more supports broadly, but at least let’s send an aide when you leave a hospital so you don’t come back in 30 days. That’s not going to happen otherwise. Let’s do a different kind of wound care, let’s do different kind of support services as part of better Medicare Alliance. We’re an alliance of, well, it’s now 89 organizations. We have the YMCA, we have Meals on Wheels. You know, the demonstration program that showed if you delivered frozen meals, 10 of them post hospitalization for frail poor elderly, they did not come back to the hospital as often. It was something like a 30% or 40% reduction. That’s enormous. And that’s 10 frozen meals, and it’s also somebody eyeballing the patient and talking to the a little bit. But we’re seeing this with the exercise programs we thought were probably frivolous. Turns out it helps if you’re diabetic. We talked about that a bit this morning with the diabetes prevention program. So really understanding. It’s hard to have – it’s a rare person who absolutely follows every instruction that they are given, whether you’re poor or you’re not, and so getting a little help to make sure you do it, but particularly if you don’t have those supports is really important. JULIE APPLEBY: So, Mark, could you describe what a high value service is and who decides that and then, what are the current incentives to pursue those high value services and what are the disincentives, and are they falling mostly on the payers or on the consumers. Big question. MARK FENDRICK: Big question. Who decides has come up from the very first time that Michael Turner and I came up with this idea: more of the good stuff and less of the bad stuff. The good news is, is that there have been organizations doing quality metrics long before we’ve been talking about value based insurance design. So this is the National Commission on Quality Assurance, the National Quality Forum – everyone, especially foundations, including the cardiologists and the dermatologists and the radiologists. They all have metrics that have been available for a long time. I hope we have a conversation very soon that we’ll be able to push beyond what I call the low-lying fruit below the ground services for which Americans are not covered well and increasingly covered less generously. Such as everyone, including on Capitol Hill, knows that diabetics need to have access to an eye doctor. So the diabetic eye exam has been on any quality metric, every one that I’ve seen for over 20 years. So first off, in commercial plans, that 90% of diabetics have the same coverage for eye exams as non diabetics and actually the coverage is getting worse, and in Medicare, because of the ant