Zohydro ban: Disagreeing with Governor Patrick

Massachusetts Governor Deval Patrick is trying to ban Zohydro ER, a new prescription painkiller, under a state of emergency he’s declared to combat opiate abuse. I agree with the Governor that opiate addiction is a huge problem in Massachusetts (and many other places) but the attempt to ban sales of Zohydro is a bad idea that’s likely to have a negligible impact on the addiction crisis while potentially harming one of Massachusetts’ most important industries.

The argument against Zohydro ER (the ER stands for “extended release”) is that it promotes abuse by providing a higher dosage in one pill than comparable immediate release products and that it lacks tamper resistant features that could make the pill harder to abuse. That’s probably why the FDA’s own advisory panel voted overwhelmingly against approval and why the drug has taken so much heat.

Historically states don’t attempt to interfere with the FDA approval process, but Patrick argues that approval is only a minimum requirement for sale and that states are free to impose additional restrictions beyond what the FDA mandates.

Here’s why I think Patrick is misguided:

The drug does address an unmet need and has real benefits

  • It allows some people who need round-the-clock pain relief and who currently use immediate release drugs such as Vicodin to take fewer pills and to avoid Tylenol (aka acetaminophen or APAP) that is typically combined with hyrdocodone and which can harm the liver

The harms presented by this drug are not unique, and the formulation technologies available to deter abuse are not especially effective

  • Some painkillers –such as Oxycontin and Opana ER– have been reformulated to make them harder to abuse, but others including the generic version of Opana ER are available without tamper resistance
  • Search Google for how to defeat tamper proof Oxycontin and you’ll find simple and effective methods to do so. Sure there’s some value to adding such technologies but it’s no cure-all

It would be bad news to establish the precedent that states could place additional restrictions on approved drugs

  • It really perplexes me that Patrick would promote the idea that FDA approval is insufficient to allow a drugmaker to sell its product throughout the US. Is he nuts? It’s a novel idea, laughed at by the first judge –but who knows how other judges will rule and what other states will seek to do if the principle is established
  • It’s expensive and difficult to get a product from lab to market as is. And, regardless of the merits of the Zohydro ER situation, it’s a bad idea overall to make marketing a new drug even harder. Add more uncertainty, cost and hurdles and it will reduce investment in R&D and may eventually have an adverse impact on the availability of new products for patients. Massachusetts is home to many pharmaceutical and biotechnology companies, so I’m especially surprised Patrick would take this step, which is so contrary to the state’s economic interests

The FDA’s decision to approve Zohydro surprised me and many others. It may or may not have been the best decision. But it’s a bad idea for individual states to try to overturn the approval through unilateral actions.

By healthcare consultant David E. Williams of the Health Business Group

ICD-10 delay –I’m quoted in AIS Health

ICD-10 is grounded again

ICD-10 is grounded again

I was surprised –like many others– that the latest temporary “doc fix” bill also delayed the implementation of ICD-10 coding for a year or more. Everyone I know had expected the real deadline to be October of this year. We were told as much by CMS leader Marilyn Tavenner in her keynote address at #HIMSS14 in late February:

“There are no more delays and the system will go live on October 1. Let’s face it guys, we’ve delayed this several times and it’s time to move on.”

But she doesn’t run Congress and they decided to do their own thing.

AIS Health (Health Plans Are Not Happy After One-Year ICD-10 Delay Slipped Into ‘Doc-Fix’ Bill) asked me for my perspective on the delay:

David Williams, co-founder of the Health Business Group and MedPharma Partners consultancies and author of the Health Business blog, tells HPW that he thinks the consistent and public drumbeat of negative news that has come with the Affordable Care Act (ACA) rollout has something to do with the congressional action on ICD-10. “I think it actually ties into the challenges of the implementation of the ACA….People are wary of sudden switchovers after seeing the various delays in mandates of the ACA.”

If I had been lobbying for a delay (I wasn’t), I would have pointed to the disastrous launch of the federal –and some state– insurance exchanges under ObamaCare and said we don’t want to see something like that for ICD-10 in October, just before the elections. Delaying for a year or more will provide more time for testing, something the exchanges seemed to have skipped. I would also have pointed out that the administration has repeatedly pushed back deadlines, some at the last minute. That line of reasoning could have been persuasive to those on both sides of the aisle, and it’s my guess that such logic was employed.

Whoever paid their lobbyists to pursue this outcome must be pleased with their investment. I wonder if they’ll try for a further extension next year. If so, they’ll have to reveal themselves and face some strong counter lobbying by ICD-10 proponents, who won’t be caught sleeping twice.

photo credit: Chris Devers via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

GetWellNetwork CEO speaks about patient engagement

Michael O'Neil, CEO of GetWellNetwork

Michael O’Neil, CEO of GetWellNetwork

Michael O’Neil had the misfortune to contract non-hodgkin’s lymphoma while in graduate school. His medical outcome was good but his experience as a patient was not. He founded GetWellNetwork (GWN) to provide an interactive patient engagement solution to help patients move from dependence to independence in the course of their care. The company’s solutions are found in 200 hospitals and are credited with lowering readmissions, increasing staff responsiveness, and increasing patient satisfaction with pain control.

I caught up with Michael at #HIMSS14 in Orlando and asked him to tell his story.

By healthcare consultant David E. Williams of the Health Business Group

Should step therapy and prior authorization be outlawed?


In ‘Fail first’ fails patients in the Boston Sunday Globe, a patient with depression decries his health plan’s use of “step therapy,” which requires members to try less expensive drugs before switching to pricier products.  This is a brave article –the author is going public as a transgender man and as someone who suffers with depression– and I agree that he should not have to endure what he’s been going through. In his case the drug that worked for him was put onto the list of drugs requiring prior authorization. He had to spend endless time with the insurance company and get his doctor to advocate for him to keep him on his therapy.

The author would like to see insurance companies barred from using step therapy and prior authorization, “particularly when insurance companies are still turning profits on our premiums.” That’s a simple solution that will appeal to many readers. After all, the insurance company is standing in the way of what’s best and also inconveniencing the patient and doctor along the way. Yet this solution too simplistic and ignores the broader context in which this situation is unfolding.

As a society we’ve handed health insurers much of the responsibility for controlling costs, while also imposing a series of constraints on them that limit their scope of action. ObamaCare, which I support, takes this approach even further and puts the rest of the US in a similar position to where we are in Massachusetts.

In a more typical insurance business –like life insurance or liability insurance–  the insurance company succeeds by refusing to insure customers who are likely to file claims, increasing rates after claims are filed, and writing policies in such a way as to exclude most things that are likely to happen. There is regulation, but in general you’ll struggle to get life insurance if you’re about to die or if you flunk your medical exam, and your car insurance rates will rise if you get a speeding ticket or cause a crash. In many parts of the country, health insurance has worked like this as well.

But under RomneyCare and now ObamaCare, health plans can’t charge more for people with pre-existing conditions –such as depression– and can’t refuse to accept business even from customers who will definitely be unprofitable. Not only that, but even when insurers do a good job of controlling costs, their profits are capped due to minimum medical loss ratio regulations. If they don’t spend enough on medical costs then the excess premium is returned to the customer.

Before we place yet another restriction on cost containment methods for health plans, let’s look at the broader picture.

First, rising health care costs are a huge problem for employers, individuals and taxpayers. Have your raises been low for the last several years? It’s probably because your employer is paying more for health insurance instead of giving you a salary boost. Is your town having trouble balancing its budget and struggling to find funds to build new schools or hire teachers? A big driver is the rising cost of employee and retiree health care. So it’s really important to bring healthcare costs under control. Step therapy and prior authorization are reasonable ways to do it.

The price differences and impact on premiums are not trivial. The May 2014 issue of Consumer Reports compares prices of drugs before and after they go off patent. Two of the eight drugs on the list (Cymbalta and Abilify) are used for depression. One just went generic and the other will be generic next year. After three years off patent, Cymbalta is expected to cost $27 per month for the generic v. $538 for the brand, and Abilify $45 v. $900. In other words, these drugs will be 95% cheaper once the generic market kicks in. As someone paying insurance premiums, I would rather have someone use a product that costs 5% if it works just as well, including drugs that are generic right now.

Naturally, pharmaceutical companies will push newer, higher-priced products. That’s their job as profit-maximizing companies, and they have a wide array of marketing and sales tools available to them to make it happen. (Unlike health plans, pharmaceutical companies’ profits are not capped.) On the other side, the health plan needs a set of tools to deploy to keep things in balance. In today’s world of biologic drugs that cost tens or hundreds of thousands of dollars it’s prudent to expect most patients to step through a process of trying less expensive treatments first, especially when those treatments may work just as well or better and be less dangerous. If we want –as the author does– to have fully unrestricted access, then that would require some regulation of the price of drugs. Take that too far, however, and the incentive to develop new and innovative medicines will be compromised.

Step therapy and prior authorization are legitimate and even necessary tools. This doesn’t mean that these approaches shouldn’t be scrutinized. In particular, the author implies (although doesn’t come right out and say) that he went through a series of drugs before finding the one that worked for him. If that’s the case, then he shouldn’t be forced to go back and try ones that have already not worked for him. But it’s not clear that this is what’s happening.

Balancing cost, quality, access and convenience in today’s healthcare system is not easy. Making things better requires something more than legislating further restrictions on health insurers.
photo credit: torbakhopper via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

Give Boomer Esiason a break on birth comments

Retired football star and current radio host Boomer Esiason has opened the floodgates of righteous indignation by suggesting that the Mets second baseman should have encouraged his wife to have a scheduled C-section before opening day. That would have prevented him from missing the first two games of the season when he flew home to be with her.

Esiason got the blowback that he should have expected, and made a lengthy apology for his comments today.

I’m happy though, that this mis-step has turned into an opportunity to educate people about the dangers of early elective delivery. There’s actually been a major, successful effort underway to reduce the use of early elective deliveries. Such deliveries –either induced or scheduled C-sections before 39 weeks– represented 17 percent of births in 2010 (as high as 25 percent in some states). As of 2013 the rate has fallen dramatically, to less than five percent according to the New York Times.

It turns out babies born at 37 or 38 weeks have a lot more health problems then those born at 39 or 40  weeks, even though it doesn’t seem that such a short time difference should be so important. So I hope the reaction to Esiason helps to get this message across.

Esiason is getting the word out. Here’s what he said:

I’m very grateful to my many friends over at the March of Dimes who graciously reached out and re-educated me that if a pregnancy is healthy, it is medically beneficial to let the labor begin on its own rather than to schedule a C-section for convenience. In fact, babies born just a few weeks early have double the risk of death compared to babies born after 39 full weeks of pregnancy. As their promotional campaign says, ‘Healthy babies are worth the wait.’ And as a proud father, I couldn’t agree more.

I find it quite interesting how societal expectations about fatherhood have changed in the recent past. A generation ago, the notion of a father being in the delivery room was unheard of. Fifteen years ago I had a job interview with a large financial services company. The hiring manager (in his early 30s at the time) told me the job required an all out commitment, and that while he hoped to be present at the birth of his child, that wasn’t really the way things were prioritized there. I didn’t agree with that sentiment then, but it was the norm in many places.

So it’s interesting to me that Esiason took it for granted that the player would be present for the birth –he didn’t seem to question whether work should come first.

Esiason said the wrong thing, but I think we should cut him some slack. First of all, being a football quarterback is different from being a baseball second baseman. Baseball teams play 162 games per season, NFL teams only 16. A star quarterback plays every game, whereas even star baseball players get a day off from time to time. So maybe we can accuse Esiason of lack of empathy for thinking about how he would have behaved, not what a baseball player would do. But I understand his point about not wanting to miss a game.

Esiason is 52 and times have changed. He gets part of the new way of thinking –dad should be there for the birth. But he screwed up by suggesting unnecessary surgery. And while I don’t fault him for not knowing that earlier births aren’t good for babies, at least it gives people a chance to bring it up and make it known to a wider audience of would-be fathers who might otherwise not be paying attention.

By healthcare consultant David E. Williams of the Health Business Group


Office of Recovery: Avellone proposes strong response to substance abuse (transcript)

Joe Avellone (D), candidate for Governor

Joe Avellone (D), candidate for Governor

This is the transcript of my recent podcast interview with Joe Avellone, Democratic candidate for Governor of Massachusetts.

David E. Williams: This is David Williams from the Health Business Group. I’m speaking today with Joe Avellone, Democratic candidate for Governor of Massachusetts. We spoke previously about healthcare policy in general. We’re going to speak today about substance abuse.

Joe, it’s great to have you on today.

Joe Avellone: I’m pleased to be here. Thank you.

Williams: Joe, why are you making substance abuse such a high priority issue in the campaign?

Avellone: Well, this is an issue that is quickly becoming a major healthcare crisis in our state. We’ve always had addiction problems, of course, of various types. over our history. But with the development of the new powerful health, the new powerful oral narcotics that had been in the market for the past 15 years, we’ve seen a huge acceleration of young people who are very quickly addicted to these painkillers either by using them recreationally or if it’s just happening or even starting out with sports injuries. And from there, becoming so quickly addicted they move on to other things, in particular, heroin.

And this has been a new phenomenon. Over the past 15 years, the rate of prescribing these drugs had gone up 300% and the rate of actual overdose deaths and prescription pills had gone up 300% in the same time period. So we’re seeing something that is reaching significant public health crisis proportions. It’s really being driven by the use of these powerful oral prescription drugs that then lead to other kinds of addiction.

I have seen the human face of this all throughout the Commonwealth over the last year. I’ve been running for over a year and I’ve been in 130 cities and towns. It really comes up in lots and lots of communities. So it’s affecting lots of communities all across the Commonwealth, certainly in our big cities but also in our smaller towns. And it’s in particular affecting children at relatively young ages in their early to mid-teens. So they first experience this and often are addicted within weeks of starting to take some of these kinds of oral medicines.

Williams:   Talk a little bit more about this heroin issue because I’ve heard this as well. People start with oxycontin or something similar and then when their prescription runs out and they found out how expensive it is to buy those pills on the street, they end up on heroin. Is this just something people say for shock value or is it really happening in any significant numbers?

Avellone: No, unfortunately, it’s really happening in very significant numbers. The addiction potential for these powerful oral narcotics – oxycontin, even Percocet, the other kinds of new opiates – is so strong that within weeks of either experimenting or taking for a mild medical problem, the young people in particular are often addicted. And then, they start down this road of taking them out of their parents’ medicine cabinets or their neighbors, et cetera, and using them at parties. But soon, at $30 a pill, which is about what these things cost on the street, they become so addicted that they move to heroin. And heroin to them does not hold the fear that grips all of us who are a little older. It’s much cheaper than these pills at $7 a bag versus the $30 for a pill. It’s now so plentiful and easier to use than it used to be. So there is a very quick transition and before you know it, you have a lot of young people from middle class families who were playing by all the rules and, all of a sudden, went off the rails with taking these prescription drugs and then end up on heroin within months.

And then, the heroin itself, as you know, ushers in all kinds of other issues especially if it’s using needles. You’re exposed to all the blood-borne diseases and also the heavy addiction and the need to find more heroin.

Williams: Now, clearly, the state’s been paying some attention to substance abuse. What are we doing right and what are we doing wrong on this topic in Massachusetts at the moment?

Avellone: Well, we have a substance abuse department in our public health department and we have a drug monitoring program for these prescription drugs. But all of it is not nearly enough to be effective to combat what is really an epidemic.

And I think that’s the point and that’s why I formed the Office of Recovery. In the end, we’re going to need a lot more capacity. We need to do multiple things that we’re not doing now and we’re certainly not doing on the scale in order to meet the need that is out there.

Williams: Have you seen other states or other countries that are doing things better? Are we a laggard here or is it just that the problem has come up so quickly that others have not come up with a good response either?

Avellone: No, I don’t think we are a laggard in the traditional sense. I think if we’re viewing this as a traditional problem at the level that which we all thought it was affecting our population, our Bureau of Substance Abuse is doing an adequate job. But that is not where we are. What is happening is this is mushrooming, it’s affecting many more people. And we are not at all treating it in the way that we should: dealing with it as a crisis, which is really what it is.

Williams: You’ve announced a plan for this area. What are its key components?

Avellone: I’ve announced the formation of Office of Recovery. This will have to be at the state level because it affects so many towns and cities across our Commonwealth.  It has to be high in the Office of Health and Human Services, so it will be a direct report in the Executive Office. We’ll take in the current Bureau of Substance Abuse because those traditional roles that are being played there would need to continue, but we need to expand it.

The Office of Recovery will, first of all, increase our capacity. We do not have nearly enough capacity to deal with either detox or rehab or the sober houses along the spectrum. We need to reimburse our providers more to bring more capacity on line. Increasing capacity is the first part of this.

This Office will have a whole series of regional coordinators that will, in a very publicized way, make it possible for people to have one number to call and they know to call this number when they need treatment. One of the problems of intervention is making sure that the treatment is available and that people can get into treatment right when they need it, right when that window is open.

And we know that window’s not open very long. People, when they finally get the resolve that they can actually treat themselves, they have to move on to make a big change and we need to find them and they need to find treatment then. And that’s what the regional coordinators will do.

In addition, I’d like to staff them with people who’ve been in recovery. There’s a large recovery community that can be very helpful to people who are suffering from addiction and really help them clear the course and get into treatment.

In addition to standing capacity and the regional coordinators, we need to change the way insurance coverage works. Right now, part of the problem is gaps in insurance coverage and slow approvals. And that, once again, creates roadblocks in the system where people are stuck in detox because they can’t get to rehab or they’re stuck in rehab because they can’t get into the next step. Or they have to wait for approvals and if the approvals don’t come, once again, they fall back into their addiction and are lost.

Another key component of this is to move away from putting minor drug offenders in jail. Right now, we have many thousands of people in our county jails; about 75% of them are there for drugs or drug-related problems; and a large percentage of those are addicted. The males are in jail in these county jails for approximately a year, and they cost about $46,000 a year. If we were not putting people in jail and were using that money differently, which we will in my administration, that would cover a lot of treatment.

The vehicle for doing this is drug courts. We have about 21 drug courts around the Commonwealth. We need to have about 50, people estimate. We need to make sure we have it in every jurisdiction. These drug courts operate specialized programs that help people not only not go to jail but then move through their recovery and guide them through their recovery. Specialized courts cant do that.

And finally, we need to much more aggressively step up our drug monitoring. We do have a drug monitoring program but obviously, the prescribing patterns are not what they should be. We are over-prescribing either wittingly or unwittingly in a large amount. There are so many of these pills sitting around unused in medicine cabinets. That’s how the diversion occurs, especially with these young people.

I have heard so many stories from mothers and parents of addicted children, of the fact that they were getting prescriptions for wisdom teeth or other relatively minor ailments that they don’t even want. They have so many pills and would have these pills sort of sitting around. And this is a big problem.

So we have to be much more vigilant about our prescribing practices. I’m going to work with the Massachusetts Medical Society on education programs and also with the Board of Registration in Medicine to make sure we have people who are knowingly prescribing the things that they are appropriately dealt with.

So, these are the major components of my Office of Recovery but I want to go beyond that. I think we need to deal with this as a region as well.

Williams: Joe, we’ve been talking mainly about how these prescription narcotics are causing problems in terms of addiction leading to heroin. I want to ask you about two other substances and how and if they fit in here. One is alcohol, the other marijuana. I’ll separate those out.

Alcohol, often people talk about the large impact that it has relative to higher profile and scarier sounding substances. And then on marijuana, we seem to be on a path toward outright legalization as we’ve seen elsewhere, which seems to be going sort of in the opposite direction from a public health standpoint.

How would you view those substances fitting into the Office of Recovery?

Avellone: I think alcohol should be incorporated in that. I spent a fair amount of time in the treatment facilities, for example, the Dimock facility in Roxbury and also SSTAR, which is a wonderful facility in the Fall River area. And clearly, they treat alcohol as an addictive substance like the other drugs that they deal with. There are some differences but they accommodate those differences in the program. It clearly destroys lives just as surely as these powerful opiates do. So I do think that this is part of our issue and a problem that ought to be addressed to the Office of Recovery.

I feel a little bit different about the marijuana. I don’t think that would be the main focus of this right now because I want to deal with the more powerful and addictive drugs that are essentially killing people and ruining lives and destroying families right now. And that’s why, alcohol and in particular, these opiates, especially prescription drugs and then heroin.

Williams: When you put these plans in place for the Office of Recovery, what would be realistic or aspirational to expect the impact to be? Is it possible to really take this problem on or are we really just talking about taking a little bit off the edges of it?

Avellone: No, I think it really is possible. I think we have to understand how acute the problem is right now. Now, just to deal with the overdose deaths alone, which is certainly the tragic end state of this, we have had 11 overdose deaths per 100,000 of the population. So, that’s over 600 a year. And we know that’s just the tip of a very large iceberg of people whose lives are destroyed or being destroyed but are living and going through a living hell every day.

But just dealing with overdoses, those are the statistics. They’ve gone up to 11 per 100,00 from 7 1/2 per 100,000 just ten years ago. So, it’s rising rapidly. That’s a big change. We heard about the fact that we had 185 overdose deaths just in the last three or four months, and we know that was a very incomplete number because it didn’t even deal with Boston and Springfield, our major metropolitan areas. We know that even at 11 per 100,000, which has been released as statistics, it’s certainly going to be more than that next year and rising relatively rapidly.

So, I know this is an issue that we can definitely, if we treat it aggressively, do something right. We know that treatment plan works and we also know that right now, we’re not treating it adequately at all.

The biggest thing of all the Governor can do and which I would certainly do is to take the stigma away from addiction. I think part of why we treat this inadequately and why people don’t seek treatment is because of our attitude about it.

However, I think we now recognize that this is a health problem and this is something that the Governor needs to take the lead in. It’s not a moral issue. It’s a health issue and we have to treat it that way. If we can remove the stigma, then a lot of things become easier. Getting people into treatment, moving people away from jail sentences and enabling people to rebuild their lives, which they can if we can get them the right treatment.

Williams: Joe, you talked about the societal cost here and even some hards cost in terms of the cost to incarcerate someone. But in setting up an Office of Recovery like this, I’m sure there are new budgetary expenditures that are needed. What’s the order of magnitude of those and how do you finance such an effort?

Avellone: The cost is about $1,000 per person but the benefit to cost ratio of treatment is huge. Many studies show that it’s something like seven to one. And those benefits come from several different sources. First of all, let’s just start with jail. Right now, we’re putting literally thousands of mostly young people in jail for minor drug offenses related to their addiction. That’s at $46,000 a year because as I said, in the county jails, the males are there for about a year.

If we just, next year, incarcerate 500 less, then that’s a fraction of the 10,000 people that are in the county jails. That’s $23 million plus for treatment. So that covers an awful lot of treatment. Literally, incarcerating people less almost covers the whole total cost of the treatment. In addition to that, the healthcare cost is much less. If people are successfully treated, there are many fewer trips to the emergency room and they have many fewer other high costs due the healthcare issues that the population with addictions have.

So this is more about moving money in the budget that we already have because of new expenditures that we’re not incurring. And I believe that we can do this without a big increase in the budget. That’s why it has to be done as a high priority in the Governor’s Office because it’s going to take moving dollars away from some parts of our budget and into others. And doing that in a very, I would say, calculated way. It’s going to take leadership to do it but I think the analysis will bear us out that we can move the dollars and accomplish much.

Williams: Joe, you have been having a quite a comprehensive discussion here about issues of substance abuse in a Commonwealth and in your plans that will be able to address it. Are there topics that we have not addressed that we should do today?

Avellone: Thank you, David. I would like to talk about the regional initiative I’m proposing. I’m going to, once elected, pool together the other Governors and the whole Congressional delegation in the region. So with six states – that’s six governors, 12 senators and 21 congressmen – I believe that we can be more successful in some respects with this operating as a regional initiative.

And the first is to go put a lot a pressure in the FDA. The FDA needs to have a much higher safety profile when approving new narcotics. And I think this is a failing. I think they were essentially suffering now from something that they should have done ten years ago. I think going forward, we have to make sure that they’re not approving narcotics that are powerfully addictive and yet easily available. That really is what has led to this great acceleration.

I also believe we can put some pressure on the pharmaceutical industry as well.

As a region, we have a lot more clout to deal with the FDA and with the pharma industry. I also think we can work together to cut down on the smuggling of heroin. The second half of this is the fact that heroin is so available and young people in particular moved to it as prescription drugs become harder to find than the heroin. We need to shut down the heroin pipeline and I think we can do that more effectively as a region.

I think also as a region we can learn best practices from each other and potentially even share facilities to deal with the ups and downs of our capacity needs. So, I believe this is something that we can effectively treat as a region and I intend to lead our efforts to do that.

Williams: This is David Williams of the Health Business Blog. I’ve been speaking today with Joe Avellone. He’s been talking about substance abuse and has proposed an Office of Recovery to address these issues.

Joe, thank you so much.

Avellone: Thank you very much, David. It’s my pleasure to be here with you.

By healthcare consultant David E. Williams of the Health Business Group