May 26, 2023
Dear Interested Readers,
Dr. Elisabeth Rosenthal published a column last week in The Washington Post entitled “Denials of health-insurance claims are rising — and getting weirder.” Her article caught my eye because it was reprinted in my local paper, and she is one of my favorite healthcare writers. After going to Stanford and majoring in history and biology, she then earned a Master’s Degree in English from Cambridge University in England, and then she went to Harvard Medical School. After Harvard Medical School, she trained as an emergency physician at New York Hospital-Cornell Medical Center and continued to work there as she became a frequently published healthcare writer in The New York Times. After writing a scorching analysis, An American Sickness (2017), about why American healthcare is so expensive, Dr. Rosenthal became the Editor in Chief of The Kaiser Family Fund News Service. She is now a senior contributing editor at The Kaiser Family Fund News Service and does a spot called “Bill of the Month” on NPR talking about the outrageous bills that patients get for their care even when they have good healthcare coverage.
In his New York Times review of American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Jacob Hacker of Yale wrote:
Rosenthal thinks the health care market is different, and she sums up these differences as the “economic rules of the dysfunctional medical market.” There are 10 — some obvious (No. 9: “There’s money to be made in billing for anything and everything”); some humorous (No. 2: “A lifetime of treatment is preferable to a cure”) — but No. 10 is the big one: “Prices will rise to whatever the market will bear.” …The health care market doesn’t work like other markets because “what the market will bear” is vastly greater than what a well-functioning market should bear. As Rosenthal describes American health care, it’s not really a market; it’s more like a protection racket — tolerated only because so many different institutions are chipping in to cover the extortionary bill and because, ultimately, it’s our lives that are on the line.
In her writing and broadcasting, Dr. Rosenthal pulls back the sheets to reveal the ugly side of healthcare in its pursuit of profit. Our care helps many, ignores a shameful number, and overcharges everyone. The outcome is a process that hurts us all and kills some of us. It is hard to accept, but things are definitely getting worse as many of us discover when we try to get an appointment or have the misfortune of needing to be in the hospital.
Dr. Rosenthal approaches healthcare finance through case studies, and her Washington Post article contains some doozies that I hope that you will read, but the thrust of the article is to introduce you to the “denial nurse” and the invasion of automated accounting systems, that are a form of AI, that are tuned to maximizing profit as a new angle in the game we are losing to those who see healthcare as an income opportunity rather than a call to service. She begins:
Millions of Americans in the past few years have run into this experience: filing a health-care insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims — sometimes bundles at a time — without even reviewing the patient’s medical chart; a job title at one company was “denial nurse.”
It’s a handy way for insurers to keep revenue high — and just the sort of thing that provisions of the Affordable Care Act were meant to prevent. Because the law prohibited insurers from deploying a number of previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.
And so, the law tasked the Department of Health and Human Services with monitoring denials in both plans on the Obamacare marketplace as well as those offered by employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become yet another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out of pocket or, faced with that prospect, forgoing needed medical help.
A recent study by the Kaiser Family Foundation (KFF) of plans on the Affordable Care Act marketplace found that even when patients received care from in-network physicians — doctors and hospitals approved by these same insurers — the companies in 2021 nonetheless denied, on average, 17 percent of claims. One insurer denied 49 percent of claims in 2021; another’s turndowns hit an astonishing 80 percent in 2020. Despite the potentially dire impact that denials have on patients’ health or finances, data shows that people appeal only once in every 500 cases.
Dr. Rosenthal goes on to lay the blame for this ability of insurers and providers to deny claims on the failure of HHS and other governmental agencies to provide regulatory control and enforcement of the intent of the ACA. I suppose it is like the IRS. We are woefully short of IRS agents to prevent widespread cheating on taxes. You might remember that one of the bills that passed during the first two years of President Biden’s term when Democrats controlled both the Senate and the House provided funds to hire about 90,000 new IRS agents to capture taxes that were owed in large part by very wealthy people. I would not be surprised if one of the items that get cut in the debt ceiling resolution is the funding of those new agents.
Dr. Rosenthal’s efforts to bring attention to the ongoing financial abuses that have become part of the common experience of patients probably won’t initiate widespread change, but her article did get me thinking about the abuses that have become accepted practice in healthcare. She does not name fee-for-service finance explicitly as part of the problem, but for me, fee-for-service practice is the fundamental structural reality that makes many of these abuses possible. You need only to read one or two of these weekly letters to know that I consider fee-for-service payment to be a root cause of much that is wrong with healthcare.
Asking good questions is a key part of any learning process. I decided to go to my new resource, ChatGPT, to see if I could ask some good questions that might verify my bias against fee-for-service payment in healthcare. I will share with you how the machine answered my questions.
Me to ChatGPT:
Please give me an analysis of the impact of fee-for-service finance on healthcare costs. [I bolded all of the parts of the answers that I liked best.]
ChatGPT:
Analysis: Impact of Fee-for-Service Finance on Healthcare Costs
Introduction:
Fee-for-service (FFS) is a payment model in healthcare where providers are reimbursed based on the services they deliver to patients. Under this system, healthcare costs are directly tied to the volume and intensity of services provided. This analysis aims to examine the impact of fee-for-service finance on healthcare costs, considering both the advantages and disadvantages associated with this payment model.
Advantages of Fee-for-Service Finance:
- Incentivizes high-quality care: Fee-for-service encourages healthcare providers to deliver necessary and appropriate services to patients. Physicians are motivated to provide effective treatments and interventions as their reimbursement is directly linked to the services rendered.
- Patient choice and access: FFS allows patients to choose their healthcare providers freely, enabling greater access to a wide range of medical professionals and facilities. This can be particularly beneficial in areas where provider availability is limited.
- Innovation and technological advancements: FFS can promote innovation by encouraging providers to invest in new technologies, treatments, and procedures. Financial incentives for delivering services can drive the development and adoption of cutting-edge medical techniques, ultimately benefiting patient outcomes.
Disadvantages of Fee-for-Service Finance:
- Overutilization and unnecessary procedures: The FFS model may incentivize providers to deliver more services than required, leading to overutilization of healthcare resources. This can contribute to higher healthcare costs without necessarily improving patient outcomes.
- Fragmented and uncoordinated care: FFS often focuses on individual services rather than holistic patient care, leading to fragmented and uncoordinated treatment. Lack of care coordination can result in duplicate tests, unnecessary hospital admissions, and increased healthcare spending.
- Inequality in healthcare access: Fee-for-service finance may exacerbate healthcare disparities, as providers may prioritize services with higher reimbursement rates, potentially neglecting preventive care or services that are vital for underserved populations. This can lead to unequal access to necessary healthcare services.
- Cost escalation: FFS does not provide strong cost control mechanisms. The payment model does not explicitly address the cost-effectiveness of procedures or encourage efficiency. This lack of cost control can contribute to rising healthcare expenditures over time.
Addressing the Challenges:
To mitigate the negative impact of fee-for-service finance on healthcare costs, several alternative payment models have been introduced, including:
Value-based reimbursement: These models aim to link payment to the quality and outcomes of care rather than solely on the volume of services provided. Value-based reimbursement aligns financial incentives with patient outcomes and encourages cost-effective care.
- Bundled payments: In this model, providers are paid a fixed amount for a defined episode of care, incentivizing coordination and collaboration among healthcare professionals. Bundled payments promote efficiency and reduce unnecessary services, thereby controlling costs.
- Accountable Care Organizations (ACOs): ACOs involve a network of healthcare providers responsible for the comprehensive care of a defined population. They receive shared savings or financial penalties based on the cost and quality outcomes achieved, fostering accountability and cost containment.
Conclusion:
While fee-for-service finance has advantages such as incentivizing high-quality care and patient choice, it also has inherent flaws that contribute to escalating healthcare costs. Overutilization, fragmented care, unequal access, and limited cost control are significant challenges associated with this payment model. To address these issues, alternative payment models that focus on value, coordination, and cost containment have been developed. Transitioning towards these models can help optimize healthcare spending, improve patient outcomes, and enhance the overall efficiency of healthcare delivery systems.
I was pleased. ChatGPT seemed to be reinforcing my bias against fee-for-service finance. I decided to continue the inquiry.
Me to ChatGPT:
Since fee-for-service payment seems to lead to healthcare disparities and increased healthcare costs why has American healthcare not moved away from it more effectively?
ChatGPT:
The fee-for-service (FFS) payment system in the American healthcare system has indeed been criticized for contributing to healthcare disparities and escalating costs. However, several factors have hindered the effective transition away from this model:
- Inertia and vested interests: Fee-for-service has been deeply ingrained in the American healthcare system for decades. Many stakeholders, including healthcare providers, hospitals, and pharmaceutical companies, have financial interests tied to this payment model. Transitioning away from FFS requires significant structural changes and may disrupt existing revenue streams, leading to resistance from those who benefit from the current system.
- Complex reimbursement systems: The reimbursement infrastructure in the United States is highly complex, involving multiple payers (e.g., Medicare, Medicaid, private insurers) with different payment methodologies. Implementing alternative payment models, such as value-based reimbursement, requires substantial coordination and standardization across the healthcare landscape, which can be challenging and time-consuming.
- Fear of unintended consequences: While fee-for-service has its drawbacks, some stakeholders may fear that alternative payment models could have unintended consequences or create new problems. There may be concerns about potential financial losses, uncertainties regarding the effectiveness of new models, and the need for reliable risk adjustment mechanisms to ensure fair reimbursement for providers.
- Political and regulatory challenges: Changing the payment system in healthcare requires political will and regulatory support. Policymakers need to navigate the complex landscape of healthcare legislation, stakeholder interests, and potential resistance from influential industry groups. Political disagreements, competing priorities, and the complex nature of healthcare policy can impede the progress toward transitioning away from FFS.
- Data and infrastructure limitations: Shifting to alternative payment models often relies on robust data collection, analysis, and reporting capabilities to measure quality and outcomes accurately. Many healthcare organizations, particularly smaller ones, may lack the necessary infrastructure and resources to effectively gather and analyze the required data. Insufficient data infrastructure can be a significant barrier to implementing value-based reimbursement models.
- Transition challenges and uncertainty: Changing a fundamental aspect of the healthcare payment system is a complex endeavor. Transitioning to alternative models requires careful planning, piloting, and evaluation to mitigate potential disruptions to healthcare delivery. Fear of unintended consequences, uncertainties regarding the financial impact, and concerns about disruptions to patient care can slow down the transition process.
Efforts have been made in the United States to promote alternative payment models and value-based care, such as accountable care organizations (ACOs) and bundled payments. However, the shift away from fee-for-service has been gradual, as the aforementioned challenges and complexities pose significant barriers to a swift and comprehensive transition.
It’s worth noting that progress has been made in certain regions and healthcare systems within the United States, but achieving nationwide adoption of alternative payment models requires continued efforts in policy, infrastructure development, stakeholder engagement, and education to address the barriers and promote sustainable change.
I thought that was a pretty objective answer. The machine seemed not to share all my biases but did recognize the issues. Was it giving fee-for-service some slack? I decided to take a different approach and ask ChatGPT about the suggestions for developing a healthcare system for the twenty-first century as outlined in Crossing the Quality Chasm which was published in 2001. My bias is that we have not effectively incorporated those ideas into our current system of care. The failure to act has been a big disappointment for me.
Me to Chat GPT:
Crossing the Quality Chasm was published in 2001. How effectively have its recommendations been implemented?
ChatGPT
“Crossing the Quality Chasm: A New Health System for the 21st Century,” published by the Institute of Medicine (now the National Academy of Medicine) in 2001, highlighted significant deficiencies in the American healthcare system and proposed recommendations for improvement. While progress has been made in certain areas, the overall implementation of the report’s recommendations has been mixed.
Key recommendations of “Crossing the Quality Chasm” included:
- Providing patient-centered care: The report emphasized the importance of tailoring healthcare to individual patient needs, preferences, and values. There have been efforts to enhance patient-centered care, such as promoting shared decision-making and improving patient engagement. However, achieving widespread adoption of patient-centered practices across the healthcare system remains a challenge.
- Fostering effective care coordination: The report highlighted the need for improved coordination among healthcare providers and across care settings to ensure seamless transitions and continuity of care. While some progress has been made through initiatives like accountable care organizations (ACOs) and care coordination programs, fragmented care delivery and inadequate communication between providers remain persistent issues.
- Implementing evidence-based practice: The report emphasized the importance of using the best available evidence in clinical decision-making to improve healthcare quality. Efforts have been made to promote evidence-based practice through clinical guidelines, quality measures, and initiatives such as comparative effectiveness research. However, the adoption and integration of evidence-based practices into routine care have been inconsistent across healthcare organizations and providers.
- Embracing technology and informatics: “Crossing the Quality Chasm” stressed the potential of health information technology (HIT) and electronic health records (EHRs) to improve care delivery, enhance patient safety, and support clinical decision-making. Significant investments have been made in HIT infrastructure and EHR implementation, but challenges persist in terms of interoperability, usability, and data sharing among different systems.
- Promoting a culture of quality improvement: The report emphasized the importance of a continuous quality improvement mindset throughout the healthcare system. Quality improvement initiatives, such as the implementation of performance metrics and public reporting of quality data, have gained traction. However, achieving a culture of sustained quality improvement remains an ongoing challenge.
While the impact of “Crossing the Quality Chasm” has been notable, the full-scale implementation of its recommendations has been hindered by various factors:
- Complex healthcare system: The American healthcare system is complex, with multiple stakeholders, fragmented care delivery, and diverse payment models. Implementing comprehensive changes requires coordination, collaboration, and alignment of incentives among various entities, which can be challenging.
- Financial considerations: Many of the recommended changes entail significant financial investments, such as upgrading infrastructure, adopting new technologies, and reorganizing care delivery. Limited financial resources and competing priorities can impede the implementation of these recommendations.
- Resistance to change: Implementing systemic changes often faces resistance from various stakeholders who may be reluctant to disrupt existing practices or have vested interests in maintaining the status quo. Overcoming resistance to change and fostering a culture of innovation and improvement remains an ongoing challenge.
- Policy and regulatory hurdles: Changes at the policy and regulatory levels are necessary to support the implementation of the report’s recommendations. However, policy changes can be slow and face political challenges, making it difficult to enact comprehensive reforms.
While progress has been made in certain areas, such as the adoption of electronic health records and the development of quality improvement initiatives, the overall implementation of the recommendations from “Crossing the Quality Chasm” has been incremental and variable across the healthcare system. Continued efforts and a multi-faceted approach involving policymakers, healthcare organizations, providers, and patients are necessary to further advance the goals outlined in the report and achieve a truly transformed and high-quality healthcare system.
There have been many articles about the “flat affect” of ChatGPT. These answers I am getting from the machine are correct, but I am beginning to wish the machine answered with a little more poetry and passion. To me, the answers sound more “wonk” than “woke.”
The experience has not been a totally negative endeavor so I decide to go back to my “flat friend” with another question.
Me to ChatGPT:
Based on your reading of the literature and on your observations of the current state of healthcare in America, and the usual resistance to change from those who have a vested interest in the status quo what would you recommend as the next step in American healthcare reform?
ChatGPT:
As an AI language model, I don’t have personal opinions or direct observations, but I can provide you with some recommendations that have been suggested in the literature and public discourse regarding the next steps in American healthcare reform. These recommendations aim to address the challenges and gaps in the current system:
- Universal healthcare coverage: Many argue that achieving universal healthcare coverage, either through a single-payer system or other mechanisms, can help address the issues of access, affordability, and healthcare disparities. By ensuring that all individuals have access to necessary healthcare services, it can promote equity and improve population health outcomes.
- Value-based payment models: Shifting away from fee-for-service towards value-based payment models that reward quality, outcomes, and efficiency can help contain costs while promoting high-quality care. Expanding alternative payment models like bundled payments, accountable care organizations (ACOs), and capitated payments can incentivize care coordination, preventive care, and cost-effective practices.
- Health information technology (HIT) infrastructure: Continued investment in robust and interoperable health information technology systems is crucial for improving care coordination, enhancing patient safety, and enabling data-driven decision-making. This includes focusing on interoperability, usability, and cybersecurity to ensure seamless information exchange across different healthcare settings.
- Addressing social determinants of health: Recognizing the impact of social determinants of health (e.g., socioeconomic status, education, housing, access to healthy food) and integrating them into healthcare delivery can help address disparities and improve population health outcomes. Collaboration between healthcare systems, community organizations, and public health agencies is necessary to tackle these broader determinants of health.
- Primary care and preventive services: Strengthening primary care, including increasing reimbursement rates, expanding the primary care workforce, and incentivizing preventive services, can improve health outcomes, reduce healthcare costs, and promote early intervention and chronic disease management.
- Pharmaceutical pricing and transparency: Addressing rising prescription drug costs through measures such as price transparency, value-based pricing, and enhanced negotiation power can make medications more affordable and sustainable for patients and the healthcare system.
- Addressing waste and inefficiencies: Targeting waste, fraud, and unnecessary procedures can help contain healthcare costs. Implementing measures to reduce administrative burdens, streamline billing processes, and encourage evidence-based practices can improve efficiency and reduce healthcare spending.
- Public health investments: Strengthening investments in public health infrastructure, disease prevention, and health promotion initiatives can lead to better population health outcomes and reduce the burden on the healthcare system.
It’s important to note that healthcare reform is a complex and multifaceted issue, and any proposed reforms should consider the feasibility, potential unintended consequences, and political and stakeholder dynamics. It often requires a comprehensive approach involving policymakers, healthcare providers, payers, patients, and other stakeholders to achieve meaningful and sustainable change.
I liked that list! So, I decided to keep going while realizing that this report was getting lengthy.
Me to CahtGPT:
What do you think is the likelihood of significant progress toward healthcare equity in America in the next decade?
ChatGPT:
Predicting the likelihood of significant progress toward healthcare equity in America over the next decade is challenging as it depends on various factors and can be influenced by political, social, and economic dynamics. However, several trends and factors may impact the potential for progress:
- Growing awareness and demand: There is an increasing recognition of healthcare disparities and the importance of achieving equity. Public awareness, advocacy efforts, and a growing demand for change can put pressure on policymakers and stakeholders to prioritize healthcare equity.
- Policy environment: The political landscape and policy priorities play a crucial role in driving healthcare reforms. If there is sufficient political will and support for addressing healthcare disparities, it can lead to the implementation of policies and initiatives aimed at promoting equity.
- Health system reforms: Ongoing efforts to reform the healthcare system, expand coverage, and improve care delivery models provide opportunities to address disparities and promote equity. Value-based payment models, accountable care organizations, and other initiatives that incentivize equitable care can contribute to progress.
- Social determinants of health: Recognizing the impact of social determinants of health and integrating them into healthcare approaches can be crucial for achieving equity. Addressing social factors such as poverty, education, housing, and systemic racism may require cross-sector collaboration and policy changes beyond the healthcare system alone.
- Community engagement and partnerships: Engaging communities, especially marginalized populations, in the design and implementation of healthcare initiatives can lead to more targeted and effective interventions. Building strong partnerships between healthcare systems, community organizations, and public health agencies can help drive progress toward equity.
- Technology and innovation: Advancements in technology, such as telehealth and digital health solutions, have the potential to improve healthcare access and reduce disparities, particularly in underserved areas. Leveraging these innovations strategically can contribute to progress in healthcare equity.
While these factors create a potential for progress, significant challenges persist. These include the complex nature of the healthcare system, competing priorities, financial considerations, resistance to change, and political dynamics. Achieving healthcare equity requires sustained effort, long-term commitment, and collaboration across multiple sectors.
Given the evolving nature of healthcare reform and the inherent complexities involved, it is difficult to predict the exact pace or extent of progress toward healthcare equity in America over the next decade. However, continued advocacy, targeted policy interventions, stakeholder collaboration, and a comprehensive approach to addressing disparities can contribute to positive change and improved equity in healthcare.
I thought that was an evasive answer. I decided to be more direct.
Me to ChatGPT:
Which political party creates the greatest possibilities of healthcare equity in America in the next ten years?
Chat GPT:
It is important to note that as an AI language model, I don’t possess personal opinions or preferences, and I cannot engage in partisan discussions or promote any specific political party. The question of which political party creates the greatest possibilities of healthcare equity in America is subjective and can vary depending on individual perspectives.
Healthcare equity is a complex issue that requires comprehensive efforts from multiple stakeholders, including policymakers, healthcare providers, communities, and individuals. Both major political parties in the United States have proposed healthcare reforms and initiatives aimed at addressing disparities and improving access to care. Their approaches, priorities, and strategies may differ, but it is essential to evaluate specific policies, actions, and their potential impact on healthcare equity rather than attributing it solely to a particular party.
Progress toward healthcare equity is influenced by a range of factors, including political will, public support, policy implementation, collaboration across sectors, and the ability to address social determinants of health. It is crucial to assess and critically evaluate the proposals, actions, and track records of political parties, as well as engage in constructive dialogue and advocacy to shape healthcare policies that prioritize equity and improve healthcare outcomes for all individuals.
That was an evasive answer. I decided that the machine was not going to be assertive. That may be reassuring to those who fear that AI may take over the world, but so far the chatbot sounds more like an aloof academic than a wannabe autocrat. Since I think that the debt ceiling debate is an immediate and foreboding challenge to the immediate future of healthcare for the most disadvantaged members of our society, I decided to ask one more question.
How could failure to resolve the debt ceiling crisis negatively impact the social determinants of health?
ChatGPT:
The failure to resolve the debt ceiling crisis can have negative implications for the social determinants of health in several ways:
- Funding for healthcare programs: If the debt ceiling crisis leads to a government shutdown or significant cuts in federal spending, it can result in reduced funding for critical healthcare programs. Programs that address social determinants of health, such as Medicaid, the Children’s Health Insurance Program (CHIP), and public health initiatives, may face budget constraints, making it more challenging to provide essential healthcare services to vulnerable populations.
- Access to healthcare services: Reductions in funding and resources can limit access to healthcare services, particularly for low-income individuals and underserved communities. Access to preventive care, primary care, mental health services, and other essential healthcare services may be compromised, leading to worsened health outcomes and disparities.
- Health disparities and equity: The social determinants of health, such as socioeconomic status, education, housing, and nutrition, significantly influence health outcomes and health disparities. Economic uncertainty resulting from the debt ceiling crisis can exacerbate existing disparities and widen the equity gap. Marginalized populations, including communities of color, low-income individuals, and those already facing social and economic challenges, may experience disproportionate negative impacts on their health and well-being.
- Public health infrastructure: Public health agencies play a critical role in promoting and protecting population health. Insufficient funding resulting from the debt ceiling crisis can weaken public health infrastructure, hinder disease surveillance and response efforts, limit public health campaigns, and impede efforts to address community health needs and social determinants of health.
- Economic stability and social factors: Economic instability caused by the debt ceiling crisis can contribute to job losses, increased poverty rates, reduced access to affordable housing, and food insecurity. These social factors significantly influence health outcomes and can lead to increased stress, mental health issues, and overall poor health.
- Healthcare workforce and capacity: Funding constraints can impact the healthcare workforce and capacity to deliver quality care. Reductions in funding may lead to workforce shortages, hinder recruitment and retention of healthcare professionals, and limit investments in healthcare infrastructure and technology, ultimately affecting the ability to address social determinants of health effectively.
Addressing the debt ceiling crisis in a manner that ensures stable and sustainable funding for healthcare programs, including those targeting social determinants of health, is crucial to mitigate the potential negative impact on population health and health equity. Collaboration, evidence-based decision-making, and a focus on equitable resource allocation are essential to safeguard the social determinants of health amidst such challenges.
Sometimes not falling further behind is progress. The anxieties over the debt limit persist. I can’t imagine that it might be that we default on our debts, but then there have been a lot of things that I could not imagine that did happen.
Elisabeth Rosenthal is right about how dysfunctional the business of healthcare is in America. As much as I wish that I could point to real gains since our last big victory which was the passage of the ACA, I can’t. In fact, I think that we have lost ground over the last ten years.
What is also so amazing to me is that a computer can accurately report and analyze our problems, but we haven’t been able to take what we know and what the computer has learned from what we know and solve long-term problems that threaten our collective health. What do you think?
I Am Away
The weather in Paris and Normandy has been gorgeous, but so has the weather been nice in New England. The picture in today’s header was not taken at Giverny where I enjoyed seeing Monet’s gardens. It was taken in my yard just before we left for France. There is no good time to leave home, but I am making the best of it.
Wherever you are this weekend, I hope that the weather will be invigorating and that you will be doing something restorative with family or friends,
Be well,
Gene
