Archive for March, 2017

Republicans pull their American Healthcare Act before a vote, and dodge a catstophe. But, their good fortune will be short lived without action before year’s-end.

March 30, 2017

There are a lot of folks pointing fingers at each other and casting blame upon conservatives for the House leadership’s decision to pull the AHCA. The Freedom Caucus is being criticized but the Republican Party should thank the Caucus for its courage and for honoring its commitment to voters. The AHCA would not have been successful in any of its goals and would have been a devastating burden to Republicans if it had passed not to mention the extra pain for all of us premium paying citizens.. 

Didn’t you think it was actually embarrassing to watch, over and over again, as proponents referred to the AHCA as a “repeal” of the ACA. How could anyone say with a straight face and a modicum of conscience that the AHCA was a “repeal” bill?

If passed, the AHCA would have left in tact the mandate for individuals yet no real incentive to enroll which would have decimated insurers and forced rates higher than they might otherwise have gone. The AHCA left the mandate for employers along with the burdensome annual reporting requirements intact. The AHCA addressed the “mandate” issue by setting the penalty to zero. These actions would have left intact the means for future Congresses to re-instate the mandate penalties thus re-instating the mandates for individuals and employers.

It also retained the Cadillac tax , the benefit mandates including the essential health benefits, and included no steps to expand ERISA or make selling across state lines a reality as well as many of the taxes and most of the premium increasing restrictions. There are many more aspects of the ACA left intact by the AHCA all of which would have caused premiums to continue to increase, discouraged insurers from participating, and allow future congresses to restart all of the ACA with little effort.

So, the Freedom Caucus saved their Republican colleagues butts (I meant major embarrassment) and certainly trouble in the 2018 elections. But this good fortune for the Republicans won’t last long if they don’t follow up with a real plan to repeal and replace before the end of 2017. If our citizens, especially the ones paying premium but receiving no subsidy, are still suffering from the burden of the ACA come January/February of 2018 then the elections in 2018 will be a disaster for Republicans. The Democrats will be able to take advantage of this Republican failure for huge gains.

Let’s face facts, the Republicans had 7 years to create a replacement for the ACA with Paul Ryan as Speaker for 2+ years. One would think that 7 years is more than enough time to craft a better product than they tried to force through and upon us last week.

But Dems should not cheer too long or too loudly  because without major corrections the ACA, which Dems currently own, will implode from its own ill-conceived creation causing untold harm to our citizens, providers, businesses and our economy. I’m not being political, merely stating the obvious.

Now, there is time and support for the Republicans to redeem themselves in the eyes of their supporters who heard the campaign promise over & over of “repeal and replace”. I know I make it sound simple but they do have a blank canvas on which to create the true replacement for a repealed ACA.

Let it start with the Repeal Bill that both Houses passed 15 months ago when it didn’t mean anything. But this time add the provisions to phase out Medicare expansion while phasing in the means to help the poor, phase in the tax credits and tax deductibility and so forth. They could add in all of the other provisions we have discussed in previous blog posts.

Do that and the “moderate” Republicans along with many moderate Democrats would be forced to stand side by side to support the bill. If it repealed the ACA entirely as the candidates promised, eased in the changes to state-run Exchanges and Medicaid with concern for our most vulnerable citizens, create provisions that allow small insurers to compete with the BUCAs, and expand ERISA, then it would pass. Plus, it would gain votes from a surprising number of Democrats, at least those in areas plagued with the ACA-caused trouble  of only one insurer and no real choices for citizens.

Didn’t it feel like the effort to push the AHCA was rushed and poorly prepared? Now, if they truly want to honor their commitment to voters, the Leadership can take action to repeal and replace in a timely yet thorough manner that brings people along with the legislature. Pushing the AHCA, as the proponents tried to do last week, smelled to much like the Democrat processes in early 2010 and late 2009. And wow did that smell, right?

Bernie Sanders says he plans to introduce a “Single Payer” bill in the Senate, for the umpteen time, so maybe the Republicans can introduce a free-market working reform solution that that doesn’t leave the less fortunate in a jam while giving the remaining 300,000,000 of us Americans access to truly affordable quality health plans.

Rather than criticize the House and Senate leadership for concocting the inadequate AHCA that would serve no purpose let’s focus on potential solutions and results.
After all that’s why it’s called “the Solutions Based Healthcare Blog”.

I’m interested in what you think and remember, we’re all in this together.

Mark Reynolds, RHU

The need for Tort Reform is often associated with increasing healthcare costs and premiums. Is it possible to eliminate the affects of “defensive medicine” with tort reform legislation?

March 23, 2017

For the past 30 years we have heard the cry for Tort Reform. Is it true that providers practice “defensive medicine” out of fear of malpractice lawsuits and does it impact the cost and manner in which providers render care. Tort reform and malpractice awards in California have been somewhat contained because of Tort Reform legislation in 1987, often referred to as the “napkin bill” which refers to the initial process in which two CA legislators drew it up. But, has it helped hold down healthcare costs and premiums?

Don’t worry, this Post is not about that CA legislation or even potential legislative language that might be included in the new American Healthcare Act. Personally, I think it is possible to add straight forward language to the AHCA that would limit malpractice lawsuits but it might not control healthcare costs and thus might not help lower premiums.

Why would I suggest that we can create language in legislation to limit malpractice lawsuits without affecting healthcare costs? Because I am, as we all need to be, a student of human nature which helps us predict the effect of legislation intended to change behavior. Sounds silly but it’s a fact and let’s review why.

By human nature I am referring to the habits one establishes either knowingly or not in our every day life to gain or avoid a certain outcome. Providers fall into a unique category and regardless whether their actions are life-saving or preventive in nature a doctor’s practice will develop habits that may not be easily changed. In a doctor’s world a patient might be in pain plus someone else is usually paying the bill.

That isn’t to say that legislation can’t stop certain human activity completely simply by creating consequences to a certain action. For example, the risk of paying a $175 ticket and increased auto insurance rates for driving while talking on one’s mobile phone seems to have made an impact on that behavior.

However, we must also realize that a doctor’s request for more tests are often more than defensive. They may truly be diagnostic in nature to assist in treatment decisions which add a dimension not common in the habits for most of us in society. For years insurers, self-funded employers and other experts have complained that doctors run-up costs by over prescribing diagnostic tests and procedures, such as MRIs for example, simply to avoid malpractice lawsuits. This is why & where the term “defensive medicine” was  first muttered.

Doctors do have two additional variables affecting their decisions. One variable is the patient who may be expecting or even demanding a battery of tests that the attending doctor does not think are necessary. It’s  common for doctors to treat patients who are truly suffering and may have been for months or years. In those instance, how does a doctor say no to a patient’s demand or even pleading request for more diagnostic procedures. The patient wants the doctor to prescribe immediate pain-relieving treatment. Most of us will never be in that dilemma requiring us to decide the appropriate level of diagnostic cost necessary to determine the correct path of treatment.

The second variable is that in most cases a third party is paying for the doctor’s bill. Sometimes extra tests might seem worthwhile to a doctor if it makes the patient feel better emotionally. Who among us can honestly say we would not prescribe more evaluation even if the cost of that extra evaluation would not lead directly to a better decision. Saying “No” to a patient is not always easy and remember somebody else is usually paying the bill.

Imagine for a moment that you are a doctor who has been forced to practice defensive medicine for 20+ years. You’ve had your Malpractice Insurer scare you with tails of tort awards. You’ve attended countless industry seminars at which the fear of malpractice lawsuits is emblazoned on your brain. Or maybe you work for a large corporate practice that wants to avoid malpractice suits but also enjoys the extra revenues earned by extra diagnostic testing. Imagine any of those situations; then you go back to your practice Monday morning to see patients. How would you overcome the habit of practicing  “defensive medicine”?

But here’s a twist to this story about Tort Reform. I actually believe that after doctors have had time to practice their chosen “healing” profession, in a non-threatening legal environment, that the level of care as well as the cost and outcome of care would be better than it is now. I also think that, in time, patients would start to be more satisfied with the level of care they receive and may even learn to be more interactive with the doctor than they are currently.

I am sure this sounds odd coming from an admitted cynic of human nature. But, while human beings may be flawed in many ways I believe human nature, at least concerning our own healthcare, could begin to do the right thing.

We’ve discussed before that healthcare costs are the summation of the unit cost of care multiplied by the number of units of care consumed. When we talk about Tort Reform and the power of human nature it is easy to see that controlling the resulting value  of that equation is not an easy calculation.

It sounds naïve to state publicly that a solution to healthcare reform which combines patients and doctors and payers then adds big pharmaceutical & medical device companies, plus attorneys and legislators would be an easy system to reform?
However, I think it is possible as you have read in previous posts.

The hard part will probably be convincing legislators that they should want to make a difference and improve our healthcare delivery system rather than just making a difference for their own career or party. Sorry for that one last bit of cynicism.

We still need to discuss what Tort Reform language can be fashioned into the AHCA. We’ll tackle that over the next couple weeks.

Let me know what you think.
And remember, we’re all in this together!

Mark Reynolds, RHU


Republicans released their Repeal & Replacement Plan. What’s being attacked and what’s missing that would make it work.

March 16, 2017

The Republican’s (Repubs) long awaited Repeal & Replacement (R&R) bill, The American Healthcare Act (AHCA, has been released. One did not need to be Carnac-the-Magnificent (for you Johnny Carson fans) to know how the press and the Democrats would respond. Heck, they were already predicting Armageddon and they had not seen anything except the stale talking points we all were tired of hearing. Hey, maybe they have a little Carnac in them, too.

Last week, as I said, I read the bill twice and no I’m not a lunatic. My first read was to look for certain highlights. The second read was with a notepad to write down and track amendments vs repeals and changes that made sense or not. I noted two pages single space worth of changes. My first summary was that the Repubs can’t really continue to include the word Repeal in their description of the bill. The second opinion was that it will be hard to fight for and defend.

Our politicians are so far apart that they often can’t see the good in something for fear it might not benefit themselves and this bill will not encourage too many Repubs to fall on their swords for it. That sounds pessimistic but don’t you know its true. So, let’s identify the talking points that are being used by the opposition press, pundits, and politicians after the release. We all know they have been working on their talking points just as carefully as the Repubs worked on the AHCA.
Then we’ll point out a few things in the bill that concern us and should be addressed.

First, we’ll look at the naysayer talking points:

  • 20 million Americans will lose their coverage.
  • People covered now will have their pre-existing conditions denied.
  • Millions may be forced into bankruptcy.
  • Mothers and babies will not get the care they need.
  • Women will be denied access to reproductive services.
  • Women will not be able to afford their birth control pills.
  • The poor will be left on the streets without care.
  • Insurance companies will gain huge profits as they deny claims.
  • Seniors will see their life’s savings stolen then pushed over a cliff. I don’t know how Seniors got into this discussion but trust me, they will be used.

Wow, that was a pretty easy list to create and took me about 15 seconds. You and I both know that the replacement plan offered by the Republicans will not harm anyone nor will it cause anyone to lose coverage. That does not seem to matter in the amped up political media we see today.

However, the AHCA released last week is missing or at least silent on a few big issues that may be deal breakers. Let’s review a couple:

  • It does not actually Repeal the ACA as stated in the first paragraph which reads clearly “We Amend”.
  • It does not repeal the Employer or Individual Mandates. It simply reduces the penalty to zero. This may be trickery because, unless corrected, that means a future congress, either Dem or Repub, could easily reinstate the penalties for either Individuals or Employers, or both.
  • As noted above, it does not technically repeal the mandate individuals so it needed some tool/teeth to encourage continuous coverage. It will allow insurers to surcharge an applicant’s premium 30% if there has been a gap in coverage greater than 63 days in the preceding 12 months. I assume this was to placate the insurers but it will do little to encourage coverage or reduce premiums.
    • That means our citizens will be able to put off paying for premium until they get a bad diagnosis then enroll. There will be situations in which we’ll see hospitals pay premiums for these late enrollees so that the member’s hospital claims can be paid by a health plan, just acquired.
  • It is silent on most of the “rating restrictions” that have artificially pushed up premiums such as the Minimum Loss Ratio.
  • It does modify the premium ratio for oldest vs. youngest from 3:1 to 5:1 but that is not enough. Remember pre-ACA that ratio was 7 or 8:1 which allowed insurers to rate appropriately. Rates for the young and old were not artificially increased to meet some uninformed bureaucratic limit.
  • The proponents of the AHCA rely too heavily on expanding HSAs. I’m all for HSAs but HSAs won’t work for a large share of our population for good reasons; and the Dems will use this to scare the uninformed and  everyone else.
  • It is silent on selling across state lines. This solution is now being scoffed at by both Repub and Dem which makes  me wonder if it will be in Phase III as Speaker Ryan promised.
  • It leaves the Medicaid expansion in place until January 1st, 2010. It also added a monthly redeemable tax credit which looks like a new entitlement. If promoted well this could be good strategy because we need to allow for the folks currently being subsidized and provide a phase out period as premium come down and coverage improves.
  • The last thing I’ll mention is that it allows for individuals to deduct a good portion, if not all, of their premium on their tax returns. Long over do.

Maybe the most frustrating discussion will center around “how will the Repubs pay for this plan”. It’s amazing that our Politicians struggle with letting the citizens keep at least some of their own hard earned money. That mentality implies that reductions in taxes or fees are impossible because of their attitude that you can’t reduce revenues unless you pay for them. Geez, why do citizens need to pay for retaining a larger portion of their own income?

Personally, I’m not looking forward to the pundits and their talking points. Just as the Republicans annoy us with their wailing call for HSAs so will the Democrats annoy us with horror stories of sickly mothers and starving babies, the likes of which Alfred Hitchcock would not believe.

I often  say that I’m an optimist trapped in a cynic’s body which is not good DNA for the conflict ahead of us. But, the optimist in me predicts that the Republicans are fully aware that they must produce results and that people can’t lose anything that they’ve already been given. So, let’s see how the Republicans respond to the flack headed their way.

Love your feedback so let me know.
And of course you know that we’re all in this together!

Mark Reynolds, RHU
(559) 250-2000

Why do Politicians inject so much Government control into Healthcare Reform? Is it an addiction? Let’s see.

March 9, 2017

Before we start we must first agree that no one understands to much about the American Healthcare Act (AHA) which the Republicans presented yesterday as a replacement for the ACA.

Will there be just this single bill collaborated upon by the varied opinions within the Congress? Or will we see multiple bills offered by competing politicians each thinking theirs is the best? Or will it become a series of smaller bills designed to focus on specific segments of the healthcare delivery and finance system?
The one fact we know is that until yesterday we had seen nothing  except “talking points”.

I have read the bill twice so far. I know what you’re thinking but I had the time and I’m interested. One thing seems consistent and that is the Government’s “hand” in determining how too & how much. Why do they do that?

The Government needs to do just a few things then get the hell out of the way.
You’ve read our ideas about how to fix the system in previous posts.
In this bill they did not do enough “repealing” and not enough “replacing”.
Here are just a couple thoughts:

  • Make health insurance premium 100% tax deductible for anyone who pays it.
    • Their attempt at this in the AHA is admirable but confusing as it discusses monthly credit amounts and monthly limitations. It could be simply “If you pay for it you get to deducted it on your taxes.”.
  • Make all plans for individuals and families guaranteed issue with no pre-ex.
    • They eliminated the mandate penalty and opted for a surcharge on premium of 30% if coverage is not continuous. This will not do the trick for insurers.
  • Eliminate benefit mandates:
    • EHP Sunset in 12-31-19, which is good.
    • Insurers free to offer any plans they desired as of 10-1-17. But, this is questionable because the AHA still refers to “credible coverage”.
  • Eliminate rating restrictions and obstacles. They missed this one:
    • AHA changes premium ratio allowed from 3:1 to 5:1. Not enough.
    • Prior to ACA the ratio was as high as 8:1 which is better.
  • Left the Medicare expansion for states & tax credits below the poverty line:
    • They did both and allow “expansion states” to continue Medicaid until 1-1-20.
    • “Non-expansion” states will give eligible members monthly refundable tax credits.These will be set up to pay directly to insurers by 1-1-20. It is just a slight twist in the approach to subsidies used on the ACA.
  • Did not include:
  • ERISA Pre-emption to allow carriers and plans to sell across state lines.
  • ERISA Pre-emption to stop state legislatures from stifling stop loss plans for small employers as done in CA, NY and other states.
  •  NO new benefit mandates from states or Feds for five years. It’s unclear how much freedom insurers will have to build plans the market demands.
  • Make HRAs and MERPs available to implement on all plans.
  • Allow carriers a reasonable corridor for Risk Adjustment Factors.
    • So, the underwriting will be Guarantee Issue but the rates will remain higher than needed because carriers have no protection against adverse selection.
  • All insurers must publish and release statistics and experience data.
  • Tort reform: Loser Pays and/or Fixed Attorneys at 15%.
  • Health plan commission set at level 7% and does not increase as premium does.
  • Providers must post their rates per service. Hospitals must post their outcome statistics as well as infections, error rates, and other outcome data.

They included language about wellness and prevention but it is not clear as it refers back to current language, which would be ACA language. Let’s hope they don’t get entangled in clever wellness and preventive health strategies. Unless we are going to get serious about tackling the two biggest issues affecting healthcare cost, that being smoking and obesity, then  pushing wellness will be like pushing a rope up hill.

It’s said that one should not go grocery shopping when one’s hungry. I guess it should be said that one should not write a Blog Post when one’s fed up, right? But it is difficult to not be frustrated with a Congress that over 7 years voted 50+ times to Repeal & Replace as well as campaigned for re-election promising R&R but deliver very little.

It’s complicated for sure but after 7 years one would think that a replacement plan would have more meat on the bones. The AHA offered will need huge changes to be acceptable to the folks and that time will give more opportunity for special interests to get their fingers into the design.

In previous Posts we have laid out a number of issues and ideas to repair our system, bring down costs, and provide better benefits. The Republican American Healthcare Act includes just a few of those ideas. Let’s all hope that we witness some statesmanship from our legislators in the coming weeks as it will be needed in order to carry this bill through..

Anyway, that’s my 2 cents worth. What do you think?
And remember, we’re all in this together.

Mark Reynolds, RHU


Can RBP “Reference Based Pricing” help reduce premiums. Absolutely, but there are additional advantages, as well!

March 2, 2017

Reference Based Pricing “RBP” is a method or calculation for setting the reimbursement levels and thus the payments to providers on the services they provide. It is not new, in fact one could say it has been around since the implementation of Medicare back in the 1960s. But few people have heard of it, many people misunderstand it and no one is discussing it in Washington for addressing healthcare reform. So let’s see how it works and how it would help.

It’s referred to as Reference Based Pricing because the reimbursement to providers is determined (based) on a percentage relative to what the Federal Government would pay providers under Medicare. For marketing purposes some try to use clever descriptions such as Value Based Pricing or Virtual Pricing but the basic concept is fairly simple.

How reimbursement levels are set for Medicare
Medicare and Medicaid payments to providers are determined by CMS. The Omnibus Budget Reconciliation Act of 1989 introduced a new way to determine reimbursements to providers. It was called the resource-based relative value scale (RBRVS).

The intent was to create a uniform and objective payment system to address the large payment disparities produced under the traditional usual, customary, and reasonable (UCR) standard. The new scheme was adopted over a five-year transition period. The reimbursement level factors in both the CMS determined cost of a service rendered by geographic area plus a reasonable profit level for providers. Medicare and Medicaid (Medical in California) pay for healthcare for three large groups of Americans: Seniors (65+), folks under 65 who are qualified as disabled, and the poorest of our citizens (Medicaid). Due to the populations it covers, Medicare/Medicaid are the largest payers of healthcare services in the United States.

Obviously, Medicare wants to keep its claim costs controlled, at least tax payer hope so,  but Medicare also realizes that providers must be paid fairly  in order to  accept Medicare patients. This symbiotic relationship between payer and provider is a benefit for healthcare providers. In addition, the majority of providers will accept Medicare level reimbursement because providers don’t want to miss out on that huge base of potential customers. Finally, with this market power, Medicare can set its reimbursement levels lower than most if not all PPO plans and providers will still accept it.

Now apply RBP to private plans
If Medicare can control its costs as described above then why not apply RBP to private plans for the benefit of Individual & Family Plans and for employer group plans. RBP is being tried on Employer Self-funded or Stop Loss plans in many areas so it is not new but it is also not wide spread or common.

Typical reimbursement levels applied on private RBP plans are 125% to 150% of Medicare which means if a doctor would accept $100 from Medicare a private plan would pay $125 to $150 for that service. Sounds reasonable doesn’t it?

This RBP method may not save insurers a great deal on Office Visits or simple x-Rays compared to PPO plan discounts but it makes a huge difference when applied to expensive services such as MRIs & CT scans, surgeries and treatments for cancer and other serious illnesses. I have witnessed premium levels reduced 15-40% compared to similar PPO plans simply because providers would be reimbursed using RBP.

Remember from earlier posts in which we discussed the impact of access vs. costs. If premiums can be reduced simply by paying providers at a level 25% to 50% higher than what the same provider would accept from Medicare then don’t you think we should try it?

How have provider’s reimbursement levels been determined traditionally?
Applying discounts to provider’s retail charges in private plans has occurred in four general methods and date back to 1973 and in some circumstance even earlier.
Those three methods are:

  • PPO or Preferred Provider Network– This method was allowed by laws enacted back in 1973. These new laws allowed providers to group together to set pricing. That sounds simple but without the PPO Law of 1973 it would have been unlawful for providers to share and set prices due to anti-trust and collusion laws in existence.
    • As one expects in a capitalistic free market society new companies were started for the sole purpose of pulling individual providers together into a “network” which was then rented to health plans as a PPO Network. The health plans wanted to rent the PPO networks to make it easier for plans to set premiums and pay claims. A new market was thus created.
    • As more companies built their own PPO networks to rent to health plans it caused competition and helped keep reimbursements to providers controlled.
  • Retrospective Reimbursement– This method, created in the late 1980s, help’s control larger claims and is usually unseen by members. This method negotiates with providers after a claim is incurred in an attempt to further reduce the cost of claims  of a larger dollar amount. If a plan can negotiate a hospital/surgery bill down from $300,000 to $250, 000 then it is a worthwhile incentive.
    Again, companies were formed to help plans negotiate these larger cost claims.
  • UCR or Usual, Customary & Reasonable– this method, the oldest method, is applied by collecting what doctors charge in every zip code in the US for every service code under which claims can be submitted. In other words, in every zip code it is determined what the average provider charges for every service available. Of course, there are private companies that collect this information and sell it to plans.
    Then plans can use this information to determine how much their plan will pay on a claim by paying a percentage of the average cost for a zip code. It’s often called a “cutback” and if you have ever gone “out of network” on a PPO plan then you have seen this method applied to your claim.
  • Capitation- This is how HMO plans pay providers. A set amount is paid to a provider each month regardless if the provider sees any patients. As everyone knows, on HMO plans members declare their PCP (Primary Care Physician) which is the provider the member must see first before going to a specialist, etc. That PCP gets paid to manage the care for the patient and gets paid the capitation fee regardless if the patient is seen or not.

Those four methods of setting reimbursements to providers are still the primary tools for controlling what providers get paid. To an outsider it may seem odd to set reimbursement levels in a free market country but can you imagine what providers and hospitals would charge if there was nothing in place to set reimbursements. Yikes!

Now Back to RBP because there are advantages in addition to controlling costs
If RBP becomes more prominent among plans then we may see several additional advantages in addition to lower premiums. Here’s a couple:

  • When RPB becomes more prominent or even common then it will begin to function as a PPO by default. If providers accept the RBP reimbursement then you create a virtual PPO which will eventually provide more providers for your choosing.
    * Remember, “If you like your doctor you can keep your doctor”? Well in a virtual PPO setting its possible that you will be able to see any doctor you choose. That’s one.
  • Out of Pocket costs for members will be lower. Your plan will still have a stated OOP but if your provider of choice accepts lower reimbursements then your out of pocket on each service will be lower and your money will last longer. That’s two.
  • Over time providers learn to be more efficient and will set their budgets based on these RBP payment schedules which can further stabilize pricing. That’s three!

It’s a simple statement but the cost of healthcare can be reduced to the simple equation of “Unit Cost of Care” times the number of “Units consumed”. If we can reduce Unit Cost then its a start.

More plans are using the RBP method for reimbursement today than 5 years ago and the trend is toward even more. Most of the growth is in single employer plans that are self-funded by the employer. Clearly employers, which pay the lion’s share of healthcare cost in the US, are incentivized to control cost. So, just as the federal government is trying to control Medicare cost, employers are finding RBP helpful to control their cost.

If carriers could implement RBP on fully insured group plans as well as Individual & Family Plans then the growth in RBP would quickly establish a true virtual PPO Network.

Will legislators interfere in this RBP trend that is growing every year? Probably, but it’s hard to argue with the results. If healthcare cost is Unit Cost times Number of Units Consumed then we must either reduce the unit cost or the number of units consumed. Which do you think would be easier to reduce?

Let me know what you think.
And remember, we’re all in this together!

Mark Reynolds, RHU