In more from the HIT conference, Leo Barbaro the network management services VP for Wellpoint Northeast (Blue Cross NH, Connecticut, Maine) gave a talk in which he jammed together an ePrescribing talk with his P4P talk and gave some ideas about what’s working to combine P4P and encourage ePrescribing as part of it. It’s an excellent talk with lots of info, and you can download a PowerPoint of it here.

Wellpoint is moving towards P4P for all products, rather than just for HMOs. They’re also starting to move quality payments away from HEDIS measures to paying for IT use.  Now that Wellpoint is big enough to swing a bigger stick in many markets they’re starting to consolidate their P4P programs.  In the 3 states Barbaro runs they give physicians points for doing the right thing. You can get 15 points out of 100 for adoption ePrescribing and another 25 if you prescribe all the generics you could.  And if a physician gets to 80 points out of a hundred they get a 6% bonus payment on top of the FFS payments you get anyway — so the ePrescribing and generic substitution part is half-way there.

He also talked about Wellpoint’s technology Investment. This is $30m spent by the non-Anthem part of Wellpoint, (CA, GA, MS and WI) which offered free technology to 25,000 doctors in those states. 19,000 accepted –6,000 told them to go fish. For those that wanted ePrescibing Wellpoint gave them Allscripts or Zixcorp and paid for it for a year.  For the rest they gave them a Dell desktop and connected them to a clearing house. 86% went for the desktop, only 14% took the ePrescribing package for which Wellpoint comped the $59 a month cost for a year. It seems that the rest were just getting a free computer to give to Betty in the front office and that that part of the giveaway had little value other than to make the physicians a little happier.

Of the 2700 who took the ePrescribing package, 2,000 registered on the system last year but only about 200 are using it with 30,000 Rxs submitted electronically.  This program started in Fall 2004 so there is indeed some ramp-up to go, but in general, as Wellpoint’s chairman Len Schaeffer said,  "free isn’t cheap enough". They are though doing a formal evaluation of both sides of the deal which will be available eventually.

The initial conclusion is that ePrescribing is not high on the radar screens of physicians, and getting to the small provider is a significant challenge.

Wellpoint  did on another study in the northeast (Barbaro’s region) with a big MSGP (26 docs) to whom they gave an ePrescribing system. They found that with an ePrescribing system costs per Rx went down 2% in the Q3 2003  compared to Q3 2002,  even though the number of scripts written continued to increase. As a control group they used other docs in the same region who’s costs per script went up 6%. Overall the PMPM costs of drugs for the target group was still higher that the control, suggesting that those docs were higher prescribers overall. But lots of other factors were being introduced at the same time. Most importantly they increased their level of generic prescribeing 4%, more than 4 times that of the control group.  Which is a pretty sobering thing for pharma to consider until you realize that something like 30% of scripts written are never filled and presumably eScripts will be filled more or less automatically.

Barbaro’s view is that at some point if providers don’t have the systems to show that are giving value then they will just get less money. But this is going to be a long long haul.

A doc from Colorado somewhat disagreed and says that money would be better spent to get ePocrates to put PBM formularies on their software. He said that it’s just too hard to do ePrescribing without a full EMR.  He thinks that it’ll fit their workflow better.

A tough topic for sure. The next day Mark McClellan from CMS said that ePrescribing will be mandatory for Medicare part D by 2009.  But I’m not sure if that means mandatory for all doctors or just mandatory for the plans to accept eScripts. If it is mandatory for all doctors then we’ve only got three years to sort this out, which basically cannot be done — unless someone can show me another market that went from 5-10% penetration to 100% in three years!

So there’ll plenty more to say about this whole topic in the future.

Meanwhile I didn’t go but here’s the slides from a presentation about Kaiser’s EMR.

There’ll be more about McLellan either later today or tomorrow, but the hotel didnt have Wi-Fi so I wrote my notes by hand!! And typing them up later loses out to going to see the replay of today’s Chelsea v Barcelona Champions League game!

UPDATE: I am delighted to report that Chelsea beat Barcelona 4-2 in one of the better European Chanmpionship games of all time, going through to the next round.

Now and again, THCB stands back and takes a look at actual medical care delivery.  Today we have a new contributor, Pamela E. Mack, who explains some of the difficulties she has had being a very involved patient with diabetes, but one who may not be suitable to the "bullying" that I have described as integral to disease management.

I want to tell my own story, to illustrate the limitations of the standard approaches to diabetes pushed by the health care system. I have found a way of managing my diabetes that works wonderfully for me. I don’t think it would work for most people. But what bothers me is that the people who might benefit from this approach will probably never learn about it. I wish that doctors and diabetes educators had a way of offering patients choices to help them find the approach that works best for them. If you want to skip my personal story and go straight to learning about the approach I use, go to What they don’t tell you about Diabetes. Jenny tells it better than I can, and has done some fascinating research on the history of the current system of American Diabetes Association guidelines (those of us who follow the very tight control approach think those guidelines are misleading at best and probably harmful).

I was 48 when I was diagnosed with diabetes, about 60 pounds overweight but somewhat fit (I walked regularly). I didn’t know much about diabetes because there is none in my family, but I had had a 10 lb. baby and one random high blood sugar (I was tested when I went to the local urgent care center with a yeast infection). So I kept insisting to my doctor that I be tested for diabetes every year, though my fasting blood glucose numbers were in the 90s and he would tell me not to worry. Finally I did have a high fasting blood glucose test result and my doctor told me I had diabetes. He told me to lose weight by eating less and suggested I start testing 3 or 4 times a week at different times. He said I would need medication if my numbers kept getting worse.

I was in shock for a few days and then started looking for information on the internet. I quickly learned of Gretchen Becker’s excellent book: The First Year: Type 2 Diabetes, which helped me particularly with my feelings that the diabetes was my fault. I didn’t want to go on a diet because I had struggled for years to get out of a selfpunishing attitude towards food (I have some issues about that left over from childhood abuse).

I decided that rather than trying to lose weight, I would make my first goal to control my blood glucose. I came upon someone on the internet who used the line "My body, my science experiment," and I knew I had found the approach that would work for me. I decided to use a set of goals I found on the Internet. I was convinced by the argument that the best way to avoid complications was to get blood glucose down into the normal range. My goals were A1c under 6, fasting blood glucose under 110, blood glucose one hour after eating under 140, bg two hours after eating under 120. (These recommendations are only for people who are not prone to hypos.)

These are much tighter goals than those recommended by the American Diabetes Association. The justification for such tight goals comes from studies of at what A1c level complication rates begin to rise–actually 5.5 for heart disease. To meet these goals I did not follow any standard diet, but rather tested 7 times a day (first thing in the morning and one and two hours after every meal) and adjusted my food choices according to the results. If my bg was higher than my goals, I didn’t eat that food again or ate it in smaller quantity the next time. I found I had to limit my diet to about 75-100 grams of carbohydrate a day. I try to use carbohydrates with lower glycemic index, but for me glycemic index doesn’t make that much difference, low g.i. carbohydrates still send my blood glucose high if I’m not careful about the total amount of carbohydrate I eat.

I didn’t count calories or restrict how much I ate, although obviously my choices were much restricted. If I was hungry I ate a snack, usually of nuts or cheese. What was amazing was how much less hungry I was. My blood glucose must have been going high after meals for years, and when it came back down a couple of hours later I felt very hungry. Controlling my blood glucose but not restricting how much I ate, I lost five pounds a month for six months. Despite the doctors who say "just lose weight," losing weight didn’t make my diabetes easier to control—I had to eat just as carefully to keep my bg under control.

I knew I would be doing this for the rest of my life, so I looked for ways not feel deprived. For example, as an occasional treat I can eat cheesecake for dessert, and it won’t send my bg high. I try to be careful about saturated fat but I have always had excellent cholesterol numbers (HDL higher than triglycerides in U.S. numbers), so I don’t worry too much. I’m clearly an atypical diabetic but all I get from the medical establishment is the assumption that all type 2 diabetics are the same.

One thing I discovered is that if I craved something that I thought would spike my bg, I could prevent the spike by going for a long walk. I began to think of exercise as a way of burning up the glucose my body was having trouble handling, and upped the intensity by walking more steep hills in my neighborhood. Then six months after diagnosis I tried running. I loved it, much to my surprise, but I started to have hip problems, so I switched to bicycling. Knowing that to help my bg it was important to exercise regularly, I bought a good bicycle and set myself a training goal—to ride a 60 mile organized ride four months later. I studied carefully how to fuel myself—at one point I took a 7 hour bike ride testing my bg every 30 minutes. I found I needed to eat more carbohydrates during but not after a long ride (that is unusual–most people do need to eat more after).

I did the 60 mile bike ride without pushing myself, so I got more ambitious. I rode a 100 mile organized ride two months after that, and then decided my next goal would be a sprint (short) triathlon about a year after I started biking. I’m currently (February) biking for at least an hour at least three times a week, swimming for over an hour in a masters workout twice a week, and running one and a half miles three times a week (building up very slowly to avoid joint problems). In seven months of more intense exercise I have lost another 25 pounds. Five pounds more and I won’t be overweight any more. My latest A1c was 5.4.

Diabetics like to quote the line that the best way to a long and healthy life is to be diagnosed with a chronic disease and take good care of it. I am healthier than I have been in years, more selfconfident, and having a lot of fun turning myself into an athlete. At the center of that for me are two things. One is the sense of control I get from treating my body as a science experiment and testing my bg to see the impact of what I eat (now usually just fasting and once after each meal). The other is the idea that it is possible to control my diabetes so well that I can postpone complications, hopefully indefinitely.

The medical establishment has been unsupportive of my approach. I’ve talked to diabetes educators at two different local hospitals. One told me that she had to teach the American Diabetes Association recommendations in order to get insurance reimbursement. The other claimed to be supportive of my approach, but kept insisting to me that complications were inevitable. (Nobody had done studies of complication rates in diabetics who kept their A1c under 6.) My new doctor was reluctant to prescribe me so many test strips, saying that sounded awfully compulsive. Her nurse kept asking weren’t my fingers sore (no). My doctor has become more supportive–she can’t argue with the results.

On Feb. 2, The Health Care Blog included a mention of the importance of: "making sure that diabetics and other chronically ill patients actually get the routine care and routine bullying that they require to stay healthier." The point is correct—many doctors don’t push regular monitoring and care of diabetics. I get an A1c every 3 months because I buy a home test—my doctor is happy with annual testing. But even at their best, doctors can only respond to routine changes on an every three month basis. I can do a lot more by adjusting my behavior according to my blood glucose several times a day. I realize that a lot of patients aren’t interested in being so proactive. But some, at least, are going to respond better to being offered control of their own health instead of bullying.

I’ve seen people who already have complications who respond to the very tight control approach, for example one person on the internet who says she has neuropathy pain whenever her bg goes about 140. But I think it is particularly valuable for people like me who got diagnosed before they had complications. Whether or not we succeed in putting off complications until we are 95 years old, we surely are putting them off for years and reducing our future health care costs. Yet many health plans refuse to pay for so many test strips. Doctors necessarily focus on sicker people, but it is discouraging not to get support. I haven’t been told yet that I don’t really have diabetes, but I’m expecting it. I do–it takes steady hard work in managing food and exercise to keep my bg in the normal range.

There aren’t any one-size fits all solutions for diabetes, even at a given stage. Any formal program has to push the recommendations of the American Diabetes Association, which are harmfully out of date in their goals and their blanket opposition to low carbohydrate diets. Research is mostly on medication. So the system ends up discouraging those people who might be able to take control of their diabetes and get healthy.

Oren Grad, a physicians and an independent consultant whose work focuses on policy and strategy in the health sciences, didn’t think much of what Greg Pawelski said yesterday on THCB about cancer research being aimed at the wrong things. Nor did he much appreciate the way that he said it. Again, I’m no expert in these issues and, although I have some sympathy with the position that we do too much at the margin in oncology that promotes the profit of the oncologists rather than of the patients, I understand that this is a very, very delicate area. Greg has good reasons for holding his positions, but here’s Oren’s explanation of why he’s wrong.

I have to say that Greg Pawelski’s post today on cancer research was annoying. I think he’s out of line in both tone and substance, and his "expose" is in fact pretty stale by now.

It’s not as if the leadership of NCI aren’t very well aware of the issues Greg raises, as well as many more that he doesn’t. The CTWG initiative described in these links is but one of several being pushed vigorously by NCI director Andrew von Eschenbach. A lot of very smart, very busy people both within and outside NCI are currently chewing up substantial time figuring out how to adjust NCI’s approach to meet today’s challenges rather than yesterday’s.

From a scientific perspective as well, the implication that Greg’s found magic answers that are being scandalously overlooked is way off base. Both metastasis and ways of individualizing treatment are very much on people’s minds, and will, appropriately, see increased research effort in coming years. Only time will tell whether the insights brought by these efforts will in fact pan out in improved patient outcomes. Cancer is fundamentally a very hard problem.

It’s certainly difficult to redirect a large public agency like NCI quickly. But as a long-time observer of cancer research policy and bureaucratic politics, I do think that as the current initiatives play out we can expect to see changes that will help NCI respond more effectively to new scientific findings and opportunities.

Greg Pawelski has posted frequently on THCB about cancer care. On the occasion of cancer becoming the nation’s biggest killer for those under 85, he appeals for sensible use of scientific funding to go after the process behind metastasis.

The Associated Press reported that Cancer is the Top Killer for Those Under 85. There has been no real progress in the treatment of most common forms of cancer. Recent NCI data showed that U.S. cancer mortality rates have increased and age-adjusted cancer mortality rates in response to treatment have not improved in several decades, despite the introduction of many new drugs. There is a mind-set of cancer culture that pushes tens of thousands of physicians and scientists toward the goal of finding the tiniest improvements in treatment rather than genuine breakthroughs, that rewards academic achievement and publication over all else.

The January 10, 2002 issue of the New England Journal of Medicine noted that 20 years of clinical trials yielded survival improvement of only 2 months for patients with advanced lung cancer. It also pointed out that oncologists at a single institution may obtain a 40-50% response rate (not cure) in a tightly controlled study, but when these same studies are administered in a real world setting, the response rates (not cure rates) decline to only 17-27%.

In the March 15, 2004 issue of the Journal of Clinical Oncology, an editorial stated that a review of all the large, prospective, randomized trials published comparing the newer taxane-based regimens, none of these regimens have increased either complete response rates or overall survival, with median survivals remaining at two years or less. This is precisely the same results which were being obtained 30 years ago.

The results of nearly 30 years of clinical investigation in the treatment of patients with cancer, neither standard or high-dose regimens had done a great deal to improve the outcome of patients. For over the past 20 years, they relentlessly combined chemical agents in various regimens with ever-increasing dose intensity and the survival for patients is exactly the same, less than two years. Not a hint of significantly improved survival.

In the March 22, 2004 issue of Fortune, an extensive expose of why there has been no progress in drug treatment of cancer in three decades, the author writes that it is not localized tumors that kill people with cancer, it is the process of metastasis, 90% of the time. Aggressive cells spreading to the bones, liver, lungs, brain or other vital areas, that are wreaking havoc. You’d think cancer researchers would be bearing down on the intricate mechanisms of invasion and spread? However, according to a Fortune examination of NCI grants going back to 1972, less than 0.5% of study proposals focused primarily on metastasis, trying to understand its role in cancer or just the process itself. Of nearly 8,900 NCI grant proposals awarded in 2003, 92% didn’t even mention the word metastasis.

So pharmaceutical companies don’t concentrate on solving the problem of metastasis (the thing that really kills people); they focus on devising drugs that shrink tumors (the thing that doesn’t). There is a national problem in the way we treat the problem. It is time to set aside empiric "one-size-fits-all" treatment of cancer for "individualized" treatment based on testing the individual properties of each patient’s cancer.

So I spent the last couple of days at a disease management conference that focused on diabetes care.

There is general agreement that — at least 15 years since everyone has understood the problem — the health care system suffers from a lack of transparency, information systems, rational incentives, and care quality. Diabetes care is a microcosm of that. Type II Diabetes is a disease that’s primarily caused by years of poor living and poor care (obesity and metabolic syndrome being typical precursors). Once people get it less than 50% of them are correctly diagnosed, and after that the care of diabetics tends to be poor. Only around half get all the recommended tests and care that they need. And yet for a long time (since the DCCT trial back in the early 1990s) it’s been well known that regular monitoring of blood glucose levels can reduce the risks of further damage from diabetes. And those risks are nasty and expensive–blindness, limb amputations and heart disease. Getting diabetics to do all the things that they should do to reduce their dependence on glucose, and control their insulin levels is a great application of the education, monitoring and bullying that is modern disease management.

Disease management really started out as a front for drug company marketing so that they could pretend that they could work with PBMs and wrap services around their pills that would improve patient care. Of course they were also taken by the concept that disease management programs tend to suggest that sick people should take more drugs than they currently do. Of course some of those drugs might be generics….

But when you get beyond the high meaning rhetoric, disease management is complicated and confusing. Within the population with diabetes there are levels of illness, not to mention co-morbidities. Within disease management there are different ways of getting to patients (such as occasional mailers, phone calls, and constant monitoring via telemedicine). Once you get into the management of diabetics (or any other disease management program) it gets more complicated depending on who you are. Integrated systems want to control the costs of their sickest members; health plans typically want to sell value added services to their customers; and employers (and government) want to try to prevent the costs with their disease. But we live in a world where most diabetes disease management is developed for the less sick diabetic patient in a commercial population, while the greatest need — and potentially greatest savings — may be for a much sicker diabetic on Medicare or Medicaid.

But at a practical level, that all means that there is no clear focus on which patients to pursue. Should health plans be looking at their healthy commercial populations, or should they be ignoring them and going after the really sick people in their plans –who may be on their way into Medicare within a few years and give them no return? In the commercial world disease management services for diabetics cost something like $3 pmpm. Intervention using a telemedicine system (like the Health Buddy) can be around $50 pmpm. Obviously you need some pretty immediate savings if you are spending that much, and the VA at least seems to have decided that it is getting a return. But then again, Florida Medicaid in a rather biting criticism of Pfizer Health Solutions last year, felt that the returns from phone-based DM weren’t so great. But overall I came away from the conference no clearer on where on the financial graph the lines of the cost of intervention versus the value of the benefit intersect. And I’m not sure that anyone else really knew either.

What was interesting is how little was known about what the real ROI of different interventions on different types of people. One plan sent out postcards even though they believed them to be ineffectual because a drug company sponsored them. I mentioned to the people next to me that DM had gone full circle and was back to being drugcompany marketing. Even the phone calls may or may not be effective depending on their frequency and what was communicated in the call.

There’s an initiative in Tennessee, run by the Center for Evidence-Based Medicine at Vanderbilt in which the Blues are paying primary care docs to act as educational coaches for diabetics. This seems to be working (although it’s early days) and is having some good results, as are the folks at the VA with their nurse practitioner-led interventions and monitoring. But overall this is an industry that really doesn’t have its story straight as to what works consistently, and what’s worth paying for.

And of course while most payers don’t know if they can look forward to reaping the benefits of a costly intervention down the line, selling DM services will remain problematic. That’s why the Medicare CCIP demonstration projects about to take place are so important. The Medicare population is ground zero for DM especially for diabetics. Let’s hope that the CCIP experience tells us what DM can hope to achieve, and give us a level playing field on which to judge the value of the various interventions.

Careful readers of this blog will have noted that along with reporting about the change in reimbursement for cancer drugs (and to get the real scoop on that you should see JD Klienke’s excellent article in Health Affairs), there’s also been a trend generally in favor of chemo-sensitivity testing before chemotherapy–largely considered a fringe activity by mainstream oncologists. Then this week the NEJM had an article generally in favor of pre-chemo testing. Did the appearance of this article mean that oncologists were moving the way of the pre-chemo testing radicals or did I as the dumb layman misunderstand it? I asked Dr Harvey Frey, who has written for laymen on this subject for THCB before but has generally not been in favor of it, what he thought.

I think you’ve got it right.

Now oncologists guess at prognosis and probable effective treatment based on how a cancer looks under the microscope, how extensive it is when found, and some blood tests. But even within the groups they’ve determined that way, there are still huge variations in actual patient response and survival rates. Since they never know who needs the treatments for sure, many patients are treated who might not need the treatment, and some get ineffective treatments before finding an effective one, and since the treatments are not innocuous, that’s bad.

They first tried doing sensitivity testing by growing cancer cells with different chemotherapeutic agents. For a variety of reasons, that never was very helpful. For years they have thought that, if only they could determine the actual genes responsible for cancer, they could break down the large heterogeneous groups into smaller groups with better defined responses, and spare many patients any treatment at all.

This study is a start toward that end, but still a small step. The technique doesn’t require that they try to grow the cells, but can be done on regular biopsies as obtained now. But so far all it’s shown is a correlation between their test and survival. They haven’t yet shown that they can predict response to hormones or chemotherapy. But there’s every reason to hope that they will ultimately be able to make such predictions, at least with better accuracy than we can now.

Last week there was remarkably little fuss in the health care press about the introduction of the new Medicare CCIP (DM-type) programs. I suggested that provider groups had been left out of the running when these programs were awarded. Gordon Norman, who runs DM at Pacificare and has contributed an excellent article on DSM to THCB in the recent past, and I agree that few provider organizations in the US would be able to run these big DSM demonstration projects, and that even fewer provider groups base their business on a preventative care and population-health coordination model (for the good of their own fiscal health). But I went further in suggesting that the ideological bias of this Administration and Congress was for private plans and organizations to solve the future issues facing Medicare, rather than the public program creating its own initiatives, or working with predominantly non-profit providers. No one would seriously disagree with that, but my connection of that fact with the non-appearance of providers or non-profits on the list of CCIP award winners has caused Gordon to disagree. He writes:

I have to call "Foul!" on your conspiracy theory…

It’s not evident from your blog entry today that you are aware of the latest DM Demo offered by CMS expressly targeted to providers and consortia where providers would take a lead role — the CMHCB Demo. (Here’s more detail on the CMHCB). Far from being the case that providers are "locked out" of the DM groundswell — if providers (remember, I am one of the guilty here) had manifested a sufficient collective will and effort to design a health care system that is primarily patient need-centric, then better integration of chronic care for patients, among providers, over time, across sites, among comorbidities, and embracing the biopsychosocial model might already exist and have obviated the need for a "DM industry" in the first place.

I can imagine my medical colleagues lamenting: "If only someone had accountability for that system’s performance (like oft-maligned executives in the managed care?), perhaps faster progress would be possible." As it stands now, it’s much easier for those who comprise our system to stand on the sidelines, as if helpless, and criticize others who are attempting to fill the care coordination vacuum of their own creation. At its best, DM is an "aftermarket fix" that can work surprisingly well under the right circumstances — that doesn’t mean it is superior to an "factory installed" integrated approach to better chronic care management by health care providers. "Systemness" is a fundamental property that is largely lacking in our health care system today, contributing to an inefficient, expensive, unfriendly, frustrating, and mediocre quality ecology for U.S. healthcare. When are providers going to become responsive to this obvious and growing need as an organized force? We’ll see how many line up for the CMHCB demos — I personally hope there are many and that they do well, since the DM need requires a very inclusive "DM tent" to address the gap between actual and ideal coordinated care. (And just wait for the Boomers…)

By the way, CMS made a commitment to those conducting the BIPA DM Demonstrations that it would not establish competing DM demos or pilots in their regions (e.g., CA, AZ, TX, parts of LA) which would jeopardize the results of this critically important DM study that will provider policy makers (CBO), advocates, and skeptics alike with rigorous RCT DM outcomes at least 1 if not 2 years in advance of the CCIP results. This was neither an arbitrary, capricious, or political decision, but rather a responsible approach to conducting a demonstration study without contamination that would confound the results.

Now I admit that my expertise on the finer points of CMS demonstration programs is limited, and I asked Gordon to confirm for me that the CMHCB awards are way smaller than CCIP and getting a much lower profile. Gordon stresses that CMS has reserved these for providers and that that’s the point!

Yes, the scale is different for CMHCB per award (though no specific limit on # of awards), somewhere between 800 – 3,000 depending on several factors — but that’s the point: it was designed specifically for providers. How many provider groups do you think could amass a patient population that would provide more than 3,000 Medicare FFS patients (HCC scores >2.0) willing to voluntarily participate in such a program with a 6 month recruitment window? Not many.

BIPA is 30,000 total enrolled maximum (+ another 12,000 controls which awardees also have to recruit, unlike CCIP or CMHCB design).

You and Mel Gibson and Oliver Stone should get together on the movie…

I told Gordon that if we were going down the Lethal Weapon path I’d rather make a movie with Danny Glover, and that anyway Michael Moore is already making this movie apparently. But slightly later I got a little more information from another of my DM sources, suggesting that there is trouble with the physician group practice demonstration. Apparently provider groups are dropping out from applying because OMB has changed the payment incentive formula. This is for one of the CMHCB demos that Gordon was talking about, and it looks like it’s in big trouble in advance of the award being announced. This is unconfirmed scuttlebutt and I personally don’t have the time to check it out, so please let me know if you can confirm or deny. But if true, it’s an interesting story, and adds a little fuel to the conspiracy theory fire about the Adminstration tilting the DM demonstrations towards the people it likes.

Paging Mr Stone…….