Tag: Quality

QUALITY QUICKIE: Seniors on the wrong drugs–Medicare & doctors on the wrong incentive plan

Two amazing articles in the NY Times in recent days show that–as John Mattison from Kaiser told me in 1996–although we know what to do we don’t know how to do it. First off a study of a PBM’s database containing all prescriptions written in 1999 for 765,423 patients over 65 found that 21 percent of the patients had at least one drug on a list of drugs potentially dangerous for seniors, and that half those prescriptions were for drugs considered to have the potential for serious adverse effects. (Here’s the California Healthline link with more details).Then we come to Thursday’s NY Times article about the long-term failure of what appeared to be a successful disease management project in Washington state–again because the incentives were in the wrong place. I think that the way Medicare (and other insurers) set up their incentives is mostly to blame. But The Industry Veteran has a more familiar foe in his sights:

Now believe it or not, fixing this isn’t that hard. In the bad old days of HMOs–the early 1990s–Friendly Hills medical group and others in southern California would get all their senior patients into a brown bag lunch, tell them to bring all the pills they were on, and then pharmacists would basically go around the getting the patients off all the drugs they shouldn’t have been on at all or ones that counteracted each other. And this was prior to computerized pharmacy records! Why hasn’t this spread (other than Caremark/Medpartners buying and destroying Friendly Hills in the mid-1990s)? Well Medicare doesn’t reward that activity, but it does reward the multiple visits to doctors to get multiple scripts. And even though doctors know that this is both bad medicine and a safety risk, there’s been no national movement to do much about it.

The subdued, temperate mice in healthcare analysis (I think he means me!–Ed) consider me entirely too hostile because I refer to physicians as Mafiosi and whores, but here’s an article from Wednesday’s NY Times that should elicit temperate responses only from corpses and theocratic fascists. Written by Gina Kolata, a groupie for anything in a lab coat, the article discusses a pilot program, called a "shared care plan," that Medicare ran in Washington state among people with concomitant diabetes and CHF. The program has two components: greater access to medical records via IT and the use of non-physician, clinical care specialists.

To paraphrase the gist of the article, physicians, patients and their families have access to a patient’s computerized medical records. This allows patients to note changes in their reactions to medications. Every physician in the geographic area can access the updated medical records. Then the clinical care specialists serve as personal assistants to severely ill patients, going with them to doctors’ offices, being available by cellphone to answer questions, and teaching them to manage their diseases. The program has reduced doctor visits and medical complications. Patients with diabetes have lower glucose levels, those with congestive heart failure have remained stable instead of getting worse, and third-party payers such as Medicare save money. Therein lies the rub. Participating in the program costs each doctor in the group $500 a month over four years for the electronic medical record system while other innovations, such as group office visits and e-mailing with patients, receive poor reimbursement, if any. As a result, physicians say they will refuse to participate in the program after the pilot ends.

Hell, we don’t need John Kerry to replace George Bush, we need Harry Truman to draft these Mafiosi physicians into the Army. Then they’ll comply!

As you know as a subdued temperate mouse I’m a sucker for those nice doctors but on the other hand, doing demonstrably the wrong thing because it pays better doesn’t appear in in the version of the Hippocratic oath I remember. So this is a clear case where Congress needs to step up, and in a bi-partisan fashion institute both pay-for-performance for Medicare to get us away from the FFS treadmill and hold hearings to shame the AMA and the rest of the "Mafiosi" into doing the right thing, right away. It’s been long enough.

QUALITY: Millenson demands a shock to the system

Writing an Op-Ed in USA Today, Michael Millenson says that making a national error reporting system voluntary won’t work. The Senate voted 98-0 to create such a system last week and USA Today had an editorial saying that it was a good idea, but should have gone further. In some ways that such articles appear in the mainstream press shows the great progress since the IOM issued the To Err is Human report, given organized medicine’s ability over the previous century to quiet the incipient debate on the medical error and quality topic, (as detailed by Millenson in the wonderful Demanding Medical Excellence). But the IOM set out a goal of a reduction in errors of 50% in five years. Well the report was issued 5 years ago next month and no one is pretending that target has been reached (outside of LDS hospital in Salt Lake City, scroll down here to the June 10 entry for more on that)Here’s what Millenson said yesterday:

While voluntarism is valuable, it has been five years since a landmark IOM report made patient safety a public scandal. During that time, doctors and hospitals have not voluntarily organized to stop the preventable deaths and injuries of hundreds of thousands of patients with anything close to the energy used to battle malpractice awards worth hundreds of thousands of dollars.

Doctors and hospital managers are not venal and uncaring. In fact, many care so much that they find it too painful to face up to the commonplace nature of errors. As a result, doctors routinely protest that the patient-safety issue is overblown. I’ve seen it firsthand hundreds of times. If you really believe in systemic change, you have to be willing to shock a lethargic system into abandoning the status quo.

The way to do that is with the mandatory reporting of serious errors. In Minnesota, for example, progressive hospitals supported the mandatory reporting and analysis of 27 serious events, along with appropriate confidentiality and legal ”safe harbor” provisions. Moreover, errors are tabulated and made public each year. Across the U.S., a few courageous hospitals even involve patient representatives in error-prevention panels.

No member of Congress would think of making airline-crash prevention voluntary. Protecting the sick and the vulnerable among us is surely at least as important.

QUALITY: More ammo for the malpractice debate

The rhetoric continues to be turned up in the "debate" about malpractice. This LA Times article suggests that a RAND study found that California’s $250,000 cap on non-economic damages in pain and suffering awards dramatically cuts the amount that juries want to give to seriously wronged patients. Incidentally juries are not told about the cap, so when they come back with a number it is reduced by the judge. Perhaps if more juries knew about that the awards for "economic" losses which are not capped would be much, much higher. In any event, expect far more cases, like the one reported via Michael Millenson’s talk about the woman who had both breasts wrongly removed due to a pathology error, turning up in the press.

Politically, though, this all seems to be at a dead end. If the current House and Senate can’t get anything done…well they’re hardly likely to become more Republican after the next election, are they? And when the Presidency changes hands next year, a real-to-god trial lawyer will be the vice-President (cue angry emails from my few Republican readers). Anyway, my point is that there are not the votes in the Senate to do anything about it, and I don’t hear even too many AMA members or Republicans wanting to abolish the Senate (although some on the left do!).

So perhaps the answer is to try something radically different. Taking malpractice out of the courts, and into expert based truly neutral arbitration. Having firm rules of adherence to evidence based medicine. Admitting medical errors, and compensating for them fairly from a national fund. Trying to improve the practice of medicine rather than the practice of defensive medicine. I don’t know the full extent of the answer, although there are many reasonable proposals out there. I do know that the current insistence on a California-model nationwide is not going to fundamentally solve the problem, and isn’t going to happen. So we might as well go for a big goal that makes a difference rather than failing to achieve a small one that doesn’t.

QUALITY: Do we need national standards for pay-for-performance?

A couple of weeks back there was an interesting signal that something that’s been debated by policy wonks for some time may be impinging beyond the fringes of the real world of health care. Jack Bovender, CEO of HCA the biggest for-profit hospital chain called for Congress to create standards for pay-for-performance programs. Meanwhile the Leapfrog Group, the employer group that’s been pushing P4P, has created a web site to help y’all keep up with the multiple P4P programs out there. (Here’s the press release).

So it seems that these programs are getting enough attention outside the sideshow health care worlds of California and Massachusetts, that HCA–which doesn’t have any facilities in those states–thinks that it needs someone to regulate and standardize the myriad of programs that, as a major provider, it’s going to have to deal with. In general I’m a fan of standardization in health care. The Dartmouth folks have shown that there’s far too little standardization of care delivery, and P4P programs are in some ways intended to reduce that practice variation. However when we hear calls for standardizing the process and demands for Congressional oversight, we should be very cautious. Firstly, P4P is very new. We don’t really know what works and Medicare (by far the most influential national payer) has yet to start its much vaunted demonstration projects in P4P. So trying to regulate the "answer" is way premature. Secondly, when you hear of a big player like HCA wanting regulation, that usually means that it believes it can do better influencing (or taking advantage of) the regulators than it can working with payers in the open market. And, let’s face it, HCA’s track record in that arena is not exactly full of sweetness, light and innocence.

QUALITY/POLICY: Who’s telling the truth in the malpractice debate?

The answer, is of course, no-one. And this interesting web site, a non-partisan organization like the Center for Public Integrity hated equally by everyone, has an article about Bush’s use of Mark McLellan’s research which said that some 8-10% of HC costs were caused by defensive medicine,. It says something I didn’t know which is that the CBO looked into the research and couldn’t duplicate it. But that’s not the real issue. The real question is when those "defensive" tests and procedures were ordered, did the doctors and providers get paid? The answer is of course yes. Which means that getting rid of defensive medicine will mean reducing providers incomes. Is that what the AMA really wants?

QUALITY: The nursing shortage, with UPDATE from The Industry Veteran

Yesterday I ended a piece on medical safety with a reference to a well known British agony auntie advice columnist who will not go into hospital unless she’s at the point of death, primarily because of the lack of training (and lack of professionalism) of the staff she saw in her last visit where she contracted a severe nosocomial infection. One issue that she included was the relative lack of RNs who were involved in patient contact.

Another issue, detailed well in this article from March 2004, has been the impact on patient safety of overwork for nurses. The story cites a malpractice case where 2 nurses had over 40 patients to look after, and at least one terrible diagnosis fell through the cracks to terrible effect for that patient’s future. Consequently several states, notably California, have mandated nurse to patient ratios (usually 1 to 6), and the initial news seems to be that it is improving patient care. However, a new article by the Univ of Pennsylvania team (lead author is Ann Rogers, but nursing staffing guru Linda Aitken is a co-author) suggests that increased work weeks, increased shift lengths and unexpected but forced overtime is also bad for patient care and increases error rates. As the article is behind Health Affairs’ fire wall, I’ve quoted a chunk of their findings and recommendations:

    "Our analysis showed that work duration, overtime, and number of hours worked per week had significant effects on errors. The likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting of 12.5 hours or more (odds ratio =3.29, p =.001). Working overtime increased the odds of making at least one error, regardless of how long the shift was originally scheduled (OR = 2.06, p = .0005). Our data also suggest that there is a trend for increasing risks when nurses work overtime after longer shifts (OR = 1.34, 1.53, and 3.26 for scheduled eight-hour, eight-to-twelve-hour, and twelve-hour shifts, respectively), with the risks being significantly elevated for overtime following a twelve-hour shift (p = .005). Although the effects of working prolonged shifts were clearly associated with errors, there was no interaction between scheduled shift duration and overtime (p = .17). Finally, working more than forty hours per week and more than fifty hours per week significantly increased the risk of making an error. Results were somewhat similar for near errors."

The article concludes with a recommendation, which is similar to that made by the IOM last year:

    "Hospital staff nurses’ long hours may have adverse effects on patient care; we found that both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours. Because more than three-fourths of the shifts scheduled for twelve hours exceeded that time frame, routine use of twelve-hour shifts should be curtailed, and overtime–especially that associated with twelve-hour shifts–should be eliminated".

But there is a huge YABBUT behind all these numbers, and that YABBUT is the severe shortage of nurses (and allied staff) in the US.

The average age of a working RN is 43 and by 2010 it will be pushing 50. Admission to nursing schools is slightly up but the number of individuals sitting for the nursing exam is flat, and far too few new nurses are coming into the workforce. Increased demand based on the aging of the population (the 85+ group is doubling between 2000 and 2010, and of course the baby boomers start turning 65 in 2010) means additional demand for health care services. More, sicker patients plus fewer nurses to care for them means this problem will get worse, so the likelihood is more rather than fewer medical errors in the future. This is all well captured in the 2002 JCAHO report, Health care at the Crossroads.

126,000 nursing positions are currently unfilled in hospitals across the country. Some estimates are that by 2020, there will be at least 400,000 fewer nurses available to provide care than will be needed. Turnover rates are at about 20% a year, and it costs nearly an annual salary to replace a nurse.

This is probably the biggest single problem facing hospitals today. So in the words of Valdimir Ilyitch, What is to be done? There seem to be two main strategies. The first is to buy in talent from abroad. This has worked relatively well for physicians–roughly 20% of new residents each year are foreign medical graduates (who tend to stay here). This may not exactly be good news for other countries, many of whom already have bigger nursing shortages than the US. For instance the Pasadena Star-News reports on importing nurses from Mexico, while nurses are being recruited from the Philippines, China and India. While this is all at some cost to the medical care of the people in those countries, as an immigrant myself I would never blame any individual for coming to the US to try to do better for themselves than they can at home. And of course the money sent home to their families often means that one nurse is supporting many people.

The second solution is to replace (the lack of) nurses with technology. Much of the recent hospital investment in IT is moving towards attempting to change the process of a nurse’s workflow. Too much time is spent recording patient information and fetching supplies, rather than directly delivering patient care. If IT systems can directly capture information from medical devices (i.e. blood pressure, pulse, etc) then nurses could spend less time recording that in the chart. If robots can bring supplies direct to the bedside then nurses won’t need to go fetch them and could stay with their patients. Even something as simple as the soon-to-be ubiquitous Vocera "no-hands" communications badge can save nurses’ time from answering the phones and returning pages.

Nonetheless, the nursing shortage is a real challenge for American healthcare (I’m not so convinced about the "physician shortage" by the way!). And it’s a challenge that has a serious negative impact on the quality of care being delivered. However, I have some confidence that in 10 years time, the use of technology will improve the job of the nurse which will eventually cause more Americans to choose nursing as a career, and finding it a rewarding one psychically as well as financially. I hope I’m right, otherwise it will be grim to be old and sick in 20 years time if you can’t afford your own private nurse.

UPDATE: My cautious optimism that IT would help guide us out of the nursing shortage mess did not sit well with The Industry Veteran, who leaves his lair of pharma exclusivity to talk about nursing. But don’t worry, he stays in character with his remarks about doctors! So in an attempt to keep my email box from overflowing with his MD admirers, I’ve hidden his comments in this update!

    As far as the nursing shortage, so what else is new? My memory of this subject goes back to the 1950s, and even then, the lack of good nurses was considered a major obstacle to quality care in hospitals. Nurses’ hours are too long, performance suffers, enrollment in nursing programs fails to keep pace, yaddada, yaddada. I must say, Matthew, I don’t share your optimism that more IT will substantially improve the situation. More IT can help, but so can good shoes, meditation, chair massages and a hundred other measures. To extend your analogy, when Comrade Vladimir asked how we might transform the plaintive cry, "What am I to do," into the search for concerted action ("What is to be done?"), he specifically disdained tinkering around the edges and adopting increments that perpetuate the alienating system.Hospitals have always appeared to me as the most caste-ridden social organizations in the country. At the top sits a small group of physicians and senior administrators who earn large incomes and receive extraordinary deference. Everyone else works undesirable hours under problematic conditions, receiving mediocre compensation for jobs that require high skills and induce substantial stress. Want to get more and better nurses, lab techs, radiology techs and the rest? Well if your universal panacea is IT, my universal villains are the f

QUALITY: Hospitals remain dangerous, but talking about the issue makes them safer

I saw Michael Millenson doing Grand Rounds at UCSF last week. Michael, who has been mentioned in THCB a number of times, is a former journalist who has become something of a "bete noir" to organized medicine–or at least would be if they paid him any attention. While the AMA debates not offering care to trial lawyers, Millenson continues to point out the general "Silence" of leading medical organizations on the medical safety issue. The case he discussed at the UCSF Grand Rounds concerned a woman who’d had a double mastectomy for breast cancer that was later found to be a case of wrong identity on the pathology slides. The case was used by trial lawyers responding to Bush’s attacks on them over malpractice caps. Of course the AMA and its political allies have plenty of other human interest stories of counties where there are no obstetricians/brain surgeons/pediatricians because of the cost of malpractice insurance.

However, this fight between the lawyers and the doctors continues to miss the point, which is that we are a long way from achieving widespread use of evidence-based medicine. One little thing that might help is the "signing" of body parts by the surgeon prior to surgery, now as the Washington Post reports it is recommended as standard. I recall that before knee surgery in California at Stanford Hospitals in 1996 I wrote "Not This One" in marker pen on my healthy knee, and that got the admitting nurse very annoyed. At least the medical error debate is now in the open.

What’s not so in the open is the in-hospital infection issue. Millenson suggested last week that a nosocomial infection during on of Cheney’s heart procedures, or (my preference) perhaps during Ashcroft’s recent stay in hospital, would really put that issue on the front burner. (They could of course have a complete and full recovery afterwards!) Maybe not, but he found for me a really vicious example in the UK, where the medical safety debate has been even slower to develop than over here. This one concerns Claire Rayner, who is the British equivalent of Ann Landers. In this interview she hammers on the issue of infections caused by sloppy hygiene in hospitals. Take a read, And before you say it couldn’t happen here, be assured that it is happening here too — unless the IOM is making it all up.

Claire Rayner ascribes the problem to a decrease in standards of nursing care, directly associated with an increase in the number of less-well trained people dealing directly with patients. Interestingly enough Linda Aitken’s academic work has shown that there is a relationship in quality of care and outcomes based on the overall level of nurses’ education in a hospital staff. So Rayner may be on to something there. In any event, the more known about this issue, the better, and whatever Newt Gingrich and anyone named Kennedy say, IT is not a guaranteed standalone fix here. We need a system change.

QUALITY: The “White” Wall of Silence, by MATT QUINN

In Washington state a doctor wants a fellow doctor suspended over malpractice testimony. Matt Quinn (again endearing himself to my physician readers, and now getting THCB on the California Correctional Officers Association hit list too) comments:

    More intra-physician contentiousness regarding the malpractice issue with some advocating reprisals on docs who serve as expert witnesses against other docs… I thought that was limited to cops and prison guards!

    While I’m sure that there are plenty of docs who are more than willing to say just about anything on the stand for a buck, wouldn’t having (either or both) institutionally agreed-upon care standards (by which to validate testimony) and quality ratings for docs make things much clearer for juries?

    Again, this speaks to the state of the medical profession… and the AMA and other institutional organizations should step up to take the megaphone away from those who act like children…

QUALITY: More evidence on the scantity of EBM

In this post, a little more from last week’s IFTF meeting. The variation in practice of evidence-based medicine was described in a speech by Bern Shen, as one of the major "impediments" to health and healthcare. THCB readers, MedRants readers and all health policy wonks (via Wennberg’s work at Dartmouth) have long known about this problem. A typical example was in the Journal of the ACC (here’s the abstract) last week, showing that heart patients usually don’t receive appropriate post-discharge drug therapy:

    Dr. Javed Butler from Vanderbilt University in Nashville, Tennessee and colleagues assessed ACEI (ace inhibitor) use among 960 hospitalized heart failure patients. They discovered that 55 percent of the patients were discharged with an ACEI order. By postdischarge day thirty, 77 percent had filled their ACEI prescription, but by one year only 63 percent were still taking the medication. "Although we expected the rate of long-term use to go down over time, we were surprised at the magnitude to which it did," Butler said in a statement.

    Moreover, if patients are not prescribed an ACEI at discharge, the chance of initiating one in the outpatient setting is "very unlikely," Butler told Reuters Health. For patients with no discharge order for ACEIs, only about 12 percent had been prescribed one by 30 days. By one year, only 19 percent of were current ACEI users.

Of course, as I’ve blogged about before, the solution is not that simple. It’s very hard for physicians to practice the "right" way all the time and even harder for them to communicate this to their patients. It requires education of physicians and patients, and the installation of sophisticated tracking information technology. None of these three are particularly in evidence in the US, although as I’ll describe in a post later this week, the Brits are marching down this path, at least for primary care.

At the meeting Dr. Catharina Maulbecker Armstrong described a service she’d been involved in running in Switzerland, where high end executives were advised about what their course of treatment should be based on the latest protocols. The service consulted with the patients’ doctors about their clients’ treatment course, but soon found that the doctors were calling them asking advice about treatment protocols for other patients. As she put it, the doctors otherwise were relying on their 20 year old memory of their medical school professors’ 20 year old memory of what to do! OK, so that’s a little over-simplified, but it does reflect the underlying the problem–physicians are taught to be independent actors relying on their memory, working on one area of the body. Moving to a medical education system based on doctors leading a team (which includes the patient), using information systems to apply the latest medical knowledge and viewing the care of the patient holistically is a non-trivial challenge.

However, Michael Millenson,author of Demanding Medical Excellence and the quality bete noir of many doctors, was also at the meeting. Although he had some uncharacteristically charitable words for some hospital folks who were making the effort to improve quality across the board (in the pursuit of reduction of medical errors), he was a little scornful of their pleas for grant funding to help them do it. As he pointed out, the folks in the room from GM and other big manufacturers probably didn’t rely on Foundation grants to improve their quality–it’s part of what the market demands. It’s the interference with that "market" demand by the medical profession that has radicalized Millenson. (I’ll be reporting on his upcoming speech to a bunch of doctors at the end of the month, or maybe I’ll be carrying back his body to his family!)

QUALITY: Pay for Performance, Care Management and the scribblings of defunct economists

Back in 1997 when IFTF was working on the 10 Year Forecast of Health and Healthcare, our chief economist Greg Schmidt vehemently decried capitation and FFS as unsustainable systems and said that a rational market would develop in paying for medical excellence. He convinced us all to put something called "Performance-based reimbursement" in our forecast, and our final forecast suggested that by 2010 some 20% of reimbursement for the health care system would be in some kind of pay for performance manner. Remember what Keynes said about us all being "slaves of some defunct economist"?

This week two different sets of leading health care luminaries have put the state of Pay for Performance and its related cousin of plan-based care management in their sights. Brad Strunk and Robert Hurley at HSC have an issue brief looking at the spread of "P4P" in several of the markets that HSC tracks. Their analysis is that P4P is plan driven and a response to try to tease out some of the "good effects" of capitation. (You remember the pre-Helen Hunt period when capitation was supposed to encourage long-term thinking in care management, and innovation in improving patient services?) It’s obviously also a way for plans to try to establish some limited control over provider behavior during a period when visions of a return to 1973 and the "Golden Age" have been terrifying the plan medical directors trained at the temples of the prophets Enthoven and Berwick.

Berkeley’s Jamie Robinson (the other Reggie Herzlinger fan) and CHCF’s Jill Matthews Yegian have an online piece in Health Affairs which summarizes the plans dilemma nicely:

    "Health insurers are under conflicting pressures to improve the quality and moderate the costs of health care yet to refrain from interfering with decision making by physicians and patients"

. That’s really what health plans efforts to create better care for their members have evolved into.

Their article is an accurate parsing of the state of the art of DSM as managed by major health plans (or more accurately their data jockey and care management subsidiaries). They parse care management it into Identification (either data based, self-assessed by patients or more likely gained via notification from physicians that something bad is happening) and Intervention. Intervention tends to happen well when a nurse gets the patient on the phone (the American Healthways or Lifemasters model) and not so well when a medical director is trying to change physician behavior one doc at a time (the initial Active Health Management model).

Robinson and Yegian basically call the state of medical management out as being nothing more than a minor attempt to keep some level of quality improvement in the system while not upsetting providers or patients very much. They also doubt that there is much bang for the buck in these programs beyond a narrow segment:

    "The health plans’ medical management programs are designed, packaged, and priced with modest expectations for what they can deliver. All programs assert that they generate a positive return on investment, with the benefits in lower medical costs exceeding the administrative costs of identification and intervention. The positive return on investment is predicated on the modest level of investment, however, and a major ramping up of medical management programs would not generate commensurately higher returns and slay the dragon of cost inflation and quality deficiency."

In other words they seem to think that Wennberg and the Dartmouth crowd’s jobs are safe for now.

In a follow-up piece Victor Villagra notes that as health plans have developed DSM outside of the "traditional" provider system, no one has dealt with the complex question–"Can DM Organizations Support Small-Practice Adoption Of The Chronic Care Model?" It’s not hard to see Robinson and Yegian’s answer as being "No".

I’m not quite so certain. Somewhere in the bowels of the malpractice debacle a reasonable debate about following evidence-based medicine is trying to get out. If you think about it care management is all about extending evidence-based medicine over the continuum of care. P4P is merely about trying to encourage that trend. While the defeat of managed care in the court of public opinion and in the boardrooms of insurers seems more or less final for now, there are two things leading me to believe that the war is not yet over. First, it’s just the right thing to do, and you know what Churchill said about Americans doing the right thing. Secondly, and rather more known to motivate Americans, it’s the money. If aggressive private sector negotiating doesn’t work to restrain health care costs, something else will find its place. Stein’s law says that if something’s unsustainable in the long run it will end. At some point 15-20% rises in health care costs every year is unsustainable. The combination of EBM, care management and P4P has the kernel of a promise to reduce the care variation, the unnecessary care and the dumb care that is responsible for a big chunk of the $1.6bn spent every year.

So round one to the system, but I for one still believe that the question of Greg Schmidt’s "defunctness" is still up in the air.

The IFTF Forecast from 1998