News and Features: Features
Healing health care
Do Bob Master and Rushika Fernandopulle have the cure for what ails American medicine?
Through the fall,
and on into winter, health care was everywhere in the news, with one story after another about problems with various aspects of the rollout of the Affordable Care Act. The one that seemed to capture all the woes with fitting digital-age symbolism was the virtual meltdown of the Obamacare website, the main access point to the new health plans developed under the law.
Stern-faced administration officials from the president on down vowed to pull out all the stops to get the site working. The underlying message seemed to be that, despite some bumps in the road, we are on the way to getting health care right. But as serious as the problem is, fixing a faulty website is hardly the biggest health care challenge facing the country. In many ways, it is American medicine itself that is broken.
The law takes some steps to try to address that. But if you set out to design from scratch a system to deliver compassionate, high-quality health care and do so in as cost-effective manner as possible, you would probably change nearly everything about American health care.
Bob Master and Rushika Fernandopulle are trying to do just that. They do not preside over any massive health care bureaucracy or powerful government office, but that is not where big health care change will come from.
The two Boston physicians are trying to remake health care from the ground up. They have each developed innovative primary care practices that try to deliver good care not by battling through nonsensical reimbursement rules and all the maddening limitations of our current system, but by clearing those obstacles out of the way and making patients and their needs the central focus of the organization and delivery of health care.
Master has been able to cut in half the days elderly patients with multiple health problems spend in the hospital. That might be because he sends nurses on house calls to check on patients, or provides home aides who make sure they are taking medicines on schedule. Or it might even be because he will use health care dollars to get patients a ride to church each week. With social isolation among the elderly a common trigger for depression, which can often start a downward spiral of serious health problems, a $10 transportation charge might be the most powerful — and cost-effective — preventive medicine available.
Fernandopulle’s primary care teams, meanwhile, gather in a “huddle” each morning to share information and strategy on patients being seen that day as well as on those who aren’t but whose health they are keeping tabs on. They might hop on Skype to chat with a patient, or even to follow-up on a recent visit and see how well a rash is clearing. Avoiding unneeded office visits can free up time for doctor visits or regular sessions with a “health coach,” a key part of his plan. Those visits might lead to a breakthrough that gets a patient ready to finally deal with a decades-long weight problem.
In some earlier versions of the model, Fernandopulle was able to decrease overall health care costs by 10 to 15 percent by giving patients more primary care attention.
The two doctors have zeroed in on something that is counterintuitive in the era of MRI imaging, laser-guided surgery, and pharmaceutical answers to every woe: The thing most needed in US health care is not more treatments or more money, but greater connection between patients and health care providers. That can improve our system’s success at keeping people from needing all those high-cost treatments, which are regarded as shining successes of modern medicine but just as often represent its failure.
We now spend $2.6 trillion every year on health care, nearly 18 percent of the nation’s gross domestic product, a share that is more than 50 percent higher than any other country. Warren Buffett calls rising health care costs the “tapeworm” of the US economy, eating away from the inside at the productivity and competitiveness of US business, while straining public budgets.
“In the beginning there
was Bob Master.”
What do we get for our orgy of health care spending? Since 1960, the US has dropped from 12th to 46th in infant mortality, and from 16th to 36th in life expectancy. We’re literally bursting at the seams with soaring obesity rates, setting Americans up for all the chronic disease complications that follow. When they do, our system falters badly. In the case of high blood pressure, one of the most common serious diagnoses in advanced countries—and one that is almost entirely controllable through good treatment — it is well-managed in only 44 percent of Americans who suffer from the condition.
“We continue to spend considerably more on health care than our counterparts in Europe, and what’s shocking and upsetting is that outcomes are often worse,” says Melinda Abrams of the Commonwealth Fund, a New York-based health policy foundation.
Spiraling costs and subpart outcomes are, in many ways, the logical results of a system that delivers disorganized and fragmented care, with patients bouncing from specialist to specialist, highly-trained doctors who tend to zero in on the malady or body part that is their expertise while ignoring the fuller picture that forms a patient’s complete health profile. Meanwhile, the fuel driving the system is a misaligned health care financing structure that reimburses doctors and hospitals for each visit or procedure. In so doing, it encourages that fragmented system of care as well as over-treatment with unnecessary procedures and tests. Rather than providing incentives to help patients stay healthy, it rewards failures of care that result in return visits to doctors or readmission to the hospital.
For more than a decade, the manifesto detailing what ails the US health care system has been a 2001 report from the Institute of Medicine. “Between the health care we have and the care we could have lies not just a gap, but a chasm,” it said.
Fernandopulle: An innovator
with a sense of urgency.
That seems like an awfully grim assessment of a health care system that continues to lead the world in the development of cutting-edge treatments and miracle drugs. But there is a fundamental paradox in US medicine, one that lies at the heart of the problem that Bob Master and Rushika Fernandopulle are trying to untangle.
“A lot of people say we have the best health care system in the world, which in some ways we do,” says Fernandopulle. “If all of a sudden you were diagnosed with a rare cancer or needed a very high-tech procedure or drug, this would, by all means, be the place you would want to come. Unfortunately, that’s not the problem. The problem is the millions and millions of people who’ve got very common conditions—diabetes, hypertension, heart disease, etcetera —which we don’t treat well at all, and not because we don’t have the tools to treat them. It’s that our systems are not designed to actually fix the problem.”
As John McDonough, a Harvard School of Public Health policy expert, puts it: “What to do is not the puzzle. How to get there is the puzzle.”
Master and Fernandopulle may be putting together the pieces.
MASTER OF PRIMARY CARE
If our health care system does a poor job at treating common conditions, it does an even poorer job at that for those with multiple serious diagnoses. These, of course, are the patients for whom quality, well-coordinated care could make the biggest difference.
When considering health care costs, policy experts often cite the “80/20” rule, which refers to the fact that roughly 20 percent of any population will account for 80 percent of its total health care spending. Bob Master has spent his career focused on that 20 percent. During his medical training, the observation that our health care system performs worst among those who need its help the most convinced Master that there must be a better way to organize care.
“The sicker one is, the more socially and medically complicated one is, the less our current system of care meets their needs and the more such individuals are on their own,” says Master. He says such patients are left feeling like “an anonymous piece of baggage” being shuttled through an impersonal system of medical encounters.
Master has a warm, down-to-earth manner. Favoring sweaters over suits, he seems like the doctor who might have emerged if Mr. Rogers had gone to medical school. People in health care circles talk about Master in reverential, sometimes even biblical, terms when describing efforts to improve primary care in the US medical system.
“In the beginning there was Bob Master,” says Robert Restuccia, executive director of Community Catalyst, a national health care advocacy organization based in Boston that works closely with Master.
McDonough, the Harvard health policy professor, calls Master “probably the most important person in primary care in the United States today.”
For decades, Master has toiled as a largely unsung hero of American health care, devising better ways to care for the some of the poorest and most needy patients in the country. That is beginning to change, as the health care world wakes up to how potent his low-tech, patient-focused model could be.
Master, the grandson of Russian Jewish immigrants, was born in Roxbury and raised in a working-class household in Lawrence. Early on, Master says he saw how the fragmented way care was delivered, the fee-for-service payment system, and lack of attention to the social factors that can affect a patient’s health all “subverted the goals of so many of us who became clinicians or physicians.” He says it became clear that what patients needed was an “interdisciplinary care team,” which included doctors and nurses as well as non-medical members, who could work together to coordinate care and help guide patients through the often dizzying labyrinth of modern medicine.
“When you have that vision, it’s kind of a North Star” for how to proceed, he says. “A lot of the way I was trained had to be unlearned.”
Master was involved in several innovative practices that honed this approach, starting with a Jamaica Plain clinic in the late 1970s called Urban Medical Group. One of the most frustrating aspects of the work was trying to care for patients who were covered by both the federal Medicare program and the state-based Medicaid program for the poor. Taking care of these patients, usually poor and elderly, meant navigating through huge government programs, each with its own set of complicated reimbursement rules and sometimes conflicting regulations.
A decade ago, Master helped found the Commonwealth Care Alliance, one of the first programs in the country granted waivers from the federal government and state officials to develop a demonstration project to better coordinate care to those covered under both programs. It has mainly focused on seniors, but has also provided care for a few hundred younger people covered under both programs because of severe disabilities.
Now caring for more than 5,000 patients, the Boston-based organization operates from 25 different primary care sites across the state. In caring for these so-called “dual-eligible” patients, the program does not use the standard fee for service payment system, in which the government gets billed for each visit or procedure. Instead, it gets a single “global payment” to cover all of a patient’s health care needs, a figure that is adjusted by the government programs based on the patient’s health profile. Meanwhile, the Alliance is given wide latitude to organize patient care and use the payments as it sees fit, without following the extensive rules governing Medicare and Medicaid expenditures.
That means giving patients access by phone to a clinician at all hours, and sending nurse practitioners to make house calls. It might even mean buying an air conditioner for someone with severe respiratory disease, something that would never be covered under standard Medicare and Medicaid rules, but might do far more to improve or maintain their health than any expensive drug or hospital procedure.
The program will even pay for a patient’s transportation to church or other community activities. It’s not our usual idea of medicine, but Master and other health care innovators say it should be. We should be treating the whole person, not a discrete diagnosis, they say. For some elderly patients, isolation can be the gateway to declining health.
“You’re cut off from the very things that make life worth living, and when life isn’t worth living, people check out,” says Master.
For Raymond Burcham, the things that make life worth living include Daisy, his frisky Welsh Corgi mix, and an ability to live independently in his modest Chelsea apartment. A cheerful 80-year-old who holds forth from a favorite recliner in his living room, Burcham is good- natured but not in great health. He suffers from diabetes, high blood pressure, and heart failure, and has severe back pain that can be limiting. His daily schedule includes 11 different medications.
For all of that, Burcham is more full of playful one-liners than complaints when Nida Lam, a nurse practitioner with the Commonwealth Care Alliance, comes to see him one afternoon in early December.
“How are you doing with your medications?” she asks.
“My blood sugar is continuing to run a little high,” says Burcham, a widower.
He and Lam go over his blood sugar readings. He measures it several times a day on a device that records the levels so that Lam can review two weeks’ of readings. Lam sees that at one blood sugar check he was hypoglycemic, with a dangerously low blood-sugar level.
“Were you feeling lightheaded?” Lam asks about the episode, which can result in fainting.
“No, I just called out, ‘Charlene, I need something to eat.’ That’s the advantage of having her in the house,” he says.
Charlene is Charlene Roberts, a friend of Burcham’s who shares his apartment. Under the flexible approach of the program, she is paid for 21 hours of work as a “personal care assistant,” making meals, driving him to appointments and, importantly, helping oversee his pharmacy-sized complement of medicines, including the insulin that must be drawn up into syringes and injected twice a day.
Lam adjusts Burcham’s insulin dose, something she carefully goes over with him and Roberts, who jots down notes.
Asked how he would make do without Roberts, Burcham says, “It’d be tough, it’d be very tough. I wouldn’t be on schedule. I’d probably forget to take my morning this or my evening that—these zillions of pills I take. I like this situation,” he says. “I’m more independent here than I would be any other way.”
Care for elderly patients like Burcham does not come cheap. Commonwealth Care Alliance typically receives $1,000 to $5,000 a month from Medicare and Medicaid to care for patients. Three-quarters of them, a group that includes Burcham, are considered “nursing home certified,” meaning they are compromised enough that Medicaid would cover full-time nursing home care.
Raymond Burcham and Daisy.
The coordinated care he gets
has helped him remain in his
Chelsea apartment. “I like this
situation,” he says.
That’s why the sort of wrap-around care the program provides potentially could be such a benefit not only to patients and their quality of life, but to the budgets of government programs.
An analysis from 2008 showed that Commonwealth Care Alliance patients were hospitalized for about half the number of days as a comparable population of patients getting typical care in a fee-for-service structure. For the much smaller population with severe disabilities, the average monthly medical costs were $3,061 compared with $5,210 for similar fee-for-service patients in the Medicaid program.
A 2012 policy brief from the Kaiser Family Foundation examined nine studies of programs serving dual-eligible patients, including the Commonwealth Care Alliance. It concluded that there is no clear overall evidence yet of net cost savings from such efforts and cautioned that large savings may be difficult to achieve.
Harvard Business School professor Michael Porter has trained his sights on health care in recent years, and on what he calls “value-based” medical care. It’s a way of looking at health care that considers the quality of that care and patient outcomes as well as cost. He calls the work Master is doing among extremely high-cost patients “a national model.”
Health care policy is finally taking note of that. The Affordable Care Act established an office specifically assigned to the task of better coordinating care for patients on both Medicare and Medicaid. Under a new demonstration project this office is running in 15 states, tens of thousands of “dual eligible” patients are being enrolled into practices that follow versions of the Commonwealth Care Alliance model of care. The CCA itself is dramatically expanding under the new initiative, enrolling thousands of low-income patients 21 to 64 years old who have pronounced health care needs, including physical disabilities as well as serious mental health diagnoses. The Commonwealth Care Alliance’s new “One Care” program for these patients was the first of these new demonstration projects in the country to get underway, and more than 3,000 patients have enrolled since its launch in October. The Alliance could have as many as 20,000 patients enrolled over the next one to two years, which would push its $300 million budget to an astounding $1 billion.
Medicare spending reached $592 billion last year and is projected to hit $1.1 trillion by 2023. There are about 9 million Americans eligible for both Medicare and Medicaid. They account for 21 percent of Medicare enrollees but 31 percent of its costs. They represent 15 percent of Medicaid enrollment but 39 percent of its outlays. Just as outlaw Willie Sutton said he robbed banks because it’s where the money was kept, caring for these patients is where the most intensive government health care spending occurs, making it easy to see how even modest savings could multiply into a lot of money.
What happens with the 15-state project “will be very significant,” says Restuccia, director of the Community Catalyst advocacy group. “The whole country will be looking at this.”
BREAKING THE RULES
Master’s patients are the canaries in the health care coal mine. The shortcomings of the siloed care that US patients get show up first in these high-need patients, who easily fall through the cracks and end up with an avoidable hospital stay, or worse. They are also the patients for whom a dramatically restructured primary care model like the Commonwealth Care Alliance can make a clear difference.
Jerome Foureau getting a
blood pressure check at Iora Health’s|
Care clinic in Dorchester.
Rushika Fernandopulle has set out on an even bigger challenge: to remake health care in a way that delivers better care at lower cost not only to the sickest patients, but to everyone.
The 46-year-old Harvard-trained doctor still serves rotations at Massachusetts General Hospital, where he did his residency training in primary care. “You walk around the wards and you say, ‘What percentage of these patients in the hospital might not have been here if they actually had better primary care?’” he asks. You can ask the same question in the emergency room, he says. “The answer is probably 40 percent to both those questions,” says Fernandopulle.
He says those patients represent the failures of primary care, the results of a health care system that’s doing a miserable job at keeping people healthy and staving off avoidable—and much higher cost—types of treatment. That convinced Fernandopulle that fixing health care means fixing primary care, and that anything that just tinkered around the edges wasn’t enough.
“What everyone else is doing is making incremental changes to the system,” he says. “They’re taking the existing model and tweaking it, but we know health care is fundamentally broken. Maybe we should just start over. Maybe what we need is a new entrant who can just break the rules.”
Fernandopulle talks about the failures of US health care with a take-no-prisoners urgency, and he shows little restraint in dismissing reform efforts he regards as token moves unlikely to yield meaningful change.
Three years ago, convinced the only way to help drive transformation of the system was by demonstrating it himself, Fernandopulle founded Iora Health, a for-profit company that now operates four primary care practices, including one in Boston that opened last year. Fernandopulle has drawn $20 million in venture capital from investors betting Iora’s rule-breaking model of primary care might be the right medicine for what ails US health care.
The premise is straightforward, and has similarities to Bob Master’s work. Fernandopulle says just 5 percent of US health care spending goes to primary care, while we spend 95 percent on everything else, including that big chunk he sees regularly at Mass. General that he says represents primary care’s failures. Iora asks the sponsoring employer groups or unions it works with to roughly double the outlay for primary care—from about $25 to $30 per month to $50 to $60. In return, lora promises a much more comprehensive model of care—and aims to show that it can more than make up for that added primary care premium through savings of “downstream” costs.
Born in Sri Lanka, Fernandopulle came to the US with his family at age 2½. By his third year at Harvard Medical School, when students began spending a lot of time on hospital wards, “it was pretty clear how screwed up the health care system was,” he says. “We design drugs and procedures, but we let how we deliver it all to patients just happen.” He studied public policy at Harvard’s Kennedy School, which helped him realize that he not only wanted to care for patients, but wanted to help transform the entire system.
He directed something called the Harvard Interfaculty Program for Health System Improvement, meeting with policy big wigs at the university, but also traveling to scout out ideas. He and a partner opened a primary care practice in Arlington that set out to implement many of the same principles his company is now applying. “We got some opposition from the powers that be around here. We were accused of raising expectations and making other practices look bad and upsetting the status quo,” he says. “Of course we would plead guilty to all of the above.” He says one insurer stopped contracting with them, and it proved difficult to sustain the model under fee-for-service payments, since the practice encouraged patients to do things like email simple questions rather than come in for an appointment, the sort of innovation that makes tremendous sense, but can’t be billed for under conventional insurance rules.
Fernandopulle then helped develop primary care models for two big employers and a union group—Boeing in Seattle, a major Atlantic City hospital in New Jersey, and the union for workers in that city’s casinos. “Give us this extra money for primary care,” he told them, “and then we’ll save money on the back end, and they can see the data.”
Drug spending went up “because people were actually taking their medicines,” he says. But emergency room visits fell—by nearly half in the Atlantic City practices. Hospitalizations there were down 41 percent, and overall net spending decreased about 15 percent.
The Seattle and Atlantic City projects restricted enrollment to workers with preexisting, serious health problems. In that way, they resemble the focus of the Commonwealth Care Alliance on high-need patients.
Iora has enrolled about 5,500 patients in its four practices: one set up with casino workers in Las Vegas, another for employees at Dartmouth College, a third through a Brooklyn organization for freelance workers, and a fourth with the Dorchester-based New England Carpenters Union. The Las Vegas practice is restricted to higher-need workers, but the other three are open to all.
The practices get a fixed global payment to provide primary care. They don’t charge any copays—“why do we want to discourage people from getting care?” asks Fernandopulle, one of his many jibes at mainstream US health care. The teams that care for patients include a doctor and nurse, but the backbone of the practices are health coaches—four for every one physician—who are able to devote a lot of time to getting to know patients and helping them craft health plans and then follow them.
The use of health care coaches, some with backgrounds in health fields but others with none, borrows heavily from an approach used in poor countries, where health care professionals are scarce. Well-known Harvard doctor Paul Farmer has used the model in Haiti, and Fernandopulle spent time in the Dominican Republic during medical school, where he saw its impact first-hand.
“This is all about engaging patients,” he says. “You need doctors to make the medical decisions, come up with the right diagnosis and the right treatments. But that isn’t the hard part. The hard part is figuring out how that treatment gets played out in the patient’s life.”
“We can spend that extra time, develop that relationship, which gives the freedom to patients to speak more to what’s going on their lives,” says Mike Jeudy, a health coach at the Carpenters Union clinic in Dorchester.
That’s the sort of relationship Jeudy has formed with Jerome Foureau, a millwright who starting getting his care last summer at Iora’s Carpenter Care practice. He was overweight and suffering from high blood pressure that led the team to put him on medication. But he’s been working steadily with Jeudy, a former wellness director at a New Hampshire YMCA, and has lost 32 pounds since August. “Mike helped me out a lot—with exercise and what to eat,” says Foureau, who says he’s cut out red meat, among other changes. His blood pressure is still high enough to keep him on medicine, but it’s heading down.
Jeudy knows a lot about diet and exercise, but it’s connecting and developing a rapport with patients that’s at the heart of the model.
“Before, I didn’t go to the doctor much,” says the 50-year-old Foureau. “Now, I feel like I’m going to see my friends. I’m not joking.”
So far, just 200 union members have joined the start-up practice, the most recent of the Iora offices to open. “Anecdotally, the level of satisfaction is sky high,” says Mark Erlich, head of the New England Carpenters Union and a member of the board of MassINC, the publisher of CommonWealth. It’s harder to know what will happen with health care costs, the main motivation for the union. “From a common sense point of view,” says Erlich, “it’s just a much smarter way of delivering quality medical care that, in my view, has a much stronger likelihood of containing costs in a way that the standard medical care delivery system does not.”
Health care experts, however, say Fernandopulle faces a tricky challenge.
“It’s really hard to save money on people who are healthy,” says Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice. “Rushika’s problem is there are a lot of people who have bad health behaviors who are not sick but who will be sick. Someone who’s smoking and is way overweight and has high blood pressure may not have obvious heart disease now or peripheral vascular disease. But it’s coming. It will have a different time horizon and different pay off,” he says of what Fernandopulle is doing.
Dr. Arnold Milstein, a Stanford health policy professor, worked with Fernandopulle on the projects in Seattle and Atlantic City. “Iora is a completely different kettle of fish that focuses on a much harder problem,” he says of the effort to provide more primary care and reduce spending in a more mainstream population. “The evidence to show that it can be done is much less well established.”
Fernandopulle says there may indeed be a longer payoff, though he says preliminary data from the site treating Dartmouth College employees is already encouraging. “It’s starting to seem like we may even be saving money after a year,” he says, citing a 30 to 40 percent reduction in the costs for medical specialists.
But he says there is also a moral dimension to the effort to transform primary care for everyone, not just the highest-need patients. “To say, ‘Sorry, you’re not sick enough. Go back to your usual crappy care and when you get really sick we’ll take care of you,’ is not the answer,” he says. “That’s the system we’re trying to fix.”
For nearly four decades Bob Master has worked at what often seemed to be the margins of US health care, trying to call attention to the value of a more integrated, patient-focused form of primary care. “For a long time, we all felt like the little match girl outside the party. We were out there in the community and there is a big party of big hospitals and specialists and technology inside,” he says. “That was the happening thing, and you’re scratching on the window and saying, ‘what about us?’”
Master and others who have been doing similar work are suddenly being invited to the dance. There is growing recognition that the party of big hospitals and specialists and technology has not brought us to a health-care promised land. The tools they offer can be lifesaving when appropriately deployed. But putting these features at the center of a system with little coordination, one that is awash in vested interests rewarded by greater utilization of high-cost health care, has not served patients well and has put the country on an unsustainable course.
While headlines about the Affordable Care Act have focused on the faulty website and health plans people had that aren’t deemed adequate by the law, the reform also contains a lot of provisions designed to move US health care closer to the sort of model Master and Fernandopulle are putting into practice.
Along with the 15-state demonstration project that the Commonwealth Care Alliance is part of, the law has also created a pilot program to test caring for Medicare patients through “accountable care organizations.” These are affiliated groups of doctors and hospitals that agree to care for a set of patients using global payments to try to save money, while being evaluated according to a set of quality criteria designed to ensure they are not doing so by scrimping on needed care. Massachusetts is home to five of the 32 so-called Pioneer ACOs the government approved, and four of the Bay State pilots have shown promising initial cost-savings results. Meanwhile, Blue Cross Blue Shield of Massachusetts has also taken a leadership role nationally in moving away from fee for service coverage through a program similar to ACOs called an “alternative quality contract.” A total of 640,000 Blue Cross members in the state are now covered under these contracts. The first two years of results show a slowing of spending growth and improved quality of care.
Overall, the Affordable Care Act is already being credited with driving the biggest slowdown in US health care spending on record.
Master says the sorts of changes being brought by the law and other pressure being put on the system “would have been unthinkable in the past. So you put all this together and you have all the elements for real transformation,” he says. “We finally think the winds may be with us rather than in our face.”
Fernandopulle, whose passion for “bringing the humanity back to health care” is matched by an impatience with getting there, doesn’t think the law goes nearly far enough in bringing needed changes in how care is delivered. “Giving all these people access to a system which is wasteful and achieves poor outcomes is setting the house on fire, because it’s not clear where this money is going to come from,” he says of the expansion of insurance coverage under the Affordable Care Act. “There’s an awful lot of smoke and mirrors and noise going on, and it’s not entirely clear that a lot of actual care is changing for actual patients.”
“I completely agree with Rushika that stronger medicine was indicated,” says Milstein, the Stanford professor. “But I don’t think it was politically realistic to think it actually could have been done. There are very powerful lobbying forces that push for the status quo. You have to go for the strongest medicine that current politics will allow.”
That means Master and Fernandopulle will, at least for now, continue to serve as the shock troops in the effort to transform US health care, trying to disrupt the status quo and challenge the system by showing what’s possible.
Porter, the Harvard Business School professor, says change has to come from within health care, from those providing actual care to patients, but he thinks we’re on the right track.
“These are the innovators,” Porter says of Fernandopulle and Master. “These are the people that have a history of pushing the envelope, and in both cases they’re pushing it in the right direction.”