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A Healthy Blog

Massachusetts health care – wonky with a dose of reality

August 10, 2016

Originally posted by the Center For Health Care Strategies (CHCS)

Achieving health equity is a growing priority among health care stakeholders. However, until recently, many efforts to achieve equity have been focused on increasing access rather than addressing specific inequities. This is particularly true in oral health, where major barriers to access such as limited insurance coverage and insufficient workforce capacity persist. As a result, the Center for Health Care Strategies (CHCS), with support from the DentaQuest Foundation, led the Advancing Oral Health Equity learning collaborative to help oral health stakeholder organizations examine the impact their programs have on oral health equity and develop targeted strategies for disparate populations.

Health Care for All (HCFA), a nonprofit advocacy organization focused on achieving high-quality, affordable, and accessible health care for all Massachusetts residents, was one of five organizations participating in the collaborative. By listening to community and stakeholder groups, as well as hearing stories through its Health Insurance HelpLine, HCFA has adopted an equity-based framework and approach throughout its work. It sees inequities in oral health care as a social justice issue, believing that the social determinants of health and the intersecting issues of racism and classism affect overall health and well-being. To learn more about HCFA’s approach, CHCS spoke to two members of HCFA’s oral health care team: Kate Frisher, oral health coalition coordinator, and Kelly Vitzthum, oral health policy analyst.

Q: What kinds of activities is HCFA doing to advance oral health equity?

A: We focus primarily on policy opportunities. One example is supporting legislation that would create a new type of mid-level dental provider, the dental hygiene practitioner, also known as a dental therapist. Dental hygiene practitioners can help fill gaps in access for communities that are most in need of dental services, including rural parts of Western Massachusetts, elderly communities, and low-income urban communities of color. We’re hopeful that this new model will become a reality in Massachusetts and will also work to ensure that mid-level providers will serve the people who need them most. It’s one thing to get a bill passed, but it’s not enough to just stop there.

Q: Which populations are you focusing your equity work on?

A: It’s really easy to just say, “We’re focusing on the Medicaid population,” and leave it at that without thinking about the sub-populations that exist within the broader set of Medicaid beneficiaries. We’re finding that the population with developmental disabilities as well as individuals who live in the rural areas of western Massachusetts are both having trouble with access to oral health care.  Even just saying that we’re “narrowing down” our focus to western Massachusetts is obviously a bit of an oxymoron because it’s a huge region.

We also know that not having culturally and linguistically competent care is a big barrier to access in some places. We were really surprised to find that although there appear to be enough dentists who speak Spanish, severely lacking are dentists who speak Portuguese, the third most common language in the state. Thus, we identified Portuguese speakers as a potentially underserved group.

Q: Are there any obstacles to your oral health equity work?

A: The biggest obstacle is the separation of oral health care from the rest of health care. A lot of the oral health disparities could be alleviated if oral health care were better integrated into the health care system. We’re pursuing structural-level changes in the way that oral health care is financed and delivered to try to “bring the mouth back into the body.”

We also see diversifying the workforce to better represent Massachusetts residents as critical, especially when you look at who is going into the dental profession. Establishing more pathways into the oral health professions through outreach to minority students, recruitment of minority faculty, and targeted financial incentives such as loan repayment programs will help.

Q: How does HCFA plan to advance oral health equity in Massachusetts going forward?

A: Through the learning collaborative, we’ve highlighted an ongoing priority: oral health surveillance. There aren’t many oral health care datasets available, so we have identified collecting those data as one of our top priorities. We are also making sure that oral health is being addressed within Massachusetts’ new accountable care organizations. Ensuring that these new delivery and financing models establish equitable ways of providing care is a critical part of the implementation process. This is in line with a broader attempt to increase the prominence of oral health at the systems level.

Progression toward oral health equity will happen with interventions that address specific barriers identified at the community level. Health Care for All’s strategies to improve oral health data collection, diversify the dental workforce and improve cultural competency will increase the availability of oral health care for those whom need it most in Massachusetts — and may serve as a promising path for other communities across the country.

--June Glover, Program Officer, CHCS and Teagan Kuruna, Communications Associate, CHCS

August 9, 2016

This blog was originally published on Community Catalyst’s blog Health Policy Hub

As states across the country look for ways to combat the ongoing opioid crisis, one overlooked issue is how we address the impact of this crisis on our communities’ youngest. Infants exposed to opioids in utero may experience a variety of potentially debilitating symptoms associated with opioid withdrawal, collectively known as Neonatal Abstinence Syndrome (NAS). As the opioid crisis and NAS receive greater attention, children’s advocates and public health professionals have pushed for more focused strategies and greater resources to assist. Efforts have focused not only on those infants specifically diagnosed with NAS, but also on additional substance-exposed newborns (SEN) who may experience problems related to other types of prenatal substance exposure.

At the federal level, the Protecting Our Infants Act of 2015, sponsored by Rep. Katherine Clark (D-MA) and Sen. Mitch McConnell (R-KY), helped bring greater attention to the issue, particularly the need to gather data to comprehensively assess the impact on infants and their families over time. Increasing awareness is an important first step in reversing the rise in newborns exposed to harmful substances. And while there are numerous efforts on the ground to combat the epidemic and support infants and their families in recovery, many are reliant on finite resources and have yet to be integrated into a system that will ensure their long-term sustainability.  

In Massachusetts, over the past year, Community Catalyst’s New England Alliance for Children’s Health (NEACH)convened a working group of practitioners, early childhood specialists, advocates and public health stakeholders to help the state take the next step to advance uniform policies across human and health services to support infants and their families. With the help of the Children’s Health Access Coalition (CHAC), the working group pushed the state to take more concrete steps to improve care for substance-exposed newborns. These efforts produced a resounding victory last month – the state’s FY 2017 budget included language establishing an inter-agency task force dedicated to addressing NAS and SEN. The relevant section declares that “all executive agencies work in coordination to address the needs of newborns, infants and young children impacted by exposure to substances.”

Importantly, the taskforce brings together state agency leaders who play an important role in the care of children and their parents. This list includes the Secretary of Health and Human Services, the Attorney General, the Commissioner of Children and Families, the Commissioner of Mental Health, the Commissioner of Public Health and the Executive Director of the Massachusetts Health Policy Commission. Additionally, an advisory council of experts and community leaders was formed from across the continuum of care for infants and parents experiencing the effects of substance use disorders. The establishment of this task force is a major step forward and presents a considerable opportunity for improving the care and outcomes for parents with substance use disorders and their children throughout the Commonwealth.

While the establishment of the task force is but one step in addressing a very large problem, it does make significant progress around coordination and communication among state agencies – one of the greatest barriers to establishing comprehensive systems of care on a state-wide basis. Due to the multiple issues involved, NAS and SEN necessitate the involvement and interaction of several agencies and departments. As states look to address NAS and SEN, the ability to coordinate effectively will be critical to ensuring the development and implementation of successful plans.

--Ben Koller, Program Associate, Community Catalyst Aliiance for Children's Health

August 1, 2016

The purpose of health insurance is twofold. First and foremost, it serves to protect a person’s health. Without coverage, people are more likely to delay getting needed care. But, almost as importantly, coverage ensures financial security. Even a routine procedure like an appendectomy could mean financial ruin for the uninsured. An important new study, The Effects of the Massachusetts Health Reform on Household Financial Distress, published in the American Economic Journal, sheds light on the economic impacts of the 2006 Massachusetts health reform. The conclusions suggest that the effects of sweeping health reform extend far beyond better health outcomes; expanding coverage may actually help to lift people out of the hole financially, ultimately driving opportunity for economic growth.

The study compared financial characteristics of people under age 65 in Massachusetts to other New England states, before and after full implementation of the Massachusetts health care law in 2008. The model took into account which subgroups were most heavily affected by the reform. Before the reform, from 1999-2005, Massachusetts followed the same financial trends as other New England states. After the expansion of coverage in 2008, Massachusetts suddenly deviated. The authors concluded that higher coverage rates directly and significantly contributed to the following outcomes through 2012:

  • improved credit scores,
  • reduced total debt,
  • reduced total amount and percent of debt past due, and
  • reduced probability of personal bankruptcy.

Just to be sure about health reform’s causal effect on improved financial well-being, the authors conducted an analysis of individuals over age 65 in Massachusetts, since this age group was essentially unaffected by the reform. Confirming the findings, seniors’ financial outcomes did not change relative to those who gained access to insurance under the reform.

The authors conclude:

Our analysis shows that health care legislation has implications that reach beyond health care providers and the uninsured, and extend into credit markets, benefiting not only uninsured households who gained coverage, but also creditors who served these households. Our finding that credit scores improved as a result of the reform indicate that the reform increased future access to credit for those individuals who gained coverage. These results show that health care reform legislation has pervasive effects not just on health and the use of health services, but across many measures of household well-being.


Chart adapted from paper, showing decline in Mass residents with over $10,000 in debts.

Particularly striking is the fact that these financial improvements took place in the midst of a serious economic recession. It prompts the question: did the 2006 health reform help mitigate some of the recession’s worst effects for the state of Massachusetts? Common sense economics says that if people have less bad debt, less likelihood of declaring bankruptcy, and better credit, they will have better economic opportunities. Greater numbers of economically healthy individuals means a more prosperous economy as a whole. A higher credit rating means better prospects of home ownership. Less unpaid debt means more money flowing through various sectors of the economy. Less personal bankruptcy means – well, let’s just say we know what happened in the 2008 financial collapse.

Again, Massachusetts leads the way in demonstrating the far-reaching beneficial impacts of universal healthcare. The nation should take note.

                                                                                                                                                                         -- Mike DiBello

July 26, 2016

In mid-June, MassHealth took another step towards payment and care delivery systems reforms with the release of their 1115 waiver proposal (background: section 1115 of the Social Security Act allows the federal government to authorize state demonstration projects to improve Medicaid). Through the 1115 waiver, MassHealth is requesting authority from the federal Centers for Medicare and Medicaid Services (CMS) to restructure MassHealth care delivery through implementation of Accountable Care Organizations (ACOs) and expand substance use disorders services. MassHealth is asking CMS for a $1.8 billion up-front investment over five years to support transition toward ACO models, including direct funding for community-based providers of behavioral health and long-term services, as well as funding for for safety net programs, including the Health Safety Net – this is important, as under the current waiver, a significant portion of Safety Net Care Pool funding is set to phase out by June 30, 2017.

The public comment period closed on July 17th, with many stakeholders weighing in. Health Care For All helped draft and submit several sets of comments on a range of issues covered in the waiver proposal, with common themes around ensuring access to care, member choice, consumer protections, and monitoring and oversight. One set of comments we organized included these 29 organizations:

Logos of groups commenting on 1115 Waiver

Use these links to read our submitted comments:

The next step is for MassHealth to submit their 1115 waiver proposal to CMS. CMS will send MassHealth a notice of receipt within 15 days of submission, and that notice initiates the start of a 30-day federal comment period.

 

 

July 25, 2016

It’s a horrible name, but a great program. And with HCFA’s support, the Massachusetts state legislature just saved its funding for this year.

“Detailing” is the term used to describe the marketing of prescription drugs to doctors, pressing them to prescribe specific drugs for their patients. Detailers are sales representatives who travel to physician practices to deliver sales pitches lauding the benefits of their drugs. Often, detailers provide a free meal and drug samples as an enticement for providers to listen to their spiel. Detailers only work for name brand drugs; there are no detailers for generic alternatives.

“Academic detailing” is just the opposite. Independent experts meet with doctors, and go over current scientific information on a class of drugs, informing doctors on all the research, and making unbiased recommendations based on comparative evidence, including cost-effectiveness. The result is better patient outcomes, and lower health care costs. One study from Harvard Medical School found that each dollar spent on academic detailing saved two dollars in prescription drug costs.

For several years, Massachusetts has operated an academic detailing program, operated by the Department of Public Health. For this coming fiscal year, the plan was to focus the $150,000 program on how to best prescribe pain killers, to avoid the over-prescribing of prescription opioids. But when the fiscal year 2017 budget was presented to Governor Baker, he vetoed the funding for the program.

Last week, the legislature overrode the veto, by a 122 to 31 vote in the House, and a 36 to 3 vote in the Senate. During the override debate, Senator Mark Montigny spoke out passionately in favor of the program:

“We're not only fighting the opiate crisis, we're also fighting price-gouging by the pharmaceutical companies. This is exactly what should be done. Instead of having folks running around offices selling things they aren't even qualified to sell half the time. I think this is a great program.”

HCFA continues to press for effective prescription drug policies that save money and improve care. In addition to support for academic detailing, our prescription drug policy agenda includes greater transparency around drug prices, and eliminating copays for cost-effective preventive care. We’re very pleased that the academic detailing program survived, and will continue to press for a consumer-focused policies in this area.

-Brian Rosman

July 20, 2016

The Oral Health Advocacy Taskforce (OHAT) has a new initiative: integrating oral health into the rest of the health care system. OHAT’s new Oral Health Integration Project (OHIP) kicked off this past May and has hit the ground running. Over the past couple of months, OHIP members and stakeholders have put their heads together to think about what oral health that is fully integrated with the rest of the health care system could look like.

There is currently a significant opportunity to elevate oral health in health care here in Massachusetts. As explained in previous blog posts, MassHealth is proposing substantial changes to its program with the renewal of its 1115 Demonstration Waiver, to be approved by the federal government. At stake is 1.8 billion dollars over five years to support MassHealth’s transition to Accountable Care Organizations (ACOs). ACOs are a new way to pay for and deliver care that works by bringing together providers to coordinate high quality health care – care that we believe should include oral health.

MassHealth’s released Waiver Proposal touches upon oral health in a few important ways, and briefly outlines the inclusion of oral health metrics in the ACO quality measure slate as well as contractual expectations for ACOs around oral health. OHIP is pleased to see that oral health is included in MassHealth’s future plans for restructuring and is urging MassHealth to expand its efforts in this area.

OHIP submitted formal comments to MassHealth pushing for more robust ACO standards that would facilitate increased integration of oral health. A summary is listed below:

  • ACOs need to have accountability for oral health and dental services, and dental services should be phased into ACO total cost of care
  • Dental providers should be allowed to join ACOs and take part in risk-sharing arrangements starting in the first year of ACO roll-out
  • ACO payment methodologies for dental and oral health services should incentivize high-value, evidence-based, preventative care
  • Delivery System Reform Incentive Payments (DSRIP) funds should be used to transition the delivery system to adequately address oral health
  • Oral health quality metrics can help tie oral health into overall health in ACOs and should be strengthened
  • Oral health should be integrated into all aspects of care coordination
  • Roll-out of dental services inclusion in ACOs should first consider piloting
  • ACO governance, quality, and clinical committees should have representation from oral health clinicians
  • There should be adequate consumer protections built-in throughout the ACO structure

Take a look at OHIP’s full set of comments here.

Kelly Vitzthum

July 19, 2016

Last Thursday, the Health Connector Board met to update their bylaws, award conditional Seal of Approval to health and dental plans, and review the Health Connector’s FY2016 final and FY2017 proposed administrative budgets. Materials from the meeting can be found here.

Executive Director’s Report

Health Connector Executive Director Louis Gutierrez provided updates on Connector activities.

  • July enrollment increased by 10,500 members
  • 7500 members were overcharged for their premiums; the Connector has worked with Dell to rectify the situation and ensure members receive refunds
  • Risk adjustment payment to carriers increased by $84 million, largely due to an increase in Qualified Health Plan (QHP) member months
  • The Health Connector is considering their options to the Small Business Health Options Program (SHOP) and employee choice program. The Health Connector cancelled the SHOP procurement after not receiving any good options.
  • Preparations for 2017 Open Enrollment are under way.

In response to the SHOP updates, Board members discussed and inquired as to whether implementing a SHOP system would be a waste of time and money and whether this feature of the ACA is able to be waived. Gutierrez responded that it is waivable under Section 1332 authority, but it would be very difficult to obtain approval. The Health Connector is considering a shared platform with other states such as Connecticut, Rhode Island and Washington DC as an alternative.  

Patricia Wada provided an update on the roadmap for IT systems upgrades. The next release in August will focus on repairs and user experience upgrades to prepare for 2017 Open Enrollment, allow for Spanish language notices, and plan management features. The HIX system is a joint effort between the Health Connector, MassHealth and Mass IT. One Board member questioned whether the IT system will be impacted by MassHealth’s delivery system redesign and implementation of Accountable Care Organizations (ACOs). Gutierrez responded that this is on their radar and they are planning very far ahead.

Update to Bylaws

Ed DeAngelo and Ashley Hague presented proposed updates to the Health Connector Board bylaws, which have not been updated since the Connector’s inception in 2006. Updates focused on the designation of the Secretary of Health and Human Services as the board chair, the allowance of Board members to be notified of scheduling matters via email, the shift of responsibility from Executive Director to a Health Connector employee to be responsible for meeting minutes, and the allowance of the election of a vice chair to occur any time during the final quarter of the year, depending on each monthly agenda were each enacted.

There were also a few contractual updates to the bylaws. This included the an update to the minimum dollar value (from $5,000 to $15,000) for contracts that do not require a formal vote, but do require a written notice to the Board 5 days before execution. The type of “contract” requiring Board vote was then specified as “any and all types” except for extensions, amendments and work orders that cost less than a quarter of the original contract, as long as the cost is noted in the most recent Board approved fiscal budget. The Board voted unanimously to approve the amended bylaws.

Conditional 2017 Seal of Approval

In response to the 2017 Seal of Approval RFR, there will be a 25% decrease in health plans offered through the Connector when compared to 2016. Unlike 2016, when only non-standardized Bronze plans were offered, the Health Connector created, two new Standardized Bronze plans - one MCC-compliant and the other  has-compatible. All carriers opted for the MCC-compliant Bronze  plan design. In addition, the second standardized Gold plan was also eliminated. In total, 10 medical carriers responded to the 2017SOA ,submitting 62 QHPs for both non-group and small group shelves.

Notably, one of the new goals of the SoA expressed by the Health Connector is  enhanced substance use disorders treatment 2017 ConnectorCare plans will offer enhanced access to Clinical Stabilization Services and reduce the cost burden for key MAT (medication-assisted treatment) and associated services.

Another change is the requirement for QHPs to include pediatric vision and dental services, as per the State’s updated Essential Health Benefits (EHB) requirement Requiring Pediatric dental EHB coverage would move the Health Connector into parity with the off-exchange market, increasing the accessibility of these services. While one carrier cited operational challenges as a barrier, most opted to include pediatric dental benefits into their plans. On the dental carrier side, there were not many changes to the requirements and offerings of Qualified Dental Plans (QDPs).

The Health Connector voted and approved the 2017 Conditional Seal of Approval for  recommended QHPs and QDPs from the following carriers:

  • Altus Dental
  • Blue Cross Blue Shield of MA
  • Boston Medical Center HealthNet Plan
  • CeltiCare Health
  • Delta Dental of MA
  • Fallon Health
  • Harvard Pilgrim Health Care
  • Health New England
  • Minuteman Health
  • Neighborhood Health Plan
  • Tufts Health Plan – Direct
  • Tufts Health Plan – Premier

Health Connector FY2016 & FY2017 Administrative Budgets

July 19, 2016

This blog post was originally published on Community Catalyst's blog Health Policy Hub

I recently attended Health Care for All’s (HCFA) 4th Annual Patient and Family Advisory Council (PFAC) Conference in Massachusetts, which was incredibly informative and inspiring. HCFA was a major force behind the passage of the 2008 law that required all Massachusetts hospitals to establish PFACs, and for the past eight years, has provided technical assistance, training and networking opportunities to strengthen patient and family engagement in hospitals.

So, what are PFACs and why do they matter? According to the Agency for Healthcare Research and Quality, PFACs are bodies made up of individuals who have received care at a hospital (or their representative family members) and are able to offer feedback and insights to inform and improve hospital care delivery, policies and operations to most effectively address patient and family needs and preferences. PFACs have the potential to help improve overall systems and processes of care, which can lead to better health outcomes for patients, as well as improve financial performance of health care organizations.  PFACs are a great example how to actively and meaningfully engage consumers in order to realign the health care system and place consumers at its center.

But establishing a PFAC is only the first step. Learning how to make it meaningful is an entirely other story. And that’s what the HCFA conference was all about. It began by offering a three-part vision of what constitutes authentic engagement: First, engagement is purposeful; second, engagement is effective; and, finally, engagement isequitable. The conference covered a lot of ground across these three themes, providing the nearly 300 participants with opportunities to discuss everything from building internal credibility for PFACs, to creating effective meeting agendas, to understanding why PFACs should care about and provide their perspectives around quality measures. Most importantly, the conference provided PFAC members from across the state with an opportunity to network with – and learn from -- one another.

One cross-cutting theme of the day was the importance of consumers being engaged at every level, and from beginning to end of all hospital processes. Examples abounded, including in sessions focused on engaging patients in research as partners rather than subjects, integrating patients into hospital committees, and identifying the PFAC’s role in shaping hospital community health assessments and activities in order to best address identified needs.

Another theme was the importance of recruiting a diverse PFAC membership that represents the patient population by race, ethnicity, language spoken, sexual orientation, gender, age, disability status, employment status and so forth. One PFAC’s approach to recruiting and retaining diverse members included developing a Diversity, Equity and Inclusion Council that supports other PFAC members in understanding how to be more inclusive of people from different racial and ethnic backgrounds. Another PFAC in the state is working to adapt educational materials for different age groups, particularly older adults, by ensuring materials are printed in large, bold text and colors that are easy to read. Several PFACs are changing their meeting times or incorporating virtual meetings and social media in order to accommodate members who are working parents or others who have difficulty getting to in-person meetings.

The conference helped me better understand some of the challenges and opportunities PFAC members face as they continue to develop and establish their roles within health care organizations here in Massachusetts. I also walked away from the conference with an increased appreciation of the role consumer health advocacy organizations like HCFA can play – through convenings, trainings and providing a space for PFAC members to connect – in supporting these councils so that their engagement is truly purposeful, effective and equitable.  

- Angela Jenkins, Project Manager at Community Catalyst 

July 12, 2016
New residents at BMC attend orientation, which includes a workshop on the social determinants of health. (Martha Bebinger/WBUR)
New residents at BMC attend orientation, which includes a workshop on the social determinants of health. (Martha Bebinger/WBUR)

Last week WBUR reported on an effort to improve doctor-patient relationships by training medical professionals in social determinants of health. These recognize that our health is largely determined by our access to social and economic opportunities, not direct medical care. Some of these factors include access to housing, nutritional food, education, and income supports, among many others. This piece highlights a program that is being implemented at Boston Medical Center, in which resident doctors are being trained to find out what kinds of barriers their patients may face when it comes to being healthy and staying healthy. In an effort to improve patient-centered care, similar trainings to the one at BMC are also being offered to doctors at various hospitals around the country, including Johns Hopkins in Maryland and at Dell Medical School in Texas.

Everyone in Massachusetts deserves the opportunity to lead a healthy life, and it is in our best interest for all doctors to be trained in how health may be affected by social factors. By looking at health from a more holistic perspective, health care professionals can aid in the transformation of the medical system and improve health outcomes. Health Care For All strongly supports the move to address social determinants of health. We believe that there is great value in this approach, as it helps to build patient-centered care and has the potential to positively impact our communities by promoting health equity. 

--Angela Swanson

June 30, 2016

Meals influence doctors' prescibing of brand name drugsRecently, a study (read about it in our post here, and see the Wall Street Journal chart at right) found an unsurprising correlation: doctors receiving free food from pharmaceutical companies are more likely to prescribe higher-priced brand-name drugs; even when the food costs less than $20. So of course, that's how the drug companies market their pills.

Now, a Boston Globe/ProPublica analysis provides insight into the scale to which doctors are receiving payments from both the pharmaceutical and medical device industries. Bottom line: a lot of docs are getting a lot of meals paid for by pharma. A few highlights:

  • Over 50% of affiliated doctors at some Massachusetts community hospitals received payments.
  • At some hospitals, almost everyone was on the take: 77% of doctors at Baystate Noble Hospital in Westfield received payments, mostly in the form of meals. At Mercy Medical Center in Springfield, it was 74%; at Harrington Memorial in Southbridge, it was 71%.
  • Most meals were provided while drug industry representatives provided information on brand name medications for asthma, high cholesterol and blood clots.

The Globe reached out to two doctors who each reported over 200 meal payments during 2014 for comment, but they refused to return multiple emails and phone calls from the paper. At Mercy Medical Center, the Globe reported this non-answer answer:

Mercy Medical Center said it monitors company payments to doctors and has “confidence in our physicians to do the right thing.’’ When they don’t, its statement read, “we take action.” The hospital declined to comment further.

While state law limits drug marketers to providing "modest meals" as part of educational forums, we reiterate our call to tighten the state regulation of what's modest. After all, the state definition was drafted in consultation with pharma lobbyists, and it essentially imposes no real limits. And this new research points to the need to also curb the number of meals provided, as well as the cost per meal.

                                                                                                          - Mike DiBello

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