"Health Care For All" in lights on a bridge

A Healthy Blog

Massachusetts health care – wonky with a dose of reality

January 31, 2016

Headline: Patient Confidentiality Bill Moving Through Statehouse

In a step towards victory for patient privacy, the Massachusetts legislature’s Joint Committees on Financial Services and Health Care Financing reported favorably on one of HCFA’s legislative priorities, “An Act to protect access to confidential healthcare.”  The new bill, S. 2081, sponsored by Senator Karen Spilka and Representative Kate Hogan, is now before the Senate Ways and Means Committee.

Health insurers routinely send out an Explanation of Benefits (EOB), detailing the type and cost of medical services received, to the primary subscriber each time an enrollee on the plan accesses care. Sensitive health information is frequently disclosed in an EOB, violating the basic right to privacy for anyone enrolled as a dependent on another's health plan, such as a young adult, minor, or spouse. Young adults and minors are particularly likely to not seek care for sensitive services when worried that their parents will find out.

The bill would remove a crucial barrier to accessing health care by ensuring that when multiple people are on the same insurance plan, confidential health care information is not shared with anyone other than the patient.

The bill's legislative progress was covered by the AP, and appeared at a number of state news sites:

Sen. Jamie Eldridge, co-chairman of the committee, says the bill is particularly important given that more young people are obtaining health insurance through their parents under President Obama’s health care law.

The Acton Democrat says the state must be vigilant in making sure that all patients’ health information remains confidential.

Democratic Sen. Karen Spilka says victims of abuse and minors are often reluctant to seek certain types of treatment, fearing that their abuser or parent will learn details.

Last July, the committee heard testimony in support of the bill from patients, health care providers, and members of the HCFA-led Protecting Access to Confidential Health Care (PATCH) Alliance.

If your Senator is on the Senate Ways and Means Committee (see list here), please contact them in support of the bill.

  -- Jessica Imbro

January 29, 2016

Baker admin files FY 2017 budget

On Wednesday, Governor Baker released his proposed state budget for fiscal year 2017, which begins on July 1, 2016. While the budget provides for an approximate 5% growth rate for MassHealth spending, administration officials had projected that total MassHealth expenditures would rise around 8% next year, due to increases in the caseload and medical inflation. As a result, the budget calls for spending cuts in a number of areas, and freezes in many reimbursement rates.

The cuts were covered in an article by the Springfield Republican State House reporter Shira Schoenberg: Gov. Charlie Baker's budget finds ways to trim MassHealth spending:

Some advocates worry that proposed changes could limit access to some benefits.

One change is MassHealth is moving more people away from fee-for-service plans toward managed care organizations, where a provider group is paid one fee to coordinate all of a patient's health care. The state will eliminate some benefits from fee-for-service plans and keep those benefits in managed care plans, as an incentive to switch. These benefits include physical, occupational and speech therapy, chiropractic benefits and vision. ...

But the health care advocacy group Health Care for All opposes the changes. Restricting benefits in fee-for-service plans "unnecessarily restricts member choice and may impose barriers to accessing certain benefits and providers," said Health Care for All Executive Director Amy Whitcomb Slemmer. Locking members into one plan for a year, she said, "can have a negative impact on access to care and reduce flexibility to find a network that meets the members' individual needs."

In another area, the state has a Health Safety Net plan that reimburses hospitals and community health center for caring for uninsured or underinsured residents – generally, people who do not qualify for other plans, such as illegal immigrants and people waiting for employer-sponsored care. The state wants to lower eligibility from individuals earning four times the federal poverty level ($47,000 for an individual) to three times the poverty level ($35,400), according to Health Care for All.

"It will get a very fair look, because I think our goals are the same." - Sen. Jim Welch

"This would hurt their ability to get the health care they need and stay healthy," said Health Care for All research director Brian Rosman.

Health Care For All's Executive Director, Amy Whitcomb Slemmer, issued the following statement in response to the Governor's proposed budget:

"Health Care For All appreciates Governor Baker's budget proposal that preserves and invests in many critical health-related programs.

"We especially applaud the decision to maintain dental benefits for adults in MassHealth. Having access to good oral health care is critical for vulnerable populations in order to prevent health complications.
 
"We are also pleased that the Governor proposes to keep MassHealth payment rates steady, and even increase some rates for behavioral health and substance abuse services under the MassHealth program. We know that paying fair rates to providers will encourage more to accept MassHealth coverage, increasing access to needed care for patients seeking diagnosis and treatment.
 
"However, we strongly disagree with the proposal to lock MassHealth members into a specific managed care plan for 12 months. This can have a negative impact on access to care and reduce flexibility to find the network that meets the members' individual needs.
 
"We oppose his proposal to restrict benefits for some in MassHealth in order to push members into managed care plans. This unnecessarily restricts member choice and may impose barriers to accessing certain benefits and providers.
 
"We are also deeply concerned about proposed cuts in eligibility for the Health Safety Net program. This increases the risk of medical debt for low- and moderate-income residents who are uninsured or underinsured.
 
"We are encouraged by the Governor's focus on solutions to family homelessness and support his call to raise the Earned Income Tax Credit (EITC) to 50%. This credit provides a valuable increase in a family's income that has been shown to have multiple beneficial impacts, particularly for children. Research has shown that the EITC can be linked to improved child health, better academic performance, and higher income levels as adults.
 
"We look forward to working with the Baker Administration and the legislature to advance policies and regulations that aim at improving health care access and health outcomes for all Massachusetts residents."
The budget next will be considered by the House Ways and Means Committee, and then the full House, followed by the Senate,with their action expected in the spring and early summer.
 
January 27, 2016

The Massachusetts House of Representatives today took a major step to address health disparities by passing legislation creating an Office of Health Equity. The bill passed by an overwhelming 152 to 4 vote.

The bill (H. 3969) has been a long-time priority for Health Care For All. It creates an Office of Health Equity within the Executive Office of Health and Human Services (EOHHS), charged with creating an annual plan for the elimination of health disparities in Massachusetts and working with other state agencies, including agencies dealing with housing, transportation, public safety and labor, on disparities reduction initiatives to address the social factors that influence health inequities.

Bill co-sponsor Representative Jeffrey Sánchez spoke passionately in support of the bill on the House floor:

Today is a really big day. It's another chapter in our road to health reform. Minorities have a disproportionate burden of death and disabilities Seventy-five percent of spending are on chronic diseases. The are conditions that are preventable and disproportionately affect people of color. African American and Latino citizens have a higher mortality rate and worse health outcomes. ... The benefits of a dedicated office of health equity are clear. It will improve the communication and the coordination and duplication across state agencies to make sure that we're using our scarce dollars to make a better impact and to make sure we leverage cross sector experience and foster mutual understanding and also to serve as a single point of access for partners outside of state government. We have to make sure disparities don't continue to broaden.

Also speaking was the bill's other co-sponsor, Representive Byron Rushing:

When we look at statistics like black residents having a higher death rate from asthma than other groups, when we look at statistics such as black and Hispanic babies have a 3 times and 2 times higher respectively infant mortality, we are not talking about other parts of this country. We are talking about Massachusetts from Boston to Pittsfield. We are talking about our own population.... This is complicated. It will not be solved overnight but it will never be solved if we are not consistently paying attention to it, and that's where this piece of legislation comes in. By establishing this office under the governor, we will now have a place that will be consistently looking at a strategy that will involve much more than only the medical establishment in looking to end these disparities. We will have an office that will be consistently working on this work and reporting on all of this progress so that we will be able to be involved in an educated set of policies and suggestions for future changes.

Over a decade ago, HCFA convened the "Disparities Action Network," which brought together dozens of groups in support of the bill. The group continues to advocate on disparities issues, and was active today expressing strong support for the bill to the House members.

The bill now goes to the state Senate.

              -- Brian Rosman

January 23, 2016

The legislature's Joint Committee on Health Care Financing held a session last week in Springfield, looking at the impact of skyrocketing prices of prescription drugs. 

Among those speaking was HCFA Executive Director, Amy Whitcomb Slemmer. She brought real-life examples of the how high drug costs are hurting people in Massachusetts:

  • Recently our HelpLine heard from a consumer named Jessica who sought our assistance in September. She called us because her mother has been prescribed a treatment for psoriasis – a chronic and sometimes painful skin condition, that costs her family $400 per month. Without some sort of subsidy or relief, each month Jessica’s family finds itself having to choose between her mother’s injection drug treatment and meeting their rent and food needs. 
  • In October we talked to Beatriz whose daughter’s college insurance plan did not cover the cost of an incredibly expensive drug that she relies on to stay well. Her daughter was struggling with what to do, and eventually dropped out of college, qualified for a different health plan which provided access to her needed medication, but cut her off from a college education.
  • We also heard from HelpLine caller Marisa, who has type 1 diabetes and is fortunate enough to have employer-sponsored health insurance. Marisa struggles to meet the out of pocket costs of paying for frequent co-pays and meeting her deductible as she keeps herself equipped with the appropriate medication and diabetes supplies. One of the ways Marisa chose to cut costs was to cut way back on food, which not only saved her money, but created a drop in her blood sugar. During a doctor’s visit, she was warned about the potential irreversible harm she might cause herself, so she has left her own apartment, and moved back in with family in order to save money and afford the medicine and health supplies she needs.

We called on the legislature to take strong action to reduce the high cost of prescription drugs. One proposal we supported is pending legislation to provide transparency for prescription drug costs. This concept was also endorsed by the Health Policy Commission, which focused on prescription drug cost transparency in its Cost Trends Report recommendations last week (see slide 36 in this presentation for details).

Following the hearing, Slemmer was interviewed by Springfield's Channel 22 about the issue. Click on the graphic below to see the full video interview:

HCFA ED Amy Whitcomb Slemmer interviewed about prescription drug costs by Springfield's channel 22

 

             -- Brian Rosman

January 22, 2016

Earlier this month, Health Care for All actively contributed to the Health Policy Commission’s public hearing concerning their ACO (Accountable Care Organization) certification standards. ACOs provide coordinated care through their doctors, hospitals and other clinical and non-clinical staff, working together to improve the quality and affordability of care. HCFA representatives Steve Slaten, Valerie Spain, Brian Rosman, Alyssa Vangeli, and Helen Hendrickson testified at the hearing, offering consumer viewpoints on how to strengthen the proposed standards.

HCFA Leadership Council members Steve Slaten and Valerie Spain testify on ACO standards

HCFA’s Leadership Team representatives Dr. Stephen Slaten and Valerie Spain (pictured above) spoke as consumer representatives at the hearing. Slaten, a psychologist, advocated for the meaningful inclusion of consumers in the governance of ACOs. The inclusion of independent consumers on ACO boards—at least two, he argues—would improve accountability. He spoke from personal experience with doctors who did not keep the patient's best interest in mind. To really shift care to be patient centered, it requires the message from the top be, “no, we really mean it this time.”

Spain, too, spoke for consumer engagement and transparency. She called for meaningful consumer engagement through consumer advisory councils to ACOs, with a built-in feedback loop, public annual reports, and professional support. She urged the Commission to "...be bold. We are at a juncture of great opportunity. Boldness will bring a groundswell of support from disability groups, non-profits, and consumer organizations. Go as far as you can, you’ll have room to step back if needed. Don’t go halfway–if you go halfway everything will coalesce around halfway measures."

HCFA's Brian Rosman and Alyssa Vangeli spoke about the need for ACOs to play a role in population health. "Perhaps the 'C' in ACO should also stand for 'Community'," Rosman said. Because ACOs are responsible for keeping their patients healthy, they should identify the particular needs of its patient population based on criteria that includes social determinants of health, which could include factors such as homelessness or unstable housing, age, primary language, race and ethnicity, geography, gender identity and sexual orientation. ACOs should engage Community Health Workers, who can bridge the needs of patients outside clinical care. Vangeli emphasized that holding ACOs accountable for improved health and experience of care will require quality measures that are focused on outcomes and patient-reported data. She asked that the HPC work with ACOs and payers to monitor and track under-service and underutilization. ACOs should educate their enrollees on what an ACO is, the benefits of care under the ACO, and the responsibilities and rights that accompany receiving care from an ACO.

Helen Hendrickson spoke on behalf of HCFA's Oral Health Integration Project, and advocated for the inclusion of dental care and oral health in the ACO design. The need for improved access to dental care is an imperative, Hendrickson emphasized. “Dental decay is the most prevalent chronic disease among children,” she said attested. Poor oral health has also been linked to chronic conditions, including heart disease, diabetes, and stroke. And there are significant costs to the overall healthcare system. In Massachusetts, MassHealth paid $11.6 million from 2008 to 2011 for emergency room dental care for adults. She suggested PCPs offer oral exams and referrals to dentists when needed. The proposal does not explicitly include oral health providers and Hendrickson urged the Commission to revise several standards.

Written public responses to the ACO plan can be sent to the Health Policy Commission at HPC-Certification@state.ma.us. Comments must be received by 5:00 pm, January 29th.

            -- Jessica Imbro

HCFA Volunteers assist several hundered people with enrollment in Framingham
January 21, 2016

Nearly 300 individuals gathered at Fuller Middle School in Framingham this past Saturday, January 16th, seeking health care coverage enrollment and navigation assistance, as well as other health services. Health Care For All’s ‘Grand Enrollment Event’ featured more than 70 HCFA staff and volunteers, including Spanish and Portuguese-speaking health insurance Navigators and Certified Application Counselors. Volunteers helped 154 individuals, 107 of whom were uninsured upon arriving to the event, to enroll in health care coverage.

Volunteers helping people enroll in health coverage

86% of event attendees self-reported as Portuguese-speaking, while only 10% reported speaking English.

“Massachusetts has the nation’s highest rate of health insurance, with over 97 percent of the population covered; however there are areas in the Commonwealth where many remain uninsured. Framingham, for example, has a significant number of uninsured residents, and we know that many uninsured residents speak a language other than English. Today, we are here to help people navigate the enrollment process in English, Spanish and Portuguese,” said Amy Whitcomb Slemmer, Executive Director of Health Care For All.

State Senator Karen Spilka at HCFA enrollment event in Framingham

State Senator Karen Spilka (above), as well as State Representatives Chris Walsh and Carmine Gentile welcomed the group. Also attending were Louis Gutierrez, Executive Director of Massachusetts Health Connector, and Michael Hugo, Chair of the Framingham Board of Health, as well as Edna Smith, chair of the Community Health Network of Greater Metrowest (CHNA 7).

The ‘Grand Enrollment Event’ was a part of a larger Open Enrollment effort conducted by the Health Connector and MassHealth, as well as numerous community organizations and health care providers statewide. Massachusetts residents have until January 31st to apply, enroll in a health plan, and pay their premium for coverage for 2016. Please call HCFA’s HelpLine at 800-272-4232 if you or someone you know needs help applying or renewing their health care coverage.

January 19, 2016

Last week, the Connector Board met to share progress during open enrollment, discuss proposed policies for a federal State Innovation waiver, and voted on a restructured contract with customer service and billing vendor Dell. Materials from the meeting can be found here.

In addition, the Board bid a fond farewell to Dolores Mitchell, who is retiring after nearly 30 years leading the Group Insurance Commission (GIC), the agency that provides health and other benefits to state and certain municipal employees. Dolores has served on the Connector Board since its inception, and for much of the time has been the Board’s Vice Chair. Thank you, Dolores for your important leadership in health policy formulation and implementation in Massachusetts!

Open Enrollment & Outreach Update

Open Enrollment update 1-14-16

The 2016 Open Enrollment period – November 1, 2015-January 31, 2016 – is going much more smoothly than the past several years. For one, IT systems improvements have made applying and shopping for coverage simpler. Second, Health Connector members enrolled in a plan in 2015 do not have to actively re-enroll if they want to keep their plan – they just need to keep paying their premium. However, they do have the option to switch plans at any point during the open enrollment period.

There are about 189,000 members enrolled in 2016 coverage (January or February start date) through the Health Connector. The retention rate for renewing members is about 92%; the vast majority of whom stay within the same metallic tier as in 2015. Nearly 28,000 of the 189,000 enrollees are new. “New” means that the members were not enrolled in MassHealth in 2015 nor enrolled in the Health Connector through the newer IT system (hCentive) in the past year. Of all new members, 88% reported being previously insured while 12% reported never having had insurance before. According to the Health Connector, preliminary data suggest that their and Navigators’ targeted outreach efforts are prompting the uninsured to sign up for coverage, particularly in the top 10 communities with the highest numbers of uninsured.

Last week, the Health Connector sent a communication to members enrolled in Bronze plans reminding them to review their benefits and that they still have time to switch plans. 1095 tax forms will be sent to Health Connector enrollees who received advanced premium tax credits (APTCs) in 2015; they have already let these members know to wait until they receive this form to file their taxes. In addition, the Health Connector is sending emails, preparing press releases, and supporting Navigator events to educate the public about the January 31st open enrollment deadline, as well as preparing call and walk-in centers for the increased volume towards the end of the month.

In addition, the Health Connector is outreaching to potential members about the possibility of enrolling in health insurance outside the open enrollment period should they encounter life changes, or “qualifying events.” The Health Connector is working with the Division of Unemployment Assistance (DUA) on a mailing to educate employers about Health Connector coverage as an alternative to COBRA for employees leaving their jobs, as well as options for non-benefit eligible employees.

EOHHS Secretary and Board Chair Marylou Sudders asked whether there had been a cost-benefit analysis of the Connector’s outreach efforts, as the rate of uninsurance in Massachusetts has held relatively steady at 3-4% since passage of health reform in 2006. She expressed concern about the sustainability of the state’s programs, including Connector and MassHealth, and the need to discuss cost. Connector Deputy Executive Director Ashley Hague responded that while the uninsurance rate has remained relatively stable, it’s not likely the same people who are included in that rate over time. There is a lot of fluctuation in health insurance coverage as people experience life changes. Audrey Gasteier, the Connector’s Director of Policy and Outreach, added that they are looking at Department of Revenue (DOR) data to determine how many of the 3-4% of uninsured are the same people and whether most uninsured are experiencing gaps in coverage rather than chronic uninsurance.

State Innovation Waiver Update

Basic requirements for a federal 1332 waiver

Section 1332 of the Affordable Care Act (ACA) gives states the option of waiving certain provisions of the ACA. The Health Connector has led a robust stakeholder process to help inform their policy direction for the State Innovation Waiver opportunity, and has a web page dedicated to the topic. After receiving input from various stakeholders, the Health Connector has proposed a two-phase process. For Phase 1, the Commonwealth will seek an application with the federal government to allow Massachusetts to continue rolling enrollment and quarterly rating in the small group market. Under a separate provision of the ACA, Massachusetts was able to keep these features of the small group market until 2018. If accepted, the 1332 waiver would allow Massachusetts to permanently maintain these provisions.

December 23, 2015

Last week Health Care For All submitted comprehensive recommendations to MassHealth regarding their development of Accountable Care Organizations (ACOs). ACOs represent a new way to pay for and organize health care delivery, by bringing together doctors, hospitals and other health care providers who work to give coordinated, high quality care to their patients. 

MassHealth is engaged in a process of consultation with health care stakeholders and the public to establish the contours of their ACO transition. You can read more about MassHealth's thinking on ACOs in this presentation. Here are two of their slides:

MassHealth ACO slides

We agree that MassHealth has an opportunity to promote approaches to payment reform that fundamentally transform the way care is delivered. ACOs should deliver high quality, high value care that treats the individual as a whole person and ensures coordination of care, improved communication, member support and empowerment, and ready access to health care providers, services and community-based resources and supports. The goal is not just better health care, but better health for the entire state.

There’s a lot of detail in our full recommendations (download the document here (warning: 29-page pdf)), along with examples from other states. Below is a much-abridged summary of our recommendations:

Member Protections

  • Monitor and track underutilization: ACOs should establish internal monitoring mechanisms for under-service to safeguard against potential incentives to deny or limit care, especially for members with high risk factors or multiple health conditions. MassHealth should monitor under-service by assessing claims data and health outcomes over time to identify patterns of variation.
  • Protect member choice of providers
    • Network adequacy: Members should have access to care across the continuum, which includes reasonable access to a sufficient number of primary and specialty care physicians, facilities, and other providers, as well as benefits delivered in a timely fashion within a reasonable distance. ACOs should have continuity of care provisions for contracting with providers outside of the ACO.
    • Attribution methodologies: Attribution methods should involve member choice to the maximum extent feasible. MassHealth should not establish a lock-in period forcing members to remain in their ACO for a particular period of time.
  • Ensure robust appeals and grievances procedures: ACO grievance and appeals processes should be easily accessible. MassHealth should establish a single source of information and accountability for under-service through an ombuds program model.

Member Engagement at Multiple Levels

December 16, 2015

Good dental care is critical for overall healthOn Monday, the bill to authorize dental hygiene practitioners was reported favorably out of the Joint Committee on Public Health. The bill (reported as a new draft, S. 2076), sponsored by Sen. Majority Leader Harriette Chandler and Rep. Smitty Pignatelli, establishes a new mid-level dental provider that would help increase access to needed dental care across the Commonwealth.

Known in some other states and countries as dental therapists, dental hygiene practitioners would be able to provide basic dental services, including fillings and simple tooth extractions, and help increase access to dental care for people who struggle to find dentists in their area and/or whom accept their insurance. Though MassHealth covers 40% of the state’s children, most dentists do not accept it, and a shocking proportion of children have untreated oral decay, affecting their ability to eat, learn, and play, and costing the state millions in expensive emergency room visits. Massachusetts also currently has 64 Dental Health Professional Shortage Areas (DHPSAs), with the problem only expected to get worse.

We need dental providers that can deliver care to those who need it the most. Dental hygiene practitioners could work in settings such as schools and nursing homes to make sure those who have a hard time accessing care can receive it. They may also work directly with dentists, allowing practices greater financial flexibility to see more MassHealth patients.

HCFA’s Executive Director Amy Whitcomb Slemmer recently published an Op-Ed in both Quincy's The Patriot Ledger and The Enterprise in Brockton discussing the importance of mid-level dental providers in improving access issues.

We are happy that our policymakers are pushing forward this bill and are excited to work with the Dental Care for Mass Coalition to support this legislation. The bill was referred to the Joint Committee on Health Care Financing, and we urge them to quickly report it out favorably.

    -- Kelly Vitzthum

December 11, 2015

Yesterday, the Health Connector Board met to discuss two topics: 2016 open enrollment and transitioning to the federal risk adjustment program. Materials from the meeting are posted here: https://www.mahealthconnector.org/about/leadership/board-meetings.

Over 180,000 enrolled, halfway through open enrollment window

2016 Open Enrollment Update

Half-way through open enrollment for 2016 health coverage, which runs from November 1, 2015-January 31, 2016, more than 180,000 individuals are enrolled in a qualified health plan (QHP) through the Health Connector for January 1, 2016 – inclusive of ConnectorCare, QHP with Advanced Premium Tax Credits (APTCs) and unsubsidized coverage.

One of the reasons Open Enrollment is going more smoothly this year is that the Health Connector is conducting auto-renewals. While members enrolled in Health Connector coverage in 2015 can switch plans at any time during Open Enrollment, members who did not actively choose a plan in November were automatically enrolled into a plan for 2016. Put simply, if a Health Connector member likes their plan, they do not need to do anything – except pay the updated premium – to keep that plan in 2016.

According to the Health Connector, customer service performance has greatly improved from the last Open Enrollment period, and the launch of additional walk-in centers throughout the state and the ombudsman services provide consumers with additional ways to get help with the eligibility and enrollment process.

Risk Adjustment Update

The Affordable Care Act (ACA) requires implementation of a Risk Adjustment (RA) program, which provides payments to health insurance carriers with plans that have higher-than-average risk (i.e., members with more health care needs) funded by transfer payments from health insurance carriers with plans that have lower-than-average risk. Both federal and state methodologies for RA result in significant transfers of money among carriers, as some will have to pay and others will receive payments.

Massachusetts is the only state to run its own RA program, administered by the Health Connector, in collaboration with other state agencies. The federal Centers for Medicare and Medicaid Services (CMS) runs the RA program for every other state. The Commonwealth’s authorization from CMS to operate a state-based RA program runs out at the end of 2017. Health Connector staff proposed that Massachusetts transfer over the RA program to the federal government after the state-based program ends.

Various factors played into this recommendation, including the requirement for a federal extension of authorization to operate the state-based program, federal approval of the payment methodology (which currently very closely follows the federal methodology and would need to be replicable in other states), and higher costs. The RA program is funded through an assessment on carriers, which is twice as expensive as the federal rate for the state-based program, the cost of which is ultimately passed on to consumers. Thus, the Health Connector is not planning  to pursue federal authorization to operate the state-based RA program for the 2017 benefit year and beyond. However, upon urging from Secretary Marylou Sudders and a few Connector Board members, the Health Connector will notify CMS that they may explore re-establishing a state-based program in the future.

The next Connector Board meeting is scheduled for Thursday, January 14th at 2:00pm at 1 Ashburton Place, 21st floor, Boston.

               -- Suzanne Curry

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