Insight, analysis & opinion from Joe Paduda
You gotta see this.
I’m much embarrassed to inform you, dear reader, that Tinker Ready of Boston Health News published the latest – and greatest – of the health wonkosphere last week, while I was asleep at the virtual switch.
Tinker’s HWR is here; you have to see the video of the AHIP singers.
No, really, you have to!
Paraphrasing Sen Ron Wyden (D OR) produces the most accurate soundbite description of the House’ health reform bill.
Is this the best we can do?
If the answer is yes, we’re in deeper trouble than even I thought. I’m really disappointed with the Republicans. They are supposed to be the budget hawks, but instead they’ve spent their time railing against abortion funding, illegal immigrants, and death panels, along with scientific research and taxes on device manufacturers. Instead of attempting to govern responsibly, they’ve abandoned all morality in their quest to re-energize the lunatic fringe of their once-dominant party. Now comes news that Maine’s Susan Collins is convening news conferences to rail against the cost of the bill.
With all due respect, Senator, this isn’t exactly new news. Now you’re getting concerned about cost? After nine months of debate, discussion, and appearances on Meet the Press? Not to single out Collins; at least she’s finally saying something rational about cost.
While there’s plenty of blame to pile at the door of the Republicans, it is the Democrats who are to blame for coming up with a huge entitlement program set up to do nothing but grow.
Cost containment as proposed in the bill is in the form of cuts to Medicare totaling about $420 billion, including:
– $155 billion (about) from price cuts to hospitals,
– reductions in Medicare Advantage subsidies,
– increasing drug rebates payable to CMS, and
– requiring CMS to negotiate with pharma for Part D drugs.
Then there’s a potpourri of funding for Accountable Care Organizations, better primary care coordination, research on quality and effectiveness, and other should-have-been-doing-all-along initiatives.
As for real cost containment, methods/techniques/tools that can actually reduce cost over the near term in the public and private sectors? Bupkus. Nada. Zippo.
Sure, at some point in the future this research will result in data we can use to recommend more changes. But by that time we’ll be broke, and China will own everything of substance.
Oh, and when insurance underwriting reform kicks in health plans will have to take all comers, yet at 2.5% of adjusted gross income, the mandate penalty is not tough enough to force compliance. What we’ll get is individuals and families buying coverage when they need it, only to drop it when the condition is fixed/surgery completed/rehab over. And under the terms of the House bill, you could fall off your motorcycle, buy insurance, get treated, and then stop paying premiums when your rehab is over.
I’m no fan of the insurance industry, but that just isn’t fair. And lest you think this isn’t going to happen, talk to Charlie Baker, former CEO of Harvard Pilgrim Health in Mass. It’s happening in Massachusetts today.
Drastic times call for drastic measures. If we aren’t going to seriously consider Wyden-Bennett – and more’s the tragedy if we don’t, then we need cost containment with teeth.
How about starting with normalizing treatment costs for specific conditions? The huge and wildly inappropriate variation in practice patterns and costs associated with conditions such as COPD and back pain and prostate cancer and diabetes and dozens of other conditions have to stop. Medicare should, and could, gradually ratchet down reimbursements across the country till they are match global reimbursement for care delivered by delivery systems that are demonstrably efficient and deliver quality outcomes – Mayo, Lahey, Geisinger, et al.
Or develop an all-payer fee schedule (similar to the one in Japan) allowing all payers access to the Feds negotiating power.
Crazy? Sure. But the current bills will not reduce cost inflation. And therefore, sure as the sun comes up tomorrow, within ten years you will be paying $30,000 for family coverage. And pretty poor coverage at that.
What does this mean for you?
Despair? Disgust?
The use – and misuse – of technology in medicine is not only a major cost driver, it is also a major cause of unnecessary pain and suffering.
Far too many carotid endarterectomies were performed in a misguided effort to reduce
If we are to have any hope of slowing down the rate of increase in medical costs, we have to stop the abuse of unproven and potentially harmful technology.
WorkCompCentral [sub req] has a great piece on a program run by the State of Washington that does just that. The Health Technology Assessment program “assesses various devices, procedures, medical equipment and diagnostic tests, then issues recommendations that public payers must follow[emphasis added]. Those public payers include the Department of Labor & Industries, which runs the state’s monopoly workers’ compensation program.”
According to an article in the New England Journal of Medicine, HTA determines reimbursement on these technologies for programs including:
“Medicaid, the workers’ compensation program, the state government employee benefit plan, and the corrections department [which] provide $2.9 billion in benefits annually to approximately 773,000 Washington citizens through direct fee-for-service plans”
Before the wingnuts start spouting about death panels, know that the HTA has been widely accepted by politicians from both parties, it passed with a single ‘nay’ vote in 2006, supported by both the state Hospital and Medical Associations, and while individual conclusions may draw opposition, the program itself is viewed very positively.
The process is rigorous. According to the NEJM;
“The program’s assessments are based on a thorough, systematic review of the evidence related to the effectiveness, safety, and cost-effectiveness of a product or service, with each type of evidence examined separately. After considering the “most valid and reliable” evidence on all three of these dimensions, the health technology clinical committee — which must be made up of practicing clinicians — arrives at one of three recommendations: covered without conditions, covered with conditions (such as criteria defining medical necessity), or not covered. The entire process must be transparent.”
HTA is important because it shows what can happen when government intervenes intelligently and carefully. So far, HTA has rendered opinions and set policy on:
* Arthroscopic surgery for osteoarthritis of the knee. (Not covered.)
* Discography for uncomplicated degenerative disk disease. (Not covered.)
* Implantable drug-delivery systems for chronic, non-cancer-related pain. (Not covered.)
* Lumbar fusion for uncomplicated degenerative disk disease. (Covered, with conditions.)
* Upright or positional medical resonance imaging. (Not covered.)
* CT colonography. (Not covered.)
* Pediatric bariatric surgery. (Not covered for patients 18 or younger. Covered with conditions for patients between the ages of 19 to 21.)
These actions have reduced costs by over $20 million since its inception three years ago.
What does this mean for you?
Payers should look closely at following Washington’s lead.
The most significant charge leveled against Sandy Blunt, former CEO of the North Dakota State WC fund, never should have been brought. And if it wasn’t, he would never have been convicted of a felony.
Blunt was charged with authorizing sick leave for and failing to collect moving expenses from a Fund exec who was terminated within two years. In theory, if he left within the two years, the moving expenses paid by the Fund should have been reimbursed.
Turns out that the prosecutor who brought the charges, Cynthia Feland, knew that failing to collect the moving expenses was not a crime – yet she brought charges anyway.
She had in writing that the ND Attorney General advised state auditors in October of 2006 that the exec did not voluntarily leave and thus there was no legal authority to collect. This fact was then put in writing to Feland a year before the trial and she
– added it as a crime just weeks before the trial and
– withheld the memo proving it was all legally done, thereby not giving the defense exculpatory evidence she was legally required to provide.
Feland clearly violated her obligation not to bring charges without probable cause, she violated her obligation to turn over witness statements, she violated her state obligation to turn over exculpatory evidence, she violated her federally mandated “Brady” obligation to turn over exculpatory evidence, she violated Blunt’s due process rights by not allowing him a preliminary hearing for probable cause on the issue, and she lied right to the Judge’s face in open court about the whole thing (including that it was in the audit when it was not).
I repeat my query from earlier this week:
What in the hell is going on in North Dakota?
And why is there no coverage of Feland’s potentially criminal activity in the press up there?
Is North Dakota some third world country where the State’s employees can decide which laws they are going to comply with based on what best suits their personal/political needs? Where a person’s personal and professional life can be ruined in what can only be a personal or political vendetta? Shouldn’t someone from the State, the FBI, or another law enforcement entity be investigating Feland?
What does this mean for you?
If Sandy Blunt can get absolutely screwed by the system, so can you.
Thanks to the good folks at Workers Comp Insider, I learned of an intriguing study conducted by Conning and Company that concludes (in part) that private work comp insurers don’t perform as well as public ones.
Here are a couple of excerpts from the article in Insurance Journal:
– 25 public and quasi-public workers’ compensation insurance plans perform better financially than the private market in a number of performance categories and at least as well when it comes to the bottom line.
– public workers’ compensation providers tend to have higher losses than the workers’ compensation insurance industry as a whole, they more than offset those losses with lower expenses, higher investment returns, bigger dividends to employers and better injury prevention efforts.
– through more stable reserves and superior investment income, state funds have managed to achieve operating income on a par with that of the workers’ compensation industry as a whole.
– Spurred by their mission that includes improving safety and their state’s economy, state funds blunt the impact of bigger losses through concerted loss prevention efforts. As Jablonowski put it, “They are able to convert the marginal and poor risk into something better.”
The public providers offer employers significantly higher dividends, which provide an incentive for businesses to adopt safety measures. These dividends can also create a competitive advantage and build customer loyalty, according to the study.
Congratulations to the good, hard-working, effective folks at SCIF in California, Texas Mutual, NYSIF in NY, the North Dakota state fund, Beacon Mutual in Rhode Island, and the rest of the state funds. While all is not perfect, and as Peter Rousmaniere has pointed out, often quite a distance from perfect, some of the findings of the Conning study are illuminating.
I’m also thinking the study should be carefully reviewed by Federal legislators, as the conclusions may help inform the discussion about the public option in health reform. I’d point to them to this quote:
“When you look at the entire insurance world, there are obviously insurance companies in the private world that do a great job of loss prevention control,”[the study’s author said] “But the unique thing about funds is that they all do it. Twenty-five of them and they all do it. So it’s not a random sample; it’s a sample that suggests that this group puts an emphasis on loss prevention control.”
That’s exactly, precisely what we need to do with health care – prevent preventable claims that lead to high costs and lousy outcomes.
What does this mean for you?
Once again, the health insurance world can certainly learn something from workers’ comp.
For the update, see UPDATE below.
Also, if you would like a copy of Todd’s marketing presentation, email me at infoAThealthstrategyassocDOTcom. The presentation is not copyrighted, marked confidential or proprietary, or otherwise protected from distribution.
Original post
The world of work comp managed care is highly competitive, with vendors willing to push pretty hard to win business or hold on to customers. That’s the way the market is, and as long as these practices don’t cross the line, may the better competitor win.
But sometimes that line is crossed.
A work comp PBM took my copyrighted work and without my permission, used it in a marketing presentation. They also copied my Survey of Prescription Benefit Management in Workers’ Comp and distributed it without my permission.
Not only that, but the PBM mischaracterized the work in such a way that it appeared I endorsed their approach and business model, if not them specifically.
I’ve repeatedly asked the PBM to retract their statements and have yet to receive confirmation that they did so. Rather than continue to spend money on attorneys, I’ve decided to publicly disavow any connection between myself, my firm Health Strategy Associates, LLC, and the WC PBM consortium I work with, CompPharma, LLC, and the PBM in question – one WorkComp Rx, Inc, and WCRx’ President, Greg Todd. Todd is also affiliated with Integrated Prescription Solutions.
Here are a couple specifics.
The introductory slide in a WorkComp Rx marketing presentation (entitled HSA Comparitive (sic) Summary ) states the: “findings [of my firm’s Annual Survey of PBM in WC] support WCRx’s performance Is The Best-In-Class”. No, it most definitely did not.
Another slide showed WCRx’s inability to comprehend the survey. The slide reads “Typical PBM Pharmacy network size is 55-58,000 pharmacies of which “penetration rate” is approximately 65% which totals 38,000 participating pharmacies”, showing his firm didn’t understand the definition of ‘network penetration’, which is not how many pharmacies participate but what percentage of scripts are processed thru the retail network. This led to this wildly inaccurate conclusion:
WCRx’s pharmacy network includes 99.7% of all US pharmacies (64,000+) and a 100% “participation or penetration” rate. That is more than 30,000 additional pharmacies with 100% participation than any competitor.
Yet another slide stated that the Survey found that Third Party Bills “…amounted to 40% – 50% of all W/C pharmacy bills.” Nowhere in the Survey do those words appear.
There are plenty more examples of misinterpretations, fabrications, and distortions, but you get my drift. It could be that Todd et al just don’t understand the work comp business, as his company’s website reads in part:
“Workers’ compensation is mandatory medical insurance that is paid for by employers and is required by law in every state.”
There are two errors here – WC is not mandatory in every state (i.e. Texas) and is not ‘medical insurance’.
UPDATE – IPS changed its website yesterday; the new description of work comp reads as follows:
“Workers’ compensation is a form of insurance that provides compensation medical care [sic] for employees who are injured in the course of employment, in exchange for mandatory relinquishment of the employee’s right to sue his or her employer for the tort of negligence.”
end of UPDATE
It also states that work comp medical spend is broken up thusly:
Hospitals & Physicians: $18.4 billion
Physical Medicine: $8.8 billion
Pharmacy: $6.0 billion
Diagnostic Services: $3.2 billion
DME/Home Healthcare: $3.2 billion
Cost Containment (UR): $1.8 billion
Perhaps Todd et al made these data up themselves, or have a source I’ve never heard of, or used data from one state to extrapolate to the rest of the country (no source is cited); I don’t know where else they could come up with these statistics, certainly not from NCCI or WCRI or NASI or DoL BLS reports.
When I learned of the misuse of the Survey’s findings and unauthorized duplication of the Survey itself, I immediately contacted my attorney, who sent a firm but polite letter to the PBM’s president, Greg Todd, a man heretofore unknown to me. The letter asked Mr Todd to stop using my material, inform all those he or his employees or agents had shared my material with that this was unauthorized, and tell them that I had not and did not endorse his company or approach.
Mr Todd sent a letter back telling me that I was fortunate to have his company spreading the word about me and my firm. But before he sent that letter, he called me and asked if this was about CompPharma, the consortium of workers’ comp PBMs I work with and am a part owner of. I said no, it was not; he replied that he knew other CompPharma members were using my work, whereupon I told Todd if they were it was with my permission. He then offered to join CompPharma and inquired about the fee.
He could not seem to understand that this was not about a fee. This was about his company doing something it should not have done, misusing my work and using my reputation and credibility to help him sell his stuff.
A follow up letter to Mr Todd went unanswered. As it appears that Todd is not going to respond to my request that he retract his statements and stop using my materials, I have no choice but to get the message out myself.
I am not today, have never been, and will never be affiliated with, work with, endorse or recommend WorkComp Rx, Integrated Prescription Solutions, or any other firm associated with Greg Todd. Any use by Mr Todd or anyone at either of those firms of any work product of Health Strategy Associates, LLC, CompPharma, LLC, or myself is done without my knowledge or permission.
A few states deliver high levels of benefits to injured workers at low premium rates, and a few deliver low benefits at high premium rates. Peter Rousmaniere’s assessment of each state’s work comp system not only tells us which states fall into which categories, but provides insights into the ‘why’ as well.
For example, NJ NY and Montana have the highest work comp insurance costs, but very low benefits. And Massachusetts is at the opposite end of the spectrum, with low premiums and high wage replacement benefits for injured workers. (Mass doesn’t treat providers nearly as well, as the Mass fee schedule is among the lowest in the country, while medical costs are not)
Peter delves into the whys, and among his findings are:
– five states deliver both low premiums and high wage replacement benefits (IA AZ VA NV MA)
– five states are the polar opposite, with high premiums and low benefits (AK CA NJ NY MT)
and then there’s the majority of states which fall in between costly/poor benefits and cheap insurance/good benefits.
Peter also notes that there is a wide disparity among states in median duration of disability, ranging from 4 days in the best states to 12 in NY.
While some states seem stuck in a dysfunctional morass, making little progress, California’s recent success in dramatically reducing premiums and costs should encourage all state legislators to get cracking. Reform can be done, even in a state as large and diverse as California. Montana, which is tiny by comparison and much more homogeneous, should find reform a much less difficult task.
What does this mean for you?
Find out how your key states are ranked, and you may well find where you’ve got problems in your comp program.
Few things I’ve encountered in my twenty-five-plus years in the insurance business are as outrageous as the prosecution of Sandy Blunt, the former head of the North Dakota work comp fund.
I’ve posted on this case several times; what originally caught my attention was the announcement that Bryan Klipfel, a former State Trooper had been named the head of the ND work comp fund.
According to a local paper in ND, when asked about his qualifications, Klipfel said “I’m going to work with Bruce (Furness) for a couple of weeks, and I’ll just have to learn some of that information as time goes on…My strong points are that I have leadership ability, and I understand human resources, how to deal with people. And I think that’s the big part (of the job) right now.”
That got me thinking – “He’s going to learn on the job? While getting mentoring for a ‘couple of weeks”? In a business that is incredibly complex? At a time when investments and reserving practices are critically important? And his qualifications are his understanding of human resources and leadership ability?” – with the result that I dug deep into the story, only to find out what can only be characterized as a witch hunt, conducted for unknown reasons by a prosecutor’s office that went way beyond what could be construed appropriate behavior.
The deeper I dug, the stinkier it got. Blunt was convicted of felony charges, which could only be brought because the prosecutor ‘rolled up’ several smaller charges related to gifts for workers (trinkets, food for parties, etc) and his authorization of sick leave. In fact there aren’t any charges that Blunt took money himself.
At the time, I thought ‘Ok, so Blunt made a few bad decisions and/or didn’t follow all the rules by the book. But a felony conviction for a sick leave authorization and some inexpensive ‘gifts’?’ Seemed wildly excessive – at any other big organization – public or private – this wouldn’t merit anything more than a reproachful email from the corporate compliance officer/legal counsel.
Turns out it was way more than ‘wildly excessive’; the Blunt conviction was the result of egregious prosecutorial misconduct.
The prosecutor didn’t give Blunt’s attorney exculpatory evidence – evidence that would have proven that the sick leave charge was insignificant – it wasn’t even a concern to state auditors who had gone thru the state fund’s books with a fine-toothed comb. More importantly, the prosecutor didn’t give the memo from the state auditor pertaining to this issue to Blunt’s attorney.
Anyone who’s watched even a little TV knows that prosecutors MUST give all evidence to the defense. Anyone except Cynthia Freland, the assistant state’s attorney who tried the case.
I have no idea what in the hell is going on up in North Dakota, but I do know this. Sandy Blunt is a decent, honest, very capable guy who has been absolutely screwed, apparently in no small part by a prosecutor who broke the law.
Blunt is currently appealing the case before the state supreme court, primarily on the basis of the prosecutor’s ‘roll-up’ of charges. His contention appears to be because one of the charges was thrown out, the jury should have been allowed to consider each of the other charges independently, which not coincidentally may well have resulted in acquittal as the remaining alleged offenses may not have met the standard for a felony conviction.
If there’s any justice in this country, Blunt will be acquitted and Freland fired and investigated for possible commission of a crime. Regardless, Blunt’s reputation will be forever tarnished with his professional life ruined due to some bizarre personal vendetta on the part of an at-least incompetent and possibly criminal state prosecutor.
Disclosure – I’ve come to know Sandy pretty well. I called him to hear his side of the story earlier this year. He is a very smart, humble, positive gentleman who is a consummate professional. Sandy and I have worked together on a couple projects, and I have been very impressed. Sandy’s performance at the ND Fund speaks for itself – and I can – and will – put my personal reputation on the line for him.
It’s a no-brainer.
We now know who will replace Ingenix as the nation’s provider of usual, customary and reasonable (UCR) data; we also know when (by the end of 2010). As to the how, that’s a bit less certain.
Syracuse University will be the home of a non-profit data house’ to be called FAIR Health (Fair and Independent Research Health); Cornell, Upstate Medical Center, SUNY Buffalo, and the University of Rochester will also contribute (got to spread the largesse around). (full disclosure – Syracuse is my alma mater)
The new entity will be funded at least in part by the $100 million NY Attorney General Andrew Cuomo has gotten in settlements from Ingenix’ UCR database customers. In addition to Cuomo’s successes, Ingenix’ parent company, UnitedHealth Group paid $350 million earlier this year to settle a class action suit, and other legal action is continuing which Cuomo expects to add to the $100 million total. The cash will be used to develop the database and set up a mechanism to deliver data to payers and consumers via a website. This last is a great idea – providing health care consumers and providers with access to UCR data should help promote transparency and enable price comparisons by consumers and price competition by providers.
FAIR will be headed up by SU Professor Deborah Freund, an expert in health economics, Distinguished Professor of public administration and economics in SU’s Maxwell School and Senior Research Associate at Maxwell’s Center for Policy Research. Dr Freund has a wealth of experience on the academic side of health policy and economics and has published on a wide range of topics in those fields.
I’ll see if I can stop in for a chat when I’m back up on the Hill in January for another alumni meeting.
The timetable seems…aggressive – there’s a lot to do to avoid some of the problems that plagued Ingenix’ MDR and PHCS databases; non-existent quality control on source data and inadequate volume of data in some areas are just two of the problems that led to the settlements. While Freund et al at FAIR may want very much to provide comprehensive, clean data that covers all procedures delivered by all providers, they don’t control the quality, accuracy, and consistency of the data collected by health insurance companies and other payers. And after the Ingenix debacle, they sure want to be absolutely positively comfortable with their data before they release it to the public.
My guess is the website and initial data will be up and running by the end of next year, but it won’t be comprehensive. Even if FAIR is able to come up with standards and a rigorous QA process, it will take more time for payers to develop and implement processes to ensure the data they provide FAIR meets those standards.
And you can bet your last hundred million that no payer is going to send data they aren’t absolutely sure is up to snuff.
What does this mean for you?
Good news, as the new UCR provider will help reduce payers’ exposure.
Health plans have a new vendor to work with – on the vendor’s terms.
Over the longer term, there’s another ‘outcome’ – Health data quality is about to go under the microscope, and the view may be pretty ugly. Healthplans and other payers may well have to upgrade their technology, training, and staffing to meet FAIR’s demands
Background
For those who don’t follow these things on a daily basis (hard to believe I know), some background. Years ago, the health insurance industry’s lobbying and service arm (HIAA) aggregated and compiled physician charge data as a service to its members. HIAA collected the data and fed it back to members, who then used the data to determine how much they should pay providers in specific areas for specific services (services defined by CPT codes). HIAA was taken over/disappeared about a decade ago, and Ingenix took over the aggregation and distribution of the data, which has become known as “UCR” for “Usual, Customary, and Reasonable”.
For about ten years, all was fine, at least as far as most insurers were concerned. Sure, physicians complained at times and consumers railed about the low reimbursement paid by companies citing their UCR, but the complaints didn’t really make any difference until Cuomo got involved. The problem arose when a few folks in New York complained about the amount they still owed providers after their insurers had paid their portion – according to Ingenix’ UCR. After a lengthy investigation, Cuomo found reason to charge UHC and other insurers, and that action ultimately resulted in this settlement.
It’s been a wild party in the comp world – and a long one too. A brutal hangover may well be next for work comp payers.
Those who remember the late nineties are getting increasingly nervous, as well we should. The longest soft market in my memory is still around, doggedly refusing to firm up – as it should have, long ago. Work comp premium rates continue to decline, especially in key states such as California (down by a whopping two-thirds in five years) and Florida (an equal drop over six years). Most other states have also seen precipitous declines, driven by successful reforms and a decline in frequency.
Yet medical severity – the comp industry’s somewhat-misleading term referring to medical cost – continues to increase in most jurisdictions.
Pause and think about that. Workers comp insurance costs have dropped by two-thirds over five years. Two-thirds. How is that possible? Does that make sense? Is there any way that’s sustainable? Don’t cite statistics and financials and actuarial reports – tell me what your gut tells you.
Mine’s really queasy.
Back in the late nineties, most comp payers thought medical inflation was tamed, as their view in the rear-view mirror indicated medical trend was in the seven to eight percent range. Not so fast, the gods of workers comp proclaimed. Inflation roared in the ensuing years, crushing many payers’ financial returns and bankrupting more than a few carriers in the process.
While NCCI reports medical inflation is under control, that’s not what I’m seeing. Facility costs are trending up, driven by declining ‘savings’ from broad, generalist PPOs. Prescription drug costs are on the increase after four years of declining trend. Ancillary costs are also heading higher, especially for those payers yet to fully embrace specialty managed care programs – and regardless of what you may think, that’s most of the payers in the industry.
Today’s WorkCompCentral reports [subscription required] Liberty Mutual, the nation’s largest writer of work comp with premium of $5.4 billion in 2008, is backing out of California and very nervous about Florida. I have reason to believe the big carrier is not leaving California, but the points made in the article regarding market conditions are spot on. Employers Direct already pulled out of the Golden State, and if it weren’t for new entrants to both Florida and California competing hard for share, the market in both states may well have firmed up by now.
Yet new carriers are entering these markets – which may be either a horrible idea or a pretty smart move. Unburdened by an existing book of comp claims incurred by writing policies that I believe are increasingly underpriced, the smart ones (if there are any) may be able to prosper as the carriers who showed up early for the party are heading towards the floor.
A more likely scenario is these johnny-come-latelies will party hard to catch up, consuming large quantities of business on an empty stomach. Kind of like freshmen at their first college party, with equally unattractive results.
Is it possible that there will be a ‘soft landing’. It is, but it is much, much more likely most carriers will feel like they fell out of a moving cab onto cold, wet, and very hard pavement…
