Anthem BlueCross BlueShield, May 11, 2017

Save the ER for emergencies — Or you’ll be responsible for the cost

Going to the emergency room or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations.

But starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency (this isn’t a change to your benefits plan).

http://mediad.publicbroadcasting.net…

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Physicians protest harmful Anthem emergency care coverage policy

By Andis Robeznieks
AMA Wire, August 7, 2017

A new policy by Anthem Blue Cross Blue Shield holds patients responsible for bills stemming from care delivered in emergency departments that is later deemed nonemergent.

The AMA has asked Anthem to immediately rescind the policy in states where it has been put into effect and halt implementation in all other states.

The AMA, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) also suggest that the new policy may violate the “prudent layperson standard” which has been codified into state and federal laws—including the Affordable Care Act (ACA). The standard defines an emergency medical condition as one that manifests itself “by acute symptoms of sufficient severity” that a prudent layperson could reasonably expect that the absence of immediate medical attention could place their health in serious jeopardy. Anthem’s retrospective review appears to be inconsistent with such a standard.

https://wire.ama-assn.org…

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AMA Letter:

From: James L. Madera, MD, EVP and CEO, AMA
To: Joseph R. Swedish, Chairman, President and CEO, Anthem, Inc.

On behalf of the American Medical Association (AMA) and its physician and student members, I write to state our concerns with Anthem’s policy in several states to deny coverage of many emergency services when the diagnosis is retrospectively determined not to have required emergency care. We ask that Anthem rescind this policy in states where it has taken effect, and halt implementation in all other states.

Physicians know that patients and caregivers should never second guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion. But with this policy, Anthem is asking that patients act as highly trained diagnosticians, skills our members spent many years of their lives acquiring. Moreover, Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.

http://www.mag.org…

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Comment:

By Don McCanne, M.D.

What a bizarre policy this is. Anthem assigns to the patient the responsibility for deciding if a medical situation is an emergency. Anthem then assumes for itself the responsibility of deciding only after the care has been given whether or not it was an emergency after all, even though the perspective of that judgment can be quite different after a problem is evaluated and managed. If Anthem unilaterally decides, only in retrospect, that the patient’s judgment that this was an emergency was in error, Anthem may refuse to fulfill its obligation to pay for the emergency department services.

Think of various reasons that a decision could be made retrospectively that the visit was not an emergency. Consider those patients who are commonly blamed for wasting health care dollars by abusing the emergency department. Now back up and consider the reasons that the patients thought, before the visits, that they should go to the emergency department. Your ankle was only sprained and not fractured so it could have waited until your physician or nurse practitioner was available on Monday. You are from out of town and you found that your insulin wasn’t packed in your luggage and so your blood sugar is suddenly out of control. You feel very ill and there is an epidemic of a potentially lethal virus but it turns out that you just had a nonlethal respiratory virus, written off as a common cold, even though you really felt sick. You have a seizure disorder and are whisked away to the emergency department while still in a postictal state – the third time this happened. Although it is likely that Anthem would agree to pay for these visits, the threat of nonpayment might keep these people away in situations that might have turned out to be more serious.

Yet you hear all the time about how people are abusing the emergency department. Okay, so you hear about someone who wants a sports physical exam form filled out, but that person doesn’t make it past the triage desk. In my experiences with emergency departments, direct and indirect, I’ve decided that abuses severe enough to penalize a patient financially are so rare that they are basically a fiction that reform opponents keep propagating. Low acuity and low severity might be considered an issue, but that is still relative and not absolute, and the patient should not be penalized for having to make an uninformed decision. People do not go to emergency departments just for social visits.

Based on a “prudent layperson standard” then anyone that clears the triage desk should be assumed to be there legitimately. Under their nonpayment for non-emergency policy, either Anthem would be refusing to pay for legitimate services, or Anthem is making a major PR faux pas by issuing an unnecessary directive that will only make people angry. Either way, this is a terrible policy to establish. But what else do we expect from the private, for-profit insurance industry that places its own net profits over the health care of the patients?

I’ve decided after the fact that getting rid of the private insurers is a true emergency. Let’s do it.

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What’s Next for Progressives?

By Paul Krugman
The New York Times, August 7, 2017

For now, at least, the attempt to repeal the Affordable Care Act appears dead. Sabotage by a spiteful Trump administration is still a risk, but there is — gasp! — a bipartisan push to limit the damage, with Democrats who want to preserve recent gains allying with Republicans who fear that the public will blame them for declining coverage and rising premiums.

This represents a huge victory for progressives, who did a startlingly good job of marshaling facts, mobilizing public opinion, and pressuring politicians to stand their ground. But where do they go from here? If Democrats regain control of Congress and the White House, what will they do with the opportunity?

What would I do instead? I’d enhance the A.C.A., not replace it, although I would strongly support reintroducing some form of public option — a way for people to buy into public insurance — that could eventually lead to single-payer.

Meanwhile, progressives should move beyond health care and focus on other holes in the U.S. safety net.

So if it were up to me, I’d talk about improving the A.C.A., not ripping it up and starting over, while opening up a new progressive front on child care.

I have nothing against single-payer; it’s what I’d support if we were starting fresh. But we aren’t: Getting there from here would be very hard, and might not accomplish much more than a more modest, incremental approach. Even idealists need to set priorities, and Medicare-for-all shouldn’t be at the top of the list.

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NYT Reader Comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

Improving ACA?

None of the incremental proposals would cover everyone.

None of the incremental proposals would remove financial barriers to care.

None of the incremental proposals would return choice of your physicians and hospitals.

None of the incremental proposals would recover the profound administrative waste in our health care financing system.

Single payer?

Everyone is covered for life.

Obtaining care does not create financial hardship.

Patients can choose their health care professionals and institutions.

The efficiency gains would be enough to pay for the gains in coverage.

We need to quit pretending that patching our fragmented, dysfunctional system is almost as good as single payer. It doesn’t come close.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Perhaps the greatest fraud in health policy today is being perpetrated by the politicians – Republicans who say health care will be more affordable and accessible by taking away coverage, and Democrats who say that incremental additions to the Affordable Care Act are almost as good as enacting single payer – an improved Medicare for all.

We will continue to spend over $3 trillion on health care. That is enough to pay for a system that would be superior to those of all other nations that spend on average half of what we do. Why should we accept less, far less, which is what we would be doing if we merely patched our system – the poorest performing financing system of all wealthy nations?

Once more. Incremental changes to ACA will not fix the fundamental flaws in our financing infrastructure that may leave people sick, broke, and even dead.

We cannot let Paul Krugman rest on his Nobel laureate status as he pontificates for “a more modest, incremental approach,” while acknowledging he would support single payer “if we were starting fresh.” Well, apparently a fresh start is precisely what we need.

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Bipartisan moves to steady insurance market face same old conflicts over regulation

By Harris Meyer
Modern Healthcare, August 3, 2017

Democrats and a growing number of Republicans are eager to steady the struggling individual market covering nearly 20 million Americans to prevent an exodus of insurers and healthy customers.

Senate HELP Committee chairman Lamar Alexander (R-Tenn.), who has scheduled committee hearings early next month on how to stabilize the market, wants to go further. He has proposed expanding state innovation waivers to allow states to waive ACA insurance requirements such as minimum essential health benefits. A bipartisan group of 40 House lawmakers, calling themselves the Bipartisan Problem Solvers Caucus, has offered a similar proposal.

The GOP goal is to allow insurers to lure more healthy people into the market by offering lower-priced plans. “Any solution… should also include greater flexibility for states in approving health insurance policies,” Alexander said.

Alexander also wants to let everyone buy very high-deductible catastrophic plans, erasing the ACA’s age cap of 30. That could conceivably win support from some Senate Democrats who offered a bill in 2014 to let insurers sell cheaper “copper” plans, with a lower actuarial value than bronze plans. It raises big concerns, however, among insurance leaders and experts who say consumers can’t afford the deductibles and cost sharing under current plans.

Alexander also might try to revive a bill he introduced with his Tennessee GOP Senate colleague Bob Corker earlier this year to help consumers in counties where no exchange plans are being offered. The bill would let them use ACA premium tax credits buy plans sold outside the exchanges, including plans that do not comply with ACA coverage rules.

The Bipartisan Problem Solvers Caucus seeks changes in Section 1332 (which lets HHS grant states waivers to establish their own, customized coverage systems) to make it easier for states to win approval for setting up their own systems and to give them more leeway. House lawmakers also want to make it easier for states to enter into compacts that allow insurers to sell health plans across state lines in participating states.

ACA supporters and insurers say they’re potentially open to making 1332 waivers easier to get and more attractive to states, but only within limits. “My sense is there’s a willingness to expand state flexibility on 1332 waivers, it’s got a lot of potential,” said (Tom Daschle, the former Democratic Senate Majority Leader who’s now a healthcare lobbyist at Baker Donelson), who issued joint recommendations on that issue with former Republican House Speaker Newt Gingrich in late 2015.

Despite the looming policy clashes, some observers see a narrow window for a compromise deal on a market stabilization bill, especially since some Democrats in the past have signaled openness to letting insurers sell cheaper, skinnier plans.

http://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

One of the great faults of the Affordable Care Act is that it was designed to make plans cheaper (lower premiums) by reducing the actuarial value of the plans (the percent of health care costs that the plans would cover) by requiring higher out-of-pocket costs, especially high deductibles. Although federal subsidies have softened the burden, cost sharing has made health care much less affordable, especially for middle-income Americans. Now Congress wants to make this problem even worse.

In the name of bipartisanship, Congress would supposedly save the individual health insurance market by making plans more affordable. They would do this by allowing an even lower actuarial value – higher deductibles – thus shifting more of the costs to individuals who actually need health care. They would also allow a reduction in the benefits covered, perhaps eliminating obstetrical care, mental health services, drug dependency programs, and preventive health services. Increasing out-of-pocket costs and stripping out benefits from the plans is the exact opposite of what most Americans want.

Of course, this would not salvage the individual market. If the premiums were low enough, healthier individuals might buy these cheap plans. Given a choice, many of the healthy would not buy the more expensive, more comprehensive plans. It is the individuals with significant health problems that would buy the higher actuarial value plans. Concentrating high cost individuals in these plans would cause the premiums to skyrocket, making them unaffordable for most, and the market would collapse in a “death spiral.” In the meantime, those buying the cheap plans who then develop significant medical problems would find that they are insolvent or bankrupt because of the unaffordable cost sharing. So the market for cheap plans wouldn’t work ether.

Yes, many people are unhappy with the high premiums that they are paying and want something done about it, but, no, they do not want their plans replaced with skimpy, almost worthless coverage that potentially leaves them exposed to insurmountable debt.

What do Americans want? They want to have the health care that they need, when they need it, without having to negotiate significant financial barriers to that care. In other words, they want a single payer national health program. Numerous polls have shown that they are beginning to grasp that concept.

Congress is going home for the summer recess. Republicans will face angry voters who feel that they have been betrayed by the failure of the Republicans to deliver on their false promises for a better health care system. The Democrats will mount their white horses to spread the message that they are ready to work with the Republicans to make health insurance more affordable. Neither camp will be honest with the voters and let them know what the low actuarial plans they have in mind really are, and how little health care the plans will actually cover.

What is our task? Members of Congress returning to their home districts must hear from us, their constituents – in the loudest, most unequivocal terms possible – how we reject the fraud of cheap health insurance, and that we demand the proven model of single payer national health insurance – an improved Medicare for all.

Get out your bullhorns!

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Health reform driving payer-provider partnerships

By Les Masterson
Healthcare Dive, August 2, 2017

Payers and providers have for decades stayed in their silos, leading to a more fractured and adversarial healthcare system. That relationship, however, is starting to soften for many in the industry. Payer-provider partnerships put the two groups on the same team in hopes of reducing costs and improving care and outcomes through sharing data and better communication.

A major driver of these partnerships is the move away from fee-for-service payments and toward valued-based payments and population health management.

The payer-provider partnerships popping up across healthcare vary in type, size, location and model. There are 50/50 joint ventures with co-branding, and less intensive partnerships like accountable care organizations (ACO), patient-centered medical homes (PCMH), pay for performance and bundled payments.

The first step in these partnerships is building trust between payers and providers.

Another key is communication. (Chuck Lehn, president of Banner Health Network) acknowledged that communicating across systems and platforms between two organizations and healthcare providers requires time, attention and resources.

Caring for the whole patient works best when payers and providers share data, so there is improved care management, better interventions and better analytics around population health.

The two sides can go much deeper into care for patients by going beyond claims. In partnerships, payers shouldn’t have to wait for claims to see how their members are doing and doctors shouldn’t have to hope that their patients tell them when they have received care elsewhere.

In addition to regular back and forth, payers and providers need regular meetings, whether monthly or quarterly, that focus on strategic issues about the partnership, said (James Leatherwood, marketing communications manager at Availity).

One barrier that still needs resolution in partnerships is moving providers away from phone communication.

Leatherwood said a more efficient way is a queue system. In this system, a provider could check the status of all claims and get alerts when they need to provide more information. The system would allow providers to look in one queue, update the claims information and then move on with their day. Payers would have their own queue and would get alerts when providers have questions. This would reduce phone calls and create immediacy.

Leatherwood said the healthcare system is stuck in a “chart chase” between providers and payers, and moving to an automated queue system would be a gamechanger.

“I think in the near-term what we’re going to see is larger healthcare providers are going to be more strategic, working directly with payers. The health plans are going to be more interested not just in working with the staff level, but executive levels,” said Leatherwood.

The third part of a successful partnership is aligning incentives that focus on keeping people healthy and creating a positive healthcare experience, said (Thomas Robinson, partner at Oliver Wyman).

Partnerships must provide patients the right incentives, integration, investment, insight and innovation to work with the plan to deliver improvements across cost, quality, outcomes and experience, said Robinson.

“The point of these partnerships is to create something new, rather than just building the same old offerings with a narrow network. Successful partnerships will take the opportunity to innovate around the product and experience now that the incentives, insight, investment and integration are all for it,” said Robinson.

Aetna and Banner Health agreed on the partnership in October 2016 and have been laying out the groundwork before its launch this month in Maricopa and Pinal counties in Arizona. The two companies hope to expand the program statewide ultimately.

To prepare for the partnership, Tom Grote, who became CEO of Banner/Aetna joint venture in May, told Healthcare Dive that Banner Health and Aetna have developed joint operating committees, including marketing/sales and population health, that include members from both organizations.

The partnership looks to improve consumer experience by fully integrating providers, Aetna and administrative services, while eliminating redundancies in care and administrative problems. Aetna and Banner Health expect streamlining care and services will lead to savings for patients and employers.

(Brigitte Nettesheim, president of transformative markets for Aetna) said the partnerships are about “each side playing to its strengths, aligning incentives and driving scale.”

(Tom Leyden, director II of the Value Partnerships Program at BCBSM) said providers want to be active participants in system transformation.

“This requires ongoing support from the payer and demonstrated evidence of practice transformation and clinic results from the provider community,” said Leyden. “Administration of these programs is an integral aspect of measuring performance.”

Leyden said the payer strives to make the programs as manageable as possible because physicians need to perform many administrative tasks on an ongoing basis. BCBSM regularly solicits feedback from providers during quarterly meetings and phone calls, emails, webinars and in-person meetings on what’s working, what’s not and what needs to be changed.

“If we keep the customer — the end user — in mind and build partnerships with that as our North Star, we believe we will have a more successful, efficient and collaborative health system,” said Grote.

http://www.healthcaredive.com…

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Comment:

By Don McCanne, M.D.

Wow! These are the people who are in charge. They control the medical industrial complex. Based on this rhetoric they no longer have to be concerned about medical loss ratio minimums of 80 or 85 percent since their administrative functions have fused into health care delivery. That way they can best serve the “the customer — the end user.”

We need to throw these jerks out and establish a single payer national health program so that we can best serve, yes, the patient!

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With Tom Price in charge, doctors are winning again in Washington

By Erin Mershon
STAT, August 1, 2017

As the Senate was barrelling toward one of its votes to repeal the Affordable Care Act earlier this summer, Tom Price was corralling a small group of doctors into a tiny, dimly lit conference room in a nondescript building in downtown Dallas.

It was, on its surface, another of the health secretary’s many meetings with “victims” of Obamacare — this time with some of the conservative physicians who felt the law was hurting their patients and their own bottom lines. An official readout from Price’s staff trumpeted the eight participating physicians as “witnesses” to Obamacare’s failings.

But that wasn’t Price’s only message to the doctors, according to two participants in the meeting. The health secretary also signaled he would protect the doctors from a raft of regulations that were put in motion by the Obama administration. And although Price, a former orthopedic surgeon, didn’t address specific regulations, he made clear he was listening to the physicians’ complaints about issues like Medicare payment rules and burdensome electronic health record requirements.

Quietly, away from the spotlight cast on his effort to dismantle Obamacare, Price has been rolling back regulations that have been criticized by his former physician colleagues. And, unlike with the ACA, he has been able to do so without the blessing of Congress.

He’s given an American Medical Association committee (RUC) even more power over how much the federal government pays for different medical services. He has pitched retroactively reversing certain Medicare rules to ensure some physicians no longer face penalties they would otherwise have had to pay. He has proposed using almost $1 billion in savings that would be achieved through cuts to certain hospital payments to boost spending on physicians.

And over and over again, he has delayed Obama-era regulations that would have penalized doctors who aren’t ready or able to move away from Medicare’s longstanding “fee-for-service” approach.

As the congressman for Georgia’s 6th District, Price made no secret of his strong relationship with doctors and their specialty societies. He fought for industry wish-list items like malpractice reform and a legislative change to let doctors charge Medicare patients higher prices.

Doctors rewarded him in turn. Health care providers and groups like the AMA and the American Academy of Orthopaedic Surgeons together donated nearly $500,000 to Price’s 2016 campaign and leadership committees, according to the Center for Responsive Politics’s OpenSecrets website.

In one of his first acts as secretary, Price took aim at a bipartisan 2015 law overhauling the way Medicare pays doctors. The law — referred to by its acronym, MACRA — gives bonuses to doctors who do an especially good job at certain activities like using electronic health records, coordinating care, or improving patient safety. Those who don’t get hit with penalties, which ramp up over time.

Price voted for the law in Congress, as did many of his Republican colleagues. The AMA and other physician groups supported it, largely because the package also eliminated a different payment program (SGR) that they had been fighting for nearly two decades.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” Seema Verma, the administrator of the Centers for Medicare and Medicaid, said in a statement unveiling the proposal. “That’s why we’re taking a hard look at reducing burdens.”

The agency wants “to be responsive to the concerns of the clinician community,” it wrote in the proposal.

The regulatory changes backed by Price are about more than avoiding penalties. He has promised that his administration, unlike the previous one, will accept the recommendations of an AMA committee (RUC) that lets physicians themselves decide how much Medicare should pay them for individual services.

The controversial and secretive committee lets doctors fight out among themselves whether to pay a certain specialty less or more, as procedures become less time-intensive or less expensive (or more so), despite what critics say is an obvious conflict of interest. The AMA and many specialty societies have defended the panel, saying doctors know best which services are most complicated.

CMS is proposing the values for individual services that generally reflect the expert recommendations from the [committee] without as many refinements as CMS has proposed in recent years,” the new administration said openly in a press release.

It’s a major concession to doctors and especially specialists, who perform more of the procedures that some primary care doctors have suggested are overvalued.

“The idea they would tell staff to just leave the [panel] alone is a concession to physicians, and in particular, physicians like orthopedists,” said Dr. Bob Berenson, an internist and a fellow at the Urban Institute, who has been critical of the committee. “The specialties that do procedures do very well with these misvalued codes, like orthopedists.”

HHS, moreover, may just be getting started in its work to improve Medicare for physicians. Attached to nearly everything the agency has released this year has been a very straightforward request to doctors, hospitals, and other health care stakeholders: Tell us what regulations you want us to nix.

https://www.statnews.com…

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Comment:

By Don McCanne, M.D.

HHS Secretary Tom Price, an orthopedist and former Congressman from Georgia, has long supported measures that benefit physicians, often to the detriment of patients. His positions on MACRA and RUC exemplify this.

As a member of Congress, Price supported the Medicare Access and CHIP Reauthorization Act (MACRA) with its Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). He did so in order to relieve physicians from having to comply with the Sustainable Growth Rate (SGR) which otherwise would have caused a reduction in physician payment rates. But, as we warned repeatedly, MACRA and its predecessors would create a major burden for physicians.

It is reassuring to see that Price and CMS administrator Seema Verma now recognize this burden and want to provide regulatory relief. The problem is that their concerns are directed towards physicians rather than patients. They support other policies that would reduce coverage and expose patients to greater health care costs. Even Verma’s physician husband refuses to accept Medicaid patients.

Price strongly supports the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC). It provides advice to CMS on physician payment rates. It has long been criticized because of its bias toward procedures resulting in specialist rates that are much higher than rates for primary care. As an orthopedist, Tom Price fared very well under RUC. Again, Price is advocating for physicians when it is the patients that should be his primary concern.

What can we do? Let’s intensify our advocacy for a system that puts patients first – a single payer improved Medicare for all. We need to reach a threshold of support at which our nation’s leaders have no choice but to enact and implement a system that works best for all of us. Physicians and other health care professionals would do just fine under such a system.

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Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program

By Lena M. Chen, MD, MS; Arnold M. Epstein, MD, MA5; E. John Orav, PhD; et al
JAMA, August 1, 2017

From the Introduction

Ambulatory pay-for-performance programs provide incentives for physician practices to improve the care they deliver. The Medicare Physician Value-Based Payment Modifier (PVBM) Program, which launched in 2015, will be the largest mandatory pay-for-performance program for physicians when fully phased in. Under this program, physician practices receive penalties or bonuses (from −1% to 10% of Medicare payments in 2015) based on the quality and costs of care. The PVBM Program serves as a precursor to the Medicare Quality Payment Program, which will launch in 2019, apply to clinicians and practices, and measure performance across a broader array of metrics. Clinicians eligible in the PVBM Program include physicians, nurse practitioners, and physician assistants.

Despite the growth of ambulatory pay-for-performance programs, there is concern about unintended consequences, including disproportionately penalizing practices that care for complex patients. Prior studies have shown that patients with high levels of medical risk as well as patients with social risk factors, such as those dually enrolled in Medicare and Medicaid, have worse quality outcomes. Thus, it is possible that physician practices that care for these high-risk populations will fare poorly in pay-for-performance programs.

Key Points

Question: Was there an association between the social or medical risk of patients treated at physician practices and performance during the first year of the Medicare Physician Value-Based Payment Modifier Program?

Findings: Practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for high-risk practices.

Meaning: As value-based payment programs continue to increase in size and scope, practices that disproportionately serve high-risk patients may be at particular risk of receiving financial penalties.

http://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

Rather than being smart and actually improving our health care system by enacting a single payer program, the bureaucrats and policy community have fixated on magical solutions that supposedly would improve quality and reduce costs by paying for value instead of volume. One of these programs is the Medicare Physician Value-Based Payment Modifier Program (PVBM).

Under PVBM, “Practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for high-risk practices.”

We are penalizing physicians who take care of more socially high-risk patients and more medically high-risk patients!

Value instead of volume? Our greatest problem with volume is that we are not giving enough care to people who are uninsured or under-insured. And value? Experience in Canada has shown that bringing in patients who need care tends to displace some of the care that is of little value.

So let’s get smart. Let’s enact and implement a single payer national health program. That would bring us much more value than these rinky-dink programs such as PVBM.

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