What Interested Me About Senior Living?

040111.01TearoffSheetI have written this brief essay in response to a fund-raising effort for the cure of Alzheimer’s disease. Several of us were asked by Symbria colleague, Dr. Lori Stevic-Rust, to respond to the question, how did you become interested in the senior living industry?

The Symbria Advisory Services team is sponsoring Lori’s Walk to End Alzheimer’s®, the nation’s largest event to raise awareness and funds to fight Alzheimer’s disease. Please click on the pic above to join us in sponsoring her efforts!

What Interested Me About Senior Living?

Candidly like many people, I’m not sure it was my interest that got me started.

I was a young man with a young family and just trying to make a living. What interested me most at that time was a steady paycheck and the hopeful ability to grow into a career – whatever that meant. What caused me to stay in senior living for the past 25 years – now that I think might be worth sharing.

To me, one of the greatest advantages of being a management consultant in the senior living industry is performing site visits. Being able to travel around the country and tour different communities in different geographies; seeing the good, the bad and the regrettable. Being reminded of the work direct caregivers do every day and that mine, at best, is a supporting role backstage.

On one such occasion I found myself in New Jersey at a senior living community near to the Atlantic Ocean. It was late afternoon on a clear winter’s day, and shadows from the trees outside were inching their way across the lobby floor. I sat there admiring the beauty of a crisp, amber sky, satisfied I had completed a good day’s work. I only needed to touch base with one more staff person, and I would be on my way – back to the hotel to write up my notes and then off to explore the local area.

As I was waiting there a couple was approaching from down a long hallway toward me. They were of an age where I surmised they could be (likely were) residents of this assisted living community. Maybe they were heading out to do some exploring too. I felt happy that I had some small part in this image – part of an industry that provided a secure, caring and loving environment for this couple. That they could enjoy the fullness that life had to offer together in the twilight of their lives.

They were holding hands as they came down the hall, and as they grew closer I noticed the woman had a somewhat distant expression – a mix of forlorn and bewilderment. Her partner’s expression seemed to be one of melancholy and concern, yet stoic determination. His shoulders were a bit slouched, and I don’t know why but I did not think it owing simply to an aging posture.

There were clearly some emotional undertones here that made me quickly challenge my exploration hypothesis. Then as they neared the door it dawned on me the woman wasn’t dressed near appropriately enough to be going outside on this frigid afternoon in mid-February.

That’s because she wasn’t. And then what followed was a scene that has yet to be eclipsed in my mind by any other for its sheer heartbreaking sadness and poignancy. I can still hear their words as if they were spoken only yesterday.

“Bill, take me home . . . take me home, Bill . . . Bill, this isn’t my home . . . I want to go home, Bill . . . please, Bill! Why won’t you take me home?”

“It’ll be okay, Alice . . . it’ll be okay . . . you’re going to be fine . . . I will see you tomorrow, I promise.”

The elderly gentlemen tried earnestly, with the calmest and most serene expression as tears were welling up in his eyes to explain why this was her home now. This was, “where she needed to be.” He was unable to leave without the assistance of an aide having to gently redirect his wife. I glanced over at the receptionist who, like me, had sat silently taking this all in – wondering whether she could see I was fighting back tears. Her own only made my efforts more impossible.

The separation we had witnessed was like what one might observe at a daycare or preschool between child and parent. I would guess the relative emotions might be quite similar too: fear, anger, regret, sadness. But when a parent or guardian shows up in the afternoon, the reunion is a joy to see: an emotional reversal, all secure in the knowledge the family will be reunited at home that evening.

Bill’s wife was not going home. She had Alzheimer’s disease, and though Bill had tried to care for her at home he was unable to do so without risking injury to her or himself. She was, “where she needed to be.” Quite obviously, she was not where anyone wanted her to be.

I once had a colleague who owned several assisted living properties share with me something he regularly explained to his sales staff. He would tell them, “never forget, that even on your most successful sale it is most likely your customer will not be getting what they want.” They want to stay home. Alice wanted to stay at home.

There are some five million individuals in the United States like Alice. This is a tough industry to work in when you take to heart the challenges these individuals, their families and caregivers face every day in the communities I am lucky enough to assist. And the challenges associated with Alzheimer’s disease are right up there at the top.

I could never do the work of the caregivers that labor tirelessly to ease whatever burden they can of those afflicted with Alzheimer’s disease and their families. So I do what I am able: try and help ensure their working environment is as unencumbered, encouraging and helpful as it might be. If I can do that, then I feel like I am contributing what I can – and that is why I have stayed in the senior living industry for the past 25 years.

Cheers,
  ~ Sparky

What Hospitals Need to Understand About Housing

Blog_Sutton_GrantThere was a post in today’s HealthAffairs Blog  (see links at the end of this post) with some helpful insights on the importance of affordable housing as a key element of being able promote and sustain healthy aging. I have written rather extensively over the years in this space on this topic, and I have long been an advocate for Affordable Housing Plus Services.

I don’t recall if I’ve shared this here before or not, but I once had the opportunity to ask directly a former Secretary of Health & Human Services why there wasn’t more effective communication and coordination of policy initiatives between HHS and HUD. The response was unflattering: that was a great idea without a plausible explanation for why it had not been actively pursued. Thus be to bureaucracy.

If I could build upon the major policy themes pointed out in the HA post, something I have learned over the past five years is that a primary reason acute care providers struggle to understand post-acute care is because post-acute care is a lot more complicated than I understood. And, of course, I make that observation somewhat tongue-in-cheek because that’s all I’ve done for the past two decades.

But this article reminded me again how complex post-acute/long-term care can be. And that’s because it’s not just about providing good healthcare. It’s very much about where that healthcare is going to be provided (in what structure does the patient live). It’s about what support services are available to assist the patient with activities of daily living (in what community does the patient live). It’s about hospitality and entertainment (who wants the sole focus of their life to be an illness?) And it’s about insurance because most often care providers and/or insurers are underwriting extended care for which it is often difficult to predict duration, complexity and cost.

The same fundamental attributes that make it a complex delivery model make it a complex policy issue. Acute care providers are being more intimately connected with post-acute care providers every day through healthcare public policy initiatives. My counsel is they would do well to begin understanding the root causes of what makes post-acute and long-term care more complex than they may have realized.

Cheers,
  ~ Sparky


Read Health Affairs article here:

Integrating Health Care And Housing To Promote Healthy Aging
Read more about the authors here:
Allyson Schwartz and Anand Parekh

Principles of Alternative Payment Models Framework

HCPLANGreetings PolicyPub patrons. I would like to take a moment and share with you a whitepaper recently published by the Health Care Payment Learning and Action Network. The purpose of the whitepaper is to provide a roadmap to measure progress and establish a shared language and common set of conventions to help facilitate discussion and debate regarding alternative payment models (APM).

A group that I have actively participated in since its inception back in March of this year, HCPLAN was established by the Department of Health and Human Services, “to help achieve better care, smarter spending, and healthier people.” It’s primary purpose is to serve as a convener and facilitator (as well as catalyst) in pursuing HHS’s stated goals of:

  • tying 30 percent of Medicare fee-for-service payments to quality or value through alternative payment models by 2016 and 50 percent by 2018; and
  • tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018.

    The whitepaper identifies seven Key Principles for the APM Framework that all healthcare providers should be aware of and understand:
  • Principle 1: Changing the financial reward to providers is only one way to stimulate and sustain innovative approaches to the delivery of patient-centered care. In the future … it will be important to monitor progress in initiatives that empower patients (via meaningful performance metrics, financial incentives, and other means) to seek care from high-value providers and become active participants in clinical and shared decision-making.

    Principle 2: As delivery systems evolve, the goal is to drive a shift towards shared-risk and population-based payment models, in order to incentivize delivery system reforms that improve the quality and efficiency of patient-centered care.

    Principle 3: To the greatest extent possible, value-based incentives should reach providers who directly deliver care.

    Principle 4: Payment models that do not take quality and value into account will be classified in the appropriate category with a designation that distinguishes them as a payment model that is not value-based. They will not be considered APMs for the purposes of tracking progress towards payment reform.

    Principle 5: In order to reach our goals for health care reform, the intensity of value-based incentives should be high enough to influence provider behaviors and it should increase over time. However, this intensity should not be a determining factor for classifying APMs in the Framework. Intensity will be included when reporting progress toward goals.

    Principle 6: When health plans adopt hybrid payment reforms that incorporate multiple APMs, the payment reform as a whole will be classified according to the more dominant APM. This will avoid double-counting payments through APMs.

    Principle 7: Centers of excellence, patient-centered medical homes, and accountable care organizations are delivery models, not payment models. These delivery system models enable APMs and, in many instances, have achieved successes in advancing quality, but they should not be viewed as synonymous with a specific APM. Accordingly, they appear in multiple locations in the Framework, depending on the underlying payment model that supports them.

    HCPLAN is open to anyone interested in being kept informed of and joining the conversation on HHS’s efforts to  develop new payment models intended to be structured around all of the buzzwords you’ve heard over the past five years now: e.g., value, quality, transparency, patient activation, evidence-based, and so on.

    What it is not, based on my experience, is a veiled promotional vehicle to evidence broad-based support of new payment models that go largely unchallenged. To the contrary, there is a great deal of practical concern being expressed supported by real life experience having already pursued new payment models – the good, the bad and the ugly. To participate in HCPLAN, just visit the registration web page.

    Cheers,
      ~ Sparky

WHCOA Regional Forum

I am delighted to have received an invitation to this Monday’s regional White House Conference on Aging forum. The fourth in a five part series and being held in Cleveland, the regional forum is designed to focus public attention on the key issues of ensuring retirement security, promoting healthy aging, providing long-term services and support and protecting older Americans from financial abuse and neglect.

The Conference on Aging has been held once a decade since the 1960s, “to identify and advance actions to improve the quality of life of older Americans.” Input and engagement is being sought from older adults, as well as a variety of stakeholders sharing an interest and passion for addressing the difficult issues of providing housing, services and care for an aging population with limited resources.

The Cleveland forum is being held at the Global Center for Health Innovation, which showcases the confluence of best practices and emerging technologies impacting how care is provided and received. Northeast Ohio is a leader in advancing innovative solutions to the challenges facing older adults navigating their way through successful aging. With organizations like the Benjamin Rose Institute on Aging and the McGregor Foundation (most proud to note that both are clients of Artower Advisory Services), Greater Cleveland has a well-respected history of supplementing the area’s world class medical care with strong community-based services that enrich and protect the lives of seniors.

It is truly an honor to share the day with individuals served by organizations such as these and to hear firsthand their expectations for successful aging in the years ahead. I promise to take good notes and report back here on the key issues being discussed and debated. And with any luck, maybe a few pub patrons will want to weigh in on those issues.

Cheers,
  ~ Sparky

Does Measuring Quality Drive Value?

businesswoman drawing diagrams on wallThe Centers for Medicare and Medicaid Services today announced release of the 2015 Impact Assessment of Quality Measures Report. Designed to relate the performance on quality measures over time, it includes research on 25 quality programs and hundreds of quality measures from 2006 to 2013.

Key findings of the report include:

Overall quality measurement results demonstrate significant improvement over time.

Race and ethnicity disparities present in 2006 were less evident in 2012.

Provider performance on CMS measures related to heart and surgical care saved lives and averted infections.

CMS quality measures impact patients beyond the Medicare population.

CMS quality measures support the aims of the National Quality Strategy (NQS) and CMS Quality Strategy.

There is an old management adage that goes, “what cannot be measured cannot be managed.” It is from this vantage that CMS advocates for the role quality measurement plays in achieving the desired goals of improved access, better outcomes and lower cost (the infamous Triple Aim liberally interpreted by me). While the data may support improvement in performance indicators, that does not necessarily translate into value.

And value is (or ought to be) the universal currency of the Triple Aim

Recall, I have shared here often that value in healthcare is defined as outcomes divided by cost – and that measuring outcomes is a bit like trying to nail Jell-O to the wall. Measuring and reporting on quality in other industries has proven to be a useful endeavor that underpins market efficiencies. It’s not the availability and use of information derived from such endeavors that I wonder about – but who uses it and how.

Consumers that are armed with information on product and service quality from organizations like Consumer Reports are better able to navigate the value paradigm and reconcile their wants and needs against affordability. But in healthcare, consumers (patients) largely still don’t get to do that regardless of how much Big Data is collected, analyzed and reported on by CMS.

Will future efforts to capture all of the nuances that influence how individuals determine the value of an outcome ever be adequately captured by Big Data analytics in a fashion that such knowledge can supplant the simple effectiveness of personal decision making in a free market? CMS is banking on it.

What say you?

Cheers,
  ~ Sparky

What’s Your Quality Strategy?

04AThe Agency for Healthcare Research and Quality (AHRQ) announced today that slides are available from the February 4th National Quality Strategy Webinar, entitled Using Payment to Improve Health and Health Care Quality. Payment models is one of nine strategic levers (see below) AHRQ recommends using to drive strategic quality improvement.

The National Quality Strategy is an initiative that was established pursuant to the Affordable Care Act to, “improve the delivery of health care services, patient health outcomes and population health.” The first strategy was published in 2011; this initiative represents a nationwide effort of public and private stakeholders to align quality measures with quality improvement activities.

There are six national quality strategy priorities that NQS asserts affect most Americans:

Patient Safety
Person- and Family- Centered Care
Prevention and Treatment of Leading Causes of Mortality
Affordable Care
Health and Well Being
Effective Communication and Care Coordination

The NQS offers nine Quality Strategy Levers (core business functions that organizations can use to pursue improvement across the aforementioned priorities):

Measurement and Feedback
Public Reporting
Learning and Technical Assistance
Certification, Accreditation and Regulation
Consumer Incentives and Benefit Designs
Payment
Health Information Technology
Innovation and Diffusion
Workforce Development

The webinar presentation discusses how the ability to economically benefit from value-based payment models is negatively impacted by the inability to create outcome measurement alignment. More calls for standardization and evidence-based practices.

Making the connection between payment and quality is indeed a slippery slope and the most contentious non-access aspect of the Healthcare Reform debate. Financial reward is the most expedient means available to align incentives. But because of the inherent structural weaknesses of our current delivery system those incentives can be counterintuitive to patient welfare. If you’re in the business of serving patients, it’s critically important that you understand the nature of this debate and how it continues to play out in policy and regulatory decision making.

Cheers,
  Sparky

 

 

The slides and transcript from the February 4 National Quality Strategy Webinar entitled “Using Payment to Improve Health and Health Care Quality” are now available on the Working for Quality Web site. This Webinar focused on how using payment, one of the nine National Quality Strategy levers, can help organizations align to the strategy and promote the three National Quality Strategy aims.

 

An updated National Quality Strategy toolkit is also now available.  The toolkit includes updated graphic icons, templates for social media, newsletters, and blog content that organizations can use to share their alignment to and support of the National Quality Strategy.

 

If you have a story or case study you would like to share with the NQS audience, please email NQStrategy@ahrq.hhs.gov.

Value-Based Payment: The Rush is On!

The most opportune time to jump off a bandwagon is just before the next person jumping on tips it over. If the accelerating movement toward value-based payment (VBP) models in healthcare could be metaphorically thought of as a bandwagon, then its passenger weight increased dramatically this week with two major announcements.

First, on Monday HHS Secretary Slyvia Burwell announced that within four years half of all Medicare spending will be VPB oriented (e.g., bundled payments, ACOs, capitation models). Then yesterday several of the country’s largest healthcare systems and insurers announced the creation of a Health Care Transformation Task Force whose stated goal is to shift 75% of their business to VBP type contracts by 2020 (as in 5 years).

I have been an acknowledged student and disciple of Michael Porter’s work on value in healthcare and have written about that subject here in the past. Porter and colleague Elizabeth Teisberg wrote the seminal work, Redefining Healthcare, which buttresses much of the practical theory that has been espoused in support of VBP. In my study, however, I came to believe the underlying structural challenges of our current delivery system would take a great deal of time and effort to overcome before value could work the magic as intended. And so when I read these two announcements I had to wonder whether fools are rushing in where angels fear to tread.

In other words, it’s not the direction of the bandwagon I find concerning but the pace of acceleration. There is so much unknown and so much to be learned regarding the organizational dynamics of healthcare delivery that putting deadlines on the pace of that knowledge-building is pure folly. To illustrate, let’s just look at Porter’s strategic agenda for creating a value-based healthcare delivery system and consider each in context of what we are witnessing today.

1. Organize care into integrated patient units around patient medical conditions.
Porter has travelled the world lecturing and observing healthcare delivery systems in other countries. He provides examples of structural reorganization for patient conditions (e.g., the West German Headache Center) that have achieved substantial improvements in patient outcomes at lower cost. The concept isn’t entirely new (e.g., MD Anderson Cancer Center reorganized its outpatient care services in the early 90s under the auspices of an IPU), but still rather rare and so not very well understood.

2. Measure outcomes and cost for every patient.
Another way of saying this is be able to measure cost and quality/satisfaction at the patient level. This is without a doubt the most difficult and controversial aspect of Porter’s agenda.
In June of last year I wrote a post that addresses the inherent subjectivity of patient outcomes and its impact on the value equation. If this cannot be worked out in a manner and fashion that achieves broad understanding and acceptance across patients, providers and insurers – well, see bandwagon discussion above.

3. Reimburse through bundled prices for care cycles.
When Porter talks of bundling his focus is on tying the bundle definition to the value achieved on behalf of the patient – e.g., the patient’s experience, impact on family, lifestyle functionality, etc. What I hear about mostly are efforts to define, articulate and divide up processes and procedures related to a diagnosis and/or condition, put some probability bookends around that understanding and then compare projected average payment to cost. The ability of value to be successful as a catalyst for aligning incentives has already been lost because the focus is on process – not the patient.

4. Integrate care delivery across separate facilities
The many challenges of integrated clinical care notwithstanding, improved performance through specialization is really the key concept here. Research has shown that volume in a particular medical condition is positively correlated with patient value. This runs counter to the notion that all healthcare is local. While every day we culturally become more comfortable with this notion – e.g., international medical tourism – there are still substantial social and political obstacles to overcome.

5. Expand areas of excellence across geography
We are seeing systems like the Cleveland Clinic, Geisinger and the Mayo Clinic exporting their knowledge and expertise across geographies. But the expansion has been primarily revenue-driven (relatively more patients with the financial ability to afford services). If value is to be the driver of alignment, then eventually those organizations will also have to demonstrate how knowledge exporting not only improves outcomes at the local level but also lowers costs (much harder to achieve).

6. Build an enabling information technology platform
Hoo boy, right? The challenge here, of course as I have written before, is properly utilizing IT to facilitate and enhance the productive value of human processes. If the underlying organizational structure and processes aren’t in alignment with the goals and objectives manifested through the five agenda items above, then all we will be doing is automating a system that we said we wanted to change.

I realize some of these concepts are above my pay grade, and I continue to believe the value concept – Patient Outcomes/Cost – is the key fundamental principle of structural system reorganization. But when I step back and compare the payment and care delivery models being pursued in the name of “value” against the strategic agenda that Porter laid out I worry greatly that we are not willing or prepared to take the time or effort to understand and address fundamental areas of concern.

It’s like building a pyramid. The more time you take to create a solid and expansive foundation, the higher you will ultimately be able to build. As much as I have supported the value driving structural change paradigm I would encourage all industry stakeholders and participants to be both pragmatic and cautious in advancing on VBP models. Take the time to observe, learn and adjust – and don’t let your timeline be driven by outside sources with no vested interest in your organization – or your patients!

Cheers,
  ~ Sparky

Sorry Charlie: Too Many Sharks at the Trough

There is an old analogy in healthcare that refers to the largesse of national healthcare spending as the Big Tuna. Many sharks feed off that tuna – the extension of the analogy being that many individuals and organizations financially benefit from being in the healthcare industry without adding any real value to the consumers served by the industry – patients.

This is my interpretation of an article posted by Dr. Fred Pelzman on New Year’s Day, Return the clinician to the center of the health care experience, on the KevinMD healthcare system blog. Dr. Pelzman asks what I believe should be the quintessential question of the 2015 healthcare policy debate: “Are we allowing the health care system to be transformed by people who should not be transforming health care?”

Now, it should be remembered that it was a clinician – Dr. Donald Berwick – who popularized the Triple Aim concept that came out of the Institute for Healthcare Improvement prior to the Affordable Care Act being passed. Clinicians are not exempt from thinking big thoughts and hoping to altruistically apply that thinking to achieve goals and objectives that are widely held desirable by society. So I don’t know if getting them unselectively more involved is going to lessen the incredible waste that rightly drives physicians like Dr. Pelzman crazy.

But I do know – or rather I believe, anyway – there is a finite limit of tuna available to satiate the sharks before they start feeding on the patients. It’s indignantly ironic that clinicians are being pressured to improve performance in the name of value when a great deal of the non-clinical world is only being held accountable to producing value in the abstract – and most often ex post facto.

Unquestionably, there needs to be greater connectivity between the work performed by non-clinicians and the ultimate value produced for patients. This is not going to be any easier to measure than patient outcomes’ metrics currently being explored and tested on/by clinicians. So what? Get used to it.

As I have written before, I wholeheartedly agree with those who, like Dr. Pelzman, promote the central role clinicians must play in assessing, planning and implementing healthcare public policy. But if you look at the landscape you will see there are already quite a few retired clinicians in that space, and the system is still largely a mess. So there must be more to the story.

What do you think is missing?

Cheers,
  Sparky

Hpapyy Hlodiyas

ErodedMentalHealth_THUMBIf you have followed my blog over the past few years, you know by now that I am passionate, and write rather frequently, about mental and behavioral healthcare policy. So I first wanted to share with you an informative and powerful infographic (below) from the Best Social Work Programs website.

And secondly, I wanted to take just a moment to remind you this is an especially hard time of the year for someone you very likely know – and may even know very well. The absence of friends and family lost is felt more acutely. Pressure is greater to suppress feelings of anxiety and sadness. Failures of achievement must be reconciled with another year’s passing.

Try to remember that with few exceptions the person you know who may be struggling with mental and/or behavioral health issues finds very little joy in having a negative influence on your holidays. They did not choose to be saddled with their disease any more than those with Diabetes, Heart Disease or COPD chose their lots in life.

Here’s hoping that messages like the one below will continue to build public awareness and find their way into more proactive mental/behavioral health policy in 2015.

Cheers,
  Sparky

ErodedMentalHealth

The Cleveland Clinic’s Big Gamble

When I first started speaking on the Affordable Care Act back in the fall of 2010 one of the observations I liked to make was about needing to change the cost trajectory resulting from chronic disease. I would say something to the effect that, “if we are somehow successful at becoming more efficient, expanding access and affordability – none of it is going to matter if we cannot become a healthier country.” I didn’t have any research or statistics to support my thinking – it just seemed axiomatic given a fundamental understanding of disease incidence, costs and demographics.

My good friend and colleague Dr. Toby Cosgrove, President and CEO of the Cleveland Clinic (okay, so we’ve said hello to one another on a few flights back and forth from Ft. Lauderdale) posted an article on his LinkedIn blog this morning: New Way to Fight Chronic Disease that puts some meat on the bone of my rudimentary understanding of public health. Dr. Cosgrove notes some very basic facts about chronic disease management in the United States.

  • The CDC estimates that 75% of all healthcare expenditures in the US are attributable to chronic disease ($2.85 trillion in 2013)
  • Almost one out of every two adults (117 million) is afflicted by chronic illness
  • More information on the impact chronic disease has on our healthcare system can be found on the CDC website.

Dr. Cosgrove’s article introduces the Cleveland Clinic’s recently opened Center for Functional Medicine, which is a collaboration with the Institute for Functional Medicine led by Dr. Mark Hyman. The thematic focus of the Center is to take a more holistic approach to individual health and wellness and driving at the underlying causes of chronic disease – whether related to genetics, environment or lifestyle.

Functional Medicine is not intended to be a replacement of traditional medicine. We aren’t talking about spiritual healing, wild berries and unproven treatment regimens. It is intended to recognize and address the underlying causes of chronic disease that, if effectively addressed, will reduce the need for traditional medicine. But it also should be able to compliment and enhance the effectiveness of traditional medicine.

Given the magnitude of the problem and the impending consequences on our country it is exciting news that a medical institution no less than the Cleveland Clinic has chosen to proactively attack this problem with pragmatism and innovation. That’s the good news. Now here’s the bad: human nature is an incredibly obstinate challenge that isn’t likely to bow in the face of the best efforts of worthy institutions such as the Cleveland Clinic.

Understanding the underlying causes that lead to chronic disease is one thing. Being able to change human behavior in a manner that addresses those causes is quite another altogether. And this tees up a host of moral policy conundrums where we start to look at responsibility of the individual versus society. Demographics will intensify these to a level that I suspect will lead to significant social unrest.

So while I applaud the Cleveland Clinic for taking the bull by the horns in seeking to address this immeasurable challenge facing us, I do hope they understand what happens if they let go.

Cheers,
  Sparky

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