Last month, The American Journal of Managed Care (AJMC) hosted a panel discussion on current issues in breast cancer treatment. Participants were the moderator, Michael E. Chernew, PhD, co-editor-in-chief of AJMC, Professor of Health Care Policy, Harvard Medical School; and panelists, Sandra M. Swain, MD, immediate past president of the American Society of Clinical Oncology (ASCO) and medical director of the Washington Cancer Institute, MedStar Washington Hospital Center, and Lee N. Newcomer, MD, MHA, senior vice president for Oncology, Genetics and Women’s Health at United-Healthcare.
The panel continued a 2012 AJMC discussion regarding pertuzumab (Perjeta) which had been just received approval by the US Food and Drug Administration as a first-line treatment for HER-2 positive metastatic breast cancer in combination with trastuzumab (Herceptin). Concerns have arisen about market access, as the cost of this combination therapy is more than $180,000 for an 18-month course. The July panel opened with an overview of a new combination therapy. This article presents highlights from the panel’s recent discussion of the cost of new treatment therapies in breast cancer.
Chernew: Today, we would like to examine the use of another combination therapy, trastuzumab and [panzene] which is [Typhila] and pertuzumab, which is Perjeta. So, as we talk through this issue, concerns about which patients get these different therapies, their relative cost, and implications for outcomes will become important. I will start with Dr Swain…to understand the current treatment landscape and overview. Who are the patients eligible for these different types of therapies, and how big is the patient population?
Swain: As far as the use of pertuzumab, the current indication is for the patient to either present with metastatic HER-2 positive breast cancer, or for the patient who has had adjuvant treatment and then a recurrence, so it is first-line treatment for HER-2 positive breast cancer. The indication is for the use with trastuzumab and a taxane. For TDM-1, the indication is in patients who have had previous treatment already with HER-2 targeted therapy and usually chemotherapy, and so it is not the first-line treatment; it is either second or third-line or later-line treatment. We probably have about 8000-9000 patients that either have recurrent disease in the first-line setting or present with stage IV disease. Of those 8000 or 9000 patients, approximately 4000-5000 would actually be eligible to get pertuzumab with trastuzumab in the first-line setting. Many of those patients will have ER-positive disease also, and the physician may not want to start with chemotherapy. Not all would get chemotherapy in the first-line setting, but it could be higher.
Chernew: And that number of patients is basically over the course of a year nationwide?
Swain: Yes. For TDM-1, I don’t know the exact numbers; Dr Newcomer, if you know those numbers, it may be somewhat higher.
Newcomer: I couldn’t give you an exact number either, but I sure agree with your estimate of 8000-9000 as a nation.
Chernew: And so, either of you, Dr Newcomer if you want to start or Dr Swain, can you provide a brief overview of the EMILIA trial?
Swain: Sure, I would be happy to do that. This trial, EMILIA, involved almost 1000 patients who were randomized to either get lapatinib and capecitabine or to get TDM-1; this was after they had previous treatment with HER-2 targeted therapy. This trial had incredible results. The TDM-1 group had a statistically significant improvement and progression-free survival of about 3 months. The difference was 6.4 months with the lapatinib/capecitabine compared with 9.6 months with TDM-1. And, not only did the trial show these results, but there was a survival benefit, and the survival for the TDM-1 was almost 31 months versus 25 months. That’s a really significant increase of survival of 5 months with the use of TDM-1.
Newcomer: That’s probably one of the best responses we have seen in breast cancer in almost a decade; that would that be a fair statement.
Swain: I think also with the CLEOPATRA data, which was the first-line study with pertuzumab, trastuzumab and docetaxel versus the combination with the placebo without the pertuzumab, also a very significant progressionfree survival of 6 months and a survival benefit, too. So, I think both of them are pretty spectacular results.
Chernew: How are physicians, particularly oncologists, using these agents in practice? Is the information of the trial filtered through the practice?
Swain: I would have Dr Newcomer answer this, but I think what I see is that the doctors are not necessarily using the docetaxel with pertuzumab first line but they are also using paclitaxel, and interestingly, most recently at the ASCO meeting (May 31-June 4 in Chicago) there was a study from Memorial Sloan-Kettering using weekly paclitaxel with pertuzumab and trastuzumab showing a very high response rate. I think it was about 50%, so it was a very high response rate. So, I think the taxane really doesn’t matter there. The issue is it is very effective dual-targeted therapy with trastuzumab and pertuzumab.
Newcomer: And we did see an immediate request for those drugs as soon as they became available on the market. We are limiting the use to the actual trial from the label, so the paclitaxel would not be authorized by us, but certainly the docetaxel is and usage was immediate. I think people are very aware of these studies, because it is such a significant drug and the breast cancer patients were following this news just as closely as the physician.
Chernew: That’s wonderful. Maybe one of you can provide an overview of the Marianne trial.
Swain: This was a trial that was also on HER-2 positive breast cancer, the same as the other ones that we have already discussed, and it was over 1000 patients who had been randomized. The study actually closed, I think, last year, so it hasn’t been reported yet; it is predicted to be reported in 2014. This was a 3-arm study and the patients were randomized to get trastuzumab with either docetaxel or paclitaxel; the paclitaxel was weekly and the docetaxel every 3 weeks. Arm B was the TDM-1 plus pertuzumab. And arm C was the TDM-1 plus a placebo for pertuzumab. So I think this is a really important study, too, to see if the TDM-1 can be moved to first line.
Chernew: Genentech has applied for approval for the use of pertuzumab regimen before surgery…So I gather there are 2 other trials that’s based on, the NEOSPHERE study and the TRYPHAENA study.
Swain: Right, and we have seen in several of the neoadjuvant trials, which are fairly small trials, you know, several hundred patients, that dual-targeted therapy really does give a much higher pathologic CR, and pathologic CR means that there is no tumor in the breast and sometimes no tumor in the nodes depending on how you define it. But, for example, in the NEOSPHERE study, when they used the pertuzumab, trastuzumab, and docetaxel, the pathologic CR rate was 46%. When you only used trastuzumab and docetaxel, it was 30%. So it is much higher with the dual-targeted therapy. I was a co-chair of an FDA workshop in March addressing this question of whether pathologic CR could be used as a surrogate for approval, so (Genentech) is the first one going in to try to see if they can get approval for the pertuzumab in the neoadjuvant setting.
Newcomer: Just to make sure, because I am not sure everyone understands this, pathologic CR is associated with much better survival rates in other studies, correct?
Swain: Well, it is associated with survival rates and that was a big discussion that we had, and it is really not absolutely proven that survival will be better, because the neoadjuvant trials that have been done haven’t really [proven this] except for 1 trial. The NOAH trial did show a better outcome for those patients who had the highest path CR, but the other ones really don’t have that outcome data. So that was a big discussion and I am sure with this, if (Genentech) gets approval, it will be an accelerated approval, meaning that this is a surrogate endpoint and that they need to have a follow-up study that relates to the outcome data, as you mentioned, like survival or disease-free survival benefit.
Chernew: So as a non-physician, what I hear from this discussion is it’s an extremely exciting time in this particular clinical area and I was wondering, first, do you agree? It seems like the pace of innovation is quite rapid, but…the fiscal consequences can be substantial. Second, I was wondering what your broad thoughts are; specifically, for Dr Newcomer, how are payers assessing the value of these agents, and how are they addressing when there are other options that are available for lower cost?
Newcomer: I think we should begin with the fact that these drugs are having a very significant clinical effect. These are not drugs that help just a tiny bit, but they are making a substantial impact on both survival and how long the tumor stays away. So that has very real value. The question is, how much we can afford to pay for those kinds of responses? There are 2 things, though, that help make this more plausible for both UnitedHealthcare and for society in general. This is not a large number of patients, as Dr Swain said, 8000-9000 a year, and not all of those are eligible for therapy. So, as you spread that cost over a large population of insured patients, it isn’t very big. So, I think it will cost more money, there is no question about that, these are extremely expensive medications when they are successful and we are going to have to pass that cost on to others, but again because of the very real and significant response rate, there is value there.
Chernew: So, does that imply that both the small population and the value of the treatment are encouraging plans in some ways to promote access to these medications because of the health benefit, as opposed to discouraging access because of the cost?
Newcomer: Well, I don’t know that any health plan that I am aware of is discouraging access to these drugs. If a patient is seeing a medical oncologist with HER-2 overexpressed disease, they are going to hear about these options. I believe, and I will ask if Dr Swain agrees, but I can’t imagine oncologists not talking about this to their patients, and I can’t imagine a health plan telling an oncologist not to talk about it. The key question is just how we budget so that we have enough money to pay for these therapies.
Swain: I think it is not only that the insurance plans pay for it, but with the huge high drug cost, the copays are really high for these patients. So, a lot of them can’t afford that. So I think we really do need to look at this and address the exorbitant cost of these drugs.
Chernew: So are they being placed on a specialty tier?
Newcomer: They aren’t at United-Healthcare, and I would point out at least in our plans that the maximum out-of-pocket expense is met by every one of these patients. So plans typically have an amount of money where once you have paid that amount, everything else is covered 100%. That amount will be set by the employer; it can vary fromas little as $1000 to as high as $10,000, but there is a limit. And at that point, the patient doesn’t have to pay any more. So $10,000 out of pocket may seem like a lot of money, but when you are considering the fact that this is a life-prolonging therapy, it should be worth that both to the patient and to their family.
Chernew: And that out-of-pocket limit for a breast cancer patient, it is just what they are paying for drugs, or their overall treatment? It might be that the added cost of these medications for the patient is relatively small, because they would come close to hitting their maximum out-of-pocket anyway. Or am I wrong about how I have done that math?
Newcomer: The maximum out-of pocket applies to all of their healthcare for all of their family. So once their family has paid that amount of money, they no longer have any more coinsurance or any other expenses. And you can’t have breast cancer in today’s modern age without hitting that maximum out-of-pocket.
Chernew: Even if you don’t get these drugs?
Newcomer: Yes. Because by the time you finish your surgery, radiation, other medications, it doesn’t take very long to hit $10,000.
Chernew: So, in fact, although the person with an out-of-pocket max is paying $10,000, they are going to be paying $10,000 whether or not they have access to these particular new medications; so if I understand correctly, what the specialty tiers do or some of the other cost-share requirements, is they push you up for someone who happens to get breast cancer, they push you up for that out-of-pocket max, but they wouldn’t really influence your treatment decisions because pretty much any treatment decision you make is going to take you to that out-of-pocket max in most cases.
Newcomer: So there are 2 things we should add to that. First, these drugs are given in physicians’ offices as infusions, and specialty tiers, rarely if ever apply to those. Second, I have been talking about UnitedHealthcare plans and there may be other plans out there that put more of a burden on the patient, but the reason those plans are structured that way is to get the cost of the insurance down. So the less you cover, the cheaper the insurance, and that’s a decision in a triad that the people make when they buy their insurance or their employer does. So, we would encourage good insurance plans but they are expensive, there is no question about that today in the United States.
Swain: And what about with Medicare, do they still have that $10,000 out-of-pocket limit?
Newcomer: They don’t. Medicare patients are clearly disadvantaged there, and they are paying coinsurance or copayments forever.
Chernew: Depending on their Part D plan or their MAPD plan, if they are in United Medicare Advantage Plan, then there would be some differences?
Newcomer: Medicare Advantage Plan looks a lot more like a traditional, commercial insurance plan, in that there would be maximum out of pocket so there would be better benefits than standard Medicare. Standard fee-forservice, Medicare, that Dr Swain was talking about, their coinsurances go on indefinitely.
Swain: And those are the patients who really will be hurt by the high prices because we know about two-thirds of patients with cancer actually are in the Medicare range. So a lot of these patients that we are talking about would be getting Medicare.
Chernew: So those people of course would have (insurance)…90% of them are on some sort of Part D or other supplemental plan, but it raises a question about another population—the Medicaid population. What are states doing, if anything, related to access to these medications?
Swain: I can just talk for DC and we only get a set amount of money, which is very, very low for anything we give, we give Cytoxan or we give TDM-1, we get X amount of dollars, which is very little. So they don’t do it by drug here in DC, and I don’t know what other plans do.
Newcomer: Each individual state has its own Medicaid rules. So, there is no common answer. It is very clear, though, that each state in the country right now is facing a budget crisis in Medicaid. So I wouldn’t be surprised to hear that other states are putting up the same kind of problems that Dr Swain just described.
Chernew: And are you worried about access to these medications for people in the Medicaid population?
Swain: I am very worried about it. I am in a safety net hospital and we do give it to the patients that need it but we also have 340B pricing. So we basically can cover some of it but it is a big problem, it is a huge loss for us.
Chernew: So it would probably be useful if you said something about 340B pricing.
Swain: I just can say it this way: At our hospital, a safety net hospital, we do have a substantial number of Medicaid patients and there are big losses for us when we use these drugs, but we do use them in the patients that need them.
Newcomer: I think it is worth pointing out that 340B was—the original intent of that regulation was—to address this kind of situation that when states couldn’t pay properly for the drugs that there would be a discount for safety net hospitals, and that was the intent of the program. The hope was it would help defray the cost that Dr Swain was talking about.
Swain: And because it does probably affect 60 million people or more, who are going to be on Medicaid, I think it is a really good question.
Chernew: Absolutely. To what extent do you think the patchwork of payers and financing will impede the access to patients who might benefit from these novel therapeutic agents?
Swain: I think it will affect them greatly, because what we are already seeing is the patients are coming to hospital settings who are on Medicare and are not being treated in their doctor’s office and their infusion center because the doctors can’t afford to do it, they actually lose money, so they are coming to a higher-price facility, a hospital, to get their infusion. So I think it is really going to affect, not on the patients but the economy in general.
Chernew: There are some paradoxical things that arise in our financing system where we may end up spending more money in efforts to save money.
Newcomer: Well, it is important to realize, though, that Medicare doesn’t think that way because Medicare actually pays a hospital less for chemotherapy than they do a physician office and they underpay both of them. So, a hospital today is reimbursed at ASP + 2%; that’s obviously quite low. A physician is paid at ASP + 6%, going to 4%, going 3%. So, it is easy for me to understand that neither entity can make money and be profitable getting that kind of reimbursement for these expensive medications. Medicare doesn’t pay more if the patient goes to the hospital or the office and they are indifferent to that.
Chernew: So again, I am going to push a little bit on this because I want to know. That’s certainly true for the drug, but what about situations where if you push someone to the hospital out of the office, there is a series of other services that may be ancillary to the drug where they may pay more in the hospital setting as opposed to the physician office. Does that happen, is that a concern?
Swain: Well, the facility fee, yes.
Chernew: But not necessarily for the drug. I think what Dr Newcomer is saying, and again this is just from my knowledge, the facility fee portion is not what’s going on for the drugs, it’s all the other services or is that being built in the fragmentation the way payments are working? So the drugs may be cheaper, but all of the other things that must be delivered along with the drugs are more expensive?
Swain: Dr Newcomer may know this better than I do, but I don’t know if they are more expensive, but they are added to. You know you have a facility fee where you wouldn’t have it in a private doctor’s office.
Newcomer: Dr Swain is absolutely correct; the hospital gets to charge a facility fee for all the other things that are necessary like the lab test, the IV, etc, and that fee is more costly than it would have been to get those same services in a physician office. It pales by comparison to the cost of the drug, but it is more expensive. I think the reason that the Medicare program isn’t quite as sensitive to the fact that the patient is going to hospitals is that on the whole the costs are pretty close. Hospitals, on the other hand, have to make up those differences, as do physicians, by overcharging commercial plans. They have to make it up somewhere. So the pressure by the federal policy is applying great pressure on the private insurance programs by making their prices much higher, which they in turn have to pass on to employers. It is really a hidden form of a tax.
Chernew: Just to clarify, despite some of the efficiencies, you think that the episode cost for someone going to a hospital is in fact not that much greater than the episode cost to someone in the office because the drug price difference swamps some of the higher charges or fees for the related services?
Newcomer: For the Medicare, yes. There have been a couple of studies trying to look at that question and they have come up with an equivocal result. So, whether or not other things happen to that patient when they are at the hospital is more expensive, I think it is still a debatable point. What is clear, at least on the commercial side is that a private physician office can deliver those therapies at less cost. In the Medicare program, it is probably about the same. It doesn’t make sense to overburden our hospital systems which are already crowded and overtaxed with things that can be done in a physician’s office. It would be a better policy to have those done when possible in a private practice.
Chernew: So my next question has to do again with the patient population. In a lot of areas the concern is that the treatment move beyond those with particular indications. You mentioned early on, Dr Newcomer, that you are only approving access in the situations where the FDA has granted approval…How do plans or other payers address this, and frankly is it a good or bad thing? It might be the case that practice moves faster than approvals.
Newcomer: The key concept for us is the evidence there to support moving beyond the FDA label? And, we are already talking in this discussion about some early trials showing benefit of pertuzumab in neoadjuvant settings, smaller studies as Dr Swain pointed out. But there is evidence to support an off-label indication. We are ready to support that with coverage, but we want the evidence. We don’t want someone saying, “I think this is a good idea. I am going to try it in my patient without the evidence to support it.” We are asking for and getting some of the studies done and if the evidence shows there is a benefit, then it is worth being paid for.
Swain: Can I ask, why are you not allowing the use of paclitaxel with pertuzumab, trastuzumab?
Newcomer: It was because of the original label indication. I think the evidence is coming out…and we will eventually broaden. Our policy today is to use the NCCN recommendations and I am not aware, I would have to go check whether or not NCCN has actually changed its recommendations to allow paclitaxel at this point. So rather than UnitedHealthcare trying to monitor these things (because we don’t have the expertise here), we have relied upon the National Comprehensive Cancer Network to set the guidelines for coverage and if they change the paclitaxel, we will as well.
Swain: Okay, I think that’s good because it is so much easier to give patients paclitaxel and docetaxel. I know we had a big discussion about that, one of the people who wrote the protocol and because your up-use is a lot of docetaxel, that’s why that was chosen, because it was a worldwide study. But I think the paclitaxel is much better for the patient.
Chernew: So this raises another related question about how often UnitedHealthcare or other private insurers revisit their pathways to refine them. I gather from your answer, Dr Newcomer, that you follow other organizations and when they change you change, but there is not a set schedule for revisiting what must be a plethora of pathways and guidelines that you have?
Newcomer: No, the schedule is actually set by the NCCN and their policy is to add a recommendation for any major announcement and then they also have regularly scheduled updates for less major changes. It is not a perfect system, but I think as a general rule, they have been quite responsive. They have anticipated FDA approvals very well and get those changes made very quickly. I want to pick up on a comment…that hormonal therapy could be an early intervention for these patients. We just recently looked at our population at UnitedHealthcare that had newly diagnosed metastatic breast cancer and the patients were estrogen receptor-positive, and we were surprised to find that a very small percentage of those people are being treated initially with hormonal therapy, about 20%. And, it would be great, I was delighted to hear that because hormonal therapy can be extremely effective, it is less toxic, its responses last longer. And I wonder, Dr Swain, if some of our younger physicians may not have as much experience with hormonal therapies and may be a little less likely to use it.
Swain: Are you talking about this overall in all patients or HER-2 positive patients?
Newcomer: This was overall in all patients, not HER-2.
Swain: Well that shocks me actually.
Newcomer: Me too. I was really surprised.
Swain: We have got work to do to train our young doctors because clearly hormonal therapy gives better quality of life and in reference to the HER-2 positive population, when I give these lecture and talk about it, I always mention that because you can get some good mileage out of hormonal therapy with trastuzumab alone, for example in the first-line setting if you have someone who presents with really low volume disease, you certainly can use it and I have used it in patients and have them on it, maybe for a year or two. It certainly should be considered.
Newcomer: That’s why I put an emphasis point on it, because I think in all the enthusiasm about this drug, and it is a good one, but sometimes we lose sight of the fact that there are still some old standards that can really derive a lot of benefit for patients.
Chernew: That’s really a useful thing to remember, I think, both in this situation and just generally true. But I do want to switch for a moment to talk about companion diagnostics. A lot of these treatment regimens require different diagnostic tests to be run and I was wondering if you think that they are being used appropriately and if the payers are covering them appropriately, and the use of diagnostics isn’t or is a barrier to access to appropriate therapy?
Swain: I’ll just start out, that it is pretty standard in the Unites States to get immunohistochemistry testing for HER-2, or some places do FISH upfront looking for HER-2, and I think that’s really standard and it really doesn’t limit the use of [this] even in patients who are in areas where they may not have access to the high-priced drugs, so I don’t think that’s a limitation.
Newcomer: I couldn’t agree more. We actually measure this and our compliance rate of HER-2 testing in breast cancer patients is 99.5%. So I think the US oncologists are well aware of the biomarkers and using them.
Chernew: And are the payers assessing outcomes as they are using medications or do they rely on the evidence being generated externally?
Newcomer: We are relying on the evidence externally. We are developing measurement tools that allow us now to look at relapse rates and overall survivals for regimens. So, we have tested this in our episode pilot group and I think we are getting pretty comfortable now that that’s something that we will be able to track over time. It is important because as new regimens get approved, we will be able to do postmarketing analytics on these to say, okay, here is what the regimen is getting for a response rate in the real world, both in terms of relapse rates and in terms of ultimate survival rates. As we use the preauthorization process to basically create an intent-to-treat trial, and someone says this is the regimen I am going to use, we can then follow that patient in our databases and find out when they do relapse and start creating survival curves for regimens in clinical practice. Those patients are much different than the ones that are used in clinical trials and I think that’s going to be important information to feed back to the oncologist to say, “Here is what really happens in US with this particular regimen.”
Chernew: I have 1 last question and then I will see if you want to add anything that I have missed. There are a lot of changes going on in the American healthcare system now and a lot of talk about moving to new payment models. I know that certainly United is at the forefront of some of those changes. I wonder what your thoughts are as to how some of the incentives that are being placed upon physicians will influence their access to [nanotechnology] in general in these types of treatments in particular, for example, when risk is being pushed down to the provider level and we are moving away from our traditional fee-for-service system. Do you see or are you worried about physicians changing their practice patterns in a way that might be detrimental?
Newcomer: I am concerned we can create incentive programs that would in fact discourage the use of a good drug. Our Episode program was designed to avoid that and in the Episode program, what happens is, when pertuzumab came out—and this actually occurred when we were in the middle of that pilot, we always pay the drug at cost. So the physician did not lose money by switching his patients to pertuzumab; they didn’t make more money either. So in the current fee-for-service world, when pertuzumab comes out and they get a percentage of that as a profit margin, it is an expensive drug, they would have made more money for using it. In our Episode program, they were able to switch to the program without any penalty whatsoever because they are not at risk for the cost of the drug, but they didn’t make more money either. We change our Episode payment for caring for the patient based on outcomes and if we see that these patients are in fact living longer or having fewer hospitalizations because their disease isn’t controlled, then that will raise the Episode payment, but it won’t be raised because they switched to an expensive medicine. On the other hand, there is no penalty or no barrier for them making that switch if they believe it is a better medicine. That was set up deliberately. We have to be a little careful about capitation programs where there is a fixed pot of money because that may be too much of a barrier to using newer medications that are effective.
Swain: I agree with that and I think I am concerned about that with a highprice drug. So I think that’s why the drug pricing goes into all of it—that we need to be really careful because thes drugs that we are talking about today are exceptional. I mean, they clearly, as you said before, have a value for use and they need to be given to patients. There are many drugs that you could argue that aren’t. So I think that we need to be really careful about this.
Chernew: And Dr Newcomer, do you United is industry standard or do you think it is somewhat atypical, particularly the inclusion or exclusion of drugs in the bundle? I am familiar with some plans in which the drugs are in the bundle, and then the question of course, as you alluded to, would focus on how the bundle is updated when there are new treatment options.
Newcomer: Let’s put this in perspective. Clearly the standard today in the United States is still fee-for-service and that’s still probably representing 95% of the way oncology is paid for here. These other programs are small, they are pilot, they are being tested, and we have got a lot of learning to do. I don’t think Episodes is ready to become the payment method for the United States today. We are still trying to run the analytics this summer to find out if it has actually been effective in changing cost patterns and we should know that by the fall. We still have to do these experiments, though, because we can’t afford the current rate of care. We are going to have to do something to figure out how we take waste out of this system, how we remove those unnecessary things to allow some payment for drugs that make a difference, and pharma has a responsibility to get its cost down. We have got to find a way to produce these drugs less xpensively if we are going to continue to make them accessible to US patients.
Swain: And I think that’s very true because we can’t keep piling on these costs. If you would look at melanoma, for example, all the drugs are coming out at $10,000 a month, it has really accelerated over the last year or so. So we have to definitely look at cost. And I think what you said is really important too, is to look at these pilot programs. Because you can have unintended consequences when you do these things that you don’t predict. So I think that’s really important not to [administer to] everyone but to have the data before you implement it in all programs.
Newcomer: We need the evidence for testing these programs. We need just as much evidence for development here as we do for the drug responses.
Swain: I agree.
Chernew: Well that’s actually music to the ears of a health economist. So I think this is a fine place to wrap up this discussion.