Is This the Solution to Solve Hawai‘i’s Serious Doctor Shortage Problem?
Hawai‘i’s chronic shortage of physicians and medical professionals is showing up in longer wait-times for appointments and procedures, but that’s just the beginning. Rising costs and new regulations meant to control them will soon change how health care is delivered in the Islands. Solutions so far are few, but some hope for change is in your hands.
Illustration: Dave Murray
We like to think of health care in Hawai‘i as a given, thanks to a system that was the envy of progressives in 1974, when Hawai‘i was the first state to make employer-provided health insurance mandatory. But there is growing uneasiness these days in almost every sector of the medical community about the trend lines. “It’s the disparities,” says Dr. Linda Rosen, director of the Hawai‘i Health Systems Corp., whose 12 community and rural hospitals are often called the safety net of the system.
The four key concerns: 1) a continuing doctor shortage that no longer seems fixable; 2) a change in diagnostic coding for treatment from Medicare and the Affordable Care Act, which has overwhelmed doctors and medical practices with paperwork; 3) a shift in how Medicare and HMSA reimburse doctors, from pay per visit to a lump sum per patient that caps how much doctors can be paid in a year; and 4) a population forecast to live shorter, less-healthy lives than their parents.
But there are also great opportunities in what almost everyone in Hawai‘i health care agrees is a crisis. The most ambitious is a statewide health initiative that seeks to extend health care into every home, no matter how remote, how rural or how poor. The technology platform to make this outreach possible isn’t a pipe dream; it not only exists, it is already making medicine more accessible, and possibly cheaper, for all of us. (Odds are you’ve got it in your pocket.)
To Have and Have Not
But first, the disparities. According to the U.S. Census, Hawai‘i can claim the healthiest population in the nation. But if you live anywhere but on O‘ahu and need to see a cardiologist, neurologist, rheumatologist, neonatalist, gastroenterologist or, quite possibly, even an orthopedist, you’d better start hoarding frequent flyer miles—because you’re likely headed to Honolulu for care. And while this shortage in specialists affects everyone on the Neighbor Islands, money quickly separates the health haves from the have-nots. Care in a hub-and-spoke system like ours favors those who can afford time off from work or child/elder care, plane tickets and a place to stay.
So these are two of the disparities: location and money. “I think O‘ahu as a care hub is a terrible solution,” says Dr. Virginia Pressler, director of the state Department of Health. “Sick people need to be with their families, in their communities, not isolated in a Honolulu hospital.”
Hawai‘i residents can be proud that we were the first state in the entire U.S. to require employers to provide health benefits. But the legacy tarnishes if it’s no longer easy to find a primary care physician, the starting point for checkups, tests, prescriptions and referrals to specialists. In fact, “It looks like we’re short 400 primary care physicians in 2015, up from 300 in 2014,” says Dr. Kelley Withy, of the Area Health Education Center at the John A. Burns School of Medicine at UH Mānoa, who produces an annual workforce study.
By overloading physicians, the shortage is causing a ripple effect throughout the entire system.
Keeping Costs Down, Raising Paperwork Up
It doesn’t help that we’re in the midst of a major reimbursement shift, which many are calling the real crisis. At the federal level, instead of being paid by the visit, doctor reimbursement is tied to a patient’s overall use of tests and services—use too much, per Affordable Care Act or Medicare guidelines, and the doctor loses income. Use less, however, and the doctor can pocket the difference as an incentive to keep health costs down. Commonly referred to as “value based” or “pay for performance,” the model is actually intended to reward doctors for keeping patients healthy while holding costs down.
Nationally, the plan’s reception has been rocky. Then, in April, the Hawai‘i Medical Services Association—HMSA, our largest insurer—announced that it would align itself with the philosophy through a change in how its 3,000 member physicians and medical professionals were reimbursed. After HMSA started a pilot program, many physicians and medical professionals made their displeasure known.
The other half of the crisis is a real double whammy: the ACA’s and Medicare’s shift to an ever-more-precise electronic system of coding diagnoses which are used for reimbursement. From 2009 to October 2015, this billing system required health providers from doctors to hospitals to insurers to rely on 13,000 codes to identify treatment given. No code? No payment. Because of the mandate to convert to electronic medical records, providers were also now required to do it all electronically—a burden for all, but overwhelming for small practices and older physicians (Hawai‘i has about 700 over the age of 65).
The combined effect of the two shifts was that, according to a 2014 study, doctors are seeing nine fewer patients a day and spending a sixth of their time on administrative requirements, i.e., paperwork. It’s why critics prefer to call the “pay-for-value” model “pay for documentation.”
But, in October 2015, the new codes arrived. And there were 68,000 of them.
“There are doctors who just say, ‘I’m not going to take it anymore,’” says state Sen. Roz Baker, chair of the Senate health committee. “If we can’t figure out how to blunt that,” and keep losing physicians, “we’re going to have people who will have a hard time getting specialty care and even primary care.”
Workforce specialist Withy worries about doctors giving up practicing in favor of “reading charts, teaching, going into health administration” and joining law firms as malpractice consultants. Baker fears physicians are being tempted by concierge care—something that has popped up in Honolulu recently. How that works is, one day you get a notice from your primary care physician, informing you, and the other 2,500 patients (on average), that you’ve been dropped. Unless, that is, you hurry to join a select group of 600 who agree to pay an additional, annual, not-reimbursed-by-insurance fee that could be $1,600 or more.
This is not a viable health care plan for most of us.
The Big Short: Not Enough Doctors
It almost comes as a relief to hear that even money won’t help you if you notice a suspicious mole on your back. Because the average wait for a dermatology appointment is four months, statewide, long enough for a growth to turn malignant, you may develop cancer instead of nipping it in the bud.
The shortage is hardly limited to dermatologists. When Withy’s 2014 study added in specialists, Hawai‘i was shy a total of 685 physicians in 2014. In 2015, that rose again, with the shortage topping 20 percent.
At the UH medical school, dean Dr. Jerris Hedges has led a stoic effort to “recruit, place and retain physicians in local communities.” He and his staff and faculty have worked with the Legislature to help doctors in rural communities pay down their student loans and established outreach programs at the high school level, seeking to identify and encourage students to focus on health-care careers. They enlist residents in remote areas to embrace new doctors who might recoil at the pent-up demand they find when hanging out a shingle: “We had a Native Hawaiian doctor in Hilo,” says Hedges, “who had 1,000 patients sign up as soon as he opened.”
But nothing substitutes for more physician slots at the medical school. And that’s the bottleneck. “It takes eight years to make a doctor,” says Hedges. “We used to graduate 50 doctors a year; we’ve got that up to 60. But that’s our limit.” Says Withy, “The need goes up 50 a year.”
The Way We Were: Health Care Nostalgia
There is a lingering air of regret for what we had under Hawai‘i’s Prepaid Health Care Act of 1974. By requiring employers to provide health insurance to employees who worked more than 20 hours a week, the act created what turned out to be, when compared with Mainland states, a comprehensive and effective system. Costs were kept low and patient care outcomes high.
Acceptance of the act was helped by a strong union culture and by its resemblance to what served in the past. “Modern health care in Hawai‘i started with the plantations,” says Pressler, “so we had a system and a tradition in place. There was a plantation doctor and clinic. Along with social cohesion, people had a living wage, a roof over their heads.”
Pressler takes pains to not romanticize the hard daily work on a plantation; studies show that Island life expectancy only took off after 1950, when mechanization and labor conditions improved. But still, “They ate a good diet, with very little sugar or junk food. They walked everywhere; nobody had a car.”
Nothing lasts forever. Since the 1990s, changes in Medicare funding have eroded Hawai‘i’s health-care foundation. In a sense, Hawai‘i is paying for the sins of the Mainland’s fragmented, redundant, top-heavy and ever-more expensive health care.
Since 1980, U.S. health care costs have risen 17.1 percent in relationship to our Gross Domestic Product (the next steepest climb, 11.6 percent, belongs to France). Most of that rise, about 15 percent, is attributed to administrative costs, not actual physician care.
Electronic records, pay for value and the ACA are all justified as ways to reduce costs by collecting data that will allow pricing controls. Our spending is already low compared to the other states. But Hawai‘i is coming to resemble the rest of the nation: The number of five-person practices, the average size here, shrank by 4 percent in 2015. The assumption is that the sheer drudgery of inputting all those diagnostic billing codes have driven them to employers such as Kaiser, although some may simply have retired.
“It’s like taking Alan Wong and putting him to work at Zippy’s,” says Dr. Calvin Wong, chief of cardiology at The Queen’s Medical Center, who says he’s had to switch two of his medical assistants to work on preauthorizations and insurance claims two days out of each week.
The irony is that Hawai‘i is actually a leader in the electronic records movement. In 2006, the Hawai‘i Health Information Exchange, led by executive director Christine Sakuda, set about bringing together the hospitals, doctors, insurers and agencies. The goal: to create a statewide clearinghouse of patient information. “In January 2015, Health eNet went live,” says Sakuda. “We’ve onboarded a thousand physicians,” about a third of those practicing in the Islands.
But, just as Health eNet was gathering momentum, along came the federal Electronic Medical Records mandate (and those 13,000 codes) to bigfoot the exchange. After a two-year break-in period, which included incentives for transitioning to electronic medical records, the ACA will now be levying penalties for noncompliance. That tends to get people’s attention, even if the federal system isn’t set up for sharing the way Health eNet is. Which frustrates Sakuda: “How are you going to drive down costs if you need patient information and don’t have it? How do you coordinate care if you have a community of providers who don’t share information?”
“We have to be smarter in how we use the physician’s time and resources,” agrees Pressler. But it’s hard to argue with a federal mandate—or, as Wong found in December 2015, with HMSA. When the insurer decided to require preauthorization for all tests and procedures, outsourcing them to an Arizona subsidiary, Wong aired his complaints in the newspaper. His example of a patient whose test was denied and could have died—he later underwent a rush quadruple bypass without approval—led HMSA to publicly threaten the Queen’s chief cardiologist with a lawsuit for defamation.
Fixing Health Care by Addressing Social Issues
All this is why, instead of basking in the applause for Hawai‘i’s No. 1 ranking in the Gallup-Healthways State of American Well-Being survey, the state’s health-care agencies are planning for a cold new world. Come January, things are going to get more interesting, beginning with a couple of laws taking effect along with the change in how HMSA doctors are reimbursed.
Improving the situation means coordination among ungainly state agencies with overlapping functions and trying to slow-dance the large, prickly insurers HMSA and Kaiser Permanente. But given Hawai‘i’s Neighbor Island health deficits, its rural, remote, immigrant and low-income populations, “We have to develop a model of care that deals with social issues,” says Pressler. It’s why, Department of Human Services director Rachael Wong says, “Gov. [David] Ige told Virginia Pressler and me: ‘Go make Hawai‘i a healthier place.’”
All agree that, if there is a way to make a difference in public health, it’s with young children. So the target age is 1 to 5, but starts with the health and resources of women of childbearing age. “Our philosophy has one key question: ‘Do you plan on getting pregnant?’” says Wong.
“All this coordination will require foundational change,” adds Medicaid director Judy Mohr Peterson, whom Wong hired away from Oregon, where she led that state’s acclaimed Medicaid reform: “We’ve had a year to get ready and we’ve been talking to all the parties. We have the right leadership, the right focus and everybody, right down to the community members, is on board.”
Why is systemwide, statewide change now the goal? Because almost every party has come to the realization that the doctor shortage cannot be cured. And Hawai‘i is unlikely to remain the health poster child of the nation. That’s because those following the baby boomers are “the first generations of people who are going to see a lower life expectancy than their parents,” says Mike Gold, the CEO of HMSA. “It goes beyond the care people get; it goes to how they lead their lives, how they take responsibility for living their lives.”
A tall order, change on this scale, especially given Hawai‘i’s reputation for pythonlike coils of bureaucracy. “I think we’re on a collision course in medicine and a lot, good and bad, is about to happen,” says state Rep. Della Au Belatti, chair of the House Health Committee.
Want Something Done? Ask a Nurse
We started with the question of how to make up for the missing doctors—how, if it comes to that, to do more with less. As is often the case in medicine, when in doubt, it’s a good idea to ask a nurse.
Nurses are on the front lines around the country and APRNs, advanced professional registered nurses, “have had the full scope of authority since 2009,” says Laura Reichhardt, director of the Hawai‘i State Center for Nursing. “They can assess, treat and diagnose patients. They have prescriptive authority. Many are working in the primary care role in the state—we’ve seen a 65 percent rise in the last five years.”
Reichhardt says the 1,300 APRNs here are not working under doctors, but with them, and often independently—which isn’t true of APRNs in about half the states. “Hawai‘i was ahead of the curve,” she says of the law to grant nurses full scope of authority. “Hawai‘i always is.”
Since APRNs are in high demand around the country, simply adding more isn’t an option. It’s also hard to grow them here. Hawai‘i is actually experiencing a simultaneous glut of new nurses, many of them local graduates, and a shortage of experienced nurses of all stripes. “There are more graduates than jobs right now,” says Reichhardt. Without the experience to get hired at the large providers, our newer Island nurses have had to find work in nursing homes. Many move to get experience elsewhere. “They go to Vegas,” says Withy. “And, in five years, if we’re lucky, maybe we get them back.”
But if we can’t add more doctors and nurses, what’s left? “We can’t pay our way out of it,” says Human Services director Rachael Wong of the shortage. “How do we improve our outcomes?”
The Revolution Will Be Telehealth
How Telemedicine works
The advantage of telemedicine is how it uses common technology, especially cell phones, to link patients, doctors and specialists. Here (1) a patient with heart symptoms connects via secure Skype or similar video app with his primary care physician (2), who, after observing the patient and talking with him, can choose to contact a cardiologist or specialist (3) for real-time diagnosis and treatment. Technology thus frees up the primary care doctor to see more patients more quickly. It also relieves patients of the need to make ER visits for emergency checkups; plus they avoid the typically long waits to see specialists. (In Hawai‘i, the wait time for a dermatology appointment is about four months.)
Enter Telehealth with Senate Bill 2395, drafted by Sen. Baker, freshly signed by Gov. David Ige and taking effect in January 2017. The concept isn’t new—delivering health care via any form of media, including video, Skype, FaceTime, text message, email and plain old phone.
To grasp the possibilities of telehealth, there may be no better place to start than Kaiser’s website, kp.org. Search “tele-derm” and what pops up but a photo of a young woman in a bathing suit taking a selfie. It’s what she does next that matters: transmitting the photo—of a suspicious mole—through a secure email server to a Kaiser physician. That four-month waiting period to see a dermatologist? It’s over. For her, the nagging worry will be resolved soon, one way or another.
“I think telehealth is the wave of the future,” says Kaiser president Mary Ann Barnes, an RN. “It moves up diagnosis and treatment much, much faster. We have lots of stories of people who saw something, sent in a photo, saw the doctor that same day and had surgery. That has really saved lives.”
Hawai‘i’s bill joins a succession of bills in Congress, including a couple introduced by Sen. Brian Schatz this session. “Telehealth is expanding access to health care in Hawai‘i,” said Schatz in July’s announcement of a bill to allow nonrural hospitals and health care providers to access federal funding available for rural telehealth. Think Queen’s advising patients in ‘Ewa, or, for that matter, on a fishing boat at sea, via a secure version of Skype.
In 2008, HMSA became the first customer of American Well, which uses secure video to connect medical teams to patients. Of course, the true sign of an idea whose time has come is when Wall Street pricks up its ears. In 2015, the first IPO of a telehealth company, Teladoc, raised $758 million as shares rose 50 percent the first day of trading. A 2015 survey of global telemedicine forecast a $34 billion market by the end of the decade.
There are literally dozens of telehealth providers out there, many working on a subscription or fee-for-consultation model that the industry calls “direct to consumer.” Your doctor might be in India, or riding a ski lift in Aspen, chatting to you on a smartphone. Several sites are pitched by infomercial doctors, including Doctors on Demand, started by television’s Dr. Phil; in 47 states, it offers 10 minutes of a doctor’s time for $40. Recently, pharmacy giant Walgreens signed on with MDLIVE, former Apple CEO John Scully’s telemedicine venture, after it partnered with Microsoft Skype for Business.
Along with the doctor consultation services, a multitude of apps (see below) have hit the market, providing telehealth in as many ways as patients have devices. The much-ballyhooed “Internet of Things”—a reference to embedded computers in everything from water bottles to washing machines—has the potential to link our smartphones and Fitbits to our doctors and hospitals. It seems the Healthy Selfie Revolution will be televised.
Some of what’s out there feels like hype and probably is; some of the outfits probably offer no better consultations than you’d get Googling your symptoms. The Journal of the American Medical Association released a study last May that submitted skin conditions to various teledermatology companies. While most recognized a precancerous mole and counseled an immediate doctor visit, all missed a case of syphilis as well as other skin eruptions that signaled underlying health issues.
These direct-to-consumer platforms are distant cousins to the telehealth that is being developed to extend the reach of our health care agencies, insurers and providers, including physicians and APRNs. The state programs will be driven not by profit but by the dream of raising public health levels, without regard for income or zip code. If we want to leverage the doctors we have, “Electronic medicine is the only way to go,” says health director Pressler. Transformation master Judy Mohr Peterson says, “Telehealth is going to be the future for this state. It’s going to help people to take care of themselves in their own homes.”
Says Pressler: “We want to be in on the conversation, in their living rooms.”
It’s a vision of what Marshall McLuhan called “the electronic hearth”—a gathering place for the whole family to trade wisdom, diet advice, encouragement and, of course, diagnoses and treatment—especially psychological help. If it sounds a little Jetson-y, consider this comment from a consummate bottom-line CEO:
“Everybody in health knows that if you have a depression syndrome of some sort, then your health care use is going to go up,” says HMSA’s Mike Gold. “It just exacerbates everything. We lack the number of professionals in the state to cope with the problem. When we talk about this, and our new model of payment, it makes telemedicine more attractive to physicians. There’s a very strong place for it.”
Stroke of Genius: Telehealth’s Success
Fascinated by telemedicine as an undergrad on the East Coast, brain-and-nerve specialist Dr. Matt Koenig is a child of the marriage of medicine and communication technologies. Since coming to Hawai‘i in 2009, he’s worked to transform stroke care with the Hawai‘i Stroke Network, better known as Telestroke.
Strokes only became treatable with clot-busting drug tPA in 1996, just as Koenig was applying to med school. Trained as a neurointensivist—someone who specializes in ICU treatment of injuries to the brain and spinal cord—he looked for an opportunity to combine his interests. Hawai‘i called and he’s now the medical director of telehealth for The Queen’s Healthcare System, associate medical director of neurocritical care at Queen’s and associate professor of medicine at the UH medical school.
Speed matters after a stroke. “The brain loses 1.9 million neurons per minute,” says Koenig. Because only a stroke center can follow the protocols for administering tPA, a patient can’t be taken to just any ER. Even before an ambulance arrives, or during the ride, Telestroke allows for a video diagnosis and correct diversion.
Koenig tirelessly pulls together stakeholders in support of political action. He spent two years working on a 2014 telehealth law. But it lacked a provision for reimbursing doctors for video consultations. “It was flawed,” he sighs. He calls telehealth the thing he does to refresh himself from his not-so-cheerful main focus, brain trauma.
What surprised him this year, after the sticky experience of pushing his first bill, was how quickly the stakeholders bought in—HMSA in particular. It was clear that telehealth wouldn’t fly unless doctors were reimbursed the same for a remote visit as for an office visit. But, as the bill moved along, HMSA made the complementary change, effective January.
“We actually met with HMSA throughout this process,” Koenig says. “I was kind of asking, ‘Do you understand how big this is? If you can see patients in their homes via telemedicine and get paid for it, that is huge.’ It is a seismic shift.
“If I were them, I’d have been worried about pent-up demand, because, with telemedicine, you’re going to tap into this demand and that will lead to increased utilization of the health system, which insurers don’t want.”
Others in the health care establishment have also expressed surprise at HMSA’s decision to transform the reach of telehealth by making it profitable for providers. In one move, it also advances Ige’s and the health agencies’ dream platform, ‘Ohana Nui.
Upon a second look, Koenig saw how the big shift fit into HMSA’s long-term goals. “If you look at its alternative payment model,” says Koenig, “then it makes a whole lot more sense.” To avoid runaway expenses due to overuse of fee for service, HMSA’s new model caps doctor reimbursements by paying them a lump sum each year based on their three-year earnings average. If you’re a doctor and start seeing patients via telemedicine, Koenig says, “Then you’re saving money and using health care more efficiently. That’s what HMSA is thinking and why they don’t resist the law.”
Koenig is no Pollyanna when it comes to telemedicine; he particularly wants the state to get into the game in order to head off the kind of undisciplined, for-profit care seen in the direct-to-customer free market. “Telemedicine will grow. It’s consumer driven. What I’d like to see is the state getting together with the departments of health and human services in a very thoughtful way to really prioritize the growth of telemedicine. We don’t want hospitals playing catch-up in an uncoordinated fashion.”
Ultimately, “We need better health systems on the Neighbor Islands,” says UH medical school dean Hedges. “We’re not going to be able to train enough doctors to practice there. We need a system that will diagnose and refer patients, and we must use it relentlessly.”
As far as nurses are concerned, “When we really look at telehealth, its potential for expanding access to care is remarkable,” says Reichhardt. “We have so many remote populations who find it difficult to see a specialist, even a primary care physician. If we can utilize telehealth, we’ll see huge advances in our communities. If someone has to travel to visit a medical center, if they have to take a day off from work, or two days if they live on an outer island, if we can cut that and replace it with just an hour of telemedicine, the impact will be huge. It’s a really exciting component,” she concludes.
How soon will the latest medical revolution be televised? Numbers-cruncher Withy has an update: The number of physicians using telemedicine in Hawai‘i rose from 2 percent in 2014 to 15 percent in 2015.
Telehealth App a Day Keeps the Doctor…
Apps that turn a smartphone into a diagnostic device—often via plug-in hardware—can save patients time and stress while keeping doctors informed. Here are a few top picks:
For the Heart:
Kardia / AliveCor
This FDA-approved heart app detects atrial fibrillation, etc., by turning a smartphone into an EKG (electrocardiogram) device. Records your heart rate, emails a PDF to your doctor or a Kardia cardiologist (fee applies), archives EKGs, notes. $110 plus shipping. alivecor.com
For the Head:
Lantern’s cognitive behavioral therapy app combines daily exercises with online coaching to manage anxiety, stress, eating disorder and body image issues; from a Stanford and Washington university joint research venture. Personally tailored, 24/7 text access, $49/month. golantern.com
For the skin:
skinScan / Direct Dermatology
Turn your phone into a Class 1 medical device with skinScan, which tracks moles and puts you in touch with a dermatologist. Free. teleskin.com. Or get checked out by Direct Dermatology; $95, but it accepts insurance, including HMSA. directderm.com
For the blood:
This FDA-approved app makes monitoring insulin and following a diabetes diet into a game with both adult and child versions. Particularly useful for storing food diaries, normally a big hassle for diabetics. Free. mysugr.com
For the body:
Health starts with what we put into our bodies, and ShopWell lets you scan barcodes of more than 350,000 products to look up ingredients and health ratings. Customize it to your needs, allergies and goals. Free. shopwell.com
Making Medicine Better
How one midsize physician practice rides the waves of health care change.
After 27 years, “being a primary care physician has gotten a lot more complicated since I started,” says Dr. Michael Nagoshi of Central Medical Clinic. “We’ve gone from being the person responsible for taking care of your illness to being your health care accountant”—staying on top of all the things needed to keep you healthy.
Nagoshi had been teaching medical residents at The Queen’s Medical Center and then Kuakini Medical Center when, he realized, “I missed taking care of patients myself.” He took over for a retiring doctor at Central Medical Clinic, which, with 14 physician partners is “fairly typical of most practices in Honolulu.”
But with Nagoshi as director, the practice is hardly average. Committed to the patient-centered medical home, a model of care devised in the 1960s by Honolulu pediatrician Dr. Calvin Sia, Nagoshi and his partners treat a patient holistically. “We have a staff psychologist to help patients in quitting smoking, who have trouble sleeping, depression and anxiety. We’ve partnered with HMSA, to get us a diabetic educator, case managers for patients going in and out of the hospital. We’ve hired out-of-the-box kinds of staff: care coordinators to take care of the accounting,” so doctors are freed up.
Patient care has evolved; so has the bookkeeping. Nagoshi and the clinic were part of HMSA’s pilot program that will change doctor reimbursement in 2017. “I’m sure there’s going to be quite a bit of angst among the general physician population, but I firmly believe we have to fix the payment model if we’re going to do anything about primary care.”
It isn’t the first time Central Medical Clinic has been proactive. “In 2006 we realized we needed to get in front of electronic medical records,” Nagoshi says. “We got on it—lucky for us.” Today, that’s mandatory for Medicare and the Affordable Care Act. With that and the new reimbursement methods taking effect, “We wouldn’t be successful today without it.”