Corp Strat

The Washington Post –

October 9, 2013:

More workers at big U.S. companies will likely start paying a greater share of their doctor’s bill because of a health insurance shift forecast by benefits consultant Aon Hewitt.

Consumer-directed health plans, or CDHPs, could become the most common form of coverage offered by companies with 500 or more workers in the next three to five years, Aon Hewitt said Wednesday, as companies continue trying to cut health-care costs.

Under these plans, a smaller amount is usually taken out of employees’ paychecks for insurance. But the plans come with a deductible that can top $2,000 and must be paid before most coverage starts. That means a bill for more than $100 could replace the $20 co-payment the worker is used to after a doctor’s office visit.

It also means care like MRI exams will cost more for employees until they meet their annual deductible.

To ease that expense, CDHPs come with accounts fed by either the employer or employee through pre-tax

contributions to help cover costs.

Aon Hewitt said its annual survey of more than 800 large and mid-size U.S. employers found that 56 percent are offering CDHPs as a plan choice and another 30 percent are considering offering one in the next three to five years.

Many employers offer a choice of insurance plans for their workers, and most offer traditional plans with lower deductibles. But Aon Hewitt found that 10 percent offer CDHPs as the only option and another 44 percent are considering doing that.

Employers are considering these plans because they make workers aware of how much their care costs, which could help slow growth in health care expenses for companies. Patients tend to think more about what coverage they

need and how to get a better deal for it. That means the employee may fill a prescription with a generic drug instead of the pricier brand-name medicine. They also may look for a better deal on an MRI exam instead of heading to the nearest hospital.

Health care expenses and administrative costs for the coverage grew about 4 percent last year for employers with CDHP plans, according to Aon Hewitt. That compares with growth of 6 percent and 7 percent for more traditional health insurance plans with lower deductibles: HMOs, health maintenance organizations, and PPOs, preferred provider organizations.

Health care cost growth has slowed in recent years, but employers are still worried about it. Costs are still climbing faster than overall inflation, and companies also are concerned about a special tax on expensive health insurance coverage that starts in 2018 as part of the health care overhaul, the federal law that aims to cover millions of uninsured people.

“A lot of employers are trying to get their plans under cost control … just to avoid the impact of that tax,” said Maureen Fay, an Aon Hewitt senior vice president.

Employer-sponsored health insurance is the most common form of coverage in the United States, covering about 149 million non-elderly people according to the non-profit Kaiser Family Foundation, which researches health care issues.

Companies first started offering CDHPs to their employees about nine years ago. They made up 4 percent of all employer-sponsored plans offered in 2006, but have grown to about 20 percent this year, according to Kaiser’s annual benefits survey, which was released in August and is separate from the Aon study.

Gary Claxton, a vice president for the foundation, said he’s sure a lot of companies are considering CDHPs. Whether they wind up offering them is another matter. Companies have to spend a lot of time and money teaching their workers about the coverage, because it is different from more traditional plans.

He also noted that employers use benefits to retain

workers, and they have to make sure a switch to CDHPs doesn’t motivate their employees to leave.

Bloomberg by David Goldhill –

October 6, 2013:

Ignore the inevitable startup glitches. The new health-insurance exchanges will work just fine — in the sense that all government health-care programs work: Many people will ultimately become dependent on them for coverage. That won’t mean the exchanges have fulfilled their promise, however.

Forget the superficial comparisons to a commodity exchange, an online retailer or even a bulletin board. The health exchanges won’t resemble any other marketplace. Over time, rather than encourage insurance providers to offer ever more attractive and affordable policies, the exchanges are poised to push up the cost not only of insurance but also of health care itself. That means, if the history of U.S. health-care policy is any guide, the exchanges’ very “success” will have the effect of limiting access to care for the 30 million people who are estimated to remain uninsured.

Why are things set to go so badly? Because the architects of the health-care exchanges have relied on three crucial assumptions, all of which are probably wrong.

First, they have assumed that if insurers are prevented from competing on benefit design or on underwriting, they will compete on price. But why should they compete at all?

Limited Competition

The exchanges embody what seems like a simple trade: In return for many new customers, insurers accept broad restrictions on their freedom to design and market policies. The biggest requirement is that they agree to insure at the same policy price any and all customers, regardless of their health (with only small formulaic adjustments for age and smoking). From a consumer point of view, that sounds great, and indeed it’s one of the most popular elements of the Affordable Care Act. But from the insurer’s perspective, it courts disaster. With too many sick or high-risk people in its pool an insurer can lose money. So the insurer’s smartest approach is to set premiums high enough to make a profit even if it winds up with a lot of sick beneficiaries.

Competition among insurers is supposed to counteract this incentive, but the exchanges can perversely limit competition. The same pricing transparency that makes it easy for consumers to shop enables insurers to make sure they don’t charge less than their competitors do. This is how airlines take advantage of their electronic exchanges. It’s not as if insurance is currently a competitive market; even most private companies have trouble getting more than one bid for employee coverage. Rather than compete aggressively for customers, insurers can use exchanges to informally divide the market among themselves at high premiums.

Understanding Health Insurance Exchanges

The designers of the health-care exchanges have also assumed that consumers, by shopping for the best deal, will drive down premiums. However, a major flaw in the design of insurance subsidies will insulate almost all of the initial customers — the estimated 20 million subsidized households — from concern about how much their policies cost.

Now, it’s not supposed to work this way. Only those Americans who don’t get insurance at work and who have income that puts them between 100 percent (138 percent in Medicaid expansion states) and 400 percent of the federal poverty level are eligible for exchange subsidies. As income rises within this bracket, the subsidy shrinks. But in practical terms, everyone who is subsidized has an infinite subsidy that will make them insensitive to premium levels.

How can that be? Let’s take an example. A family of four at 138 percent of the poverty level ($32,499) has its premium capped at 3.29 percent of income or $1,071. The rest is subsidy. So, if the cost of a silver plan is $10,000, the subsidy for this family

is $8,929. A family at 400 percent of the poverty level ($94,200) has to pay up to 9.5 percent of its income for a plan, or $8,949. So the same $10,000 premium carries a subsidy of only $1,051.
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Insurer’s Perspective

But now look at those two families from the insurer’s perspective. A $10,000 plan already costs more than the maximum amount either family would pay. If the insurer raises the premium to $10,001, both families get $1 in additional subsidy. If it raises premiums to $11,000, both families get $1,000 in additional subsidy. In other words, no matter how much an insurer raises rates, a subsidized household pays zero more.

The second-cheapest silver plan is the benchmark for setting subsidies. How can insurers push up premiums artificially on this plan when there are platinum, gold and bronze plans also for sale? Again, easy. By law, these other plans differ from silver primarily by the amount of beneficiary cost-sharing. So the insurer can simply price a silver plan as high as possible, and then adjust the premiums for the other plans accordingly. If these prices end up being too high to attract any actual customers, who cares?

Why would an insurer lose the opportunity to share 20 million price-insensitive customers just to compete for a

smaller number (the Congressional Budget Office estimates 4 million by 2016) of low-profit price-sensitive ones?

There’s one more big assumption about the exchanges at work: that the price of health insurance passively mirrors the price of health care. But there’s plenty of evidence that insurance itself can drive up the cost of care — when both insurers and beneficiaries are undisciplined in controlling prices. In what may be the single greatest source of unintended consequences in the Affordable Care Act, insurers are now required to spend at least 80 percent of revenue from premiums on care. Superficially, this means that if they set premiums too high, they will have to eventually refund much of the money that they don’t end up spending on care. But let’s say you’re running an insurance company. You can find ways to spend more money on beneficiaries’ health care — say, with more generous definitions of free preventive care, more expansive rehabilitation services or higher reimbursement rates on doctors’ services — and keep 20 percent of the all money you bring in. Or alternatively, you can spend less on care and give refunds. Easy choice.

Wrong Incentives

In the end, we have incentives for insurers not to compete, for customers not to care about price, and for insurers to drive up the cost of care. Not much of a marketplace, is it?

Of course, it’s still possible that unsubsidized people will flock to the exchanges (especially if many middle-income Americans lose access to coverage at work), rebalancing insurers’ competitive interests. Or that the growing cost-sharing in all insurance will continue to moderate overall demand for services. Or that insurers will figure out clever ways to segregate price-insensitive (subsidized) buyers from price-sensitive ones.

What’s more likely, though, is that the exchanges will fit into a long pattern of U.S. health-care policy: They will serve a constituency (a policy triumph) while driving up the cost of care (which will be blamed on external factors).

When Medicare was enacted in 1965, seniors spent about 10 percent of their income on health care and worried about the cost. Today, seniors spend almost double that — about 17 percent of their income — on health care and, of course, still worry about cost. Medicare exceeded its

budget projections from day one, and its unlimited-entitlement structure led to an explosion in the volume of care. Nevertheless, the program is hailed as a great success in many corners, and its beneficiaries consider it irreplaceable.

The new exchanges will undoubtedly also be hailed as a success — no matter how much havoc their perverse incentives cause.

Associated Press –

September 25, 2013:

You might be pleased with the low monthly premium for one of the new health insurance plans under President Barack Obama's overhaul, but the added expense of copayments and deductibles could burn a hole in your wallet.

An independent analysis released Wednesday, on the heels of an administration report emphasizing affordable premiums, is helping to fill out the bottom line for consumers.

The annual deductible for a mid-range “silver” plan averaged $2,550 in a sample of six states studied by Avalere Health, or more than twice the typical deductible in employer plans. A deductible is the amount consumers must pay each year before their plan starts picking up the bills.

Americans looking for a health plan in new state insurance markets that open next week will face a trade-off familiar to purchasers of automobile coverage: to keep your premiums manageable, you agree to pay a bigger chunk of the repair bill if you get in a crash. Except that unlike an auto accident, serious illness is often not a self-contained event.

Avalere also found that the new plans will require patients to pay a hefty share of the cost — 40 percent on average — for certain pricey drugs, like the newer specialty medications used to treat intractable chronic diseases such as rheumatoid arthritis and multiple sclerosis. On the other hand, preventive care will be free of charge to the patient.

“Consumers will need to balance lower monthly premiums against the potential for unpredictable, expensive out-of-pocket costs in plans with higher deductibles,” said Caroline Pearson, a vice

president of the private market analysis firm. “There is a risk that patients could forgo needed care when faced with high up-front deductibles.”

Responding to the Avalere study, the Obama administration acknowledged the new plans aren't as generous as employer coverage, but said they nonetheless represent a big improvement over currently available individual policies, which can have gaps in coverage and even larger out-of-pocket costs.

Also on Wednesday, the administration unveiled premiums and plan choices for 36 states where the federal government is taking the lead to cover uninsured residents. Insurance markets that go live Oct. 1 will offer subsidized private coverage to people

who do not have health insurance on the job, including the uninsured and those who currently buy their own policies.

Before new tax credits that work like a discount for most consumers, premiums for a mid-range “silver” benchmark plan will average $328 a month nationally for an individual, the administration report found. Beneath that average are wide differences for individuals, depending on where they live, how much they make, and other factors.

Health and Human Services Secretary Kathleen Sebelius said the average consumer will be able to choose among more than 50 plan options.

“For millions of Americans, these new options will finally make health insurance work within their budgets,” Sebelius told reporters in a preview call Tuesday. The markets — called “exchanges” in some states — are the only place where consumers will be able to get a tax credit for health insurance.

HHS estimated that about 95 percent of consumers will have two or more insurers to choose from. And the administration says premiums will generally be lower than what congressional budget experts estimated when the legislation was being debated. About one-fourth of the insurers participating are new to the individual coverage market, a sign that could be good for competition.

But averages can be misleading. When it comes to the new health care law, individuals can get dramatically different results based on their particular circumstances.

Where you live, the plan you pick, family size, age, tax credits based on your income, and even tobacco use will all impact the bottom line. All those variables could make the system hard to navigate.

For example, the average individual premium for a benchmark policy known as the “second-lowest-cost silver plan” ranges from a low of $192 in Minnesota to a high of $516 in Wyoming. That's the sticker price, before tax credits.

In the three states with the highest uninsured population, the benchmark plan will average $373 in California, $305 in Texas, and $328 in Florida. Differences between states can be due to the number of insurers competing and other factors.

“One surprise is Texas,” said Larry Levitt of the Kaiser Family Foundation. “That is a state that has put up roadblocks to implementation, but the premiums there are below average.”

The second-lowest-cost silver plan is important because tax credits are keyed to its cost in local areas.

But consumers don't have to take silver. They can pick from four levels of coverage, from bronze to platinum. All the plans cover the same benefits and cap annual out-of-pocket expenses at $6,350 for an individual, $12,700 for families.

The big difference is cost sharing through annual deductibles and copayments. Bronze covers 60 percent of expected costs; silver, 70 percent, on up to platinum at 90 percent. Bronze plans have the lowest premiums and the highest cost sharing.

As the Avalere study

showed, premiums aren't the only factor consumers should weigh.

The flurry of new reports comes as the White House swings into full campaign mode to promote the benefits of the Affordable Care Act to a skeptical public. Congressional Republicans, meanwhile, refuse to abandon their quest to

derail “Obamacare” and are flirting with a government shutdown to force the issue.

Starting Jan. 1, virtually all Americans will be required to carry health insurance or face fines. At the same time, the health care law will prohibit insurance companies from turning away people in poor health, or charging them more.

Firms won't be fined

for not telling workers about Obamacare
Reuters by Lewis Krauskopf –

September 12, 2013:

Employers will not face a penalty if they fail to inform their workers by October 1 about changes under President Barack Obama's healthcare law, the administration said, in what will likely come as a relief to many small businesses.

The federal government is requiring businesses to notify employees about the new health insurance marketplaces created by the law that are set to start enrolling millions of Americans beginning October 1.

Employers are also required to inform employees that they may be able to get lower-cost insurance on the exchanges, but if they buy insurance on the exchange, they may lose their employer contribution.

Media reports have said that many small businesses had been unaware of the requirement, and therefore were at risk of potential penalties.

A notice posted on the Department of Labor's website on Wednesday said employers cannot be fined for failing to provide such notice.

“If your company is covered by the Fair Labor Standards Act, it should provide a written notice to its employees about the Health Insurance Marketplace by October 1, 2013, but there is no fine or penalty under the law for failing to provide the notice,” the Labor Department said, under the heading “FAQ on Notice of Coverage Options.”

Businesses covered by the FLSA have annual sales of at least $500,000.

A Labor Department spokesperson confirmed on Thursday that businesses faced no consequences for missing the deadline.

Asked why the department posted the notice, the spokesperson said: “The reason all the FAQs go out is to provide further clarity.”

Some labor attorneys had been speculating that businesses that miss the deadline would face fines of $100 day per worker, in line with other penalties under the Affordable Care Act, said John Barlament, an employee benefits attorney with the firm Quarles & Brady.

“It's helpful for employers to have that clarification,” Barlament said. “There was some uncertainty before about whether or not there was a penalty.”

Barlament said most large employers were aware of the notification requirement.
“But among smaller clients you do see a little bit less awareness of this, and some of them probably would have been caught a little flat-footed here,” Barlament said.

Insurers in California's new health insurance exchange are holding down premiums by limiting choices, raising concerns that patients will struggle to get care.

By Chad Terhune, Los Angeles Times
September 14, 2013, 6:34 p.m.

The doctor can't see you now.

Consumers may hear that a lot more often after getting health insurance under President Obama's Affordable Care Act.

To hold down premiums, major insurers in California have sharply limited the number of doctors and hospitals available to patients in the state's new health insurance market opening Oct. 1.

New data reveal the extent of those cuts in California, a crucial test bed for the federal healthcare law.

These diminished medical networks are fueling growing concerns that many patients will still struggle to get care despite the nation's biggest healthcare expansion in half a century.

Consumers could see long wait times, a scarcity of specialists and loss of a longtime doctor.

“These narrow networks won't work because they cut off access for patients,” said Dr. Richard Baker, executive director of the Urban Health Institute at Charles Drew University of Medicine and Science in Los Angeles. “We don't want this to become a roadblock.”

To see the challenges awaiting some consumers, consider Woodland Hills-based insurer Health Net Inc.

Across Southern California the company has the lowest rates, with monthly premiums as much as $100 cheaper than the closest competitor in some cases. That will make it a popular choice among some of the 1.4 million Californians expected to purchase coverage in the state exchange next year.

But Health Net also has the fewest doctors, less than half what some other companies are offering in Southern California, according to a Times analysis of insurance data.

In Los Angeles County, for instance, Health Net customers in the state exchange would be limited to 2,316 primary-care doctors and specialists. That's less than a third of the doctors Health Net offers to workers on employer plans. In San Diego, there are only 204 primary-care doctors to serve Health Net patients.

Other major insurers have pared their list of medical providers too, but not to Health Net's degree. Statewide, Blue Shield of California says exchange customers will be restricted to about 50% of its regular physician network.

In response, California officials have been pressing Health Net and other insurers to add more doctors since companies filed their initial rosters in May. The state exchange, Covered California, says it will monitor enrollment closely once it begins next month and it's prepared to step in if problems arise.

“Our interest is in assuring everyone enrolled in a plan has ready access to the clinicians they need,” said Peter Lee, executive director of Covered California. “That means if a plan can't serve patients, we'll close it down from taking new enrollment. That is in some ways the nuclear option.”

Rather than mere head count, officials say they are scrutinizing what capacity physicians have to accept new patients. And to assist consumers, California will enable people to search for specific doctors online during enrollment to determine what, if any, health plans they will be part of in Covered California.

“Does the doctor have room for one more patient or 40 patients? It's about available seats,” Lee said. “We want to make sure every network has enough doctors.”

Health Net says price will probably matter most to the uninsured and people who buy their own health insurance now, so it built a narrow network to serve those “value seekers.”

“We have more than enough doctors for our projected enrollment through 2014, and we have time to adjust if it becomes necessary,” Health Net spokesman Brad Kieffer said. “We continue reaching out to providers, and we are bringing more on board.”

In recent months, the top priority for state officials and insurers has been affordable premiums. A smaller panel of doctors and hospitals generally yields lower rates because insurers can negotiate better discounts with providers who receive more patients.

Insurers and some consumer advocates think people are willing to trade some choice in order to pay less. More employers have been adopting these narrower networks in recent years to trim their own healthcare bills.

The California Medical Assn., which represents more than 37,000 doctors statewide, thinks the state is underestimating the difficulties ahead.

Based on its research, the organization is skeptical of the state's claim that its health plans will cover about 80% of all California physicians. Other doctors worry about the effect on certain Latino and African American communities that have been historically underserved.

Covered California says it's still compiling a list of all providers for the 12 health insurers in the exchange.

Supporters of the healthcare law say these types of problems are inevitable in rolling out such a massive program. Overall, they say, millions of consumers stand to benefit from guaranteed coverage regardless of preexisting medical conditions and the protection from financially crippling medical bills.

But some health policy experts say that medical costs will continue to escalate if patients can't see their doctor regularly and get the follow-up care they need for chronic conditions such as diabetes. Similar concerns over patient access have surfaced in other states such as Maine and Wisconsin.

“We are nervous about these narrow networks,” said Donald Crane, chief executive of the California Assn. of Physician Groups. “It was all about price. But at what cost in terms of quality and access? Is this contrary to the purpose of the Affordable Care Act?”

The federal law requires exchange plans to include enough providers so

that services are available “without unreasonable delay.” Likewise, state law sets various requirements for “network adequacy” so patients have enough doctors and hospitals nearby.

The differences in network size are noticeable across Southern California. Health Net has 920 physicians in Orange County, compared with more than 2,500 for Blue Shield, according to company data. Health Net has fewer than 800 doctors in San Diego County, while nearly 3,000 physicians are available in an Anthem Blue Cross plan.

In addition to doctors, some big-name hospitals may be left out. A spokesman for Cedars-Sinai Medical Center said the hospital has received many calls from patients who were worried about keeping their access to the hospital and its affiliated doctors in the new health plans next year.

Cedars-Sinai is available only on two lower-priced Health Net plans in the state-run market, according to the hospital and insurer. Anthem Blue Cross says that it's the only insurer that includes UCLA Medical Center and other UC facilities statewide.

In some ways, insurers are mimicking HMO giant Kaiser Permanente, which has limited patients to its own hospitals and doctors for decades. Kaiser is offering its full slate of in-house providers in the exchange, totaling more than 5,700 doctors in the Los Angeles area.

Newly released data show the pricing power of these tighter networks. In Los Angeles County, Health Net is consistently the lowest-cost option for a mid-level Silver plan across various age groups.

A family of four in Norwalk earning $65,000 annually would pay $384 a month for a Health Net policy, after taking into account a federal subsidy based on their income. For a policy with identical benefits, Blue Shield was next at $477 a month and Kaiser was the most expensive at $602.

The cheapest Silver plan for a couple in their mid-50s earning nearly $100,000 a year was also Health Net at $781 a month. An Anthem policy costs $897.

Consumers can check prices at http://www.coveredca.com.

“Health Net will get a lot of business with those rates,” said Glen Futterman, a health insurance broker in Woodland Hills. “But no one mentions you might not be able to see your doctor.”

Companies sweating Obamacare tax—and acting on it: Study

CNBC.com | Wednesday, 21 Aug 2013 | 11:53 AM ET

Mid- and large-sized companies overwhelmingly expect health-care costs to increase under Obamacare—and most are eyeing possible changes to their health insurance offerings because of a looming excise tax for pricier plans under the health-care reform law, a new survey of employers finds.

In fact, 40 percent of 420 companies surveyed by Towers Watson said they will be changing their insurance plans' designs in 2014 in light of the coming excise tax as well as to control employee-related health costs.

And nearly 60 percent of the companies view private health insurance exchanges as a possible way to control their health-care and administrative costs by shifting the work of insuring their workers off

to those exchanges in the future.

But most of those companies—which collectively employ 8.7 million people—don't have firm near-term plans to do so.

The study also found those same companies are increasingly unlikely to offer their employer-sponsored plan for retirees older than age 65 as Obamacare state insurance exchanges go into effect, and as Medicare remains available to those people.

The number of employers either very or somewhat likely to discontinue such plans for those retirees grows from 25 percent in 2014 to 44 percent in 2015, according to Towers Watson, the global professional services company, which released its study Wednesday.

But the same study found a very strong majority of those companies—82 percent—see their ability to offer subsidized health benefits to existing workers as an “important” as part of their “employee value proposition” for 2014, according to the study.

And 98 percent of the employers have no definite plans to discontinue health-care coverage in 2014 and 2015 and direct their full-time workers to the state health insurance exchanges.

“Most companies very much still see health-care benefits as a core offering,” said Ron Fontanetta, a senior health-care consultant at Towers Watson.

“It's a very visible benefit, and it garners a lot of attention among executives, in part because it's very visible to employees and also because it costs a lot,” Fontanetta said.

Companies taking action

However, the Towers Watson study is being released on the same day that it was revealed that delivery giant United Parcel Service told white-collar employees two months ago that UPS was excluding 15,000 working spouses from the Atlanta-based company's health plan next year because of increased medical casts, and “costs associated with the Affordable Care Act,” according to a memo cited by the Kaiser Health News service.

UPS' decision, according to Kaiser Health, is based on the ability of the affected employees' spouses to obtain insurance coverage elsewhere.

A UPS spokesman told Kaiser Health that the company expects to save about $60 million per year with that decision.

The Towers Watson study, in a reflection of the high costs that UPS and other companies are identifying and reacting to, found that the chief financial officers of the companies surveyed are increasingly involved in decision-making for those businesses' health-care strategies.

When the survey asked companies to what extent their CFOs are more involved in such decisions than they were three to five years ago, 46 percent of the companies said it was to either a great or significant extent.

Fontanetta said those CFOs aren't necessarily sitting down with benefits managers and designing health-care offerings. But, he said, “They are increasingly asking questions about 'where are we taking our future strategy? how does the challenge of offering health care reconcile with our broader financial goals as an organization?'”

“They want to understand, increasingly, what are the different strategic pathways [the companies] might take,” Fontanetta said.

Looming excise tax

At the forefront of many of those CFOs' minds, and the minds of other executives at the surveyed companies, is the looming threat of an excise tax on benefits under a provision of the Affordable Care Act that goes into effect in 2018.

That tax on the companies will initially be on health-care coverage whose aggregate cost for workers exceed $10,200 for self-only coverage and $27,500 for other coverage.

The tax is 40 percent of the amount that the worker pays in excess of those limits. Despite the fact that the tax doesn't kick in for more than four more years, it is already affecting having an effect on decision-making.

A total of 60 percent of employers said that the excise tax will have either significant or moderate influence on their health-care benefits strategy in 2014 and 2015, the study found.

“This is a big deal,” Fontanetta said of those results. “It's one of the most important findings.”

He noted that more than 60 percent of the companies expect to be subject to the excise tax, absent any changes in their health-care offerings that would avoid it.

“But we don't think companies are going to sit tight,” Fontanetta said.

—By CNBC's Dan Mangan. Follow him on Twitter @_DanMangan.