Timely analysis from our multidisciplinary team.
March 27, 2020
As the outbreak of the Coronavirus (COVID-19) affects every sector of the US economy, the US Congress and the White House came together to provide funding, supplies and regulatory relief to address the crisis. The US Senate unanimously passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act on March 25, 2020. The US House of Representatives followed suit and passed the bill on March 27, 2020. The President signed it into law shortly after. The CARES Act represents the third stimulus bill passed by Congress in response to the COVID-19 pandemic. With $2 trillion in allocations, it is the largest stimulus bill in US history. Click here for a summary of the legislation.
March 27, 2020
This Week’s Dose: The coronavirus (COVID-19) pandemic continues to drive activity in Washington, DC. This week, Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the third relief and support bill in response to the pandemic. Read our in-depth summary of the CARES Act or listen to our overview on the latest episode…
March 20, 2020
The response to the coronavirus (COVID-19) continued to dominate lawmakers’ attention. The Senate passed the second emergency funding bill and began work on a third. The Administration released new guidance expanding telehealth services in traditional Medicare.
March 19, 2020
On March 17, 2020, CMS and other agencies released further guidance on the use of telehealth during the coronavirus (COVID-19) national emergency. The guidance implements provisions of the Coronavirus Preparedness and Response Supplemental Appropriations Act, as signed into law on March 6, 2020.
March 18, 2020
On March 11, 2020, CMS announced the Part D Senior Savings Model. The rollout of a payment model focused on reducing the cost of insulin for Medicare beneficiaries is not unexpected, it is part of a larger ongoing effort by the Administration to address the rising costs of pharmaceuticals.
March 13, 2020
Lawmakers are considering additional emergency funding to address the growing coronavirus (COVID-19) pandemic as US cases top 1,000. The Administration released long-awaited information blocking and interoperability rules.
March 10, 2020
Emma sits down with the newest member of McDermottPlus, Dr. Paul Gerrard, for a conversation about his experience and the advice he has innovators in the diagnostics space.
February 28, 2020
McDermottPlus VP Sheila Madhani and Senior Director Jessica Roth discuss CMS’s recent proposed rule making changes to the Comprehensive Care for Joint Replacement payment model.
February 28, 2020
The Administration requested emergency funding to fight the coronavirus epidemic, and US Department of Health and Human Services (HHS) Secretary Alex Azar defended the President’s fiscal year (FY) 2021 budget on Capitol Hill.
February 20, 2020
Rodney Whitlock and Rachel Stauffer are back in the Breakroom to discuss the President’s fiscal year 2021 budget and its implications for health policy.
February 14, 2020
House committees advanced legislation to address surprise billing, and the White House released the President’s budget for fiscal year (FY) 2021.
February 12, 2020
On February 10, 2020, the White House released its $4.8 trillion FY 2021 budget proposal. In the area of healthcare, the president requested $94.5 billion in discretionary budget authority for the US Department of Health and Human Services (HHS), which represents a 10% decrease from the 2020 enacted level.
February 11, 2020
On February 5, 2020, CMS issued two documents impacting the Medicare Advantage program: (1) the Medicare and Medicaid Programs: Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly Proposed Rule; and (2) the…
February 07, 2020
The House Ways and Means and Education and Labor committees released information on their surprise billing proposals, and President Trump delivered the State of the Union on the eve of the Senate’s vote to acquit him in the impeachment trial.
February 03, 2020
CMS released a SMD letter and fact sheet encouraging states to pursue block grant or per capita cap funding mechanisms through their Medicaid programs as part of the new HAO.
January 31, 2020
The House of Representatives returned from recess to continue work on legislation to address surprise medical bills and high drug costs, while the Administration unveiled a proposal to let states opt for Medicaid block grants. The Senate remained busy with impeachment proceedings.
January 24, 2020
This Week’s Dose: It was a relatively quiet week in Washington with the House of Representatives in recess and the Senate enmeshed in the impeachment trial. Activity is sure to pick up as soon as House members are back in town next week.
January 17, 2020
The House of Representatives voted to formally present the articles of impeachment against President Trump to the Senate, kicking off the trial phase of the impeachment process. The Senate trial is expected to tie-up and stall legislation in the upper chamber for several weeks, and perhaps longer. House lawmakers, meanwhile, continued to grapple with surprise…
January 13, 2020
The year 2020 is expected to be another active year for the healthcare industry. In this report, we have narrowed a vast health policy landscape to our top 10 issues of significance for 2020, and offer our consultants’ insights into what 2020 might have in store.
January 10, 2020
Congress is back in session following the holiday recess, though the exact Senate schedule remains uncertain as lawmakers negotiate the details of President Trump’s impeachment trial.
December 20, 2019
The 2019 legislative session has come to an end. Lawmakers reached a deal to fund the government through fiscal year (FY) 2020, the House of Representatives impeached President Trump, and a federal appeals court issued a highly anticipated ruling with implications for the Affordable Care Act (ACA).
December 20, 2019
Mara McDermott and Jessica Roth are back in the Health Policy Breakroom to talk about Direct Contracting, a new payment model from the CMS Innovation Center.
December 09, 2019
Mara McDermott and Sheila Madhani join Emma Zimmerman to discuss changes in the 2020 changes to the Quality Payment Program and the landscape of Advanced Alternative Payment Models.
December 06, 2019
Congress is back in town with just two weeks to address government funding and many healthcare issues. More proposals are emerging on drug pricing and surprise billing, and the House Judiciary Committee took up impeachment.
November 26, 2019
Primary Care First, a new care delivery and payment model from the CMS Innovation Center is another approach to advancing primary care. PCF eligibility and care delivery design mirror the CPC+ model in several ways, but is distinct in others. The model leverages both population-based and flat fee visit payments to promote access and better…
November 21, 2019
Mara McDermott and Jessica Roth join Emma Zimmerman to discuss changes in the 2020 Hospital Outpatient Prospective Payment System final rule related to prior authorization and the landscape of utilization management policy more broadly.
November 20, 2019
Healthcare remains a pressing concern for voters heading into the 2020 presidential election. Many of the Democratic candidates have put forward detailed policy proposals for expanding healthcare access and affordability. The table below offers a broad overview of the healthcare plans proposed by the major contenders in the 2020 Democratic Primary, focusing on coverage, affordability,…
November 15, 2019
Government funding negotiations continued against the backdrop of impeachment, and the CMS issued new rules on provider price transparency and Medicaid supplemental payments.
November 14, 2019
McDermottPlus is pleased to present The Health Policy Breakroom, a podcast dedicated to health policy updates. Our inaugural episode provides an overview of the 2020 PFS, OPPS and ASC Final Rules recently released by CMS.
November 06, 2019
On November 1, 2019, CMS released the CY 2020 Hospital Outpatient Prospective Payment System and the Ambulatory Surgical Center Payment Systems effective for services on January 1, 2020.
November 06, 2019
On November 1, 2019, CMS released the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies, which includes changes related to Medicare physician payment and the Quality Payment Program effective for services on January 1, 2020.
October 25, 2019
The House Ways and Means Committee completed its markup of H.R. 3, but floor consideration was pushed until mid-November. Seema Verma appeared before the House Energy and Commerce Oversight and Investigations Subcommittee.
October 11, 2019
Lawmakers came with big ambitions for 2019, but we are headed into 2020 with two major health policies left on life support and many healthcare programs nearing expiration.
October 11, 2019
There are 20 scheduled joint legislative days left until the current continuing resolution funding the government ends on November 21, 2019, followed by an additional eight scheduled joint legislative days until the end of the year. These are significant dates for several important healthcare programs and their funding.
October 04, 2019
This Week’s Dose: The impeachment inquiry proceedings are still moving forward, despite the Congressional recess. Surprise billing activity continued, and the Trump Administration issued an Executive Order on Medicare.
October 03, 2019
McDermottPlus is pleased to present this special report examining the state of the value-based payment movement in the lead up to the 2020 election.
September 27, 2019
This Week’s Dose: Speaker Pelosi’s announcement of an impeachment inquiry dominated the news this week, but what does that mean for health care policy?
September 20, 2019
This Week’s Dose: Speaker Pelosi released her long-awaited drug pricing bill, and the House Energy and Commerce Committee questioned drug companies’ financial motivations during a hearing this week.
September 20, 2019
On September 19, 2019, the Speaker of the US House of Representatives released a proposal to contain federal and individual spending on prescription drugs, joining Administration and Senate efforts to address prescription drug pricing. This article contemplates the likelihood of a drug pricing package and how it could come together.
September 13, 2019
This Week’s Dose: The House and Senate are back in session with two weeks to go until the government funding deadline and lots to do.
September 06, 2019
The Recess Dose: With the August recess wrapping up, we are back at the McDermottPlus Weekly Check-Up. Here’s what you may have missed over the break.
August 06, 2019
On July 29, 2019, CMS released the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies, which includes proposals related to Medicare physician payment and the Quality Payment Program. The proposed regulations will be published in the Federal Register on August 14, 2019. Comments are…
August 02, 2019
This Week’s Dose: Things have quieted down in Congress with the House out of session and the Senate wrapping up its last week before the August recess. But the agencies are still at work, so don’t totally check out just yet.
July 26, 2019
This Week’s Dose: The Senate Finance Committee finally released its drug pricing package and moved quickly to a markup. The bill passed out of committee, but work will continue before the full Senate votes. We’ll be watching closely as things develop.
July 25, 2019
There has been a surge of congressional activity relating to the various surprise billing proposals. What started out as an issue for a small Senate working group last year has turned into a major health priority for both parties in both chambers.
July 24, 2019
On July 10, 2019, the CMS published the Medicare Program; Specialty Care Models to Improve Quality of Care and Reduce Expenditures proposed rule. This proposed rule implements a new mandatory Radiation Oncology Model and furthers the administration’s goal of transitioning providers to performance-based arrangements in traditional Medicare.
July 22, 2019
This is the last scheduled week the House is in session and the second to last week the Senate is in session before the August recess. What will get done?
July 19, 2019
This Week’s Dose: The Energy and Commerce Committee held a marathon mark-up of 25 bills, including 10 health care related bills. The No Surprises Act received an amendment that adds arbitration to the payment dispute process. The House voted to repeal the Cadillac tax. And, we finally have a Congressional Budget Office (CBO) score for…
July 12, 2019
This Week’s Dose: Congress is back for the final legislative session before the August recess, and it’s all about what can get done ahead of the break. House and Senate committees have already advanced a cost containment legislation that includes surprise billing and prescription drug cost provisions, among many other things. We still await any…
July 08, 2019
They’re back… and heading into the final weeks before the August recess.
June 28, 2019
This Week’s Dose: Lots of movement in Congress ahead of the Fourth of July recess with the House and Senate both advancing a number of health care bills. President Trump also signed an executive order this week, continuing the Administration’s focus on health care transparency.
June 21, 2019
This Week’s Dose: Three weeks down, one week to go in this work period. The Senate Health, Education, Labor and Pensions (HELP) Committee is moving forward with its cost containment legislation, and the House passed the first batch of health care extenders.
June 21, 2019
On June 19, 2019, the US Senate Committee on Health, Education, Labor & Pensions (HELP) released its updated Lower Health Care Costs Act (S. 1895). This new version includes several noteworthy changes, outlined below.
June 14, 2019
This Week’s Dose: The focus was back on surprise billing this week with the third hearing of the year. We also saw hearings on Medicare for All and vertical consolidation in the health care industry, and the House advanced an appropriations package.
June 07, 2019
This Week’s Dose: Congress is back, and this week marked the start of another busy legislative session. Work continues on drug pricing, surprise billing and cost containment, and negotiations have begun on an extenders package as well.
May 29, 2019
Since mid-2018, the Centers for Medicare and Medicaid Services has been implementing sections of the American Patients First Blueprint, President Trump’s plan to lower drug prices and reduce patient out-of-pocket spending.
May 24, 2019
This Week’s Dose: We saw a flurry of activity this week related to drug pricing, surprise billing, cost containment and tobacco as lawmakers worked through their to-do list ahead of the Memorial Day recess.
May 17, 2019
This Week’s Dose: Drug pricing remains in the spotlight, but lawmakers also introduced legislation focused on surprise billing and coinsurance.
May 10, 2019
This Week’s Dose: Another busy week for prescription drug pricing. Two more hearings took place on the subject, and a handful of bills passed out of the House. Now we watch the Senate to see how it packages and advances prescription drug bills that have moved through the House.
May 03, 2019
This Week’s Dose: Lots of activity surrounding single-payer this week with a hearing, the introduction of two Medicare expansion bills and a report from the Congressional Budget Office (CBO). Hearings and markups of drug pricing bills continue as well. This legislative session is off to a busy start.
April 26, 2019
This Week’s Dose: When Congress is away, the agencies will play. The Administration made some major announcements and dropped several new important rules this week, giving stakeholders plenty to talk about (and work on) while Congress is in recess.
April 15, 2019
Let me count the ways to 100. 1. Affordable Care Act. 2. Insurance Expansion. 3. Drug Pricing. 4. Surprise Billing. 5… Ok, maybe let me count to four.
April 12, 2019
This Week’s Dose: Drug pricing continues to be the focus in Congress with multiple hearings and markups on the subject. So far, lowering drug prices remains a rare area of consensus among lawmakers.
April 05, 2019
This Week’s Dose: Health care continues to dominate much of the attention on Capitol Hill. Lots of hearings. New coverage expansion legislation. And more state action on Medicaid.
March 29, 2019
This Week’s Dose: Congress is back and busy. The ACA dominates the headlines.
March 22, 2019
This Week’s Diagnosis: Recess usually means a light week. This one is no different.
March 15, 2019
This Week’s Diagnosis: All about the budget. Medicaid work requirements back in the spotlight. Recess awaits.
March 13, 2019
On March 11, 2019, the White House released its FY 2020 budget proposal. In the area of health care, the president has requested $87.1 billion in discretionary budget authority for HHS, which represents a 12 percent decrease from the 2019 estimated level. Read on for key HHS proposal highlights.
March 08, 2019
This Week’s Diagnosis: Hearings, hearings and more hearings. FDA Commissioner Scott Gottlieb is stepping down. Budget talks heat up.
March 06, 2019
On February 27, 2019, Representative Pramila Jayapal (D-WA) and more than 100 co-sponsors in the House of Representatives introduced the Medicare for All Act (HR 1384). The bill, like its predecessors, creates a single payer, government-funded health care program. The new program would cover enumerated medical benefits, prescription drugs, vision, dental, mental health and substance…
March 01, 2019
This Week’s Diagnosis: Congress gets busy. Pharmaceutical CEOs testify and emerge unscathed. The Administration is quiet.
February 22, 2019
This Week’s Diagnosis: It’s all quiet on the Hill. Members return Monday after the first full week of district work time in the 116th Congress.
February 20, 2019
CMS released its latest payment innovation model, “Emergency Triage, Treat and Transport”, which will incentivize reducing costs for the emergency transport and care of Medicare fee-for-service beneficiaries by allowing ambulance suppliers to be paid by Medicare for transport not only to emergency departments but also to alternative sites, such as urgent care centers or primary…
February 15, 2019
This Week’s Diagnosis: Congress passed a $328 billion spending package to avert another government shutdown. President Trump is expected to sign it. Congressional hearings continue to focus on coverage and drug pricing.
February 08, 2019
This Week’s Dose: The State of the Union briefly highlighted a few Administration health initiatives. The House continues its focus on the Affordable Care Act (ACA). The Senate is pressuring CEOs from the largest drug manufacturers to testify.
January 31, 2019
This Week’s Diagnosis: Government reopens…for at least three weeks. Congress is full steam ahead, kicking off the 116th with health care hearings on drug pricing and pre-existing conditions. The US Department of Health and Human Services focuses on 2019 priorities.
January 25, 2019
This Week’s Diagnosis: Hearings are beginning and priorities are emerging. The shutdown drags on. And updates are trickling out of the Administration.
January 18, 2019
This Week’s Diagnoses: Shutdown enters historic territory. Prescription drug costs emerge as a priority issue for the 116th Congress. Committee assignments are almost complete.
January 11, 2019
This Week’s Diagnosis: Welcome back – sort of. The partial federal government shutdown drags on. We are on day 21 with no end in sight, which has shifted the focus of the new Congress away from overarching health priorities and toward continued efforts to reopen the government.
January 08, 2019
On December 31, 2018 CMS published the Medicare Shared Savings Program; Accountable Care Organizations—Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017 final rule.
December 14, 2018
This Week’s Diagnosis: President Trump clashed with House Democratic Leader Nancy Pelosi (D-CA) and Senate Minority Leader Chuck Schumer (D-NY) in a meeting this week about how to keep the government’s lights on. The President threatened to shut down the government on December 21, when the current short-term funding agreement expires, if his request for…
December 07, 2018
This Week’s Diagnosis: Memorial services for President George H.W. Bush were held this week in Washington, DC and Texas. No agreement has been reached on border wall funding, which means Members may be here through at least December 21.
November 30, 2018
This Week’s Diagnoses: Welcome back! Members are back in town for a sprint to the finish. Controversy over the House Democratic leadership elections fizzled, with the same faces in the top three positions.
November 16, 2018
This Week’s Diagnosis: Newly elected congressional members were welcomed to Washington this week, while currently serving members returned for a brief, but important post-election lame duck session.
November 09, 2018
This Week’s Diagnoses: Was the election only four days ago? Tuesday brought change to Congress. While a handful of races have yet to be called, Democrats will take charge of the House of Representatives, while Republicans will retain control of the Senate come January 2019. We have a full breakdown of what the election results…
November 09, 2018
Democrats will take control of the House of Representatives in January 2019. Republicans will retain control of the Senate, widening their margin slightly. Split control of Congress will have important consequences for healthcare policy. This article takes a closer look at how the election is likely to impact the health policy agenda.
November 06, 2018
On November 1, 2018, the Centers for Medicare & Medicaid Services released the CY 2019 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Medicare Part B [CMS-1693F] Final Rule, which includes policies related to Medicare physician payment and the Quality Payment Program (QPP). The regulations will be published in the…
November 02, 2018
This Week’s Diagnosis: While members of Congress are touting the passage of the opioid package on the campaign trail, the Administration continued releasing a series of significant health policy regulations.
October 26, 2018
This Week’s Diagnosis: The Administration remains active with the issuance of several new guidance documents, the drug pricing announcement and the President (finally) signing the bipartisan opioid legislation (HR 6).
October 19, 2018
This Week’s Diagnoses: All eyes are on the midterm election, now less than three weeks away. The House and Senate are out; the Administration continues to release health-related regulations and announcements.
October 12, 2018
With midterms less than one month away, it is relatively quiet around Washington, DC. The Senate completed its work on Thursday and now joins the House in recess until after the midterm elections.
October 05, 2018
This Week’s Diagnosis: The Senate continues to chug along with hearings, opioids and judicial nominees. All is quiet in DC on the House side – members are in their home districts campaigning for re-election.
October 03, 2018
In recent years, a number of codes on the Medicare Physician Fee Schedule have experienced significant reductions in their payment rates due to changes to a single direct practice expense input. This analysis identifies over 366 additional codes vulnerable to potentially significant payment reductions because their rate is tied predominantly to a single input.
September 28, 2018
This Week’s Diagnosis: Consideration of the Kavanaugh nomination dominated airtime in the Senate this week, but the House stayed on-task, pushing through a number of health-related bills.
September 14, 2018
McDermott+Consulting is pleased to introduce the McDermottPlus Check-up, your regular update on healthcare policy from Washington, D.C.
September 11, 2018
A recently released evaluation of the CMS Comprehensive Care for Joint Replacement Model found a statistically significant reduction in spending in both high cost and low cost areas during the first performance year. Here are our five key takeaways.
August 30, 2018
On August 17, 2018, CMS released proposed rule that would make sweeping changes to the Medicare Shared Savings Program, a federal program that incentivizes integrated health provider networks to form Accountable Care Organizations. Comments are due October 16, 2018. Our top 5 takeaways follow.
July 30, 2018
On July 25, 2018, CMS released proposed policy and payment updates affecting the Hospital Outpatient Prospective Payment System and the Ambulatory Surgical Center Payment System for calendar year 2019. Read our top 10 takeaways from the rule.
July 26, 2018
Beginning January 1, 2020, when submitting claims to Medicare for advanced diagnostic imaging services furnishing professionals and entities must certify that professionals ordering services consulted AUC applicable to the imaging modality
July 16, 2018
On July 12, 2018, CMS released the CY 2019 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Medicare Part B, which includes proposals related to Medicare physician payment and the Quality Payment Program. Read our top 10 takeaways from the rule here.
July 12, 2018
This article—the latest in a McDermott+Consulting series investigating the president’s drug pricing plans—takes a closer look at Oklahoma’s recently approved State Plan Amendment that allows Oklahoma to negotiate value-based contracts with drug makers for individuals covered by the state’s Medicaid plan.
July 10, 2018
From January through June 2018, it seemed legislative efforts to address the national opioid epidemic were the primary focus of congressional work. No fewer than eight committees in both chambers held hearings and produced numerous bills in an attempt to help address the public health crisis. These bills are in various stages of the legislative…
July 05, 2018
The Medicare Advantage Qualifying Payment Arrangement Incentive demonstration would waive Merit-Based Incentive Payment System requirements for clinicians taking sufficient risk in contracts with Medicare Advantage plans. The agency seeks comments on the information collection burdens associated with this demonstration that is under consideration for formal approval. More information on the request for comments is available…
June 27, 2018
McDermottPlus’ PERVU Calculator replicates and verifies PERVUs published by CMS, which allows McDermottPlus to simulate the impact of alternate inputs on PERVUs and to assist with the development of comments in response to Proposed and Final MPFS Rulemaking.
June 25, 2018
The Centers for Medicare and Medicaid Services is scheduled to release the 2019 Quality Payment Program (QPP) proposed rule shortly. For the first time it is expected to be combined with the 2019 Medicare Physician Fee Schedule proposed rule, which generally is released on or around July 1. Our top five issues to watch in…
June 21, 2018
On June 15, 2018, the Medicare Payment Advisory Commission (MedPAC) issued its June 2018 Report to the Congress: Medicare and the Health Care Delivery System.
June 11, 2018
On June 7, 2018, the US Department of Health and Human Services (HHS) published a Request for Information (RFI) in the Federal Register regarding formation of a workgroup to encourage investment and innovation in health care. The RFI provides investors and innovative companies in health care with an opportunity to engage with the HHS to…
April 16, 2018
High-profile hires Mara McDermott, former vice president of federal affairs at a leading physician advocacy group, and Rachel Stauffer, former Hill staffer and HHS Office of the National Coordinator legislative affairs director, join the growing McDermottPlus team.
March 06, 2018
Since the run-up to the 2016 presidential election, Donald Trump has stated his interest in controlling and lowering the high cost of prescription drugs. Until recently his administration had released limited details on possible ways to do so.
February 27, 2018
December 12, 2017
November 09, 2017
September 05, 2017
June 26, 2017
A McDermottPlus side-by-side comparison table reflecting the draft’s major proposals compared to the AHCA and the ACA is now available
November 14, 2016
It is vitally important for the health system board, as well as certain of its key committees, to receive an introductory briefing as soon as possible on the health policy implications of last week’s Presidential and Congressional elections, as they are currently understood.
October 31, 2016
CMS finalized policies for 2017 that will offer providers more flexibility and opportunity to meet requirements under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
October 05, 2016
The final lab payment amounts for several well-established tests fall well below current Medicare pricing. Stakeholders have until October 30, 2016, to request reconsideration of these rates.
April 15, 2015
With draconian 21% cuts to physician payments looming, the Senate took action late yesterday; approving H.R. 2 by an overwhelming majority (92-8), and permanently repealing the much-maligned Sustainable Growth Rate (SGR). While six amendments were considered, none survived, clearing the way for the President’s signature. President Obama has announced that he will sign the bill.
April 08, 2014
Tucked away in the recently enacted Medicare legislation is a little-noticed provision that should be drawing more attention. While this legislative change implements a seemingly benign new requirement applicable only to physicians ordering advanced diagnostic imaging services, it will likely set the stage for new controls on the use of a wide variety of services…