• Readers ask: Is there brain training for hearing loss?

    Since publication of my Upshot post about training your brain to improve eyesight for reading, several readers have asked if there are similar approaches to brain training to improve hearing.

    I put that question to some experts, but have not received any responses that suggest there is such a thing. In some cases, experts simply did not respond to my email, so maybe those experts know something but aren’t saying!

    Point being, right now I’m not aware of how to improve your hearing through brain training. If someone knows otherwise, I’m all ears.


    Comments closed
  • Prescription drugs can be effective. Taking too many can be a problem.

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.

    The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.

    Deprescribing will work only if patients also get involved in the process. Only they can report adverse effects that they sense but that are not apparent to clinicians. And they need to be comfortable weaning from or dropping drugs that they are accustomed to and believe to be helpful.

    Yet an increasing number of Americans — typically older ones with multiple chronic conditions — are taking drugs and supplements they don’t need, or so many of them that those substances are interacting with one another in harmful ways. Studies show that some patients can improve their health with fewer drugs.

    Though many prescription drugs are highly valuable, taking them can also be dangerous, particularly taking a lot of them at once. The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.

    About one-third of adverse events in hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.

    Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirds of Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.

    Some are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetes found that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.

    Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.

    For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)

    Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.

    Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.

    Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it can reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.

    So why isn’t deprescribing more widely considered? According to a systematic review of research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.

    Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.

    To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.

    Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”

    Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.


    Comments closed
  • JAMA Forum: Safe injection facilities

    Last winter, the mayor of Ithaca, New York, Svante Myrick, proposed to provide a safe and legal space in which people could inject heroin. It may sound like a radical and desperate way to reduce the harms of drug use. But its effectiveness—and cost-effectiveness—is well supported by research.

    So begins my latest post on the JAMA Forum. It’s probably got more links to studies than anything I’ve ever posted there. Take a look!


    Comments closed
  • AcademyHealth: Referral patterns and hospital-owned physician practices

    According to a recent study, when hospitals employ physicians, patients may not benefit. More in my new AcademyHealth post.



    Comments closed
  • Training your brain so you don’t need reading glasses

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    By middle age, the lenses in your eyes harden, becoming less flexible. Your eye muscles increasingly struggle to bend them to focus on this print.

    But a new form of training — brain retraining, really — may delay the inevitable age-related loss of close-range visual focus so that you won’t need reading glasses. Various studies say it works, though no treatment of any kind works for everybody.

    The increasing difficulty of reading small print that begins in middle age is called presbyopia, from the Greek words for “old man” and “eye.” It’s exceedingly common, and despite the Greek etymology, women experience it, too. Every five years, the average adult over 30 loses the ability to see another line on the eye reading charts used in eye doctors’ offices.

    By 45, presbyopia affects an estimated 83 percent of adults in North America. Over age 50, it’s nearly universal. It’s why my middle-aged friends are getting fitted for bifocals or graduated lenses. There are holdouts, of course, who view their cellphones and newspapers at arm’s length to make out the words.

    The decline in vision is inconvenient, but it’s also dangerous, causing falls and auto accidents. Bifocals or graduated lenses can help those with presbyopia read, but they also contribute to falls and accidents because they can impair contrast sensitivity (the ability to distinguish between shades of gray) and depth perception.

    I’m 45. I don’t need to correct my vision for presbyopia yet, but I can tell it’s coming. I can still read the The New York Times print edition with ease, but to read text in somewhat smaller fonts, I have to strain. Any year now, I figured my eye doctor would tell me it was time to talk about bifocals.

    Or so I thought.

    Then I undertook a monthslong, strenuous regimen designed to train my brain to correct for what my eye muscles no longer can manage.

    The approach has been reported in the news media, and perhaps you’ve heard of it. It’s based on perceptual learning, the improvement of visual performance as a result of demanding training on specific images. Some experts have expressed skepticism that it can work, but a number of studies provide evidence that it can improve visual acuity, contrast sensitivity and reading speed.

    The training involves looking at images called “Gabor patches” in various conditions. Gabor patches optimally stimulate the part of the brain responsible for vision. A great deal of the training involves trying to see Gabor patches placed between closely spaced, distracting flankers. In training, the flanker spacing is varied, the target contrast is turned way down, and the images are flashed on a screen for fractions of a second — to the point that one can barely see the target.

    Do this and similar exercises hundreds of times over multiple sessions weekly; continue for months; and, gradually, presbyopia lessens, a number of studies show.

    One study also examined functions of the eye itself and found none of these improvements were because of changes in the eye. They’re all in the brain.

    Various smartphone apps say they offer this kind of vision-improving training; I used one called GlassesOff, the only one I found that was backed by scientific studies.

    Perceptual learning can improve the vision of people who already see quite well and those with other conditions. For example, a study tested the approach in 23 young adults, around age 24. Compared with a control group of 20 young adults, the treatment group increased letter recognition speed. Similar training is an effective component in treating amblyopia, also called “lazy eye,” which is the most frequent cause of vision loss in infants and children, affecting 3 percent of the population. It may also improve vision in those with mild myopia (nearsightedness).

    It should be acknowledged that some researchers involved in many of these studies have financial ties to GlassesOff. However, other studies with no commercial links obtained similar results, and several scientists I spoke to, including those without ties to GlassesOff, thought the science behind the app was credible. One study published in Psychological Science trained 16 college-aged adults and 16 older adults (around age 71) with Gabor patch exercises for 1.5 hours per day for seven days. After training, the older adults’ ability to see low-contrast images improved to the level that the college-age ones had before training.

    Scientists don’t know exactly how perceptual learning relieves presbyopia, but they have some clues based on how our brain processes visual information.

    After first taking in “raw data” of an image through the eye, different sets of neurons in the brain process it as separate features like edges and colors. Then the brain must coordinate activity across sets of neurons to assemble these features into recognizable objects like chairs, faces, letters or words. Reading at our normal pace, the brain has only about 250 milliseconds to do this work until the eyes automatically move onto the next letter or word. Once they do so, we’re taking in more information from whatever the eyes focus on next. If we haven’t yet processed the prior set of information, we can’t understand it.

    Visual processing time is challenged and slowed by noisy images, low contrast or closely spaced information (like small fonts). There is a bottleneck in the brain as it attempts to build and then comprehend the image. Therefore, enhancing and speeding up the ability to process image components — through perceptual learning — improves a wide range of vision functions.

    What’s surprising is that this is possible in adult brains. Neuroplasticity — the ability of the brain’s processing functions to change to acquire new skills — is most strongly associated with childhood. It’s still more pronounced in children than adults, but for some skills, including vision, the brain is more malleable than once thought.

    The training with GlassesOff is long and challenging. I found it fun initially, perhaps because it was new. But weeks into it, I began to dread the monotonous labor. Yet, after a couple of months, the app reports I can read fonts nearly one third the size I could when I started and much more rapidly. According to feedback from GlassesOff, my vision after training is equivalent to a man about 10 years younger than my age. If I reach 50 — the age at which almost everyone needs corrective lenses to read — and still don’t need reading glasses, I may conclude that the training has paid off.

    As apps go, GlassesOff is not cheap. I paid $24.99 for three months of use — long enough to get me through the initial program. Upon completion, I was invited to pay another $59.99 per year for maintenance training. It’s a nice option, but the hard work and price probably mean that the bifocals market will remain strong.


    Comments closed
  • AcademyHealth: Explaining the growth in Medicare Advantage

    Medicare Advantage’s cost to Medicare is different than traditional Medicare’s. So, predicting MA enrollment is important for projecting future Medicare costs to taxpayers. We’ve entered an era in which such prediction has become difficult and more speculative. In my latest AcademyHealth post I get some help from colleagues in trying to explain MA’s enrollment growth.



    Comments closed
  • Avoiding the health care run-around

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    You’ve all experienced it: There’s a problem with your health care bill, or you have difficulty getting coverage for the care you need. Your doctor or hospital tells you to talk to your insurer. Your insurer tells you to talk to your doctor or hospital. You’re stuck in an endless runaround.

    A small patient advocacy industry has sprung up to help, but that help can cost several hundred dollars an hour. Is there a way to get the customer service we deserve?

    Turns out, some kinds of health insurance plans provide better customer service than others. Among those that do are plans offered directly by hospitals or health systems, according to results from a recent study by me; Garret Johnson, now a medical student at Harvard; and Zoë Lyon, a research assistant at the Harvard T.H. Chan School of Public Health.

    Our conclusions are based on analysis of Medicare Advantage plans — private insurance alternatives to traditional Medicare. Medicare Advantage plans are offered by major insurers like UnitedHealthcare, Humana, Aetna, BlueCross BlueShield affiliates and others. But nearly one-quarter of the plans are issued by hospitals or health systems. These provider-offered plans are more likely found in dense, urban areas in the Northeast and the West.

    The government collects data on health care quality from surveys and medical claims, then aggregates them into ratings of plans. These are publicly reported in units of stars: Five stars represents the highest quality, and one the lowest. Our study, published this month in the health policy journal Health Affairs, found that provider-offered plans have higher quality ratings.

    Plans offered by insurers have average ratings of just over 3.5 stars for both nondrug and drug service. An average provider-offered plan has quality ratings that are about one-third of a star higher for both, after adjusting for factors that could confound the comparison, like socioeconomic status and the types and number of doctors where plans are offered.

    Our study dug deeper to examine the kinds of quality enhancements available in provider-offered plans. Some aspects of quality are clinically focused. For instance, measures of preventive screening — like that for colorectal cancer — or management of chronic conditions assess the quality of care delivered by doctors and hospitals in a plan’s networks. Provider-offered plans perform somewhat better than insurer-offered plans in such areas.

    Other aspects of quality pertain to customer service. In measures of complaints, responsiveness to customers and the enrollees’ overall experiences, provider-offered plans really shine. In each area of customer service we examined, provider-offered plans are rated one-half star higher than insurer-offered ones. (This is a big difference. For comparison, over half of plans are within one star of each other in overall quality.)

    These results make some sense. When a customer has an issue — like a problem with a hospital bill — the easiest thing for a health plan to do is pass it off to the hospital. Likewise, the hospital’s easiest course of action is to blame the health plan. The patient, stuck in the middle, is not likely to rate his plan (or hospital) highly for customer service in this case.

    However, when the plan and hospital are one and the same, neither can pass the buck to the other. Problems may be resolved faster; they may be less likely to develop in the first place. This could lead to the higher customer satisfaction reflected in the quality ratings.

    If the higher ratings are enough to interest you in trying a provider-offered plan, how would you find one? Unfortunately, there’s no readily accessible source to inform consumers (or researchers) about this feature of plans. Sometimes the plan’s name gives away the relationship. The UPMC Health Plan practically has the health system that offers it right in the name — UPMC stands for University of Pittsburgh Medical Center. In other cases, consumers can identify the relationship on plans’ or health systems’ websites. For example, the Vital Traditions plan website identifies as its parent company the largest nonprofit hospital system in Texas, Baylor Scott & White.

    But in many cases, it’s not so easy to figure out. In fact, this is why there has been so little analysis of provider versus insurer plans. For our study, we had to scroll through hundreds of websites, news articles and documents to build a research data set on provider-offered plans from 2011 to 2015. Because of the work involved, there are very few studies on the subject. Another, published in Health Service Research by me, Roger Feldman of the University of Minnesota and Steven Pizer of Northeastern University, found a similar quality relationship when examining 2009 data.

    That earlier study also found that provider-offered Medicare Advantage plans charge higher premiums. But a recent study of marketplace plans found that provider-offered ones are not necessarily the most expensive. For some, a higher premium may outweigh the benefits of greater quality, but for others it may not.

    From our study, we can’t be certain that provider sponsorship of plans causes higher quality. It could be that higher-quality providers are the ones that choose to offer plans. Nevertheless, such tight integration between plans and providers is at least a signal of higher quality, even if it doesn’t cause it.

    Recent trends suggest more health systems are offering plans in other health care markets for the working-age population, not just in Medicare Advantage. Not all markets may be hospitable to provider-offered plans, however. Some systems that did offer plans are pulling back. According to The Wall Street Journal, Catholic Health Initiatives, which runs over 100 hospitals across 18 states, is divesting itself of some of its health insurance plans. After struggles with profitability, Tenet Healthcare and several other health systems have said they will do the same.

    Provider-offered plans may increase convenience for consumers. But the financial risk it confers on the organizations that offer them may be more than some can handle.


    Comments closed
  • AcademyHealth: Traditional Medicare is cheaper

    Hold on to your hat: Medicare pays lower prices than commercial market insurers. Yeah, OK, you already knew that. But what are the implications for access to care? I answer that question in my latest AcademyHealth post.



    Comments closed
  • If Obamacare exits, some may need to rethink early retirement

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It also appeared on page A10 of the February 28, 2017 print edition.

    Here’s another possible consequence of repealing the Affordable Care Act: It would be harder for many people to retire early.

    Americans reaching 65 become eligible for Medicare. Before reaching that age, some can get retiree coverage from their former employers. But not very many companies, especially small ones, offer medical insurance to retirees. If early retirees are poor enough, they could turn to Medicaid. To retire early, everybody else would need to turn to the individual health insurance market. Without the subsidies and protections the A.C.A. put in place, health care coverage would be more difficult to obtain, cost consumers more where available, and provide fewer benefits than it does today.

    That means that if the A.C.A. is repealed, retiring early would become less feasible for many Americans.

    This consequence is called job lock — the need to maintain a job to get health insurance. One of the arguments in favor of the A.C.A. was that it would reduce or eliminate job lock. With repeal of the law on the agenda of Congress and President Trump, there is renewed concern about how health insurance could affect employment and retirement decisions.

    These relationships have been examined extensively by scholars. Though not all studies have found evidence of job lock in the pre-Obamacare era, a majority of high-quality studies have. That’s the conclusion of systematic reviews conducted by the Government Accountability Office and several health economists.

    Because people approaching retirement age are more prone to illness and high health care costs, employment-based insurance is particularly valuable to older workers — so much so that many studies document that it influences retirement decisions. One study found that workers whose employers offered retiree health benefits were 68 percent more likely to retire early than those who lack employer-based retiree coverage.

    Another study found a smaller effect, 47 percent. But that study also found that workers in poor health who had retiree health benefits were 88 percent more likely to retire early compared with similar workers lacking retiree health benefits. Both those studies used data that are now several decades old. But a 2014 study that incorporated more recent data — though still pre-A.C.A. — also found that retiree health benefits encourage early retirement. The inference from these studies is that coverage options in the A.C.A. marketplaces would similarly encourage early retirement.

    Deferring retirement because of health benefits is just one form of job lock. Another example: Many studies show that spouses are much more likely to work if their partners do not have employer-based family coverage. Other studies show that workers with cancer are more likely to continue working if that’s how they get health insurance.

    Two studies led by Cathy Bradley of Virginia Commonwealth University examined working women with breast cancer diagnoses. Both studies found that those who depended on their employment for coverage were more likely to remain working.

    If not for job lock, we’d probably see greater job mobility and entrepreneurship. According to one analysis, two million more people would change jobs if it weren’t for job lock — presumably finding work that makes them happier or to which they are better suited. One study found that 25-to-55-year-old married men with no other coverage options are 22.5 percent less likely to switch jobs compared with those who have alternatives. Another study, examining 24-to-35-year-old married men, estimated smaller effects, between 10 and 15 percent.

    The evidence of sticking with jobs instead of starting a business is mixed, but the preponderance of it suggests this kind of “entrepreneurship lock” exists, affecting up to four million people. Workers without coverage from a spouse — therefore, more reliant on their own employers’ coverage — are a few percentage points less likely to become self-employed, according to one study. Similarly, self-employment spikes when workers turn 65 and obtain Medicare coverage.

    From the late 1980s to the early 2000s, tax deductibility of policies for self-employed workers was phased in, making those policies more affordable. Two studies provide evidence that this change increased self-employment. One found that it rose 10 percent among women without health coverage from a spouse versus those with such coverage. Another found that the tax change explained as much as half the total increase in self-employment between 1999 and 2004.

    All of these studies suggest that job lock would be alleviated by more available and affordable coverage outside work. Whether Obamacare did that is less clear. Many policy experts expected the A.C.A. to reduce job lock. An analysis by the Urban Institute, conducted before the health insurance reforms were implemented, estimated that the self-employed would increase by about 1.5 million individuals as a result of the law. In 2014, the Congressional Budget Office anticipated that the A.C.A. would reduce the size of the labor force by at least two million people by 2024.

    One post-A.C.A. study found that the prohibition of pre-existing condition exclusions for children increased job mobility for their parents. And in the months after the insurance market reforms rolled out, voluntary part-time work increased and the growth in the number of workers over age 55 slowed, both consistent with alleviation of job lock. But more rigorous studies of part-time work did not find an impact from the A.C.A.

    According to a review of scientific papers by the economists Jean Abraham and Anne Royalty, for the University of Pennsylvania’s Leonard Davis Institute of Health Economics, few other studies have found solid evidence that the A.C.A. reduced job lock or had other effects on the labor market. For instance, studies have not found that allowing children to stay on their parents’ insurance until age 26 has influenced the labor market choices of young adults. Nor have they found that the A.C.A. increased early retirement or employment more generally.

    One reason studies might not have found an impact on job lock could be because the law is relatively new, and there isn’t enough data available to researchers to tease out all its effects. It could also be because the law has been under siege on multiple fronts since passage, rendering its status uncertain. This may have raised doubts in workers’ minds about the wisdom of relying on it as a substitute for employer-offered coverage.

    But it is clear that with A.C.A. repeal on the table, people contemplating early retirement may need to reconsider.


    Comments closed
  • The health care system treats patients like garbage

    I started and stopped writing this post many times because it’s mostly whining. But, dammit, it’s a consumer’s right to whine, so here it is: in my experience (YMMV) — and that of many others I know — the health care system largely treats patients like garbage.

    I was reminded of this fact during my recent experience dealing with my daughter’s broken arm. It started well enough. Our pediatrician has late hours and an X-ray machine, so we were able to skip the Friday night (and more expensive) emergency department visit for our initial diagnosis, and therefore missed all the attendant waiting and frustration.

    Upon viewing the X-rays, the pediatrician conveyed that it was not a bad break and didn’t need to be addressed immediately. A brace, which she provided, was good enough for now. Fair enough. But what was our next step? “The X-rays need to be examined by a radiologist before I can tell you that,” my wife was told. OK …

    I wonder how long we would have waited for that to happen. By the middle of Saturday, we became too uncomfortable to find out, so I called the pediatrician’s office. Now, and with no further consideration of the X-rays, they were wiling to give us some recommendations for orthopedic clinics. Why couldn’t those have been given to us on Friday?

    Naturally, one clinic was closed on the weekend. But, the other, hospital-based one, had Sunday hours. Great! A call to that clinic got me a voice-mail. I left a message. I have never gotten a call back, but I didn’t wait for one. I called again later and got a person who told me they had 7AM walk-in hours. Just go to the main hospital entrance and ask for the walk-in orthopedic clinic, I was told.

    This was bad advice. After dragging my broken-limbed daughter through every door that plausibly seemed like the main entrance, we finally found someone who said we should go through the ED entrance. That was the right answer, but not what we were told on the phone.

    After waiting and registering, we finally saw the orthopedist. He was great. It was, in fact, not a bad break. Now it is safely casted. All is well. But not before we had to do a lot of legwork — and received a lot of wrong answers, promises of follow-ups that didn’t happen, etc. Meanwhile, our pediatrician has not (yet) checked in on her patient.

    I get it. She’s busy with more urgent matters. It makes sense, but it sucks, and all the more knowing that we spend a fortune for such treatment. No other business would treat customers this way. In health care, inconvenience, uncertainty, lost records, lack of follow-up and coordination, the necessity of self-advocacy, and lots and lots of waiting is the norm.

    Of course, there are some examples of good customer service in health care. I’ve even experienced them. But every tasty crumb I’m tossed just reminds me how awful the rest of the meal is.

    In his most recent article, Atul Gawande related an example of good customer service in health care. The patient, Haynes, had experienced a lifetime of frequent, debilitating migraines. None of the more standard treatments worked, so his doctor, Loder, got creative.

    The most exotic thing they tried was Botox—botulinum-toxin injections—which the F.D.A. had approved for chronic migraines in 2010. She thought he might benefit from injections along the muscles of his forehead. Haynes’s insurer refused to cover the cost, however, and, at upwards of twelve hundred dollars a vial, the treatment was beyond what he could afford. So Loder took on the insurer, and after numerous calls and almost a year of delays Haynes won coverage.

    That’s what I’m talking about! This should be standard, but it isn’t. More typically, the patient is left holding the bag. You want the treatment you need, go fight your insurer for it. The health system is not going to help you, because it is not in most stakeholder’s interest to do so. It also should be noted that such inconvenience keeps health spending down — and I completely appreciate the need to be prudent with spending — but it still sucks for patients.

    Perhaps concierge medicine is the answer, or paying more for your own care. We’ll see, because we’re running that experiment right now. I’m not seeing a lot of movement, but maybe it’s too early or I’m unlucky. I could just be a whiner.


    Comments closed