Fortune Magazine reports on the Secretary of Health and Human Service’s ongoing process of developing an essential benefits package as required by the Affordable Care Act. The article explains (as discussed in the FEHBlog) why the outcome of this process is so important. The essential benefits package must be in place for the 2014 calendar year. Qualified health plans operating in the state health insurance exchanges must offer the essential benefits identified by the HHS Secretary.  Employer sponsored plan such as FEHB plans operating outside the exchanges may not impose lifetime or annual dollar limits on HHS designated essential benefits. It’s a big deal.

Reuters reports that Larry Merlo, CEO of CVS/Caremark, the pharmacy chain / pharmacy benefit manager, told analysts today that “Let me address the speculation with regards to the future direction of our company, “There are no plans to split up the company.”

Kaiser Health News reports on the new trend of health insurers, particularly Medicare Advantage plans, opening urgent care clinics for their members. “By giving urgent care, working longer hours, welcoming walk-ins, and offering care such as IV therapy that is not available at most doctors’ offices, the clinic can keep patients from running up big hospital bills.” Interesting.

With Congress back in session, the AHIP Hi-Wire offers a helpful status report on FY 2012 budget and related debt ceiling negotiations up on Capitol Hill.

Employee Benefits News reports on the 16th annual Towers Watson / National Business Group on Health survey of employers about purchasing value in health care. The report identifies the following top 12 tactics used by companies that consistently hold their health care cost increase at or below the median:

1. Differentiate cost sharing for use of high-performance networks or centers of excellence.
2. Reward based on biometric outcomes other than smoker, tobacco-use status.
3. Change plan options.
4. Use value-based benefit designs.
5. Reward or penalize based on smoker, tobacco-use status.
6. Audit of medical claim payments.
7. Provide employees with information on provider and/or hospital quality.
8. Use centers of excellence for treatments other than transplants.
9. Reward only those who complete requirements of a healthy lifestyle activity.
10. Require employees to complete the health risk appraisal and/or biometric screening to be eligible for other financial incentives for healthy activities.
11. Reward enrollment in healthy lifestyle activities.
12.Use hard-dollar return-on-investment calculations to support future decisions.

Business Insurance reports today that “large health insurers expect an increase in deals in the industry after last year’s U.S. health care overhaul made it tougher for smaller companies to compete.” As noted the in the FEHBlog, the Affordable Care Act also is driving up consolidation among health care providers.  It appears that one way or the other we will wind up with a single payer (FEHBlog effort at humor).

The Treasury Department and the Internal Revenue Service yesterday asked for public comment on approaches to implementing the shared responsibility provisions of the Affordable Care Act. These provisions require employers of 50 or more employee to provide health care coverage to their employees or pay a penalty. In the requuest (IRS Notice No. 2011-36), the government describes approaches for determining who is a full time employee. The comment deadline is June 17, 2011.

Finally, on the patient safety front, the AMA News reports about a federal government study finding a rapidly growing number of hospitalizations attributable to adverse medication side effects in a graying population over the period 2004-2008. “Less than a quarter of the drug-related ED visits and less than 10% of inpatient stays were due to mistakes by physicians, pharmacists or patients. The rest were cases in which patients took prescribed medicines as ordered but had side effects severe enough to send them to a hospital.” The article notes that electronic prescribing should help remedy this problem by alerting doctor #2 to the prescriptions issued by doctor #1.

Congress returns from its Spring break tomorrow. I noticed that the House of Representatives has refreshed its website. This coming week is Public Service Recognition Week as highlighted on OPM’s website.

On the good news front, “University of Wisconsin School of Medicine and Public Health researchers call it “wonderful news” that a much less expensive cancer drug seems to work well to treat the leading cause of blindness in people over the age of 50.”  According to a UW press release, “The National Eye Institute study compared Avastin, a cancer drug that is commonly used off-label to treat age-related macular degeneration (AMD) [at $50 per dose], and Lucentis, the Food and Drug Administration-approved drug for treating AMD [at $2,000 per dose]. The Comparison of AMD Treatments Trials (CATT) found that the two drugs had similar effectiveness.” At the OPM AHIP carrier conference, Robert Epstein, a Medco medical director gave a very entertaining and hopeful talk about anticipated, near term breakthroughs in these specialty drugs. Hopefully, this is just the start.

On Friday, the Health and Human Services Department issued a final rule implementing a value based purchasing program for hospital services covered under Medicare Part A. The program will not take effect until October 1, 2012, the beginning of the federal government’s 2013  fiscal year. The HHS press release explains that

In FY 2013, an estimated $850 million will be allocated to hospitals based on their overall performance on a set of quality measures that have been shown to improve clinical processes of care and patient satisfaction.  This funding will be taken from what Medicare otherwise would have spent, and the size of the fund will gradually increase over time, resulting in a shift from payments based on volume to payments based on performance. 
Some of these measures will assess whether hospitals:

• Ensure that patients who may have had a heart attack receive care within 90 minutes;

• Provide care within a 24-hour window to surgery patients to prevent blood clots;

• Communicate discharge instructions to heart failure patients; and

• Ensure hospital facilities are clean and well maintained.

The measures to determine quality in the Hospital Value-Based Purchasing Program focus on how closely hospitals follow best clinical practices and how well hospitals enhance patients’ experiences of care. When hospitals follow these types of proven best practices, patients receive higher quality care and see better outcomes.  And helping patients heal without complication can improve health and ultimately reduce health care costs.  For example, ensuring heart failure patients receive clear instructions when they are discharged on their medications and other follow-up activities reduces the likelihood that they will suffer a preventable complication that would require them to be readmitted to the hospital. 

The better a hospital does on its quality measures, the greater the reward it will receive from Medicare.  The measures selected for the Hospital Value-Based Purchasing program in FY 2013 have been endorsed by national bodies of experts, including the National Quality Forum.  Hospitals have been reporting on quality measures through the Hospital Inpatient Quality Reporting Program since 2004, and that information is posted on the Hospital Compare website. For a complete list of quality measures, visit www.HealthCare.gov/news/factsheets/valuebasedpurchasing04292011b.html.

Modern Healthcare reports that industry reaction to the new rule is mixed.  HHS explains in the press release that this rule helps achieve the patient safety and quality improvement objectives of the public/private Partnership for Patients initiative.  The AMA News reports on the medical profession’s favorable reaction to that initiative.

The Affordable Care Act required health plans, including FEHB plans, to liberalize out of network emergency room care. Medscape reports that “In a survey of US emergency physicians, more than 80% said emergency visits are increasing in their emergency department (ED), with roughly half reporting significant increases, and more than 90% expecting increases in the next year.” While the increase cannot be blamed entirely on the Affordable Care Act, the liberalized coverage must be contributing to this trend. Meanwhile Medpage Today observes that

Although hospital outpatient care makes up only 5% of all outpatient visits in the U.S., it accounts for more than one-fifth of outpatient costs, according to Agency for Healthcare Research and Quality researchers.

Looking at 2008 data from the Medical Expenditure Panel Survey, Steven Machlin and Sadeq Chowdhury, PhD, found that the lion’s share (91%) of outpatient visits occurred in office-based settings, “but these visits accounted for only 64% of all ambulatory physician visit expenditures” due to the higher cost of hospital outpatient care.
The remaining 36% of outpatient care costs were divided between hospital outpatient care (22%) and emergency department care (14%), according to the study.

The average cost of an office-based visit was $199, compared with $922 for emergency department (ED) visits and $1,275 for hospital outpatient visits, the investigators wrote. “Physician visits in [hospital] outpatient settings were considerably more likely to involve surgery than other settings, which contributed to the notably higher outpatient expenses per visit.”

Among visits where no surgical procedure was involved, expenses per visit were generally highest for the emergency department and lowest for office-based visits, they noted.
Interestingly, a higher percentage of hospital outpatient visits — 58.4% — had no out-of-pocket costs for patients, compared with office-based visits (44%). For those visits that did involve out-of-pocket expenses, the average expense was much higher for hospital outpatient visits ($121 versus $29).

FEHBlog emphasis added.

Health Leaders reported on the coming of age of so-called “patient navigators” — case managers based at the provider of care’s facility rather than the insurer’s.

These case managers tend to be registered nurses who sometimes work from a remote location by phone. Or with increasing frequency Cigna, for example, a health plan with 11 million lives, started requiring embedded care coordinators in 2008 when it signed a contract with the Dartmouth-Hitchcock physicians group in New Hampshire. Today it has eight such contracts. And they’re being added “aggressively,” says Cigna spokesman Mark Slitt, with a total of 30 physician practice contracts including that language covering nearly 500,000 lives currently.

Jennifer Farlow, RN, BSN, is one such coordinator. She began in June 2010 with Atlanta area’s Piedmont Physicians Group, which has since added two health coaches and a clinical case manager to help out. Each month she receives a list of patients with the highest medical costs, including their frequency of emergency department use, and a gaps-in-care report listing people with chronic conditions, such as diabetes, who need monitoring. She checks the files for patients who haven’t been in to see their primary care physician in a while. She gets on the phone and calls each one.

What a great idea!

This Tuesday’s Tidbits focus on prescription drugs.

The IMS Institute for Healthcare Informatics released this month a report on the use of medicines in the United States in 2010. The report notes the following trends

Total spending on medicines increased from $300.3Bn in 2009 to $307.4Bn in 2010.
• The decline in the volume of protected branded products reduced spending in 2010 by $8.3Bn compared to 2009.
• Increases in the pricing of protected branded products – without consideration to off-invoice discounts or rebates – raised spending by $16.6Bn.
• Brands losing patent protection or exclusivity in 2010 resulted in a reduction in spending of $12.6Bn.
• Spending growth for new brands was $4.0Bn in 2010.
• Spending on generics – including both volume and price effects – increased by $7.6Bn in 2010 compared to 2009.

Finally, this coming Saturday April 30, the U.S. Drug Enforcement Administration will be holding its second National Prescription Drug Take Back Day. According to the DEA press release, “More than 5,100 sites nationwide have joined the effort that seeks to prevent pill abuse and theft. This is hundreds more sites than were established for the event last fall. The free event will be held from 10 a.m. to 2 p.m. local time. Government, community, public health and law enforcement partners at these sites will be working together to collect expired, unused, and unwanted prescription drugs that are potentially dangerous if left in the family’s medicine cabinet. Collection sites in every local community can be found by going to www.dea.gov and clicking on the “Got Drugs?” banner at the top of the home page, which connects to a database that citizens can search by zip code, city or county.” The FEHBlog plans to take advantage of this opportunity.

Happy Easter and Passover! The FEHBlog is back from travelling to Argentina. Highlights of the trip included mini-trekking on the Perito Moreno glacier in Patagonia, visiting the Recoleta Cemetery (excellent English speaking tour guide), and the food.

The process of creating the list of essential benefits continues. The Labor Department’s Secretary sent the Labor Department’s Secretary a required report on benefits typically offered by employer sponsored health plans. A statement from the HHS Secretary explains that

Beginning this fall, HHS will launch an effort informed by the [Institute of Medicine] IOM’s [to be released] recommendations to collect public comment and hear directly from all Americans who are interested in sharing their thoughts on this important issue. I’m confident that this process will ensure all Americans have a seat at the table and strengthen our health care system.”

Qualified health plans operating in the state based health plan exchanges will be required to offer the HHS mandated essential benefits. Employer sponsored plans, including FEHB plans, will not be permitted to place annual or lifetime dollar limits on HHS mandated essential benefits.

HHS issued a proposed rule governing Medicare Part A payments to inpatient hospitals effective for discharges on or after October 1, 2011, the beginning of the next federal government fiscal year. The proposed rule would create a 1.5% increase in diagnosis related group payments. Also

To provide hospitals with an incentive to improve care coordination, the Affordable Care Act directs CMS to implement a Hospital Readmissions Reduction Program that will reduce payments beginning in FY 2013 to certain hospitals that have excess readmissions for certain selected conditions.  Today’s proposed rule proposes measures for rates of readmissions for three conditions — acute myocardial infarction (or heart attack), heart failure, and pneumonia.  CMS is also proposing a methodology that would be used to calculate excess readmission rates for the program.  Additional conditions may be added in future rulemaking.  The payment adjustments will apply to hospital payments in FY 2013, beginning with discharges on or after Oct. 1, 2012.

HHS is accepting comments on the proposed rule until June 20, 2011, and the agency expects to issue the final rule on August 1, 2011.

On a related patient safety note, AHIP issued a white paper on ensuring quality through appropriate diagnostic imaging. “According to the paper, health plans are using a variety of tools to help improve the quality and affordability of care patients are receiving with respect to imaging tests.  These strategies emphasize “the use of standards to safeguard patient safety and promote imaging quality, physician education, and the use of evidence-based guidelines.” Also the Centers for Medicare and Medicaid Services published a report on its physician quality reporting and e-prescribing programs

CMS’s 2009 Physician Quality Reporting System and ePrescribing Experience Report states that 119,804 physicians and other eligible professionals in 12,647 practices who satisfactorily reported data on quality measures to Medicare received incentive payments under the Physician Quality Reporting System totaling more than $234 million—well above the $36 million paid in 2007, the first year of the program. Under the ePrescribing Incentive Program, CMS paid $148 million to 48,354 physicians and other eligible professionals in 2009, the first payment year for the program. Results show that participation in the Physician Quality Reporting System has grown at about 50 percent every year, on average, since the program began.

Last month, HHS issued a long awaited proposed rule governing the participation of accountable care organizations in the Medicare Program next year. The AMA News featured a report on provider reactions to the proposed rule captioned “Skepticism greets Medicare ACO shared savings program.”

Advocate Physician Partners, an alliance of 3,800 physicians in Illinois, is in the first year of a shared savings program with BlueCross BlueShield of Illinois. Officials are studying the CMS rule, but they are not sure if Advocate will participate as a Medicare ACO next year, said Mark Shields, MD, senior medical director of the Oak Brook, Ill.-based alliance.
“It’s a significant hurdle to succeed with the Medicare ACO program as the regs are now written,” Dr. Shields said. “It’s not the place for an organization that has not already done significant care reorganization.” For instance, the ACO proposal requires that 50% of the physicians are meaningful users of electronic medical records as defined by the Dept. of Health and Human Services.

AIS reports that private insurers may diverge in certain respects from the Medicare rules when forming their own ACOs.

The Labor Department’s ERISA Advisory Council issued a report on improving Health Care Literacy, an Affordable Care Act objective. The report included the following recommendations:

Seek consistency of health care-related terminology among Federal agencies, insured and self-insured plans. The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (“PPACA” or “Affordable Care Act”) requires the Department of Health and Human Services to develop consistent definitions of commonly used terms such as “copayment,” “coinsurance,” and “deductible.” The DOL should use these terms in its communications and encourage use of these standard definitions in all benefit communications.

Permit flexibility in delivery of the summary of benefits and coverage explanation (often referred to as the “four page notice”) required under the Affordable Care Act. Plan sponsors will be required to provide this summary of essential group health plan benefits and coverage. The Council views this as a very good opportunity to promote health care literacy and believes that the DOL provide plan sponsors with flexibility to determine the most effective way to distribute this document to plan participants. 

The FEHBlog ran across the Standard & Poor’s website for its monthly healthcare economics indices for the United States. “The indices are calculated monthly, and published with a 6-8 week lag. The indices are released to the public at 9AM on the third Thursday of each month.” According to the most recent report for the month of February 2011,

Over the year ending February 2011, healthcare costs covered by commercial insurance rose by 7.97%, as measured by the S&P Healthcare Economic Commercial Index. Medicare claim costs rose at an annual rate of 3.22%, as measured by the S&P Healthcare Economic Medicare Index. This is the lowest annual rate of growth posted for the Medicare Index in its six-year history.

Well, the President gave his deficit reduction speech yesterday and there was no mention of converting the FEHBP to a premium support program as Ezra Klein of the Washington Post and the Federal Times at least hinted on Tuesday, The Federal Times now reports

Although President Obama’s deficit reduction plan unveiled April 13 does not include provisions cutting federal pay or benefits, changes to federal retirement plans are “on the table,” an Office of Management and Budget official said Thursday. “It’s not in the plan now, but it’s something we’re looking at,” the official said. Obama is not currently considering cuts to federal pay, the official said.

Congress approved the FY 2011 appropriations bill (H.R. 1473) today. The Wall Street Journal reports that “The House voted 260-167 for the measure. The Senate followed soon after, voting 81-19 for the deal.” Hopefully, this means there will be no government shutdown for at least five months, and after Congress returns from its Easter break, they can turn their attention to the FY 2012 appropriations and the debt ceiling issues, among others.

The FEHBlog, by the way, also will be taking an Easter break. My family and I will be visiting our younger daughter who is spending her semester abroad in Buenos Aires, Argentina. Her humorous blog about her adventures in South America can be accessed here.

In OPM’s call letter for 2012 benefit and rate proposals, OPM encouraged plans to reduce prescription drug expenses, which is not a simple task in a Program with 50% annuitants. Fortunately, there are a plethora of blockbuster prescription drugs that are going generic later this year and in 2012.

When a prescription drug goes generic, typically one generic manufacturer will gain rights to exclusive distribution for six months. In the case of Lipitor, which goes generic at the end of November, the lucky generic manufacturer is Ranbaxy Laboratories of India.  Lipitor, a statin used to reduce cholesterol. has recent U.S. sales of  $5.3 billion At the end of the six month exclusivity period,  school’s out. A Dow Jones story about Lipitor’s conversion to generic status notes that

Increased client sophistication on drug pricing isn’t the only factor that may limit generic Lipitor profits [by prescription benefit managers]. Experts note there’s uncertainty over how many generic competitors will enter the market, which also could affect profits. The more competitors, the lower the drug price and greater opportunity for fat margins.

In addition, Wal-Mart Stores Inc. launched a retail generics price war a few years ago when it introduced $4 prescriptions for hundreds of unbranded drugs. If enough generics manufacturers sell unbranded Lipitor, it could wind up on the $4 list, and that could pressure PBMs further, said economist Larry Abrams, who follows the pharmacy benefit management industry.

AIS Drug Benefit News featured a story on the blockbuster drugs like Plavix, Singulair, and Lexapro that will go generic next year.  According to the report,“Everyone characterizes this as a landmark event in our industry, and I think it’s real,” Robert Galle, COO of pharmacy benefit management for Aetna Inc. tells [us] “The number of drugs coming off patent will create an unprecedented amount of activity. It affects almost 20% of our total drug spend.”  The article also discusses new plan sponsor approaches to incenting plan member utilization of generic drugs.

In the call letter, OPM also encourages FEHB plans to offer their members wellness programs. Business Insurance helpfully reports that “The U.S. District Court for the Southern District of Florida dismissed a lawsuit alleging that financial incentives to participate in a voluntary wellness program as part of a health plan provided to employees by Broward County, Fla., violated the Americans with Disabilities Act.” There are other potentially tricky legal requirements around wellness programs and related health risk assessments under the non-discrimination rules of HIPAA and the Genetic Information Non-Discrimination Act (because family medical history is considered to be protected genetic information by the statute.)

Ezra Klein of the Washington Post is predicting that tomorrow the President will support the health care changes proposed by his deficit reduction commission last December which include accelerating implementation of the so-called Cadillac tax on high cost health plans from 2018 to 2014 and converting the FEHBP to a premium support plan. And the FEHBlog thought that putting off the Cadillac tax would facilitate its ultimate repeal.

The FEHBP already takes defined contribution approach to the Government contribution; the Government pays 72% of the enrollment weighted average premium capped at 75% of the selected plan’s premium (5 U.S.C. § 8906). In other words, the minimum employee contribution toward FEHBP coverage is 25% and the Government’s share of the premiums rises with the tide. In contrast, under a premium support approach, the Government would contribute a flat amount and that amount would be adjusted by general inflation. In other words, the Government contribution likely would cover a low cost plan’s premium in full. This could encourage lower income employees to join the FEHB Program, but it likely would be very disruptive, in the FEHBlog’s view. Of course, we don’t know what the President will propose and it’s a long way from a Presidential proposal to law, particularly in this Congress.

The FEHBlog is gratified that, according to Business Insurance. other experts took the same dim view of the free choice voucher provision of the Affordable Care Act that will be repealed under the FY 2011 budget deal.

According to an HHS press release, “Health and Human Services Secretary Kathleen Sebelius, joined by leaders of major hospitals, employers, health plans, physicians, nurses, and patient advocates, today announced the Partnership for Patients, a new national partnership that will help save 60,000 lives by stopping millions of preventable injuries and complications in patient care over the next three years.  The Partnership for Patients also has the potential to save up to $35 billion in health care costs, including up to $10 billion for Medicare.  Over the next ten years, the Partnership for Patients could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.  Already, more than 500 hospitals, as well as physicians and nurses groups, consumer groups, and employers have pledged their commitment to the new initiative.”  Here’s a link to a fact sheet on the new initiative. The pledge for health plans and other health care payors reads as follows:

As those who purchase health care on behalf of American consumers and provide information to help support them in their efforts to get better care we pledge to:

• Use market-based incentives, that may include payments, to promote improvements in safety and other dimensions of quality and value;

• Work with other private payers, states and the federal government to align our efforts to measure performance on quality and safety – so that patients and clinicians have the best possible information and the burden on hospitals and other providers is minimized; and

• Share information with our employees, members or beneficiaries so they can engage as active partners in getting better, safer care.

Health plans can take the pledge here.

Wow. Not only did Congress reach a compromise to avoid a government shutdown (at least for a few months), but the budget deal also will repeal one of the most potentially disruptive provisions in the Affordable Care Act, the so-called free choice voucher provision, according to a Wall Street Journal report.

Here’s how the free choice voucher would have worked. Under § 10108 of the Affordable Care Act, employees whose income is at or below 400% of the federal poverty line (approximately $45,000 for an individual and $90,000 for a family of four this year) would have received beginning in 2014 a “free choice voucher” if the employee contribution toward his or her employer sponsored coverage represented from 8% to 9.8% of his or her household income. The free choice voucher would have given the employee the value of the employer contribution that employee could have used to purchase stated based health insurance exchange coverage. If the exchange plan’s premium is less than the value of the free choice voucher, the employee would have received the balance of the free choice voucher in cash. The portion of the voucher used to purchase Exchange coverage would have been tax free.

What’s so bad about that? The free choice voucher had the potential to shred the risk pools in employer based plans, including the FEHBP.  For example, the younger employees, who weren’t covered under their parents’ coverage, could have opted into a young invincible plan in the exchange. FEHBP enrollees in living in lower cost states may have found lower cost plans in their state exchanges. (Fee for service plans in the FEHBP must offer nationwide premium rates.) In both cases, the enrollee would pocket any resulting savings which potentially could have cost employers, including the federal government, a lot of money. There will be enough changes in 2014 without this additional disruption.  

Following up on the release of an HHS strategy to reduce health disparities, AHIP’s coverage blog discusses the steps that health plans are taking to reduce health disparities — an objective that OPM shares according to its 2012 call letter.

Finally, although the FEHBlog was aware of CMS’s Hospital Compare and Nursing Home Compare websites, I just ran across this healthcare.gov website that consolidates links to all four CMS provider comparison website. There’s also a home health compare and a dialysis provider compare website. What is really cool about these very helpful websites is that the quality information reflects the entire patient base at the facility, not just the Medicare patient base.

OPM has posted updated information on the impact of a partial government shutdown which may occur tomorrow unless an FY 2011 budget deal is reached. OPM also has posted its own agency furlough contingency plan. The FEHB Program is expected to run on a normal basis in the event of a partial government shutdown.

One of the topics in OPM’s recent 2012 call letter was patient safety. The National Journal reports on three recent patient safety studies.

“There are some examples of excellence–we have many [intensive-care units] that have eradicated central line infections. But surrounding those examples of excellence we have serious adverse events going on,” said Dr. Mark Chassin, president of the Joint Commission, a nonprofit organization that accredits health care programs. 

“Every week in the United States, up to 40 patients undergo a procedure meant for somebody else or the wrong body part. We have fires that occur during operations and routine processes where patients acquire infections and have medication mix-ups.”

Although insurers can help by refusing to cover charges for hospital acquired conditions, it’s really up to the medical community to solve this problem.

Another topic is reducing health disparities. Today, the Department of Health and Human Services announced the

launch [of] two strategic plans aimed at reducing health disparities. 

The HHS Action Plan to Reduce Health Disparities outlines goals and actions HHS will take to reduce health disparities among racial and ethnic minorities. 

HHS also released the National Stakeholder Strategy for Achieving Health Equity, a common set of goals and objectives for public and private sector initiatives and partnerships to help racial and ethnic minorities and other underserved groups reach their full health potential. The strategy, a product of the National Partnership for Action (NPA), incorporates ideas, suggestions and comments from thousands of individuals and organizations across the country. The NPA was coordinated by the HHS Office of Minority Health.

The strategies are available here.