Insurers Test New Cancer Pay Systems

[Purveyor]

Source: NYTIMES

Several large health insurers, including UnitedHealthcare and Aetna, are focusing on one of the country’s most costly diseases: cancer.

The insurers have begun tightening oversight of the care provided to patients with many different types of cancer, hoping to lower expenses by experimenting with new ways to pay specialists.

UnitedHealthcare plans to announce on Wednesday a one-year project with five oncology practices, offering doctors an additional fee. The new fee is meant to encourage doctors to follow standard treatments rather than opting too often for individualized and unproven courses of therapy, which can include the most expensive drug combinations. By proposing a different type of payment structure, companies hope to lower doctors’ dependence on a system that generates substantial sums for cancer specialists who routinely favor top-of-the line treatments.

Regional insurers in some states, including California, Washington and Pennsylvania, are negotiating similar limits with doctors and their clinics. WellPoint, another large insurer, is developing a way of paying oncologists to coordinate and manage patient care.

By almost any measure, cancer treatments can be exorbitantly expensive. Cancer care in the United States costs almost $100 billion a year, and medical bills for the average patient on chemotherapy can top $100,000 a year.

Read more: http://www.nytimes.com/2010/10/20/health/policy/20cancer.html?hpw

[HopeHoops]

1. Funny how the Republicans fear-monger about "death panels" when THEY CREATED THEM!

I'm sure it is a shock, but health insurers just LOVE writing checks to Republican candidates (and who knows how much in under-the table payoffs for those that are in office).

[happygoluckytoyou]

19. ANGLE IN NV suggests paying for cancer treatment with CHICKENS

[HopeHoops]

21. Why didn't she cut to the chase and just propose CURING cancer with chickens?

Wait, are those Hispanic or Asian chickens?

[madmax]

50. You and happygolucky

have me :rofl: and you owe me a new pair of undies! Oh man :)

[HopeHoops]

51. "Would SOMEBODY get this chicken OUT OF MY ASS!"

Officer Stewey from "Me, Myself, and Irene".

On Edit: (He apparently had colon cancer)

[madmax]

52. Damn, I never did get to watch that movie.

Now with all this chicken shit going on, I have will. lol

[HopeHoops]

55. Whoa - hope I didn't introduce a spoiler. Fucking good movie. Carrey pulls it off perfectly.

It is one of those - "oh SHIT - pause it, I have to pee now" movies.

[madmax]

56. Not at all - I was catching it in bits and pieces.

I love Jim Carey. He's one of my fav's. Liar Liar, The Mask - oh hell all of them. He's the funniest and one of the most talented comedic actors. I heard he's really nuts in r/l. Aren't we all? ;)

[HopeHoops]

57. "Man on the Moon" is one of his best works.

[madmax]

58. Thank you!

I've never heard of that one. In 1999 I became a grandma for the first time and started college at 41. It was amongst the 'lost years'. This is great. Netflix here I come. :hug:

[HopeHoops]

59. He plays Andy Kaufman - documentary (or at least close) of his life.

Curiously, the guy who played the boss in the taxi shop in the TV show "Taxi" appears in the movie as his agent! I can't remember his name at the moment and have to deal with a female hormone/school incident crisis with my youngest daughter right now so I can't look it up quickly. I'll think of it.

[madmax]

63. Judd Hirsch - loved taxi

take care of the crisis and pm me anytime before we get the boot here. ;)

[HopeHoops]

64. Thanks - I knew who he was but couldn't think of the name - that be him.

[flamingdem]

53. heh nt

[global1]

2. So It Isn't The Government That Comes Between The Patient And The .....

doctor. Now we know it is the insurance company. Death panels anyone?

[sinkingfeeling]

3. My bill last year was $123,000. I had only one other previous insurance claim , in 1980, over the

42 years I've been insured.

[madmax]

4. I'm sure I'll have a good

story to post here in DU in February. Or you'll be reading it the paper.


As Joan Crawford said in 'Mommie Dearest', 'Don't fuck with me fella's.' :mad:

[flamingdem]

5. I suspect this will lead to more early deaths from cancer

... especially by cutting out experimental treatments - often that term just means not fully approved.

[Hepburn]

6. FUCK EVERYONE INVOLVED WHO IS NOT WORKING TO GET...

...HEALTH CARE AS NEEDED TO ALL WHO NEEDS IT. Experimental...whatever. If the medical provider thinks it will cure, curb pain, prolong some quality of life, then the fucking expense be damned!

:mad:

Edit for typo

[sinkingfeeling]

8. I'm about to ask you a serious question and will probably be flamed.

Why?

Why do you believe that medical care should have no limits and 'the fucking expense be damned'?

I'm asking based on two things. First, my 91 year-old mother just made a very rational decision to decline medical treatment for both her breast cancer and kidney disease (she has stage 4). And secondly, I developed tonsil cancer in 2008 and spent most of last year treating it with surgery and radiation and then treating the post-treatment physical effects, to the tune of $123,000 paid by my insurance.

I also have written instructions that should my cancer return, I will stop any attempts to repeat last year's experience. I will enter hospice for pain control.

I read an article not long ago about the new drug to treat advanced (fatal) prostate cancer for $93,000. (http://www.usatoday.com/yourlife/health/medical/cancer/2010-09-26-prostate-provenge_N.htm)
It will prolong life for about 4 months. Medicare is currently paying for this drug for men in their 70's, 80's and 90's. And some admitted they would never have the treatment if they or their families had to pay for it from their own pocket.

Do you not think there is a point where the expense of some treatments cannot be justified?

I believe that there is a limit. I had a friend for 40 years that came down with B-cell lymphoma in 2002 and went through radiation and chemo only to be re-diagnosed in 2005 with Angio-immunoblastic T-Cell Lymphoma. He refused to be put through the various recommended efforts to increase his life span by months. He died 3 months later at the age of 64.

Many of us do not want to go through high priced treatment to gain a few months or even years. Many recognize that by the time you're 80 or 90 that it's pointless.

[trayfoot]

10. One is not dead until you are dead.

I see and understand your point....BUT - each single individual should have the ability to decude for themselves whether to continue with treatment or not - the insurance companies should not EVER make that decision! A couple of months to you or me could be a lifetime of joy to someone who wants that time with their loved ones. And the more important point - corporate and/or political America should not be in the business of "pulling the plug" on ANYONE. Whatever happened to the "risks" of doing business? Seems that nowadays, corporate America assumes NO RISKS and just continues to make more profits. IMHO, if this is what capitalism has come to, then I am willing to try something else.

[sinkingfeeling]

12. I would say you didn't read the article. Insurance companies aren't making a decision to 'pull the

plug'. I would say that those who want to go on with more treatments and endure the extreme suffering that comes with them are free to do so. Just pay for extra treatment that doesn't benefit the patient out of your own pocket.

[trayfoot]

16. Sure they are "pulling the plug".......

You want people to "pay out of their own pocket"???????? Why buy insurance at all? If the vast majority of people COULD AFFORD to pay out of pocket, there would not be such a problem. Unless you are a Koch family member or someone similarly situated, then you buy insurance because you cannot otherwise afford expensive treatments. I make no apoliogies for saying that whether a person's life is extended or not should not rest with the government or the insurance company who does not want to pay to keep that person alive. If you think about it, we are all dying from the moment we are born - so that does not make a 20 or 30 something more important than an 80 or 90 something.

[sinkingfeeling]

18. Then you will continue to see medical care become available to only those who can afford it.

Somebody has to pay for those treatments that keep people alive for a couple of months. Who should it be? The government? How? No, it would be the insurance company and then everybody will see a 20% increase in their premiums or the deductible will go up to $10,000 a year.

The discussion is about treatments that do not benefit the patient. If you insist on having them, why should somebody else have to pay for them.

[trayfoot]

23. And my answer to this is.......................

that corporate insurers will continue to drive up costs whether people have "those treatments" or not. To think otherwise is downright naive! This is why we need healthcare which is NON-PROFIT in nature. Human life should not be treated as a commodity - you are saying that insurance companies should have the right to decide whether to treat someone if a certain outcome is not assured. I am saying that that decision (and all decisions about patient treatment) should be left to the patient, their doctor, and significant loved ones - not to the corporate boards of United Health Care or Aetna or whatever. According to your logic: if you happen to be in my "insurance pool" and you have a catastrophic disease which can only be mitigated and not cured, then I should complain about my money going for your care. NO! I pay for insurance, you pay for insurance, as do all others in that group. It is incumbent upon the insurance company to deliver the services we have paid for - not make excuses to try to slither out of their responsibilities just to fatten ther bottom line. My guess is that very few 80, 90, or 100 year-olds actually opt for extraordinary measures - but if they have paid their premiums, that is their right!

[sinkingfeeling]

40. If you insist on a $7000 a month drug and refuse to use the

$2500 a month one that does the same, why should the government (via Medicaid or Medicare or VA) or an insurance company pay the extra amount? How is that different than what you and I accept today from insurance companies in 'brand name' verus 'generic' drugs? If you insist on the brand name, you are required to make different co-pay than if you take the generic.
This whole article is about reducing the cost of health care. Non-profit health care would be lovely, but it isn't going to happen. Do you not believe what President Obama said last year that “huge” health care costs are the “biggest driver of long-term deficits,” ?

[Raschel]

26. These companies are stinking rich. It's like saying the union workers bankrupted the auto companies

[Raschel]

29. What do you think about this part of the article?

"Specialists do worry that the complexity of caring for cancer patients may make any hard-and-fast rules about treatments difficult."

[sinkingfeeling]

41. I think it's correct. I think the whole discussion about the extreme costs of cancer treatment

by oncologists, insurance providers, and state governments is a move in the right direction. Everybody wants the cost of insurance and deductibles and co-pays to go down, but few have any suggestions on how to do it.

As a cancer patient, I'm all for a set of guidelines to be used by oncologists.

[Raschel]

25. Well said. Thank you.

[JDPriestly]

47. I disagree. We have not yet discovered the keys to caring for people with

the various forms of cancer. It is possible that cancer is a slightly different disease in each patient. That is because the genetic makeup which affects how cells including cancer cells and healthy cells both affects the progress or cure or handling of the disease.

Cancer is simply not a one-size-fits-all disease. The more people allow themselves to go through the available treatments including experimental treatments, the more we learn and the sooner we will know WHETHER it will be possible to standardize cancer treatments and which treatments really work or do not work.

We are still in the experimental stages in cancer treatment. The insurance companies should pay their CEOs less and spend more on patient care.

[riderinthestorm]

14. Insurance companies routinely classify 20 year old treatments as "experimental"

so they can decide whether to fund them or not.

I see your point but for me, the over arching concern is that the patient gets to decide what they are going to do with their doctor (and friends and family or whoever), and NOT the insurance companies. Every patient deserves access to "top of the line" medical care in my view, if they want it. But they should get to decide that with their doctor, not an insurance exec whose looking to enrich their bottom line.

[sinkingfeeling]

20. Even if 'top of the line' does not provide a cure or prolong life by a day more than a less

expensive treatment, it should be done? And if you read the article, you would know that the decisions are still between the doctor and the patient. It implies that a lot of those 'top of the line' treatments put more money into the pocket of the doctor than anything else.

"Many specialists favor the most aggressive care even if there is little to no evidence the patient will benefit, because both doctors and patients have every incentive to spare no expense. Patients and their families often demand one last treatment. And oncologists can reap tremendous profits, sometimes earning more than half of their income on the difference between what they pay for chemotherapy drugs and what they charge the insurers for the patient’s treatment plan."


P.S. There is no mention about 'experimental' treatments.

[Raschel]

27. "Many, "can", "sometimes". Are these supposed to be facts? Looks like an ins. puff piece to me.

[Lance_Boyle]

37. cite?

"Insurance companies routinely classify 20 year old treatments as 'experimental' so they can decide whether to fund them or not."

That is an extraordinary claim in need of some backing evidence.

[defendandprotect]

30. Obviously, there's a lot to be discussed on this issue --

In the comments you're responding to, I would take them TWO different ways --

that if we had MEDICARE FOR ALL, that in the beginning we would try to sort out

what really works and what has potential of working by allowing all treatments --

HOWEVER, while strongly working on prevention -- anti-tobacoo, etal and environmental

concerns/pollution of earth -- and that gradually as we began to study and see what

was going on that we could weed out treatments that don't work.

As far as I can see, the harsher, more invasive treatments are less likely to work.

Natural means of shrinking tumors -- natural means of strengthening our immune systems

do work.

We have thousands of cancer cells floating around in our bodies every day --

the problem is our immune systems are under attack.


Sadly, like the War on Drugs, there is so much money now to be made from this War on Cancer,

that many would see themselves as being harmed by any real cure.

And, "cures" are nonsense at any rate -- we need prevention!

[Raschel]

34. "As far as I can see, the harsher, more invasive treatments are less likely to work." Not true.

They can and do shrink tumors. Some people live many years with no evidence of disease. (NED)

[defendandprotect]

35. Evidently, there is no proof of that ....

If you have a fast growing cancer, no matter what you do you will die quickly.

If you have a slow growing cancer, you can be treated in many different ways --

and one or all methods may look as if they are working.

And, most of the treatments are harsh, damaging and invasive -- there's no denying that!

[Raschel]

42. If you have a fast growing cancer, no matter what you do you will die quickly.

That's simply not true. That's just an irresponsible statement.

It depends on what stage, how you respond to treatment, your health and age, what treatment you do....

[madmax]

54. Some Dr.'s will scare the hell out of you

with time lines. One of my Dr.'s not a cancer dr. said, I've never seen a patient born with an experation date on their foot. You aren't a container of milk!! She was livid about that sort of thing.

[defendandprotect]

69. No expiration dates on trees, either -- but we understand the damage we are doing to them....

same with our own bodies --

If you're attacking and damaging Nature, then you're attacking and damaging yourself.

50% of GP's would like to be doing something else --

The rubrics of medicine as it is being taught are very restrictive --

and most GPs that and want out.

[defendandprotect]

68. Unfortunately, it is true .... PLUS, overall problems with our immune systems ....

Do you see a healthy planet?

Why would you think that we'd be healthy?

Attacking nature -- which is what capitalism does -- is the same as attacking ourselves.

[Hepburn]

66. If a patient wants the treatment and a medical doctor/provider rec's it...

...then the profit for the insurance company be damned. I sorry that I cannot be more clear than this. To me, patient treatment tops profit.

[defendandprotect]

70. Yes ... but in the long run the treatment has to be proven successful. ....

that's not happening now --

We have a slash and burn approach to cancer -- and no proof that any of it works.

[Xipe Totec]

7. Some would call these fees bribes nt

[Raschel]

17. Isn't it illegal to bribe a doctor, or for a doctor to accept a bribe in regards to patient care?

I know that drug companies bribe doctors to use their products, but a bribe to withold care?

[Xipe Totec]

46. That's exactly what it is, isn't it?

You would think the AMA would revoke licenses for accepting these kinds of bribes.

And there should be a federal law against it.

[Raschel]

9. What treatment works for me will not work for a person with a different cancer type.

Aren't there over a hundred different types of cancer?

The reason that people are living longer is due to individualized treatment.

This 'project' giving doctors money for witholding "individualized" (targeted) treatments, which DO work, is inhumane and shouldn't happen ANYWHERE much less in America.

I suppose the insurance companies don't want to pay to have a person's life extended one or five years. Of course, some people go on to live many years after treatment.

Witholding treatment. From people who have a deadly disease.
Insurance death panels.

MAKE SURE TO VOTE!!!!!!

[sinkingfeeling]

11. I guess you did not read the article. No one is being paid to withhold

treatment. The article is about "Many specialists favor the most aggressive care even if there is little to no evidence the patient will benefit, because both doctors and patients have every incentive to spare no expense. Patients and their families often demand one last treatment."

[madmax]

15. I got that too

and if you read my post I was not denied anything until all these tests were coming up negative and he ins. co. said, wtf - you can't find anything and you want to continue to do the most expensive tests. They said, we'll pay for CT scans and other types of tests but, forget PET scans. I can't get an MRI becuause I have a cochlear implant and it has metal.

My post was more of a vent ;)

[Raschel]

24. I was responding to this:

The new fee is meant to encourage doctors to follow standard treatments rather than opting too often for individualized and unproven courses of therapy, which can include the most expensive drug combinations.

So this speaks to using individualized AND unproven. Many times it's a crap shoot to find the right drug that works for a patient. Do you want insurance cos. to determine that line? IMO, this IS witholding treatment.

Bottom line, this is all about insurance companies deciding which treatment you will receive, not your doctor.

And we all know how ethical ins. companies are.

[trayfoot]

61. Why do you continue to tell

those of us who disagree with you that we haven't read the article???????

I read the article and responded to it and to your opinions.

[madmax]

13. They don't even want to pay for tests for me

that may pinpoint the cancer. The won't pay for PET scans only CT scans.

However, mine is a long convoluted story. They're still LOOKING for the cancer after 2years!! They found one tumor near my pelvis because I hit myself with a 50lb. bucket in the pubic bone. I know 'ouch'!!! - the bone was fractured. They biopsied that tumor. The biopsy was all screwed up and when I asked for a do over they said, too late you've already had one radiation treatment. Then they went ahead and did all types of tests colonoscopy, endoscopy, and everything they could think of and still no cancer. So they tell me I have (Adenocarcinoma (sp) of unknown origin.) Did 3 rounds of chemo and 14 rad treatments, blood levels went down the crapper, lost my hair, my health and just now am starting to tell them to go F*CK themselves and I'm cutting out a lot of drugs - Lexapro and other bullshit. I've had every feakin test except for an MRI. Some tests 3 times and they are ALL CLEAN - no cancer can be found.

I always consult with Dr. Google because I can find out more info and it makes sense. You should hear the shit these assholes tell me. Like I'm an idiot. My son - who is a cancer survivor, his father's side is rampant - mine not a one. He just moved here 3 weeks ago. He's coming with me to the oncologist, we'll get to the bottom of this.

Lest you think I went to some shithole hospital or dr. - this is DUKE in NC!! Want the kicker? 1 1/2 years ago - they gave me 3 years to live. Talk about a Chernobyl meltdown. WTF kind of cancer is this Ebola? One day I just wake up dead??

OP: I'm so sorry for hijacking your thread. Just felt the need to vent a little. :hug:

[sinkingfeeling]

22. Why do they still think you have cancer if all tests come back negative and clean?

[madmax]

32. I think they're afraid to admit a mistake

lawsuit. SHIT I'd pay them if they said, we fucked up but, erred on the side of caution.

I've got another scan coming up in February. I've got all my tests on Di com disc's. I'm bringing in the troops and I want them to SHOW ME what led them to lead me to the gates of hell.

I feel like I'm in the Twilight Zone of medicine.

I fired all the suckers from Duke and have 2 new dr.'s who haven't come out and said anything but, they near the edge and then scratch their balls. Sorry about the language but, if you were told you're going to be dead in three years, yet you feel healthy as a horse and they can't SHOW me anything - you get it.

However, I'll tell you this. This experience has completely changed my life for the best. I can't tell you what it's been like for me - suffice to say that I feel like Scrooge after he woke up. FREEEEEDOM I live my life to the hilt and find joy in everything. It's too hard to explain. I love it.

My son and family just moved here and I'm been having a blast helping them move in and decorate. Our relationship most of my life with both my son and daughter sucked but, over the last 2 years I met my son and his wife. Awesome, I tell you awesome.

on edit: They never got a piece of the tumor. They couldn't get it or something - I was awake. They didn't know if they had enough liquid from around the tumor to do the biopsy so they took the needle to the lab and the pathologist said, ok. They made 5 stained slides. When I asked for a second opinion the second dr. want 14 slides (the originals and only some of them stained) I think the whole thing was a muck up from the biopsy and they just ran with it.

[sinkingfeeling]

43. Congratulations! If I were you, I'd just continue to enjoy live and forget about more tests! If you

were to notice any changes; feeling tired out, the slightest weight lost, or pain, then go back and start again. Needle biopsies are a terrible way to get a diagnosis! I saw an ENT right after Thanksgiving in 2008 for what I thought was a swollen lymph node in my neck. He did a needle biopsy and it came back benign. He then said I should have the node, which he said did have a the benign tumor, removed to prevent cancer. I had the surgery in Jan. and woke up to find I had Stage IV cancer on both tonsils.

[madmax]

49. I swear you can't trust this suckers

I went in on blind faith and didn't question anything. Hell, it was Duke. By the time they did 3 chemo treatments which landed me in the hospital (didn't need chemo they said, was only boost the effects of the radiation - I was their damn lab rat) and radiation I was a mess. Plus, no one checked the blood tests I was getting each week for 4 weeks until an outside LAB called and said, is anyone looking at these blood levels!!?? I had to be admitted within 30 minutes.

My son came down and went nuts and told me these people are going to kill you! So I got new doctors and here I am. And there is such a thing as chemo brain. My memory is shot.

Thanks sinkingfeeling for letting me vent. I'm sorry to hear you had such a bad experience and hope you're doing well now. :hug: My son had Stage 3 something Hodgkin's and he's an 8 year survivor. I feel safe now that he and my daughter in law are here. I already told the dr. this scan in February is the last one - go to hell. I'll come back once a year like I go for a mammogram and leave me hell alone.

Don't believe half of what these idiots tell you - go on your gut feeling and get more than a second opinion and a third.

Live like there's no tomorrow. I was always a worrier and very disciplined about being responsible. I still am but, not to the nth degree. It's very liberating and fun ;) Sending you much love and good vibes.

[sinkingfeeling]

62. I'm with you on that! I can't wait to get back to NOT seeing doctors. I hadn't see one in 8 years

prior to that needle biopsy!

[defendandprotect]

28. The fake "War on Cancer" has only made specialists rich and given us more cancer ... !!!

Anyone notice that?

We have so thoroughly polluted our earth that Global Warming may not only destroy

humanity but may take the planet with it --

And we think that we have remained health despite this destruction of nature???

We have made ourselves ill with this industrial revolution and weapons making --

With corporations polluting the earth for dollar bill!!

The figures now are 3 out of every 4 Americans with cancer?

when are we going to work up some anger and curiosity about this?


Doctors have found ways to shrink cancerous tumors -- but they are NOT doctors practicing

in mainstream. They are treated as a danger to our official medical system!

[AngryAmish]

31. Evidence based medicine

Most of medical treatment is based on custom and practice, as opposed to things that actually work. I support the insurance companies on this one. (Actually, I think a lot of cancer treatment could just as easily be done by expert systems - but doctors don't like to be replaced by robots.)

[Raschel]

33. Custom and practice as opposed to things that actually work? Lies like that encourage this ins. b.s.

I am currently being treated with something that was not used just two years ago. And it works.

Why do people insist on spouting b.s. about cancer treatment. "It's all a scam, blah blah, waste of money, doesn't work.

I hope you never have cancer, if you haven't. If you do, I doubt you'll ask for a machine instead of a doctor.

[AngryAmish]

38. Are you amenable to proof that expert systems devise treatment plans better than doctors?

Is your belief in the superiority of doctors for treatment plans falsifiable?

Doctors, including oncologists, are invaluable. Many of them, anyway. But there is not a lot of rigor or science in medicine. A lot of what passes for science is terrible. Even the peer-reviewed stuff.

We need real science. Things like that are the only way to get there. Mistakes will be made along the way. But, in the end, a lot of useless treatment will be discarded. The good treatments will remain.

I don't understand why people fear evidence based medicine so much.

[Raschel]

44. We agree on this:

We need real science. Things like that are the only way to get there. Mistakes will be made along the way. But, in the end, a lot of useless treatment will be discarded. The good treatments will remain.

What I don't agree on is ins. cos. determining which ones are not used.

AND yes, I'd rather have a human treat me. If you want a machine, go for it.

[supernova]

48. Ins cos aren't qualified to decide EBM

That's the problem with it.

If they really wanted to run on a "we use evidence-based medicine approach" in deciding what treatments to pay for, the ins cos would agree to an impartial third party council, perhaps region based, made up of researchers, practicing MDs, and patient advocates sifting through the peer reviewed research and applying the results as they are learned.

Nah, never happen.

[defendandprotect]

36. better to ask: WHY all of these cancers ... 3 of every 4 Americans now ... !! Wow!!

[madmax]

39. I did ask why

to a Nurse Practioner at Memorial Sloan Kettering in NYC. She replied in a fip - blow me off tone, 'oh, everything causes cancer.'

I'd venture to say 'we' are causing most of the cancer - I know that was your point ;)

[defendandprotect]

67. Amazing that we hear so little about that question ... or the responses to it --

Thanks for letting us know --

:)

[JCMach1]

45. Yeah, private enterprise is soooo much better at medicine

sigh

[Vinca]

60. Somewhere big pharma is planning an attack on big insurance.

And we, the consumers (fka patients), are lost in the equation. Got to preserve those profits.

[madmax]

65. My RA dr.

is from Austria. She told me, health care for profit is the most egregious concept in this world. That's her opinion, she's an excellent caring dr. A rarity, I think.