By Laura Blinkhorn, CQ Staff

November 9, 2006 -- The current system of resolving medical malpractice through tort claims is burdensome for patients, terrifying for doctors, and expensive for the health care system, experts agreed this week. What to do about it, however, proved a much more difficult question.

At an event co-hosted by Common Good and the Harvard School of Public Health and sponsored by the Robert Wood Johnson Foundation on Wednesday, panels of academics, policymakers, and lawyers discussed the proposal of establishing specialized "health courts" that would arbitrate malpractice claims.

In the proposal, all medical injury disputes would be referred to health courts presided over by judges with expertise in medical issues. The courts would rely on neutral experts in deciding malpractice claims, rather than the current system where each side brings in experts. The current standard of "negligence" would be replaced by a broader standard of "avoidability." The courts also would use evidence-based guidelines to help decide cases and award damages based on compensation schedules.

Deterrence of medical errors—as well as compensation for the harmed patient—should be the aim of malpractice procedures, argued Michelle Mello, assistant professor of health policy and law at the Harvard School of Public Health, who pitched the proposal.

"But the tort system has generally failed in its deterrence function," she said. Health courts would establish a "culture of safety and a science of safety," she suggested.

David Studdert, associate professor of law and public health at the Harvard School of Public Health, examined similar programs in Sweden, Denmark, and New Zealand. He found that those systems allowed for more transparency in the health system. The collection of claims data in a centralized database allowed for analysis and correction of systemic problems. Data on malpractice in the U.S. is skewed, he argued, because usually only the most catastrophic errors are brought to court.

He called the current system "a weird way of looking at causality," because it focuses on a single actor rather than faulty systems and data.

Legal experts discussed the constitutionality of the proposal and concluded that it would be possible, citing examples of specialized courts that arbitrate labor and environmental disputes. Panel moderator David Kendall of the Progressive Policy Institute argued that "nothing can happen at the federal level if nothing is happening at the state level."

Other panelists and audience members raised concerns about the proposal. Jack McCarthy, president of the Risk Management Foundation, argued that "expanding the base of liability will be unacceptable to insurers." An audience member from the Consumers Union argued that the proposal "takes away the right to have one's day in court," while "creating a huge bureaucracy."

Another panel discussed the likelihood of medical malpractice reform in light of the Democratic takeover of the House and Senate.

"Caps are likely to be off the table," said Stephen Northrup, a staffer for the Senate Health, Education, Labor and Pensions Committee, referring to the Republican-favored idea of setting caps on medical malpractice claims. He said there would have to be incremental change with involvement at both the federal and state level.

He cited a legislative proposal offered in the 109th Congress, which might be brought up again in the 110th. A bill (S 1337) co-sponsored by Sen. Michael B. Enzi, R-Wyo., and Sen. Max Baucus, D-Mont., would authorize grants to the states to carry out pilot programs testing three approaches: health courts, awards by state administrative boards, or "early disclosure and compensation" programs in which providers are given immunity from lawsuits in return for speedy compensation of an injured patient.

By Jeffrey L. Austin, CQ Staff

November 7, 2006 -- A center to run trials comparing the effectiveness of drugs and medical procedures would put a check on the rise of health care costs and would promote better health practices, according to an article published Tuesday on the Web site of Health Affairs, a peer-reviewed journal.

Gail Wilensky, former administrator of the Health Care Financing Administration (HCFA), the predecessor agency to the Centers for Medicare and Medicaid Services under President George Bush, argues in the article that a center for comparative effectiveness information would allow the United States to make better coverage and spending decisions. She notes that the United States spends far more money per capita on health care than other developed countries but does not have better health outcomes to show for it. Meanwhile, health care spending is increasing at a rate 2.5 times that of the rest of the economy.

Increased comparisons of medical effectiveness is popular among those who wish to inject more competition into the health care marketplace, but manufacturers in the private sector are wary of results that would narrow treatment options to one or two high performers.

The Food and Drug Administration runs trials on drugs and devices before they are released to the public, but the agency considers their effectiveness relative only to a placebo. Wilensky argues for comparing procedures and drugs against each other.

Wilensky suggested the way forward for such an approach would be apparent once the dust has settled from today's midterm elections.

"The attractive part of this strategy is that unlike some areas in changing health care, it does seem to be less party-specific," she said, noting that the high costs are a natural barrier regardless of the party in power. "It's really a question of trying to get several hundred million dollars allocated to this as opposed to $15 million or $50 million."

The Department of Health and Human Services could create such an agency to run trials, or a freestanding entity, such as a research institute at a university, could take responsibility.

But Wilensky argues in favor of a quasi-governmental agency connected to the federal government but operating independently as a nonprofit. The bulk of its budget would come from congressional appropriations, but it would be able to accept private donations as well. The National Defense Research Institute of the RAND Corporation follows this model regarding defense issues.

In one of the three response articles posted on the Health Affairs Web site, Kathy Buto and Peter Juhn, two health policy directors with Johnson and Johnson, caution that simplistic interpretation of comparative studies' results could lead to a winner-takes-all approach to medicine, when in fact a range of options is needed to tailor treatment to individuals.

"I think some people think, 'Gee, if you do a head-to-head study maybe you could just say, we'll only cover this one treatment and that will save money,'" Buto said. "I think that the real value is going to be in getting good information about when different therapies are appropriate for the right patient."

Yet the authors agreed that the type of center envisioned by Wilensky could be useful, and they supported the kind of public–private partnership she outlined. Such an organization, they argued, could foster buy-ins from the private sector if it included companies and manufacturers in planning and was transparent in its methodology and decisions.

Wilensky is a senior fellow at Project HOPE in Bethesda, Md., which publishes Health Affairs. She wrote her article with a grant from The Commonwealth Fund. She said future articles might outline ways to move her plan forward.

By John Reichard, CQ HealthBeat Editor

November 8, 2006 -- From Medicare prescription drug coverage to health savings accounts to $15 billion in global AIDS relief, President Bush gave Republicans a way to play offense on health care as they never have before—but now that Democrats are back to barking the signals in the House and perhaps the Senate as well, it may be a case of the health care varsity taking over from the jayvee.

It's not that Democrats are necessarily more likely to score legislative wins—in fact, the opposite may be true. But their passion for all the permutations of health care means it is one of their core issues and that it is likely to receive dramatically more attention on Capitol Hill.

"Democrats are more comfortable talking about health issues," said Chip Kahn, a former Hill GOP aide who is president of the Federation of American Hospitals. "I can't say what's going to happen with enacted legislation, but I think the health care discourse will be many decibels higher because Democrats like to talk about this issue."

The party's pent-up thirst for health care oversight will lead to no end of possibilities for hearings in the next Congress, said William Vaughan, a senior policy analyst for Consumers Union. For Democrats, trying to pick among potential hearing topics will be like "trying to take a drink of water from a fire hydrant," he said.

With Bush in the White House and Democrats still too few to override legislative vetoes, the next two years might shape up as a period with lots of focus on health care problems but fewer solutions. Although that's not to say that Democrats won't have a shot at legislative accomplishments.

While some proposals are likely to seem tired old reruns destined to flop yet again—incoming House Energy and Commerce Committee Chairman John D. Dingell, D-Mich., spoke Wednesday of resurrecting patients' bill-of-rights legislation giving consumers expanded rights to sue HMOs—others are virtually must-pass measures that Democrats may be able to mold to their liking.

Vaughan said, for example, that reauthorization of legislation next year to charge drug companies user fees to review their marketing applications might allow Democrats to toughen Food and Drug Administration (FDA) oversight of the safety of prescription drugs after they are on the market.

And similar legislation to renew user fees for medical devices might provide a legislative vehicle for tougher post-marketing oversight of medical device hazards; although Stephen J. Ubl, chief executive officer of the Advanced Medical Technology Association, said Wednesday that FDA has broader authority to address those hazards in the device area than the agency does in the drug arena.

Democrats hope that hearings focusing attention on issues such as the nation's growing uninsured population and Medicare authority to negotiate directly with drug makers over Medicare reimbursement levels eventually will lead to legislation that would actually be signed into law—perhaps after 2008 by a Democratic president.

Charles B. Rangel, the New York Democrat who is expected to chair the House Ways and Means Committee, said Wednesday that since it began to appear that Democrats would regain control of the House, "I can't begin to tell you the number of pharmaceuticals and private hospital organizations that have come to me and my staff saying they would want to work with us as we put together a plan to cover those 47 million [uninsured] people who are out there."

Rangel added that "a lot of corporate people are concerned" about the uninsured as well. "Because they are compassionate? Hell no. But because they are paying for the insurance of these people directly. These people are getting health care. They're just not paying for it. The people paying for it are paying for them as well."

Vaughan, a former Ways and Means Democratic staff aide, noted the potential for extensive hearings on the uninsured. That, combined with the possibility Massachusetts Gov. Mitt Romney will pursue the GOP presidential nomination in 2008 based on his state's pace-setting health coverage plan, could create a dynamic that makes universal coverage a top issue in the election—as Democratic candidates seek to outdo Romney.

Democratic pollster Celinda Lake made a similar assessment in an appearance before an AARP-sponsored forum Wednesday, predicting that 2008 will be the "the health care election."

While universal coverage might seem like a pipe dream, Democrats and their allies giddy over the midterm election results see a chance of covering more of the nation's uninsured children through reauthorization next year of the State Children's Health Insurance Program (SCHIP).

The election results provide a "tremendous boost" for children's coverage, claimed Ron Pollack, executive director of the liberal advocacy group Families USA. "SCHIP no doubt will be reauthorized. However, since approximately nine million children continue to be uninsured, the real question before the Congress is whether the reauthorization process will expand health care coverage and provide adequate SCHIP funding for those children who don't have coverage and whose families can't afford it," Pollack said. "A simple reauthorization will be a major disappointment."

But the budget realities Congress faces are harsh and will be made even more so by California Democrat Nancy Pelosi's intention as Speaker of the House to follow "pay-as-you-go" rules in crafting legislative proposals.

"It affects everyone," Rick Pollack, executive vice president of the American Hospital Association (AHA), said. Thus if Congress takes up measures next year to extend popular tax breaks, the health care industry is a potential target for reimbursement cuts. "If you're going to spend money, you've got to cut somewhere," he said of pay-as-you-go budget discipline.

Adding to the potential reimbursement pressure is the likelihood that the Bush administration will propose cuts in Medicare payments to hospitals next year. Both Rick Pollack and Ubl expect the White House to propose those cuts, but that doesn't mean they think cuts will occur even though the "off year" after an election is normally the time to pursue reductions.

That's because campaigning for the presidency is expected to begin soon in earnest and neither party in Congress may be willing to take on cuts, Pollack and Ubl suggested. "I'm not sure I'd want to tackle the hospital lobby right out of the gate," Ubl said.

At the same time, however, AHA's Pollack noted that if both the House and the Senate come under Democratic control, "there would be a lot more pressure to reach agreement on a budget resolution." That in turn would lead to "reconciliation" provisions enforcing cost reduction to meet spending targets, he said. That in turn could create pressure to reduce hospital reimbursement, including payments for use of medical technology.

But the new Congress is likely to be unfriendly terrain for expansion of health savings accounts, a centerpiece of Bush administration efforts to make consumers more sensitive to the price and quality of health care. That could protect hospitals from a big ramp-up in pressure from Capitol Hill to post prices on their health care services.

AHA's Pollack expects lawmakers to continue to pursue "payment-for-performance" provisions in Medicare as a way to boost the value of health care spending. "The issue will continue to mature," he said. But "the Democrats will move a little more cautiously."

He said he expects the Bush administration to soon issue Medicaid regulations that would trim $12.5 billion in spending over 10 years. But he said he's hopeful that Democrats will block those cuts. Democrats in the past have sought to block similar Medicaid regulations on the grounds that they harm safety net providers.

Families USA's Pollack asserted that the outlook for Medicaid cuts has changed. "Major changes in the safety net Medicaid program, which would result in cutbacks in eligibility, benefits, and cost-sharing to low-income seniors, children, and families are unlikely to be adopted," he said "Last year's Medicaid cutbacks were adopted by a 50–50 vote in the Senate, and any such cutbacks are unlikely to receive favorable consideration now."

To the extent that cuts are in the offing, managed care plans in the Medicare Advantage program seem like a natural target given Democratic complaints about the Medicare overhaul law's payment provisions for that sector of health care.

"There is strong evidence now there is very, very large overpayment to the insurance companies," Dingell said in an afternoon press briefing. The Medicare overhaul law "was largely constructed so as to do that. And if the overpayments are as large as they appear to be, it may well be able to fill the doughnut hole," he said, referring to the gap in Medicare drug coverage in which beneficiaries pick up all of their drug costs.

Ubl opined that a $10 billion "stabilization fund" in the Medicare law also could be a target to pay for a Medicare physician payment measure that blocks a scheduled 5 percent cut in Medicare reimbursement.

But health plans say the plans have developed strong political backing as their benefits have expanded. "We have a great track record here," said Karen Ignagni, president of America's Health Insurance Plans. "We have demonstrated savings, we have demonstrated expansions, and we have a number of constituents of key members of Congress who are depending on these choices." Ignagni added, "There is a reality here that a number of core constituents for Democrats are depending on these programs and I think people are going to take account of that."

Jack Ericksen, vice president for federal relations at the Blue Cross-Blue Shield Association, said the stabilization fund should not be a target. "It was really put there to encourage Medicare Advantage to go into hard-to-serve areas, low-income areas, places where it's hard to put together networks and get plans to participate," Ericksen said. "It's not just like it's free money sitting out there."

Blue Cross-Blue Shield plans add that the new Congress likely will lessen the threat they say they faced in the current GOP-run Congress from enactment of legislation promoting association health plans. "We were concerned about that bill because we saw that it would really hurt" small employers, said Alissa Fox, association vice president of legislative and regulatory policy. "We're not sure that will be a priority in this Congress."

But drug company profits in Medicare and pricing practices by Medicare drug plans are likely to be ripe targets for oversight hearings. Dingell is a Capitol Hill legend for the toughness of his oversight hearings in the 1980s, and Michigan Democrat Bart Stupak, a passionate skeptic when it comes to the drug industry, could play a key oversight role on the Energy and Commerce Committee.

Another tough overseer of the health care industry looms large in coming hearings. Although California Democrat Henry Waxman won't be chairing the Energy and Commerce Health Subcommittee the way he did in the 1980s, Waxman is expected to delve deeply into health care issues as chairman of the House Committee on Government Reform.

Drug companies may be among the biggest targets in Democratic crosshairs, but they point out that the Medicare drug benefit is proving to be generally popular among seniors. "Today, 90 percent of the Medicare population has comprehensive drug coverage, and they are saving an average of $1,200 a year," said Billy Tauzin, president of the Pharmaceutical Research and Manufacturers of America. "Clearly, the new program is working very well and exceeding expectations."

Democrats, meanwhile, will face pressure of their own to deliver solutions to the American people for rising health care costs and the medical advances they say will come from research on human embryonic stem cells.

While they may be able to increase marketing of generic drugs through steps such as boosting funding for FDA processing of generic drug applications, legislation to allow importation of low-cost drugs from abroad won't be easy to pass. And getting legislation through Congress creating a regulatory process for approval of generic versions of expensive biotech products will involve tricky negotiations with the biotech industry and its allies in Congress and the White House.

And while health savings accounts may be anathema to many Democrats, they have proved to be popular among the many consumers who face limited options in trying to find some form of insurance protection at relatively affordable premium rates.

Democrats also now have sitting in their laps the messy problem of erasing the scheduled 5 percent cut in Medicare payments to doctors that starts January 1. Although bets are now widespread that lawmakers will put off dealing with the issue until next year, Rangel, the expected chair of Ways and Means, said he'd like to see the matter dealt with this year. "The doctors are catching hell, and I think we would like to help them," he said Wednesday. But in a statement he may find himself making on a variety of issues in coming months, he said, "I don't know where we would get the money."

AMA Board Chairman Cecil Wilson reiterated Wednesday that 80 senators have signed a letter urging GOP leaders to fix the payment shortfall before adjourning for the year.

"I think it's a fair observation to say that lame-duck sessions in general are challenges in getting things done. We understand there are challenges, but there are majorities in the Congress that understand the problem," Wilson said.

Delivering on stem cell legislation also will be difficult. Even with Democratic gains, veto-proof majorities favoring human embryonic stem cell legislation won't exist in the new Congress, said Elizabeth Wenk, deputy chief of staff to Delaware Republican Michael N. Castle, a leader in the battle to get such legislation through Congress before it was vetoed earlier this year.

But Castle isn't sticking to his pre-election assessment that passage of legislation won't happen until there is a new occupant of the White House, she said. "The political situation is different" now, she said. House and potentially Senate leaders now can be expected to bring up the legislation next year and supporters of such legislation will have the power at least in the House to add it as an amendment to other must-pass legislation, she noted.

By John Reichard, CQ HealthBeat Editor

November 9, 2006 -- Members of the Medicare Payment Advisory Commission (MedPAC) questioned Dartmouth Medical School professor Elliott S. Fisher Thursday with all the rapt attention and intensity of a consumer in a TV showroom who knows he's going to buy the megabuck, high-def, big-screen, but hasn't quite told the salesmen he'll take it. Fisher wasn't pitching plasma TVs, of course, but a payment approach that commissioners seemed to view as potentially a big advance in reducing inefficient Medicare spending.

Fisher's research excites Medicare analysts because it suggests that tens if not hundreds of billions of dollars can be saved annually in coming years without sacrificing the quality of care provided to the nation's seniors and disabled.

It shows there are sharp geographical variations in Medicare spending that have nothing to do with regional differences in beneficiary health status and that the areas with higher per capita spending do not have higher quality of care—in fact, their quality of care is lower.

Fisher's work suggests that by creating a reimbursement system that pays doctors more for providing efficient care, these variations can be flattened out over time with gains in quality and big savings to a Medicare program desperate for ways to accommodate an influx of baby boomers without busting the federal budget.

But how to flatten out those variations? Fisher argues that "organizational accountability" for long-term costs and quality is key to improving efficiency. In a presentation Thursday to MedPAC, Fisher unveiled new findings that suggest hospitals and physicians can be tied together under a payment system that would reward them if they work well together to provide quality care without performing unnecessary tests and procedures.

Fisher proposed use of the "extended hospital medical staff" as an organizational structure to hold hospitals and local physicians accountable for the quality and cost of care they provide.

Under the system, a Medicare patient would be assigned to the doctor who provides most of his or her care. Doctors in turn would be assigned to an extended hospital medical staff (EHMS) as follows: doctors who provide inpatient care would be assigned to the hospital where they deliver treatment to the greatest number of Medicare beneficiaries. Doctors who do not provide inpatient care would be assigned to the hospital where the largest number of patients for whom they bill Medicare are admitted when they need hospital treatment.

Under this approach, all but 2 percent of doctors in practices treating 500 or more Medicare patients could be assessed as a member of an "EHMS," Fisher told MedPAC.

Growth in the volume of services provided by an EHMS could be tracked by counting all services provided to the Medicare patients assigned to a doctor under the system. Those services would include care provided outside the hospital under Part B of Medicare and inside the hospital under Part A of the program.

Rather than track the efficiency and quality of 500,000 doctors individually under such a payment system, Medicare would only have to do so for 5,000 EHMS. Services provided in excess of a regional target set to limit volume increases would lead to lower payments.

The system aims to create a financial incentive for doctors to consult carefully with their peers and the affiliated hospital to avoid ordering unnecessary tests and procedures. The EHMS also would be assessed for payment purposes on measures of quality of care, which could include mammography and colon cancer screening rates, or eye exams and glucose management for diabetic patients, for example.

Hospitals "have the capacity to intervene to improve quality," Fisher noted, including the capacity to link physicians to information technology.

The system would get at two key factors that account for geographical variations in spending, Fisher suggested. One is "capacity"—the fact that some areas have more specialists and internists and hospital beds, which lead to more hospital stays, visits to the doctor, and tests and surgical procedures.

Another is that different health care settings have different "clinical cultures," according to Fisher, that affect how efficient they are in the use of medical resources.

MedPAC commissioners, to whom Congress is looking for answers to Medicare's costly-to-fix and badly flawed physician payment system, were all ears at the meeting.

MedPAC Chairman Glenn Hackbarth said he is "intrigued" by the idea of introducing geography as a factor in setting targets for service volume growth. If Medicare were to have such a system, it also would make sense to tie it to both the use of care inside and outside of the hospital, he said. And the EHMS approach would allow cost and quality assessment simultaneously, he added.

"I find your suggestion very attractive," commissioner Ralph W. Muller, an executive with the University of Pennsylvania Health System, told Fisher. "I think taking organizational structures that have been there a long time is the right way to go." Muller was referring to using local hospitals as the focal point for organizing a system of accountability.

"I really think there's a lot of potential here," enthused commissioner Ronald D. Castellanos, a Florida urologist. "I think it's absolutely the right direction," said another MedPAC member, Nicholas Wolter, a physician with the Billings Clinic in Billings, Montana.

But commissioners raised a variety of concerns, with Fisher freely acknowledging there are many questions left to address about the approach, which he described as merely having "nominated."

Among them were: adjusting for differences in the scope of services provided by doctors, fear of exacerbating existing tensions between local physicians and hospitals, and a lack of any kind of existing organizational coherence binding local doctors and hospitals in many communities.

MedPAC Vice Chairman Robert Reischauer, sensing how taken his peers seemed with the new payment approach, voiced caution. He told Fisher that he was "making me nervous because you make it sound so doable." One can draw a line around a group, "but there has to be an organization" for the approach to really foster cooperation among doctors and hospitals, he said. Reischauer also wondered how local labs, surgery centers, and nursing homes would fit into such a scheme.

"There are going to be challenges," Fisher acknowledged.

Commissioners noted that it would take a number of years for efficiencies to be realized. "This is about charting a 10- to 15-year course," Wolter said.

But MedPAC is under the gun from Congress to guide it on new approaches to dealing with physician spending and payments. It must file a report with Congress by March on the issue, and congressional health aides attended Thursday's meeting to hear MedPAC's deliberations on the issue.

Hackbarth cautioned, however, that the commission won't be able to recommend some "snap solution" for the problems with the current physician payment formula. Its report instead is likely to assess the pros and cons of various alternatives, he said.

Commissioners expressed little enthusiasm for another approach, the idea of setting volume targets on a specialty-by-specialty basis. While they expressed support for tracking volume increases in individual specialties and for an analysis of why those increases occur, specialty-specific targets wouldn't foster the kind of cooperation among providers commissioners see as needed to lessen inefficient treatment of Medicare patients.

By CQ Staff

November 7, 2006 -- Making long-term care financing a priority, investing in the long-term care workforce, and modernizing regulatory controls and incentives are all steps to improving the nation's long-term care system, according to an analysis two Brown University professors have submitted to a commission studying the industry.

The document, submitted earlier this month to the National Commission for Quality Long-Term Care, predicts the nation's long-term care system will collapse under the "massive weight of the baby boom generation" and action must be taken now to prepare for that onslaught. "If we do not begin the process of change now for this increased demand for services, it is not clear how we will manage," one of the study's authors, Vincent Mor, said in a news release.

Former Sen. Bob Kerrey, D-Neb. (1989–2001), and former House Speaker Newt Gingrich, R-Ga. (1979–99), chair the commission, whose mission includes recommending national goals and objectives for long-term care quality improvement and reporting on long-term care quality indicators and measures.

The report that Mor and his co-author, Edward Alan Miller, have compiled is an examination of the literature, statistical analysis of data and testimony provided to the commission, as well as interviews with commissioners, academics, government officials, and industry experts.

By CQ Staff

November 9, 2006 -- Physicians in smaller practices continue to lag well behind those in larger practices in reporting the availability of clinical information technology in their offices, according to a Center for Studying Health System Change (HSC) report issued Thursday.

The proportion of physicians reporting access to clinical information technology (IT) for each of five clinical activities increased across all practice settings between 2000–01 and 2004–05. But adoption gaps between small and large practices persisted for two of the clinical activities—obtaining treatment guidelines and exchanging clinical data with other physicians. The gaps widened for the other three—accessing patient notes, generating preventive care reminders, and writing prescriptions—according to the study, which was funded by the Robert Wood Johnson Foundation.

In the case of access to IT to write prescriptions, the adoption gap between small (1 to 9 physicians) and large (51-plus physicians) group practices more than tripled between 2000–01 and 2004–05, the study found. In 2000–01, 8 percent of physicians in small group practices reported access to IT to write prescriptions, with the proportion growing to 13 percent in 2004–05. In contrast, 19 percent of physicians in large group practices reported access to IT to write prescriptions in 2000–01, but the proportion grew to 47 percent by 2004–05.

"The differences may reflect a natural path of technology adoption where larger, savvier organizations adopt new technologies first and others follow, albeit at a slower rate," the study's co-author and HSC senior health researcher Joy M. Grossman said in a news release. "Or it may be that smaller practices face different and substantial barriers that affect how quickly they catch up, if ever."