Prescription databases to play a vital role in decreasing opioid abuse

In the battles against rampant opioid abuse, physicians have a strong weapon in their arsenal—state prescription databases that detect all prescriptions written for these addictive drugs.

Nearly every state has executed Prescription Drug Monitoring Programs (PDMPs), which record opioid prescribing history of a patient. By leveraging these prescription databases, doctors can access information to make an informed decision about whether sufferers are opioid abusers.

PDMPs gather and share data on prescriptions for controlled substances to flag suspicious prescribing and utilization. Although, not all states need providers to access these kinds of prescription databases prior to writing or filling a prescription.

Researchers have discovered that “must access” PDMPs, which need physicians to consult them before writing prescriptions, primarily reduced opioid misuse in Medicare Part D, based on the review of 3.5 million patient records between the time period of 2007 and 2013. At the same time, their research demonstrated that PDMPs without such compulsory provisions have no effect on curbing opioid abuse.

Regrettably, when provider access isn’t mandatory, data indicates that only small numbers of providers create PDMP logins and actually request patient histories.

“A great instance is Kentucky, which passed a ‘must access’ requirement in the year of 2012 and saw the share of controlled substance prescribers who had developed a login rise from about a third to more than 95%,” claims Colleen Carey, assistant professor of policy analysis and management in the College of Human Ecology at Cornell University.

In accordance to Carey, a healthcare economist, one of the ways states can get providers to start using PDMPs is to pass laws that need physicians to check these databases for their sufferers’ previous prescriptions. She points out that New York has the nation’s toughest laws with those requirements.

“New York (is the) strictest state needing doctors to check the opioid history of ‘every patient, every time,’ which is stronger than any other state,” she claims.

Carey and Thomas Buchmueller, a professor in the Ross School of Business at the institute of University of Michigan, co-authored a paper detailing their findings which are to be released in an upcoming issue of the American Economic Journal: Economic Policy.

“Our results recommend that PDMPs that don’t require provider participation are not effective in decreasing questionable or unsuitable use of prescription opioids,” summarize Carey and Buchmueller. “We do find evidence that ‘must access’ PDMPs have the desired impact of curbing certain kinds of extreme utilization. Particularly, such policies decrease several measures of excessive quantity and shopping behavior. The strongest laws, which cover all ingredients and settings of care and don’t require providers to be suspicious, have larger effects on utilization than weaker laws, but even ‘limited’ and ‘discretionary’ laws lower rates of shopping behavior.”

Doctor shopping is explained as seeing multiple providers to procure prescription medications illicitly. In their research on “must access” PDMPs, Carey and Buchmueller found that Medicare opioid users who got prescriptions from 5 or more physicians—a common indication of doctor shopping—dropped by 8%, while the percentage of those who got opioids from 5 or more pharmacies was reduced by 16%.

Nevertheless, the researchers also analyze that the “passage of a ‘must access’ PDMP might prompt people to cross state lines in search of less-regulated prescribers and pharmacies.”

 

Heartbeat to be possibly used as password to access EHRs

Researchers at the institutes of Binghamton University, State University of New York have devised a latest way to secure personal electronic health records (EHRs) by utilizing a patient's own heartbeat. Heartbeat can be possibly used as password to access EHRs.

"The charges and complexity of traditional encryption solutions stop them being straightly applied to telemedicine or mobile healthcare. Those systems are steadily replacing clinic-centered healthcare, and we needed to find a distinctive solution to secure sensitive personal health data with something simple, available and cost-effective," claimed Zhanpeng Jin, assistant professor in the Department of Electrical and Computer Engineering at the Thomas J. Watson School of Engineering and Applied Science at Binghamton University. Jin is the co-author of a new paper entitled as "A Robust and Reusable ECG-based Authentication and Data Encryption Scheme for eHealth Systems."

Traditional security measures--like cryptography or encryption--can be costly, time-consuming, and computing-intensive. Binghamton researchers encrypted patient data by utilizing an individual’s unique electrocardiograph (ECG)--a measurement of the electrical activity of the heart measured by a biosensor attached to the skin--as the key to lock and unlock the files.

"The ECG signal is believed to be one of the most vital and common physiological parameters collected and observed to understand a sufferer’s health," said Jin. "While ECG signals are collected for clinical diagnosis and transmitted through networks to electronic health records (EHRs), we strategically reused the ECG signals for the data encryption. Through this strategy, the security and privacy can be modified while minimum charges will be added."

Essentially, the sufferer’s heartbeat is the password to access EHRs.

The identification scheme is a combination of initial work by Jin using a unique brainprint of person rather than traditional passwords for access to computers and buildings combined with cyber-security work from Guo and Chen. Heartbeat can be possibly used as password to access EHRs.

"This research will be very useful and important for next-generation secure, personalized healthcare," stated Jin.

Since an ECG might change because of age, illness or injury--or a patient might just want to change how their records are accessed--researchers are presently working out ways to incorporate those variables.

Assistant Professor Linke Guo and Associate Professor Yu Chen, along with PhD candidates Pei Huang and Borui Li, are co-authors of the paper.

The research was presented at The IEEE Global Communications Conference (GLOBECOM 2016) in Washington, D.C., in the month of December 2016.\

Latest connections and platform expands Rochester RHIO

Rochester RHIO, a health information exchange facilitating 1.4 million consumers in thirteen upstate counties in the city of New York, has become the last of 8 regional HIEs to build links to the Statewide Health Information Network for New York, known as SHIN-NY.

The RHIO, which has been operating for ten years, has focused on developing, expanding and maintaining its business while linking to other regional HIEs in the upstate region, because that is where 90% of its business comes from, claims Jill Eisenstein, executive director.

The agency also recently completed a major platform migration, expanding its ability to send queries to downstate RHIOs, including SHIN-NY, to which it made more than 600 queries in the past month.

The new platform hosts an enterprise master patient index to recognize and reconcile duplicate patient records and an interface engine. It also supports clinical alerts to let physicians know when sufferers have been admitted to a hospital or discharged, and broadens support for HL7 CCD and CCA document exchange standards.

Low-Paid Healthcare employees join hands with nationwide protestors

Emboldened by fast-food employees, few of the nation's lowest-paid health care workers are pushing for larger wages, joining protests across the country on the day of Thursday.

The campaign comes amid moves by California and New York to gradually increase their baseline pay to $15 an hour, even as other states move to block such attempts within their borders.

"I have been a home care contributor for 5 years, and after all that time, I have to make impossible choices between rent and food for my 3 kids," D.C. home care worker Rhina Garabito claimed in a statement released by organizers of the Fight for $15 campaign.

The group claimed tens of thousands of employees took part in the demonstrations in cities involving New York, Los Angeles, Boston and Chicago, where protesters reportedly shut down an expressway ramp.

Electronic Medical Records Reconstructing Health Care Technology

Healthcare may be going through the greatest technological metamorphosis today, as the Internet of Things, smartphones and cloud computing are transforming patient care. As CIO of the University of Vermont Health Network, a 4-hospital system serving Vermont and northern New York, Dr. Adam Buckley described how his agency is leveraging tech to save lives.

Every CIO has to address different needs. What is your main focus?

Right now, we are looking at 4 things on a regular basis: First, on a high level, aligning IT investment with the overall health network strategy; Second, the subcomponents of each defined place and what will enable strategic targets; Third, our largest project is rolling out [the medical management system] EPIC, utilizing the academic center as the hub and adding in critical access, and since the medical center will effectively be hosting EPIC, we are making certain our infrastructure can support it; lastly, we are concentrating more on general security as a whole, not just particular data, but keeping everything secure.

Regarding EPIC, everyone in the network is on a complete tapestry of things. The maintaining of all these disparate systems is a Herculean task, and even though the staff does a wonderful job, it is not great for patient care. Luckily, we far and away are not the 1^st system to do a conversion, so we have others to offer (us) insight into the procedure.

SwervePay Gets Healthcare Price Transparency Leader StatPayMD

SwervePay, LLC, an innovative patient-centric payment solution in healthcare, declared its acquisition of StatPayMD to further offer healthcare customers with the data, tools and transparency required to handle their financial responsibility.

StatPayMD (formerly Symbiosis Health) is a graduate ofBlueprint Health, a healthcare IT accelerator in the city of New York, and most recently deployed at MATTER in the state of Chicago. StatPayMD makes it easy for sufferers to understand “out-of-pocket” costs before and at care. With SwervePay’s payment tool, sufferers can better interact around cost of care, understand payment options, and pay their bill on the go and in a path that is convenient for them. SwervePay gives an innovative suite of devices for making patient payments – no mobile apps, no paper, merely one-click payments through text message. The portal-free platform also alleviates manual tasks in the revenue cycle process for contributors and health systems.

The majority of negative reviews for healthcare contributors often stems from surprises in one’s medical bills, not due to bad patient care. Even though 92% of insured users are both able and willing to pay their out-of-pocket medical expenses, 15 cents of every dollar is lost on claims processing, payments, billing and revenue cycle management, totaling an approximate of $300 billion loss for the healthcare industry each year (McKinsey). To solve this issue, educating sufferers about their insurance policies and giving convenient payment choices requires to be an integral part of the patient experience.

Update to State Medicaid Launches Message

Updated Link for Montana Medicaid EHR Incentive Program Website

We apologize that our previous listserv message titled, "Arkansas, Delaware, Montana, New Jersey, New York, and North Dakota Launched Their Medicaid EHR Programs This Month" contained an incorrect link to the Montana Medicaid EHR Incentive Program website. The corrected link has been included in the message below.

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Arkansas, Delaware, Montana, New Jersey, New York, North Dakota Launched Their Medicaid EHR Programs This Month

On November 7th, the Medicaid Electronic Health Record (EHR) Incentive Program launched in Arkansas, Delaware, Montana, New Jersey, New York, North Dakota. This means that eligible professionals (EPs) and eligible hospitals in these six states will be able to complete their incentive program registration. More information about the Medicaid EHR Incentive Program can be found on the Medicare and Medicaid EHR Incentive Program Basics page of the CMS EHR website.

If you are a resident of Arkansas, Delaware, Montana, New Jersey, New York, North Dakota, and are eligible to participate in the Medicaid EHR Incentive Program, visit your State Medicaid Agency website for more information on your state's participation in the Medicaid EHR Incentive Program. Click on a State below to access its website.

• Arkansas


• Delaware


• Montana


• New Jersey


• New York


• North Dakota

As of November 7th, 39 states have launched Medicaid EHR Incentive Programs and through October, 23 states have issued incentive payments to Medicaid EPs and eligible hospitals who have adopted, implemented, or upgraded certified EHR technology. CMS looks forward to announcing the launches of additional states' programs in the coming months.

For a complete list of states that have already begun participation in the Medicaid EHR Incentive Program, see the Medicaid State Information page on the CMS EHR website.

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Six New State Medicaid EHR Incentive Programs Launched in November

Arkansas, Delaware, Montana, New Jersey, New York, North Dakota Launched Their Medicaid EHR Programs This Month

On November 7th, the Medicaid Electronic Health Record (EHR) Incentive Program launched in Arkansas, Delaware, Montana, New Jersey, New York, North Dakota. This means that eligible professionals (EPs) and eligible hospitals in these six states will be able to complete their incentive program registration. More information about the Medicaid EHR Incentive Program can be found on the Medicare and Medicaid EHR Incentive Program Basics page of the CMS EHR website.

If you are a resident of Arkansas, Delaware, Montana, New Jersey, New York, North Dakota, and are eligible to participate in the Medicaid EHR Incentive Program, visit your State Medicaid Agency website for more information on your state's participation in the Medicaid EHR Incentive Program. Click on a State below to access its website.

• Arkansas


• Delaware


• Montana


• New Jersey


• New York


• North Dakota

As of November 7th, 39 states have launched Medicaid EHR Incentive Programs and through October, 23 states have issued incentive payments to Medicaid EPs and eligible hospitals who have adopted, implemented, or upgraded certified EHR technology. CMS looks forward to announcing the launches of additional states' programs in the coming months.

For a complete list of states that have already begun participation in the Medicaid EHR Incentive Program, see the Medicaid State Information page on the CMS EHR website.

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

AMA Reaffirms Support of Health Insurance Mandate

June 21, 2011 (Chicago, Illinois) — The American Medical Association (AMA) voted to continue its support of the individual health insurance mandate last night at its annual meeting of its House of Delegates, which includes physicians representing all state and medical specialty societies.

AMA president Cecil B. Wilson, MD, spoke at a press briefing after the contentious vote: "We celebrate the democracy of our house and we celebrate that our house came to this conclusion."

Dr. Wilson noted that the AMA has a strong policy in support of covering the uninsured. He added that this vote renews the AMA's commitment to achieve this through individual responsibility for health insurance, and with avenues of assistance for those who need it. The policy advocates a requirement that those earning more than 500% of the federal poverty level obtain a minimum level of catastrophic and preventive coverage.

The AMA believes that the individual mandate is the best option available today to improve access and ensure coverage for the uninsured. The AMA also notes that there is a difference between the positions of the AMA policy that supports individual responsibility and the individual requirement provisions of the Affordable Care Act.

Prior to the vote, the AMA reviewed and evaluated alternatives to the individual mandate and described its findings in a Report of the Council on Medical Services, entitled Covering the Uninsured and Individual Responsibility. The report reviewed AMA policy and advocacy efforts on the subject and summarized the history of requiring individual responsibility. The report was hotly debated in the reference committee meeting on Sunday, and the reference committee made 3 recommendations to the House of Delegates:

• The AMA reaffirms that it is committed to health system reforms that include health insurance coverage for all Americans, and to insurance market reforms that expand choice of affordable coverage, which are consistent with AMA policies concerning pluralism, freedom of choice, freedom of practice, and universal access for patients.


• The AMA reaffirms its policy of advocating that state governments be given the freedom to develop and test different models for covering the uninsured.


• That the report be filed and adopted in lieu of resolutions 102, 109, and 114.

The first 2 recommendations passed easily through the House of Delegates. The last recommendation initiated a 40-minute debate on the House floor related to the nature of the 3 resolutions that were being rejected.

Resolution 102 asked that the AMA continue to support policies that include personal responsibility to participate in private insurance risk-pooling arrangements, such as financial disincentives (penalties) on people who choose to forgo coverage until they are sick.

Resolution 109 asked that the AMA support the use of tax incentives and other noncompulsory measures to encourage the purchase of health insurance, rather than a federal mandate, and rescind the AMA's Individual Responsibility to Obtain Health Insurance Policy.

Resolution 114 asked that the AMA reaffirm policies that provide for an individual insurance mandate, combined with sufficiently financed advanceable and refundable tax credits, as a fundamental part of market-based comprehensive health system reform.

The reference committee heard extensive testimony on all of these resolutions during Sunday's well-attended committee meeting. The debate continued on the floor of the House of Delegates on Monday. Supporters of the individual mandate noted that, in addition to improving healthcare access for the uninsured, the individual mandate would create a private-market approach to expanding coverage and choice, and thereby would promote the growth of the private health insurance market.

Speakers who wanted to modify the AMA's policy on the individual mandate expressed concerns that the AMA's Covering the Uninsured and Individual Responsibility report conflicts with AMA policy that supports freedom of choice, pluralism, free-market economic principles, and preserving the physician–patient relationship. Some physicians also expressed concern that the individual mandate equates with support for increased government intervention and interference in healthcare. Another concern that was raised was the fear that an individual mandate would lead to an increase in the number of individuals who depend on a government subsidy for their health insurance coverage.

The discussion included references to the Affordable Care Act and the Massachusetts health reform effort, both as reasons to support and to reject the individual mandate.

The debate concluded with the testimony of Leah S. McCormack, MD, the delegate from New York, who stated: "I would still give care to patients whether they had insurance or not. . . . There are some things that are more important than healthcare [insurance]. . . . That is the liberty to make my own decisions and not have the government tell me what to buy."

Throughout the debate, many of the physician speakers reflected Dr. McCormack's acute sensitivity to the health consequences of being uninsured and the effect of an individual mandate on personal liberty. In the end, the vote seemed to come down to how to balance these 2 needs.

AMA physicians voted 326 to 165 (66.4% to 33.6%) to reaffirm the AMA's position on the individual mandate. It also voted to reaffirm support for the AMA policy supporting health insurance tax credits and health insurance market regulation, health savings accounts, and direct subsidies for coverage of high-risk patients.

American Medical Association (AMA) 2011 Annual Meeting. Press briefing, June 20, 2011.

Spirometry Billing (A Reimbursement Guide)

Who should have Spirometry Testing? In earlier times there was no any real concept that how to get reimbursement against the spirometry. Afterwards, in 1994, the American Thoracic Society published an official statement of “Standardization of Spirometry.” In this statement there was seen a potential indications for Spirometry, some of which may not be covered by Medicare or other payors:

• To assess therapeutic interventions (e.g., bronchodilator therapy, steroid treatment, management of CHF, etc.)


• To assess preoperative risk


• To screen individuals at risk of having pulmonary diseases (e.g., smokers, occupational exposures)*


• To assess health status before enrollment in strenuous physical activity programs*


• To assess patients as part of a rehabilitation program*


• To assess risks as part of an insurance evaluation*


• To assess individuals for legal reasons (e.g., Social Security. personal injury lawsuits)*

*These Indications are generally not covered by Medicare. What Codes describe spirometry procedures? What are the associated payment rates? The current Procedural Terminology (CPT) codes defined below are the most common codes used to describe spirometry procedures performed. The simplicity Spirometer does not perform a respiratory flow volume loop (CPT code 94375). Note: According to the Centers for Medicare and Medicaid Service (CMS) Correct Coding Initiative, none of the procedures described by the CPT codes listed below may be billed together on the same date of service. Please consult the latest version of the National Correct Coding Policy Manual to identify rebundling combinations. Edits may be reviewed at www.cms.hhs.gov/physicians/cciedits/default.asp

CPT Code **	Description	Unadjusted 2005 Medicare Allowable***
94010 (may not be billed with 94060 or 94375 on same DOS)	Breathing capacity test	$33
94060 (may not be billed with 94010 or 94375 on same DOS)	Evaluation of wheezing (pre-and post-bronchodilator)	$55
94375 (may not be billed with 94060 or 94375 on same DOS)	Respiratory flow volume loop	$36

** Most commonly used CPT codes for spirometry. Additional codes may be found in the Current Procedural Terminology (CPT) Manual published by the American Medical Association. All spirometers may not perform all procedures identified by CPT codes. The existence of CPT codes does not guarantee coverage of payment for any device by any insurance carrier of Medicare. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines. *** Medicare allowable amounts vary by geographic region. What documentation is needed to support payment for spirometry procedures? Many Medicare Part B carriers have published Local Medical Review Policies (LMRP) that describe specific coverage guidelines for spirometry procedures. For example Upstate Medicare in New York offers the following list of ICD-9 codes, which may help support the medical necessity for spirometry testing. These codes may not be applicable in other regions of the country. For definitive coverage and payment information contact your local Part B carrier. What are general coverage guidelines for spirometry under the Medicare Program? · Local Medical Review Policies have been written by many Part B carriers, and copies may be requested through customer’s local Medicare Part B Carrier. · The appropriate combination of tests may be coded if proper clinical indication exists. Consult local medical necessity policy for Correct Coding guidelines and unbundling information. · The Medicare Program specifically excludes coverage for screening tests, including;

• Spirometric assessment of an asymptomatic patient, with or without high risk of lung disease;


• Studies as part of a routine examination; and


• Studies as part of an epidemiologic survey.

Reference:

1. American Thoracic Society (1995). Standardization of spirometry, 1994 update. Am J Respir Crit Care Med. 1995;152:1107-1136.


2. American Medical Association. Current Procedural Terminology. Professional Edition.


3. Physician fee Schedule: payment policies and relative units. Federal Register Vol. 69, No. 219, November 15, 2004.


4. Local Medical Review Policy. Pulmonary Function Testing. 2003. Update Medicare Division, New York.


5. American Medical Association. International Classification of Diseases, ICD-9-CM.

NYC system sues over massive data breach

The New York City Health and Hospitals Corp. filed a lawsuit against a data storage and transport vendor after the December theft of electronic files that contained personal or health information for about 1.7 million patients and hospital or contract employees.

The 14-hospital system said the breach involved patients, staff and vendors at Jacobi Medical Center and North Central Bronx Hospital and two health centers during a 20-year period. In letters last week, the city-owned system began to alert patients to the theft and offered free credit monitoring and fraud resolution for one year. The system notified three nationwide consumer reporting agencies of the theft.

In a news release, the system said the files were stolen after a driver for GRM Management Information Services left the company's van unlocked. A spokeswoman for GRM did not respond to a request for comment at deadline.

The data storage company dismissed the driver and notified police. The system has notified New York's attorney general, the state Office of Cyber Security and the Consumer Protection Board. The system also alerted HHS.

The New York system said it has sued the vendor to recover the costs of notification and other related damages. The system also canceled the vendor's contract.

Obama Urges Excise Tax on High-Cost Insurance

WASHINGTON — President Obama told House Democratic leaders at a meeting on Wednesday that they should include a tax on high-priced insurance policies favored by the Senate in the final version of far-reaching health care legislation, aides said.

The White House has long expressed a preference for the excise tax on high-cost plans, which health economists say could be an important tool in controlling long-term health care spending for the government and for individuals and families.

But House Democrats have resisted the idea, which is also strongly opposed by many organized labor groups — an important part of the party’s base — because the tax may hit a number of more generous union-sponsored health plans.

The Senate proposal would impose a 40 percent excise tax on the cost of individual insurance policies above $8,500 and on family policies above $23,000, with higher thresholds for retirees and employees in high-risk fields like police officers.

The tax would raise $149 billion over 10 years, according to the Congressional Budget Office. The Senate bill would cost $871 billion over 10 years, while the House bill would cost nearly $1.1 trillion.

The meeting among Mr. Obama, Speaker Nancy Pelosi and top committee chairmen responsible for the health care bill came as Congressional leaders have stepped up efforts to reconcile differences between the House and Senate bills.

Ms. Pelosi, emerging from the meeting, said she expected those differences to be worked out soon.

“We have had a very intense couple of days with meetings in our leadership, meetings with our staff,” she said. “After our leadership meeting this morning, our staff engaged with the Senate and the administration’s staff to review the legislation, suggest legislative language. I think we’re very close to reconciliation.”

Mr. Obama has mostly tried to avoid taking public positions on potential disputes between the chambers, to the point that some lawmakers, including some Congressional leaders, have complained that the White House has not provided enough guidance.

Instead, the president and some of his advisers have talked circuitously about what they believe to be some of the more useful policy goals.

The budget director, Peter R. Orszag, for instance, has repeatedly extolled the potential economic merits of the proposed tax on high-cost insurance plans, as well as an independent agency to recommend potential government savings in Medicare.

Both of those ideas were included in the Senate bill, but not the House measure.

Senate Democrats are generally believed to have greater leverage in the negotiations to reconcile the two bills because they cannot afford to lose a single vote and some centrists have warned that they would turn against the bill depending on how it changes.

The Senate approved its bill on a party-line vote, 60 to 39, on Dec. 24.

But the House does not have much wiggle room either. It approved its bill on Nov. 7 by a vote of 220 to 215, with just one Republican joining 219 Democrats in favor. That means Ms. Pelosi could spare just two votes without jeopardizing the bill’s chances.

Among the big differences between the two bills are the provisions to pay for the legislation. Both measures rely on huge reductions to slow the growth in government spending on Medicare.

The Senate also proposed an increase in the Medicare payroll tax for individuals earning more than $200,000 and couples earning more than $250,000. The House proposed an income surcharge on individuals earning more than $500,000 and couples earning more than $1 million.

Joining Mr. Obama and Ms. Pelosi at the meeting on Wednesday were the principal authors of the health care bill: Representative George Miller of California, the chairman of the Education and Labor Committee; Representative Charles B. Rangel of New York, the chairman of the tax-writing Ways and Means Committee; and Representative Henry A. Waxman of California, chairman of the Energy and Commerce Committee.

Representative Louise Slaughter of New York, the chairwoman of the House Rules Committee, also attended.

Mr. Rangel, who has expressed frustration at the pressure on the House to defer to the Senate, said he appreciated Mr. Obama’s time and attention.

“The president has been very patient with his time and understanding that we have to get 218 votes and we really have to be able to sell it — not just to our Democratic caucus, but to the American people,” Mr. Rangel said. “And we could not have asked the president to be more cooperative — even though he’s doing more listening than talking.”

Mr. Obama may have little choice but to emerge from listening mode in the days ahead. Senate leaders return to Washington next week, and pressure will only mount on him to help broker the final differences between the bills.