Patients & Seniors Family & Friends Providers

Fighting Increasing Costs and Decreasing Reimbursement.

VoCare is helping YOU (physicians, hospitals and home health agencies) in the fight against rising healthcare costs and lower rates of reimbursement. Our innovative suite of products and services, recommended by health providers like you across the country, provides significant financial and clinical benefits to providers and their chronically-ill and/or senior patients, as we help you prepare for new reimbursement models, such as ACOs and Medical Homes.

  

Providers

Making a Difference

VoCare is focused on delivering powerful, yet affordable and easy-to-use products and services that connect medical care providers with their patients. Our new technology platform delivers four key benefits to providers:

  • Reimbursement for remote care services
  • Enhanced care and safety for the patient
  • Reduced costs of patient care
  • Increased capacity for patient visits

Free Provider Software!

The medical provider only needs a computer, Internet access, and a low-cost digital camera for a PC to fully utilize VoCare. (You also have the option of using our MyHealth Tablet™.) The VoCare telehealth software used to communicate with the patient is offered to the provider at no charge. (The patient is only billed $35 per month.) There is virtually zero initial and ongoing cost to the provider to use the VoCare MyHealth Tablet™ system.

Convenient Care for Providers and Patients

VoCare provides 24/7 "live" person support that is incorporated into three product options:

  1. The My SafetyButton™ Medical Alert is a location-based Personal Emergency Response System (PERS) pendant worn around the neck or on the wrist, that offers enhanced personal protection, similar to LifeAlert®, the people that brought you "Help, I’ve fallen and I can’t get up!," and OnStar®, the popular GM safety system. Best of all, there are no boundaries or limits, so protection and service are anywhere and everywhere the user goes.
  2. The My SimpleOne™ Mobile Phone is a simple-to-use, yet powerful safety device with helpful personal assistance (via our exclusive blue OneTouch™ button) and advanced security features designed specifically for your elderly patients. You will forever be their hero for recommending this easy to use and affordable mobile phone.
  3. The MyHealth Tablet™ is an easy-to-use, wireless, portable device that supports remote audio and video between you and your patient, as well as the capture and monitoring of your patient’s vitals, including pulse, weight, glucose & oxygen level, and blood pressure.

The VoCare approach is to provide "more product for less money". We know these products need to be easy to use and affordable. You’ll probably be surprised at how much we offer for such a low cost to your patients. We are convinced we can do this with the help and support of healthcare providers across the country. It’s a big win for everyone involved, especially your elderly patients.

Every health care reform proposal before Congress over the last decade recognizes the heightened demand for primary care services and providers. One reason is that greater availability of primary as well as and preventive care has been tied to cost savings and improved quality.

How professional care givers are paid and which of their services are covered has been a contentious issue. This is evidenced by the patchwork of policies governing payment for their services by substantial variation in payment rates among state programs.

There are many federal, state and private: subsidies, waivers and reimbursement programs that will assist providers so you get paid what you deserve as the patient gets the care they need. The purpose of this section is to provide the policies and plans that are currently in place. If more details are required by a health delivery system, VoCare is available to assist in providing an in-depth analysis of the opportunities available for your specific organization.

Please review the following options for more information.

  • Medicare
  • Private Insurance
  • Medicaid
  • Patient / Self Pay
  • Accountable Care Organizations
  • Additional Considerations

Medicare

Medicare reimbursement for telemedicine or telehealth services is divided into three categories:

  1. Remote patient face-to-face services seen via live video conferencing
  2. Non face-to-face services that can be conducted either through live video conferencing or via store and forward telecommunication services
  3. Home telehealth services

Remote Patient Face-To-Face, Interactive Services

The Centers for Medicare & Medicaid Services (CMS) defines telehealth services to include those services that require a face-to-face meeting with the patient (store and forward is excluded). Such reimbursement is limited to the type of services provided, geographic location, type of institution delivering the services and type of health provider.

Facility Location

The service must be provided to an eligible Medicare beneficiary in an eligible facility (originating site) located outside of a metropolitan area. However, there is no limitation on the location of the health professional delivering the medical service (referring site).

Medicare Covered Telehealth Services

  • Consultations 99241-99255
  • Office or Other Outpatient Visits 99201-99215
  • Psychiatric diagnostic interview 90801
  • Individual Psychotherapy 90804-90809
  • Pharmacological Management 90862
  • ESRD Related Visits G0308, G0309, G0311, G0312, G0314, G0315, G0317 and G0318
  • Distant Site Facility Fee Q3014
  • Individual Medical Nutrition Therapy 97802, 97803, G0270
  • Neuropsychological Testing Administered by Computer 96120
  • Neurobehavioral Exam 96116
  • Individual Kidney Disease Education G0420 (as of January 1, 2011)
  • Individual Outpatient Diabetes Self Management Training G0108 (as of January 1, 2011)
  • Group Kidney Disease Education G0421 (as of January 1, 2011)
  • Group Medical Nutrition Therapy 97804
  • Group Diabetes Self Management Training G0109
  • Group Health Behavior Assessment and Intervention 96153
  • Family Health Behavior Assessment and Intervention 96154
  • Initial Hospital Care Services 99221 – 99223
  • Subsequent hospital care services 99231 - 99233 (Level 1 subsequent)
  • Hospital Discharge Day Management Services 99238 – 99239
  • Inpatient telehealth consultation HCPCS G0406, G0407,G0408, G0425, G0426, or G0427
  • Subsequent Nursing Facility Care 99307, 99308, 99309 and 99310
  • Neuropsychological testing (e.g.,Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test) 96119

Federal Medicare will not cover services delivered via Telehealth technologies that are not listed above as of January 2011 with the exception of demonstration projects, waivers, and other health care reform models that may be implemented in 2011 and beyond.

Medicare Eligible Providers

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Nurse Midwives
  • Clinical Nurse Specialists
  • Clinical Psychologists
  • Clinical Social Workers
  • Registered Dietitians and Nutrition Professionals

Federal Medicare will not cover telehealth services unless provided by an eligible provider from the list above. For the purposes of remote monitoring, physicians and advanced practice allied providers qualify and eligible providers and can delegate care management under the incident-to rules for physicians and non-allied provider such as certified diabetes educators.

Federal Medicare Eligible Originating Sites

(patient location when the service is provided)

  • Physician’s office
  • Hospital
  • Critical Access Hospital
  • Rural Health Clinic
  • Federally Qualified Health Center (includes CHCs)
  • Hospital-based or CAH-based renal dialysis center (including satellites)
  • Skilled nursing facility (SNF)
  • Community mental health center (CMHC)

Medicare will not cover telehealth services unless originated at the sites listed above with the exception of demonstration projects, waivers, and other sites implemented as health care reform payment strategies in 2011 and beyond.

Currently, federal Medicare Part B does not reimburse for services delivered by TeleHealth into the home and does not reimburse for store-and-forward consultations. However, Medicare does have approved CPT codes for remote monitoring, as well as telehealth visits, which can be used to negotiate payment from Medicare intermediaries, Medicare Advantage plans, and Medicare supplemental plans. Physicians should work closely with reimbursement staff to meet with and negotiate payment for chronic conditions that benefit from the use of remote monitoring for early symptom management. Medicare intermediaries and Medicare Advantage plans are based on risk contracting with federal Medicare with the intermediaries taking on some of the risk of providing coverage for a segment of the Medicare population.

Certainly, Medicare Advantage plans have significant risk in covering a certain population of Medicare beneficiaries. Intermediaries and payers offering Medicare Advantage plans will be highly interested in managing patient populations to reduce risk for the payer (avoided hospitalizations, reduced days of stay, reduced readmissions, improvement in health status, stabilized or reduced dependence on medications, etc.), much of which can be avoided through the use of remote monitoring and in the home telehealth visits. Physician practices can also negotiate with Medicare payers for care management, which includes coverage for the medical devices, and on-going monthly episode of care payments to the practitioner.

Remote monitoring data includes physiological data that is interpreted by the health care team. When physician involvement is necessary, the physician interprets the physiological data in the same manner as a laboratory test, a radiograph, or another type of test with patient results. If the patient is required to come into the office for an examination as a result of the alert from remote monitoring, the physician upcharges the visit to a higher level due to the additional remote monitoring data that is reviewed during the process of evaluating the patient.

Private Insurance

Based on Doctor Recommendation

Private payers including commercial health plans, HMO/PPOs, workers compensation carriers, and third-party administrators (TPAs) negotiate contracted rates with large health care providers and offer standard rates with discounts to smaller individual practices. Private payers are extremely interested in services, approaches, and innovative care model delivery systems that assist in helping the payer meet NCQA and HEDIS quality indicators for health plans. Remote monitoring, interactive telehealth visits, e-visits, and m-health are all care delivery strategies which assist a private payer in achieving mandated quality indicators, as proven by the published research on clinical outcomes of remote monitoring. Many payers struggle with high-cost chronic conditions such as congestive heart failure, osteoporosis/hip replacement, etc., as well as dedicating resources for care management. Most often the private payer simply case manages the patient by review of claims data and would be interested in any program a physician office could offer that would more closely monitor a patient’s condition, focusing on early symptom management, aversion of complications, and reducing, limiting, and possibly eliminating unnecessary office visits and hospitalizations (reducing utilization). Physician offices should negotiate with private payers for coverage for services delivered via TeleHealth at rates equal to in-person care for all services currently covered by the payer for in-person care. In addition, physician offices must require no restrictions on location of the patient (include home, skilled nursing facilities, and assisted living centers). Location of service should be the physician office. The Medicare model is an inappropriate reimbursement model for private payers and should not be used as a foundation for negotiating contractual rates with private payers. Moving forward, and discussed in the section below, is the option to negotiate under accountable care organizational payment structures with private payers to cover professional services and technology as a benefit to enrollees.

Physicians can propose using three telephone service codes, 99441, 99442 and 99443, when they are reporting medical care via telephone, or by telehealth in the home, that is initiated by an established patient or by the patient's guardian. The reporting physician, or a physician of the same specialty in the same practice, must have seen the patient within the past three years.

For billing purposes the AMA provides CPT codes for telephone services based on the amount of time the physician spends discussing medical matters with the patient or guardian. The time increments are:

  • 5-10 minutes for a code 99441
  • 11-20 minutes for a code 99442
  • 21-30 minutes for a code 99443

CPT code 99444 is available to physicians for billing for online patient services. The service can be reported only once for the same episode of care in a seven-day period and includes all other communications stemming from the online encounter, including follow-up telephone calls and pharmacy, lab and imaging orders.1 Physicians again, can negotiate payment for episodes of care with private payers (as well as Medicaid) under the use of on-line consultations codes when remote monitoring or home tele-visits are used to provide care.

References

  • "CPT 2008: A Glimpse of the Future of Family Medicine?" in the January issue of Family Practice Management

Medicaid

State Waiver Programs

Each state Medicaid (usually housed in Department of Human Services, Family Services, Social Services, etc. for the State) adopts its own payment regulatory or legislative language for covered services for Medicaid recipients. Several states cover, in addition to traditional interactive TeleHealth, remote monitoring, home-based services, store-and-forward consultations and visits. In addition, e-visits (use of email, third party web sites, web portals, etc.) are covered by Medicaid benefits.

The same principles for Medicare reimbursement can apply to Medicaid recipients. Medicaid agencies are often interested in remote monitoring and home TeleHealth due to the quality improvements, reduction in hospitalizations, reduction in complications, and the obvious reduction in claims costs for recipients. State agencies are in the position of creating pilots with physician practices, issuing waivers (waiving restrictions on payment or access to services), and providing services in the home. Physician practices and group practices are encouraged to meet with state Medicaid offices or state contracted HMO/PPO payers to discuss clinical outcomes studies, payer mix in the practice, and specific populations for which the physician practice provides service. For instance, a pediatric practice is in an excellent position to improve clinical indicators through increased compliance.

Please select your state below to review the state specific policies governing your area.

Patient / Self Pay

Patient Reimbursement

Accessing health care is a burden that is carried solely by patients and families. The costs in terms of time, energy, actual dollars, and community impact can be significant when an adult child is caring for an aging parent. Calculating the cost drivers of monitoring safety and wellness of the elderly by family members, costs of assisting with health care appointments, coordinating and ensuring safe medication administration, providing adequate social interactions, etc., runs into the hundreds of dollars a month for many families. In addition, the costs associated with an averted hip fracture, hypothermia, or other adverse event or omission of necessary medications and therapies, all add to the cost drivers. Patients themselves, but more often, family caregivers, are very interested in strategies that reduce the burden on caregivers.

The out-of-pocket cost of caring for an aging parent or spouse averages $5,531 a year, according to the nation's first in-depth study of such expenses, a sum that is more than double previous estimates and more than the average American household spends each year on health care and entertainment combined. In November 2007, the National Alliance for Caregiving released its study, "The Evercare Study of Family Caregivers—What They Spend, What They Sacrifice."

The Evercare/NAC study found that as many as 17 million people, or 51% of the 34 million that a 2004 NAC/AARP survey found, care for a loved one 50 years or older, and on average spend more than 10% of their annual income on caregiving expenses.. One-third of the respondents said that they have dipped into their own savings to help with care.1

Family members will be interested in any strategy that will reduce the burden and worry, improve safety and security, and assist with medical management of the elderly, disabled, or other loved one with significant health care needs. Physicians can offer a cost-based service to family members that will reduce the out-of-pocket expenses that the family carries in monitoring the aging family member. The physician can write a prescription to the patient for the monitoring devices where the patient goes to a local retailer for the systems, or can provide the systems out of the office. The second method increases inventory costs to the physician and is not the preferred model. Using a durable medical equipment model is the best system for the physician’s office. The physician then charges the patient (family caregiver system) a monthly fee for monitoring and alert management, with support for patient education and social networking with other patients in the practice with like conditions.

Read the latest on reimbursement policy:

References

Accountable Care Organizations

The following excerpt was taken from the New England Journal of Medicine article "Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform" by Diane R. Rittenhouse, M.D., M.P.H., Stephen M. Shortell, Ph.D., M.P.H., M.B.A., and Elliott S. Fisher, M.D., M.P.H (December 10, 2009).

An Accountable Care Organization (ACO) is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population. Multiple forms of ACOs are possible, including large integrated delivery systems, physician–hospital organizations, multi-specialty practice groups with or without hospital ownership, independent practice associations, and virtual interdependent networks of physician practices.1 ACOs could receive fee-for-service payment and share in any cost savings achieved relative to a risk-adjusted projected spending target for their patient population; alternatively, payment could be partially or fully capitated, with risks and gains both being shared by all providers. Performance measurement to evaluate the quality of care and to prevent potential overuse (in fee for for-service organizations) and under-use (in capitated ones) is a cornerstone of the model. Some evidence suggests that more fully integrated ACOs provide higher quality, more efficient care than smaller, more loosely organized ones.2 Challenges to the implementation of the ACO model include the need for strong leadership to address the cultural, legal, and resource-related barriers to creating new provider organizations in many communities.3

Additional background information on payment strategies for physicians under the ACO model is found in the Brookings Institute issues brief "Reforming Provider Payment Moving Toward Accountability for Quality and Value" by the Engleberg Center for Health Care Reform (March 2009).

The (ACO) model establishes a spending benchmark based on expected spending. If an ACO can improve quality while slowing spending growth, it receives shared savings from the payers. This model is well-aligned with many existing reforms, such as the medical-home model and bundled payments, and also offers additional support (and accountability) to the provider organization to enable them to deliver more efficient, coordinated care. This approach has been implemented in programs like Medicare’s Physician Group Practice (PGP) Demonstration, which has shown significant improvements in quality and savings for large group practices.

Because the groups receive a share of the savings beyond a threshold level, steps like care coordination services, wellness programs, and other approaches that achieve better outcomes with less overall resource use result in greater reimbursement to the providers. These steps thus “pay off” and are sustainable in a way that they are not under current reimbursement systems. In addition, the shared savings approach provides an incentive for ACOs to avoid expansions of health care capacity that are an important driver of both regional differences in spending and variations in spending growth, and that do not improve health.

The ACO approach also builds on current reform efforts that focus on one key group of providers, as in the medical-home model, or on a discrete episode of care, as in bundled payments. On their own, these initiatives may help strengthen primary care and improve care coordination, but they do not address the problem of supply-driven cost growth highlighted by the Dartmouth group. If adopted within a framework of overall accountability for cost and quality as is envisioned in the ACO model, both the medical home and bundled payment reforms would have added incentives to support not only better quality, but also lower overall spending growth.

By shifting the emphasis from volume and intensity of services to incentives for efficiency and quality, ACOs provide new support for higher-value care without radically disrupting existing payments and practices. The ACO model builds on current provider referral patterns and offers shared savings payments, or bonuses, to providers on the basis of quality and cost. A wide variety of provider collaborations can become ACOs assuming that they are willing to be held accountable for overall patient care and operate within a particular payment and performance measurement framework. Examples include existing integrated delivery systems, physician networks such as independent practice associations, physician-hospital organizations, hospitals that have their own primary-care physician networks, and multispecialty group practices. Alternatively, primary-care groups or other organizations that provide basic care could contract with specialized groups that provide high-quality referral services with fewer costly complications.4

Implications of the ACO Model for Physicians Using TeleHealth and Remote Monitoring

Physicians working in an ACO or using ACO strategies for care delivery are focused on improving quality, reducing complications, and meeting cost objectives in order to qualify for reimbursement, reimbursement incentives, or payment bonuses. Care delivery strategies based on quality and cost metrics often provide episode of care payments or lump sum payments for the management of a condition, such as diabetes, heart failure, or end-stage renal disease. Bonuses are typically paid as a lump sum payment. Under ACO models of payment, physicians can and should use TeleHealth and remote monitoring as one of the strategies to improve quality, reduce cost, and keep patients out of the hospital and other high-cost access points. Preventing complications by early symptom management is the hallmark of care management of chronic conditions through remote monitoring. Structuring payment negotiations with payers that include discussions of payment for TeleHealth consults, remote monitoring, and technical components, allows the physician to coordinate and drive care decisions in a manner that maximizes the health potential for the patient, meets quality metrics, and reduces cost for the payer. Models of reimbursement under a negotiated ACO contract with payers are shown by the following examples:

  1. Scenario #1: A physician uses TeleHealth and remote monitoring in the office practice through care management of a population with Congestive Heart Failure (CHF), one of the nation’s top ten chronic conditions. The physician negotiates payment for the professional component for interactive TeleHealth visits and office visits, and an episode of care payment (monthly fee for remote monitoring based on AMA CPT codes……….). The equipment is a benefit that is paid for by the payer and provided to the patient. The physician buys their own TeleHealth workstation and supports or buys into a remote monitoring web-portal for data access.
  2. Scenario #2: A physician uses TeleHealth and remote monitoring in the office practice through care management of a population with Congestive Heart Failure (CHF), one of the nation’s top ten chronic conditions. The physician negotiates payment for the professional component for interactive TeleHealth visits and office visits, and an alert management fee that is paid whenever an alert requires physician intervention and a change in the plan of care. Coding is based on current interpretation of lab values and other patient data CPT codes. The equipment is a benefit that is paid for by the payer and provided to the patient. The physician buys their own TeleHealth workstation and supports or buys into a remote monitoring web-portal for data access.
  3. Scenario #3: A physician uses TeleHealth and remote monitoring in the office practice through care management of a population with Congestive Heart Failure (CHF), one of the nation’s top ten chronic conditions. The physician negotiates payment for the professional component for interactive TeleHealth visits and office visits. The physician provides care management and remote monitoring to patients in the practice in order to manage quality and reduce costs to qualify for the incentive bonus. The physician purchases the remote monitoring equipment and provides it to the patient for an episode of care.

The scenarios can be further amended to provide the remote monitoring equipment as a benefit to patients from insurance payers, a one-time purchase by the patient, or an office based purchase by the physician and distributed by the physician to patients for an episode of care. Payment structures can include professional components only, professional components plus episode of care payments for remote monitoring, or subsequent additional payments for management of alert events.

Payment under ACO models from the federal perspective will most likely be based on the Physician Group Demonstration Project (PGP) now in its fifth year in 2010. The ten participating organizations in the 2005 PGP have been selected to be the first eligible organizations for incentive payments based on quality and cost metrics for the eligible population or practice.

Of significant value and interest is the fact that Marshfield Clinic, one of VoCare’s partner sites, was not only the most successful of these ten sites, but that their reimbursement dollars received were greater than all other nine organizations combined! Dr. Nina Antoniotti, Director of Telehealth at Marshfield Clinic, is heartily recommended by VoCare as an excellent resource to other delivery organizations evaluating options with regards to the ACO model and relative issues tied to telehealth.

References

  1. Shortell SM, Casalino LP. Health care reform requires accountable care systems. JAMA 2008;300:95-7.
  2. Tollen L. Physician organization in relation to quality and efficiency of care: a synthesis of recent literature. New York: The Commonwealth Fund, April 2008.
  3. McKethan A, McClellan M. Moving from volume-driven medicine toward accountable care. Health Affairs Blog. August 20, 2009. (Accessed October 26, 2009, at http://healthaffairs.org/blog/2009/08/20/movingfrom-volume-driven-medicine-towardaccountable-care.)
  4. The Long Term Quality Alliance. 2009. Reforming Provider Payment: Moving Toward Accountability for Quality and Value. Engleberg Center for Health Care Reform, Brookings Institute, The Dartmouth Institute for Health Policy and Clinical Practice.

Additional Considerations

My SimpleOne™ Mobile Phone

There are several organizations that can help keep you connected by making the My SimpleOne™ Mobile Phone even more affordable then it already is.

  1. Lifeline Assistance provides discounts on basic monthly service at your primary residence for qualified telephone subscribers. These discounts can be up to $10.00 per month, depending on the state of residence. To determine if your state offers these additional discounts, contact your state’s public utility commission, by visiting the National Association of Regulatory Utility Commissioners. For more information about qualifying, please visit the LifelineSupport.org website.
  2. Link-Up America helps income-eligible consumers initiate telephone service. This program pays one-half (up to a maximum of $30) of the initial installation fee for a traditional, wire line telephone or activation fee for a wireless telephone for a primary residence. It also allows participants to pay the remaining amount they owe on a deferred schedule, interest-free. For more information about qualifying, please visit the FCC's Lifeline and Link-Up program website.

Patients are in Good Hands

As the population of chronically ill patients grows, a healthcare system based solely on hospital stays is becoming less and less sustainable. With VoCare, a physician is able to maintain a close eye on the patient by accessing health data, talking directly with the patient via teleconference, and detecting health issues at their onset.

  • Physician Benefits
    • Promotes a new revenue stream via fee for remote consultation and clinical reviews.
    • Provides immediate and on-going connectivity with patients.
    • Enhances the doctor-patient relationship.
    • Creates a more efficient and profitable work-flow in provider's office.
    • Extends geographic outreach of provider services.
    • Promotes patient satisfaction and connectedness.
    • Improves patient quality of care and clinical outcomes.
    • Promotes early detection and intervention with healthcare issues.
    • Captures and transmits clear, concise and accurate patient data in a timely manner.
    • Enhances confidence in the delivery of care.
    • Provides a cost-savings approach that boosts productivity and profitability.
  • Hospital Benefits
    • Enhances revenue opportunities: A typical hospital is able to admit 200 to 300 more patients that will prove to be more cost effective and more profitable, even if the VoCare system is paid for by the hospital.
    • Reduces the cycle of emergency room visits and hospital re-admissions. 5% to 7% of ER visits are by unfunded or underfunded "frequent flier" patients.
    • Minimizes low-profit patients: Hospitals have a real financial interest in keeping certain types of patients, elderly and those with chronic diseases, from over-utilizing hospital services.
    • Reduces re-hospitalizations: 3% to 5% of ER visits are by patients who have returned within 30 days of discharge and for whom there is no additional payment. Based on current statistics, VoCare estimates that readmissions can be cut from 20% to over 50% simply by providing more effective patient management tools.
    • Assists in the reduction of time spent in hospital: Reduces Length of Stay (LOS) for problem DRG or episodic patients is an issue for all hospitals.
    • Supports Clinical Excellence: VoCare supports specialty programs and areas of clinical excellence such as cardiology, pulmonology, rehabilitation, and many others.
  • Home Healthcare Service Benefits
    • Provides reduction in operational costs: Episodic payment allows for cost savings to indirectly pay for technology.
    • Generates payment efficiencies: Pay-for-performance requirements create efficiency incentives for home health agencies.
    • Promotes cost efficiencies: Creates an opportunity to reduce 25% to 35% of nursing visits without a reduction in revenues.
    • Enhances case management of patients: Promotes improved case management of patients and integration with other providers.