AMA Conference Call on HC Reform

The AMA is doing regional conference calls on health care reform. The one for my region (PA, NY, MA, maybe others) was tonight. I gather it was the first one they've done so far, but they indicated they would be doing more.

On the call for the AMA were Immediate Pat president Nancy Nielsen, Jim Wilson, Political Education Programs Manager, and Richard Deem, Senior VP for Advocacy.

I was pretty pleased with the call and the positions that the AMA seems to be taking, so you may be pleasantly surprised.

The call started with some comments by Dr. Nielsen, then questions from the group (transcribed for the AMA reps, who read them to us), and a brief closing statement.

Dr. Nielsen opened with a discussion of HR 3200, presumably because of the push back the AMA has gotten from its more conservative members. HR 3200, in its original release addressed in positive ways, many of the AMA's highest priority goals. These included extended coverage for the uninsured, preserved choice of health insurance plans, fundamental Medicare reform including elimination of the SGR, encourages mangament of chronic diseases and coordination of care, increased payment to Primary Care Physicians with no reduction in fees to specialists.

The things in 3200 the AMA wants changed: addition of Medical liability reform; change in plan for public option fees to be 5% above medicare; and restrictions on physician ownership of hospitals.

Ammendments introduced so far include "modest" liability reforms (AMA speak for anything that is not "caps" on damage awards), including encouraging states to give incentive payments for certificate of merit and "early offer" programs, and she reaffirmed, essentially, that we're all about caps at the AMA. Also ammended, public plan participation by physicians will not be mandatory and public plan fees will be negotiable and not fixed to medicare rates.

Compromises still being sought include, in the Senate HELP committee: Public Plan similar to HB 3200; negotiated payments; the plan must be self sustaining, and compete on a "level playing field."

In the Senate Finance Committee, the bipartisan "Gang of 6" are seeking compromise legislation, but we have not seen an actual bill yet. But all indications are that this bill will NOT fix SGR (only another one year fix, then replay the annual ritual of rganized medicine fightinng to fix this again. The AMA wants to fix this with Senate FLOOR VOTE. Also concerning are possible penalties for PQRI non participation and that we may end up with co-ops rather than PO/PP. Dr. Nielsen preemptively addressed the question of why the AMA has postioned itself where it has re: HB 3200: We need insurance market reform because insurance is tenuous to the public, it is tied to jobs, it is limited by preexisting conditions and because we all pay for care given to uninsured anyway. Getting rid of SGR is a big deal for the AMA as is avoiding other financial penalties (such as with PQRI) and we do all have to be worried about costs.

She also points out that we physicians are being dealt with very fairly in HB 3200: Hospitals are going to get cuts, home health gets cuts, as do others while physicians get $230 Billion (erasing SGR debt is part of this number, but also includes higher fees for PCPs including incentives for coordinating care and dealing with chronic care patients)

Why did AMA support HB 3200 so quickly? Dr. Nielsen said that early support means something and gives us more influence; we are working with leaders in both houses and they understand Medicare must be strong(!). The AMA did not "give away" support; it was negotiated and we got things: No mandatory participation in a public plan, more money.

She points out that ranting is not useful, quiet negotiation does and is working.

QUESTIONS FROM AUDIENCE:

Q: Socialized medicine!!! Slippery Slope!!!! (I paraphrased here.)
A: NO: Americans will not tolerate it. Expanding coverage is not socialism.

Q: Will there be rationing under Medicare or under any public option.
A: NO NO NO

Q: Wwhy support anything without "significant" liabilty reform?
A: We're still fighting!

Q: How does AMA support 3200: It's awful.
A: No, it isn't. SGR!

Q: Can we have physician council to guide HC?
A: AMA may be filling this role in guiding legislation, but not clear if tere would be a way to do some far reaching council.

Q: Anything restricting physician patient relationship?
A: The AMA is FIRM in that there can be no interference in care decisions. CER will never mandate what a doctor may offer to a patient. MC is easier to deal with than PHIs(!!!), she said, from her perspective as a primary are physician. Less hoops with MC! We also want best evidence! Mr. Deem: No penalties on PQRI in HB 3200

Q: How can we support bill we haven't seen? Aren't we being used/abused?
A: Physicinas are necessary in this debate. Congress has brought actors together and said we are all in this together and we have to do this. NN thinks we are participating, not being used and we believe we have influenced the process significantly, but perhaps not on CAPS.

Q: HB 3200 better PCP fees?
A: Yes; also increased coordination of care fees.

Q: Did you read 3200?
A: Yes. We have a team that does that and they analyzed it. I have read it as well.

BIG POINT HERE: She calls out the BS email about he facts of HB 3200 as "outrageous," and notes that the AMA has reviewed, and agrees with the rebuttal provided by politifact.com.

Q: Massachusetts seems to be working well except cost controls, what now?
A: We need to learn from MA; getting people in system but costs are big issue; bigger question is how do we come to grips with our responsibility as citizens and patients and physicians and insurers? MA has shortages in work force, nursing and derm and gen. surgeons; We don't need to wait for workforce to be online before we reform HC; lead time too long for physicinas in particular. Choice of doctors and insurers key.

Q: 70-83% of peopple are satisfied with coverage; maybe they won't be if we change things; maybe Congress will lower reimbursement after the bill passes?
A: We are all nervous; but we are also the unhappiest MDs in the world. Prez says you can keep what you have; AMA is concerned about this and we want to preserve choice.

Q: Will Public Plan crowd out private insurers?
A: Bill is written so choice to join PP is limited (to the uninsured, small businesses and some others) but this could change and we must be vigilant.

Q: Why should we trust this administration?
A: Trust but verify. This is about influence and we are critical to change. It is important for us to pay attention and focus on what we agree on, and not on divisive issues.
Mr Deem: Adminstration trying to fix/improve payment formula and did something about MD administered drugs that AMA has been asking for for 8 years and we are just now getting it.

Dr. Nielsen made the point here that Obama's example of non-indicated tonsillectomy example. She thinks that was Really Bad; we know it is not like that; they got big push back.
[CMHMD: I actually agree that he really mangled this one; "inartful" was the kind way to put it, I thought.]

Q: Will there be an independent body, such as an uber-MEDPAC or IMAC, that will rule the roost?
A: Dr. Nielsen expressed concern that there seem to be expenditure targets for physicians, but not for any of the othr big players. She indicated the many if not all of these issues are "in process," and the AMA is expressing our concerns.

Dr. Nielsen added that she thought a view expressed what she called a "minority view" of physicians is that an independent council would be better than dealing with congress. [CMHMD: I don't think this is a minority view. Many health policy big wigs think having Congress function as the "Board" for Medicare is a bad thing that needs fixed.]

Q: CBO score for Senate Bills?
A: We don't know when we'll get them.

Q: Other countries physicians' have less financial pressure coming out of training.
A: We agree and are working on it.

Q: What should physicians be doing now?
A: AMA is happy to help and reach out. Like this call. Hard to say what to do; gives example of tea baggersand cautions that physicians need to be rational and let people know we want to take care of patients without government interference and make sure uninsured get in system and don't saddle kids with crushing debt. Don't fall for labels and rhetoric.

Q: What happens to HSAs?
A: Mr. Deem: HSAs stay in so far. And we will push for that.

Q: Geographic variation?
A: AMA pushing for money for IOM study. Gypsy payment floor (?)

Closing, Dr. Neilsen: This is moving target. What's the difference between an echanges and a co-ops? Exchanges are like a mall to shop; co-op like a single store where owners are also customers.
[CMHMD: I'd call this mutual insurance, and it could be a good thing if well regulated.]

CMHMD final comments: I fouund this very encouraging. There was the expected conservative push back, but that's OK, Dr. Nielsen did a great job of keeping things focused on what are truly high goals for physicians: universal access and fairness in the system. She also stuck to the markers she must or get pummelled by the membeship on tort reform and "choice," but, hey, pretty good from where I'm sitting!

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Interviews with KDKA and PCNC for Doctors for America

I had a couple of interviews with conservative talk hosts here in Pittsburgh Monday night on the Pittsburgh Cable News Channel with Kevin Miller and Tuesday morning on KDKA radio with Mike Pintek as representative for Doctors for America on health care reform. I thought I'd share, and perhaps get a little constructive input.

I have to say that I thought both hosts were fair to me, though the television host seemed to try to bait me into peripheral discussions [He is a moon landing skeptic, for instance!] while the radio host was more focused on getting detailed information out of me, which I appreciated.

The issues that seem to be the most concerning to conservatives, or at least get them the most stirred up, are those concerning the cost of the program and the impact on
the budget and, of course, taxes, the ceding of control of health care decisions, or rationing decisions, in their minds, to the dreaded government bureaucrats, and euthanasia. Believe it or not.

My response to the cost argument is the one you all know, that our current non-system costs way too much, far more than any other place on the planet, including the countries like
France and Germany who cover everyone, don't ration in any significant way, and have no longer waiting times than our own.

Skepticism abounds about drawing any lessons on health care reform from other nations, as the utter failure, in the conservative mind, of Canada and Britain, necessarily precludes us from learning anything at all from them. I did manage to point out that while both Canada and England have had problems with their systems due primarily to inadequate spending, they did manage to insure everyone. I also pointed out that in Britain, since the liberal Labor Party took over from the Conservative Thatcher/Major governments, things have improved significantly on the waiting times front.

They expressed concerns about the cost of the Public Option being thrown about of a trillion dollars or more. In the context of health care spending currently of 2.4 trillion, one trillion over ten years, or 0.1 trillion per year does not seem like much. On the other hand, we are in danger of putting a layer of something that should be good over top a heap of a messed up non-system. I specifically agreed that Obama's message that, if we were starting from scratch, single payer makes the most sense was true. “Government Bureaucrats!” Mr. Pintek played a clip of Barney Frank saying that if the public option were done well and performed well, it could very well lead to single payer. Mr. Pintek suggested that they were trying to be sneaky with this, but I suggested that if they were, this was not a very sneaky way to do it. But even if this was how it would turn out, where's the harm? If the public option proves to be so wildly popular that private insurers get crowded out and the public in the end decides that perhaps this is the best way to provide health care, isn't that a great thing? “Government Bureaucrats!”

So, rationing is next, and is always the real subtext of all of this. Both hosts were aware that insurance companies sometimes deny care, but neither seemed to consider that we
ration by income. I told both the story of a patient of mine who was a middle aged man, without insurance for quite a while. He'd had a cough for close to a year followed by an intermittently bloody cough for a couple months and then developed such difficulty breathing that he finally came to the emergency room and then into my ICU with respiratory failure. He had, by this time, metastatic lung cancer. I pointed out that while you can go to the emergency room for emergency care, the familiar canard of “they can just go to the emergency room,” rings hollow in nearly every basic health care situation. I paraphrased from a wonderful letter from the New York Times, and pointed out that ER's don't do cancer care nor manage asthma nor prenatal car nor diabetes and don't do any of the things we think of when we talk about every day health care needs.

But what about government bureaucrats rationing health care? They both seemed disbelieving that this did not seem to concern me terribly. I argued that we could be well served by a commission made up of physicians who used comparative effectiveness research and analyzed the benefits and costs of treatment to help guide us , rather than medical directors at private health insurers making these determinations.

I regret that we did not get to end of life issues on the PCNC show, but we did on KDKA. I was asked what I thought of the House Bill and what it would mean to us with respect to Advance Directives and forcing the elderly to forego treatment. I think that it will finally make decent payment available for physicians to do Advance Care Planning, which is the term for having discussions on what a patient's wishes are when they are at the end of their lives. This is a very good thing, something that physicians involved in EOL care have been advocating for for years because it is the right thing to do. I have EOL discussions with patients and families literally every day I spend in the ICU. Letting your family know what you want at the end of life is a great gift to them. I tell this to patients and families all the time and it is so true: these are agonizing decisions to make when you have not had these important discussions. If people think about this even for a minute, they will know it is true. I also pointed out that advance directives can go either way, and if you want every last treatment until they are nailing your coffin shut, you can specify that in your AD as well.

We took a few emails/calls on KDKA. The first was not so much supportive, as antagonistic to the host and the conservative listeners. Thanks, but no thanks for that email. The
second was from a nurse who wanted an “American” solution and seemed to resent my referring to France and germany, but in the end, seemed to agree that we needed reform and I think was OK with a
public option as a way to get there. I think it was at this point, Mr. Pintek caught me flat footed when he followed up and asked how Germany makes decisions on what is covered and what is not. I recalled that the benefits packages provide by the insurers there were standardized, but what I wasn't aware of was that they have a commission that does do cost benefit analysis on treatments before they are approved as benefits. This commission has been accused of dragging its feet on new treatments, but this likely reflects a bias among many physicians to not adopt treatments until the evidence is solid. This has actually been studied in the US, and Massachusetts, with Harvard and Mass General and some of the finest health care in the world has this same regional bias and are slow to adopt new treatments. I'll try to remember this for next time!

The last call was from a physician's spouse who had heard me speak about Medicare and what I consider its adequate reimbursement. The host had said he thought the reimbursement was low and that some doctors would not accept it. I pointed out that, depending upon where in the country you practice, Medicare may be your best payer (Nevada, Southeastern PA) or at least, as in the Pittsburgh area where we are, not too far off from private insurance plans. I also pointed out the cost
of $82K per physician annually to deal with insurers and billing.

I had also pointed out that most doctors support some form of national health insurance, particularly PCPs and even a majority of general surgeons, but not some specialists like radiologists, anesthesiologists, and surgical specialists. I think she was a little peeved by that, because that's what she started her comment with. She said that many doctors won't take Medicare, and especially when they go to national meetings she hears this from people around the country. I have heard this before, even from fellow Doctors for America physicians telling me what they hear from colleagues. But if you look at what Medicare actually pays us, the regional variation is very small, with the exception of Alaska (the physicians of Alaska owe fromer Sen. Stephens for that). So whether Medicare fees look like a pittance to you or not has more to do with what your private insurers are paying you than what medicare is paying you. So, certainly physicians will look at a $150 fee from a private plan and a $100 fee from Medicare and conclude that Medicare may not be worthwhile. That is not unreasonable, but when you factor in the cost of dealing with private insurers, $82K per doc or about 14% of overhead, maybe Medicare is subsidizing the private plans! Anyway, I wish I'd had the presence of mind to ask what her husband's specialty was!

Things I didn't get to squeeze in but will try to next time:

• "It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein." Teddy Roosevelt, “Man in the Arena” The Sorbonne, Paris, France, 1910

  
  

• Public
  opinion favors not only the public option, but national health insurance of some kind. And they are willing to pay more in taxes for it, even if this is phrased in such a misleading way in every polling I've ever seen.

  
  

• England's NICE, by analyzing cost of care in the context of benefits to patients has led to price reductions from pharmaceutical companies in order to meet their cutoff. And NICE can be pressured if it is felt to be making unwise recommendations.

  
  

• Having an independent commission running Medicare, rather than Congress, might be quite an improvement.

  
  

• If we do manage to get to a German or French style system, which party would be more likely to demand cost cutting resulting in longer waiting times and rationing of care?

  
  

• I was asked about Massachusetts and demurred because I really don't know enough to comment intelligently. I wish I had referred them to the PNHP site, as they have lots of information and intelligent critiques of what's going on there.

  
  

And things to add from your comments will go here:

• 
  

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Health Care in Germany

Health Care in Germany:

This is from a British source, The Institute for the Study of Civil Society

First, Germans are free to visit any doctor they like. They may either walk in off the street, or ring for an appointment that will invariably be booked for the same morning or afternoon. Consumers can and do penalise bad service. Our recent study of German consumers commonly produced reactions like this: 'I saw a long queue, so hopped on the tube and went to a different practice'; 'she was rather ill-tempered so I never went back'; 'the facilities were drab, so I went to a different one next to my office'; 'I felt rushed at his practice so didn't go back'.

Second, Germans do not have to see a GP before visiting a private specialist. GPs do act as gatekeepers to German hospitals, but about half of all specialists practice outside the hospitals. German hospitals provide few out-patient services. Instead, there are a large number of independent clinics, invariably with the most sophisticated diagnostic equipment. Most Germans have a favourite GP, although many maintain a relationship with more than one - just in case - but if they need to see a specialist they would not waste time seeing a GP first.

Third, there are plenty of specialists. Germany has 2.3 practising specialists for every 1,000 people, compared with only 1.5 in the UK.

What problems are there in Germany? The German media is not excited by the subject. There are no patients lying on trolleys in A&E. Germany suffers no real rationing. Yes, problems occur from time to time. Just at the moment, there is a shortage of nurses, and many Germans feel that care is expensive, but serious complaints are few. Nevertheless, reform is in the air. Since January 2004 members of the statutory insurance plan have had to pay 10 euros per quarter to see a GP.

The reforms also saw the introduction of charges for non-prescription drugs, and an end to free treatments such as health farm visits and to free taxi rides to hospital. This is expected to allow for a reduction in premiums from an average of 14 to 13 per cent of annual gross wages.

German satisfaction rates in 1996, the latest Eurobarometer survey, showed that the German are far more satisfied with their system than we are with the NHS. About 11 per cent of Germans said they were 'very or fairly dissatisfied', compared with 41% per cent here. And when asked whether their system needed 'fundamental
changes' or a 'complete rebuild' 19 per cent of Germans said 'yes', compared with 56 per cent of Britons.

Does the German healthcare system deliver an acceptable standard of care for serious illness to all members of society? Do the poorest in society benefit from a higher standard of healthcare provision than those in the UK? The answer to both of these questions is an emphatic, 'yes'.

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HEALTH REFORM: Poll Shows Hopes, Not Just Fears for Reform | New America Blogs

HEALTH REFORM: Poll Shows Hopes, Not Just Fears for Reform New America Blogs:

The poll doesn't indicate that Americans would prefer not to have health reform. In fact, the data shows just the opposite. When asked what they though would happen if 'the government did NOT create a system of providing health care for all Americans,' a solid majority of people were 'very' or 'somewhat' concerned that the number of uninsured people in the U.S. would keep increasing, that they themselves might be uninsured at some point and that the cost of their own health care would go up.

To us, the poll doesn't indicate support is falling apart for health reform -- it does mean that uncertainty is on the rise. This is understandable, as a lot of details are still being hashed out and even members of Congress have difficulty quickly grasping all the complexities of the policy options being discussed right now. That's why it will be important for advocates of reform, including the President, to explain it clearly (and repeatedly) in the coming weeks. Shift the focus from the scary unknown to the known -- that the current system is broken, and it's time to fix it. Because there's a lot in it for all of us.

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450,000 Doctors Demand: ‘Heal Health Care Now’ -- Media Center -- American Academy of Family Physicians

450,000 Doctors Demand: ‘Heal Health Care Now’ -- Media Center -- American Academy of Family Physicians:

Today marks the launch of “Heal Health Care Now.” This Web-based initiative (HealHealthCareNow.org) consists of several elements, including a provocative video of family doctors speaking in support of the health system reform legislation Congress is debating currently. The video culminates with a call to action encouraging viewers to let their legislators know they stand behind nearly half a million doctors to support reform. The Web site also provides a quick and easy tool that encourages viewers to contact their legislators directly.

Also today, organizations representing 450,000 doctors signed and delivered a joint letter indicating their support of health care reform to Sen. Harry Reid (D-Nev.) and his colleagues in the U.S. Senate. The American Academy of Family Physicians along with the American College of Physicians, the American Osteopathic Association, the American Medical Student Association, Doctors for America and the National Physicians Alliance signed the letter which reads in part, “We are confident that the reforms being proposed will allow us to provide better quality care to our patients, while preserving patient choice of plan and doctor.”

Two national nonpartisan health care organizations — the AAFP and the Herndon Alliance — developed the online “Heal Health Care Now” initiative in a strategic effort to counter some of the most potent anti-reform arguments with the most trusted spokespersons — front-line family doctors. The AAFP represents more than 94,000 family physicians and medical students. The Herndon Alliance is a nationwide coalition of more than 200 minority, faith, labor, advocacy, business, and health-care provider organizations, including the American Nurses Association, the American Academy of Pediatrics, the AARP, the Mayo Clinic and Families USA.

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Facts About Healthcare Costs - National Coalition on Health Care

NCHC Facts About Healthcare - Health Insurance Costs:

In 2008, total national health expenditures were expected to rise 6.9 percent -- two times the rate of inflation.1 Total spending was $2.4 TRILLION in 2007, or $7900 per person. Total health care spending represented 17 percent of the gross domestic product (GDP).

U.S. health care spending is expected to increase at similar levels for the next decade reaching $4.3 TRILLION in 2017, or 20 percent of GDP.1

In 2008, employer health insurance premiums increased by 5.0 percent – two times the rate of inflation. The annual premium for an employer health plan covering a family of four averaged nearly $12,700. The annual premium for single coverage averaged over $4,700.2

................

National Health Care Spending

In 2008, health care spending in the United States reached $2.4 trillion, and was projected to reach $3.1 trillion in 2012.1 Health care spending is projected to reach $4.3 trillion by 2016.1
Health care spending is 4.3 times the amount spent on national defense.3

In 2008, the United States will spend 17 percent of its gross domestic product (GDP) on health care. It is projected that the percentage will reach 20 percent by 2017.1

Although nearly 46 million Americans are uninsured, the United States spends more on health care than other industrialized nations, and those countries provide health insurance to all their citizens.3

Health care spending accounted for 10.9 percent of the GDP in Switzerland, 10.7 percent in Germany, 9.7 percent in Canada and 9.5 percent in France, according to the Organization for Economic Cooperation and Development.4

Employer and Employee Health Insurance Costs

Premiums for employer-based health insurance rose by 5.0 percent in 2008. In 2007, small employers saw their premiums, on average, increase 5.5 percent. Firms with less than 24 workers, experienced an increase of 6.8 percent.2

The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $12,700 in 2008. Workers contributed nearly $3,400, or 12 percent more than they did in 2007.2 The annual premiums for family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker ($10,712).

Workers are now paying $1,600 more in premiums annually for family coverage than they did in 1999.2

Since 1999, employment-based health insurance premiums have increased 120 percent, compared to cumulative inflation of 44 percent and cumulative wage growth of 29 percent during the same period.2

Health insurance expenses are the fastest growing cost component for employers. Unless something changes dramatically, health insurance costs will overtake profits by the end of 2008.5

According to the Kaiser Family Foundation and the Health Research and Educational Trust, premiums for employer-sponsored health insurance in the United States have been rising four times faster on average than workers’ earnings since 1999.2

The average employee contribution to company-provided health insurance has increased more than 120 percent since 2000. Average out-of-pocket costs for deductibles, co-payments for medications, and co-insurance for physician and hospital visits rose 115 percent during the same period.6

The percentage of Americans under age 65 whose family-level, out-of-pocket spending for health care, including health insurance, that exceeds $2,000 a year, rose from 37.3 percent in 1996 to 43.1 percent in 2003 – a 16 percent increase.7

The Impact of Rising Health Care Costs

National surveys show that the primary reason people are uninsured is the high cost of health insurance coverage.2

Economists have found that rising health care costs correlate to drops in health insurance coverage.8

A recent study by Harvard University researchers found that the average out-of-pocket medical debt for those who filed for bankruptcy was $12,000. The study noted that 68 percent of those who filed for bankruptcy had health insurance. In addition, the study found that 50 percent of all bankruptcy filings were partly the result of medical expenses.9 Every 30 seconds in the United States someone files for bankruptcy in the aftermath of a serious health problem.

A new survey shows that more than 25 percent said that housing problems resulted from medical debt, including the inability to make rent or mortgage payments and the development of bad credit ratings.10

About 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs. 11

A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses.12

Retiring elderly couples will need $250,000 in savings just to pay for the most basic medical coverage.13 Many experts believe that this figure is conservative and that $300,000 may be a more realistic number.

According to a recent report, the United States has $480 billion in excess spending each year in comparison to Western European nations that have universal health insurance coverage. The costs are mainly associated with excess administrative costs and poorer quality of care.14

The United States spends six times more per capita on the administration of the health care system than its peer Western European nations.14

Acrobat version with references is here.

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Presentation for Medicare 44th Anniversary

I gave a presentation in Avalon, PA on the occasion of the 44th Anniversary of Medicare, Thusday July 30, for Organizing for America. Thanks to everyone who came and were so kinly receptive to the talk, and of course to Terry, Al, Peter and Sylus for organizing things!

'>The slides are here.

The references in the slides are all on this blog somewhere, just search in the upper left hand corner to find them.

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