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Articles on USPS National Reassessment Program

Two More Postal Districts Added to Phase 2 of National Reassessment Process

posted April 29, 2007

From PostalReporter Reader: Phase 2 of the NRP is scheduled to commence in the Westchester NY and Salt Lake City District (UT) late April 2007, both districts. All National unions and management associations were notified on April 10, 2007 of the Implementation of Phase 2. Below is a copy of the letter sent to APWU :

USPS Implements Phase Two of Outsourcing Injured on Duty Employees

posted March 27, 2007

USPS National Reassessment Process for Injured On Duty Workers Goes Nationwide in January 2007

posted December 18, 2006

(December 18, 2006) *by Gary Neuharth -President-Bismarck-Mandan APWU Area Local #349 (via 21cpw.com)

I have been informed that United States Postal Service’s National Reassessment Process for limited duty employees is going nationwide in January, 2007. Pilot sites for NRP were NY Metro, San Diego, and Western, NY. National APWU apparently has been briefed. The USPS Area Managers will be rolling out their plan of action to USPS Districts very soon.

The USPS reassessment process will be reviewing cases of 33,707 employees whom are currently on rehabilitation / limited duty assignments. This process will determine which employees can return to available work, and who qualifies in terms of OWCP compensation. It is obvious that USPS is seriously looking at compensation eligibility.

USPS team members include senior operations manager, labor relations personnel, legal personnel, manager of injury compensation, NRP injury compensation leader, and medical personnel. It would be a good idea for APWU leaders to prepare for the USPS action if you represent employees currently on light duty. I suspect the USPS methods are to remove as many USPS employees from OWCP compensation as possible, and get employees back to work. Unfortunately, many very deserving employees will be run through the wringer, and stressed out by this process. These injured postal workers have rights, and APWU must insure that USPS follows procedures and regulations set forth in our nation’s laws.

I doubt you will find this reassessment process friendly. It comes with prescribed distrust by management of any injured employee.

U.S. Postal Service ‘Outplacement Program’ Goes Nationwide (National Reassessment Program)

The Postal Service aggressively monitors limited-duty and rehabilitation assignments, and in May 2005 notified [pdf] the APWU that the USPS would begin a reassessment of rehabilitation jobs and limited duty assignments. The “reassessments” will be implemented nationwide, by District. San Diego has become the initial site, and is set to begin late this summer. A pilot program was initiated in April 2004 in the Long Island (NY) District.

The Postal Service contends that the program is necessary because there are a declining number of jobs available for injured employees who have substantial medical limitations. If there is no medically-suitable job available for such an employee, the Postal Service will refer the employee to OWCP for placement in OWCP’s vocational rehabilitation program and eventual re-employment in the private sector.

The Postal Service has stated that the program does not establish new policy, nor does it apply any new rules or regulations. The USPS has made a commitment that any action taken as a result of the outplacement protocols will be in compliance with the Employee and Labor Relations Manual (ELM), the Federal Employees’ Compensation Act (FECA), the Code of Federal Regulations (CFR), the Rehabilitation Act, and all other applicable rules, regulations, or statutes.

Every limited-duty and rehabilitation assignment should be made on a case-by-case basis after an individual assessment. Decisions regarding the availability of medically-suitable employment must be based on the specific fact circumstances unique to each employee. Blanket or wholesale reassignments violate federal law and postal regulations.

APWU  has prepared a set of guidelines, USPS Withdrawal of Limited Duty/Permanent Rehabilitation Assignments that may be useful in determining what action to take if the Postal Service withdraws an injured employee’s limited duty or rehabilitation assignment.

OWCP - Privacy Rules, Violations - Claimants and their doctors should be well prepared when confronted with an OIG investigation -  The American Postal Worker magazine, March/April 2006 issue, pg. 45

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USPS to Implement Pilot Program to 'Outsource' Injured On Duty Employees

PostalReporter.com has received the following additional information surrounding this matter: An EEO (Edmond Walker v John E Potter Case # is EEOC No.320-A2-8390. The Agency # is CC-800-0359-03.) has been filed involving 861 Rehab postal employees from the Colorado/Wyoming District. The case is awaiting class certification. . The Colorado/Wyoming District Office has until April 21, 2004 to provide the EEOC administrative judge with the list of names of the 861 individuals whom have filed Disability complaints in the Colorado/Wyoming District . The class action certification sought by the Walker case consist of: "All permanent rehabilitation employees whose duty hours have been restricted, from January 1, 2000 to the present, in violation of the Rehabilitation Act of 1973."

Postal Employee Advocate on Outsourcing - Regarding the Outsourcing article.  Please also make the unions aware that an "individual who has partially recovered from a compensable injury and who is able to return to limited duty..at a minimum (should be) treat(ed) ...substantially the same as other handicapped individuals under the Rehabilitation Act of 1973"   5 C.F.R. Section 353.301.  That means that before any of these employees can be moved to the private sector, the Postal Service MUST perform an individualized assessment of the employee, and of postal positions available in the commuting area.  If management fails to make this individualized assessment, then they are in violation of the Rehab Act.  Additionally, if an employee partially recovers from a compensable injury, is available for limited duty work, and the agency fails to provide it, then the employee should file an appeal with the Merit Systems Protection Board. I represent postal employees exclusively in EEO and M.S.P.B. appeals.  If I can be of any assistance to postal employees, or to their unions, please don't hesitate to contact me at visit my web site at www.postalemployeeadvocate.com

As Always, I Am,
J.R. Pritchett, Employee Advocate

District Court Rules USPS violated the Rehabilitation Act- Postal Worker Fired After Eight Years Of Leave Wins Disability Case- An Illinois  Postal Clerk who was on disability leave for over eight years before USPS cut off her benefits and fired her demonstrated that the Postal Service violated the "Rehabilitation Act"  by cutting off disability benefits without investigating whether she could fill another job (4/5/04)

Jump to bottom of page to read excerpts of  USPS' Transformation Plan and Workers' Compensation Strategy. Any

April 3, 2004 

Subject:                      Outplacement Pilot Program

  To:                               All BRANCH PRESIDENTS & Stewards in Charge

                                    Executive Board Members

The Postal Service has informed the National Postal Mail Handlers Union (NPMHU), both at the national and local levels, of its intentions to implement an Outplacement Pilot Program.  The Postal Service will proceed with this program in conjunction with the Department of Labor (DOL), Office of Workers’ Compensation Programs (OWCP).  The program is intended to develop work opportunities outside the Postal Service for employees who have sustained job-related illness or injury (IOD).  The program will be initiated in the Long Island District and later will include the other districts in the New York Metro Area.  It is the intention of the Postal Service to eventually implement this program nationwide.

A meeting was held on April 1, 2004, in which the Postal Service introduced the pilot process to representatives of the local unions.  Representatives of Local 300 attended this meeting along with representatives of the APWU, NALC and NAPS.  Local 300 was represented at this meeting by President Paul Hogrogian, NY State Executive Board Member Larry Hill, and Branch Presidents Robert Lussos (Mid Island) and Kevin Tabarus (NYPMPC).  Representatives of OWCP did not attend the meeting.

At this meeting the Postal Service contended that because of a decline in mail volume, they no longer had sufficient work to keep all of their limited duty (injured on the job) employees employed.   The Postal Service explained that it was initially targeting “rehab” employees, but would later expand the program to include other limited duty employees. 

“Rehab” employees were defined as those employees who were injured on the job and who have partially recovered from an injury or illness, but have reached “maximum physical improvement” as stated by the employee’s treating physician.  In other words, permanent limited duty employees.  Should the Postal Service determine, at the installation level, that there is not 8 hours work per day or 40 work hours per week within a Rehab employee’s limitations, that employee would be targeted for participation in this program.  The initial targets will be those employees who are sent home early due to lack of work.  The Postal Service could easily manufacture a “shortage of work” by sending limited duty employees home 2 or 3 hours early a day for 2 or 3 days a week and pay the employees compensation for the hours sent home.

The Long Island District has identified 12 employees for Phase I of this program (1 supervisor, 10 letter carriers and 1 Mail Handler).  Local 300 was successful in having the Mail Handler removed from this phase of the program due to the specific, individual circumstances of his case.  Those chosen employees will be given a letter on April 12, 2004, notifying them that they will be placed on administrative leave.  These employees will also be given a CA-7 form (compensation) to be completed.  These employees will then be placed in a compensation status effective April 17, 2004.  The OWCP will then contact these employees to schedule individual interviews.

Should the OWCP successfully place these employees in positions outside of the Postal Service, the employees would cease to be postal employees. If the new positions pay less than their postal position, OWCP will pay the difference.  However, the employees would lose all postal benefits (health insurance, life insurance, TSP, etc.).  The benefits would be that of their new private employer, not the Postal Service.  The employees would also cease to accrue creditable time towards their federal retirement plans.

Local 300 believes that it is disgraceful that the Postal Service should cut ties with those employees who were permanently injured in the performance of their postal duties.  While postal managers give lip service as to how important their employees are to them, the intent of this program says otherwise.  The Postal Service wants to eliminate what it considers to be “dead weight.”  It simply is not fair to postal workers and their families that postal workers should lose their health benefits and their pensions, solely because they had the misfortune of being injured in the performance of their assigned duties.  Instead of living up to its responsibility to find suitable work within the Postal Service, the Postal Service would rather shift its responsibility and costs to the OWCP and ultimately to the American taxpayer.

Local 300 will oppose this program however and wherever we can, including through the Grievance/Arbitration, MSPB, EEOC and legislative forums.

Should a Mail Handler be chosen for this program, a grievance should immediately be filed under the following Articles:

Article 2 (Discrimination) (denial of reasonable accommodation)

Article 6 (No Lay Off)

Article 13 (Light Duty)(denial of permanent light duty) (13.2b)

Article 19 (Handbooks and Manuals)

Employee and Labor Relations Manual (ELM) section 543.93 provides that an employee can be separated from the Postal Service only at the end of at least 1-year leave without pay (LWOP).

ELM, sections 546.14, mandates that the Postal Service “make every effort toward assigning the employee to limited duty consistent with the employee’s medically defined work limitation tolerance.”  This includes work not only within the employee’s craft and installation, but also outside of the employee’s craft and installation if no work is available within the employee’s craft and/or installation.

EL-505 (Injury Compensation), Exhibits 7.1 and 11.7b provide similar protections for limited duty and rehab employees.

 EL-505, Exhibit 11.8d, states:

 “When an employee, either current or former, has partially recovered from a compensable injury or disability, the USPS must make every effort toward assigning the employee to limited duty consistent with the employee’s medically defined work limitation tolerance according to the circumstances of each case.”

 EL-505, Exhibit 11.8d states:

 “Partially-recovered employees may appeal to the MSPB for a determination of whether the USPS is acting arbitrarily and capriciously in denying them restoration.”

 ELM, section 546.4 states,

 “Current or former employees who believe they did not receive the proper consideration for restoration, or were not properly restored, may appeal to the Merits Systems Protection Board under entitlements set forth in Title 5 CFR, Part 353.”

 Therefore, any Mail Handler who is selected for this program should file an MSPB appeal claiming denial of restoration rights.  Veteran Preference employees should also file an MSPB appeal citing an improper Reduction in Force (RIF).

 Affected employees should also file an EEO claim citing denial of reasonable accommodations.

 It is also imperative that our congressional representatives be contacted to alert them to the fact that hard working, deserving, injured employees are being forced out of well paying federal jobs and forced into lower paying private sector jobs that are subsidized by the federal government.

 Should any Mail Handler receive a letter stating that they are to be included in the Outplacement Pilot Program, Local 300 Headquarters should be contacted immediately.

 Should you have any questions concerning this matter, do not hesitate to contact me.

                                     Fraternally,

                                     ------------------

                                    Paul Hogrogian

                                    President

                                    Local 300

CC:                Hegarty-President NPMHU

                       Flynn-Cad NPMHU

                       Sokolowski-NE Region NPMHU

                       File

Outplacement Pilot Program for Mail Handlers:

Date:               April 3, 2004

Senator Hillary Clinton

US Senate

Washington, DC 20510

 Dear Senator Clinton,

 My name is Paul Hogrogian and I am President of Local 300 of the National Postal Mail Handlers Union (NPMHU), which serves as the exclusive bargaining representatives for approximately 6,400 mail handlers in the New York metropolitan area employed by the U.S. Postal Service.

 The Postal Service has informed the National Postal Mail Handlers Union (NPMHU), both at the national and local levels, of its intentions to implement an Outplacement Pilot Program.  The Postal Service will proceed with this program in conjunction with the Department of Labor (DOL), Office of Workers’ Compensation Programs (OWCP).  The program is intended to develop work opportunities outside the Postal Service for employees who have sustained job-related illness or injury (IOD).  The program will be initiated in the Long Island District and later will include the other districts in the New York Metro Area.  It is the intention of the Postal Service to eventually implement this program nationwide.

 A meeting was held on April 1, 2004, in which the Postal Service introduced the pilot process to representatives of the local unions.  Representatives of Local 300 attended this meeting along with representatives of the APWU, NALC and NAPS.   Representatives of OWCP did not attend the meeting.  At this meeting the Postal Service contended that because of a decline in mail volume, they no longer had sufficient work to keep all of their limited duty (injured on the job) employees employed.   The Postal Service explained that it was initially targeting “rehab” employees, but would later expand the program to include other limited duty employees. 

 “Rehab” employees were defined as those employees who were injured on the job and who have partially recovered from an injury or illness, but have reached “maximum physical improvement” as stated by the employee’s treating physician.  In other words, permanent limited duty employees.  Should the Postal Service determine, at the installation level, that there is not 8 hours work per day or 40 work hours per week within a Rehab employee’s limitations, that employee would be targeted for participation in this program.  The initial targets will be those employees who are sent home early due to lack of work.  The Postal Service could easily manufacture a “shortage of work” by sending limited duty employees home 2 or 3 hours early a day for 2 or 3 days a week and pay the employees compensation for the hours sent home.

 The Long Island District has identified 12 employees for Phase I of this program.  These employees will be placed in a compensation status effective April 17, 2004.  The OWCP will then contact these employees to schedule individual interviews.

 Should the OWCP successfully place these employees in positions outside of the Postal Service, the employees would cease to be postal employees. If the new positions pay less than their postal position, OWCP will pay the difference.  However, the employees would lose all postal benefits (health insurance, life insurance, TSP, etc.).  The benefits would be that of their new private employer, not the Postal Service.  The employees would also cease to accrue creditable time towards their federal retirement plans.

 Local 300 believes that it is disgraceful that the Postal Service should cut ties with those employees who were permanently injured in the performance of their postal duties.  While postal managers give lip service as to how important their employees are to them, the intent of this program says otherwise.  The Postal Service wants to eliminate what it considers to be “dead weight.”  It simply is not fair to postal workers and their families that postal workers should lose their health benefits and their pensions, solely because they had the misfortune of being injured in the performance of their assigned duties.  Instead of living up to its responsibility to find suitable work within the Postal Service, the Postal Service would rather shift its responsibility and costs to the OWCP and ultimately to the American taxpayer.   Hard working, deserving, injured employees should not be forced out of well paying federal jobs and forced into lower paying private sector jobs that are subsidized by the federal government.

 Local 300 asks that you investigate this matter and provide any assistance that you can.  I will be happy to meet with you to discuss this important and urgent issue.  Thank you for your time, and I look forward to hearing from you.

 Sincerely,

 Paul Hogrogian

President

Local 300/NPMHU

Workers' Compensation and the USPS Transformation Plan

The general purpose of addressing workers' compensation in the Transformation Plan is to reduce costs to the Postal Service for injuries that are sustained on the job. The Transformation Plan states that there are specific issues under FECA that are contributing to their escalating compensation costs:

1. The Postal Service's inability to contact the employee's medical provider by phone.
2. The fact that there is no waiting period before wage-loss compensation is paid for traumatic injuries.
3. They believe that compensation rates are too generous. They propose only one rate (66 2/3%).
4. The Postal Service contends that compensation should not be a lifetime benefit. At retirement age, compensation should be adjusted to a tax-free amount equal to what a retiree would receive.
5. Medical costs are not adequately controlled by fee schedule.

They are proposing five "sub-strategies" to achieve these goals.

Sub-strategy 1: Expand the Preferred Provider Organization Program with First Health and Office of Workers' Compensation Programs. We announced in previous articles, and on the website, that the Postal Service was undertaking a pilot program with First Health to save money on medical expenses relating to workers' compensation claims. This proposal would expand the pilot from its current locations and enact it nationwide. First Health pays medical providers at agreed upon rates that are usually substantially lower than what OWCP would allow through their bill payment system. This savings is filtered back to the Postal Service.

Sub-strategy 2: Move all Federal Employees' Compensation Act recipients to FECA annuity at age 65. The plan states: "Employees who receive benefits through the FECA program will receive 66 2/3 percent or 75 percent of their basic salary, the latter for employees with a dependent. This tax free salary is extremely generous and in many instances equates to as much as 25 percent more than what the employee would receive for a comparable OPM retirement through one of the government programs. The annual compensation cost of living adjustments that are added each year to an employee on total injury disability rewards someone who stays out on compensation versus returning to work." The Postal Service is proposing a FECA managed retirement program that would calculate benefits similar to those of a normal retirement for all present and former employees over age 65 on the compensation rolls of OWCP. What this means is that once an injured worker reaches age 65, his/her compensation benefits would be recalculated from the 66 2/3% or 75% level to a figure that would more closely mirror their earned retirement benefits.

Sub-strategy 3: Encourage the Office of Workers' Compensation Programs to revise current regulations to allow for direct contact with the treating physician by the employing agency. In January 1999 OWCP amended their regulations to prevent agency personnel from contacting an employee's treating physician directly (by phone and/or in person). The Postal Service is looking to regain that right in order to explain limited duty assignments and offer options to accommodate employees. The Postal Service believes that changing this current regulation would ensure that postal managers initiated close monitoring of employees' physical condition and it would allow early worker's compensation program specialists' intervention to assist the employee in a speedy return to the work environment.

Sub-strategy 4: Private sector outplacement of Injured Postal Service employees and the creation of new internal positions to accommodate injured workers. The goals of this strategy are to successfully implement, with OWCP, an accelerated private sector placement program that reduces the amount of time necessary for an outplacement from up to two years to less than one year, and to reduce the number of postal employees in non-productive rehabilitation assignments by placing them in private sector employment.

Sub-strategy 5: Interagency work cooperation to attain organizational objectives. The Postal Service believes that cooperation must exist between them and the OWCP, especially as it relates to the timely processing of compensation claims and medical bills. The Postal Service wants to work with OWCP in developing joint strategies to achieve both agency's objectives and not at each other's expenses. The goal is to have all claims paid in a timely manner, while performing quality checks to prevent the duplicate payment of medical bills.

(source: NALC)

____________________________________________________________________________________________________

Excerpts from the  Transformation Plan

Strategy 10: Reduce Injury Compensation Costs

Substrategy 1: Expand the Preferred Provider Organization Program with First Health and Office of Workers’ Compensation Programs

Background
Expand the preferred provider organization (PPO) program with First Health throughout the Postal Service. First Health, through their hospital and physician network, is able to reduce medical fees below what Office of Workers’ Compensation Program (OWCP) allows through their fee schedule. The Postal Service is presently operational in four of ten OWCP district offices and needs to expand systemwide. First Health is also able to identify duplicate medical payments that get through OWCP’s medical bill payment system. First Health is the nation’s largest  PPO network and is presently reaching 50 percent of the Postal Service’s injured employees. Network provider bills are paid at agreed contract rates that are usually substantially lower than what OWCP allows. The Postal Service needs to expand this program as quickly as possible to maximize savings.

Milestones
* Continued expansion of program to additional Department of Labor regions (2002).
* Expansion of the program throughout the Postal Service (2003).
Metrics
The actual provider network savings to the Postal Service in dollars and the additional savings in dollars to the Postal Service by preventing duplicate payments that OWCP would have missed.

U. S. Department of Labor – Office of Workers Compensation Programs
Substrategy 2: Move all Federal Employees’ Compensation Act recipients to FECA annuity at age 65

Background
Employees who receive benefits through the Federal Employees’ Compensation Act (FECA) program will receive 66 2/3 percent or 75 percent of their basic salary, the latter for employees with a dependent. This tax free salary is extremely generous and in many instances equates to as much as 25 percent more than what the employee would receive for a comparable Office of Personnel Management (OPM) retirement through one of the government programs. The annual compensation cost of living adjustments that are added each year to an employee on total injury disability rewards someone who stays out on compensation versus returning to work.

Using a level EAS-13 as an example, if placed on compensation starting in 1993, that person would make more money staying on compensation than by returning to work. The conservative model that compares a person on FECA workers’ compensation with a post-tax working employee reveals that a person on compensation starting in 1993 would start to make more money than a working employee by 1997. Carried out a full ten years, the employee on compensation earns $1,300 more a year by staying on compensation than a working employee. Of equal concern is the second model that compares a person on compensation and that same level EAS-13 who retires. In that model, the person on compensation will make over $185,000 more than the retired employee in a ten-year period. This difference in paid income actually becomes a disincentive to retire and drives up the injury compensation costs for the Postal Service. The Postal Service cannot afford to have employees paid at a higher rate than a normal retirement, especially given that the Postal Service is charged an administrative fee on top of the actual benefits charge.

Employees commonly file for disability retirement then waive the retirement benefits to continue receiving compensation. This provides them with the highest possible income while ensuring a survivor annuity for their spouse. The Postal Service needs relief in the form of a FECA managed retirement program that equates to the same costs as a normal retirement for all present and former Postal employees over age 65 on the compensation rolls of OWCP.

Milestones
* Analyze administration proposal and develop government relations strategies (2002).
* Modify the law to be retroactive to all employees (2003).
Metrics
Substantial savings in cash payments to U. S. Department of Labor and a reduction in the Postal Service’s accrued liability
Interdependencies
Office of Management and Budget and the U. S. Department of Labor – Office of Workers Compensation Programs

Substrategy 3: Encourage the Office of Workers’ Compensation Programs to revise current regulations to allow for direct contact with the treating physician by the employing agency

Background
Prior to January 1999, postal managers had the ability to contact an injured employee’s treating physician directly (by phone and/or in person). That immediate contact gave the postal managers the opportunity to explain limited duty assignments and offer options to accommodate employees. This type of personal and immediate contact with the medical community assisted in reducing paperwork and associated medical costs. Changing this current regulation would ensure that postal managers initiated close monitoring of employees’ physical condition and it would allow early workers’ compensation program specialists’ intervention to assist the employee in a speedy return to the work environment.

Milestones
* Presentation of proposed revision to Secretary of Labor (2002).
* Series of subsequent meetings to effect the revision (2003).
* Monitor regulatory change process (2002/2003).

Metrics
OWCP agreement for implementation of regulatory change process.
Interdependencies
Department of Labor - Office of Workers Compensation Programs.

Substrategy 4: Private sector outplacement of injured Postal Service employees and the creation of new internal positions to accommodate injured workers

Background
Federal Employees’ Compensation Act regulations direct the private sector outplacement of injured
employees for federal agencies. The Department of Labor, Office of Workers’ Compensation Programs (OWCP), oversees this activity through its Vocational Rehabilitation Program. At this time, the Postal Service identifies injured employees who cannot work within their medical limitations and initiates action with the OWCP to start their rehabilitation process. However, with the continual deployment of automation equipment, the available number of employee assignments for injured and noninjured employees is being reduced as well. The OWCP rehabilitation process is based on conducting vocational testing to establish a wage earning capacity, and the training program can last from 90 days to two years. The Postal Service is quickly approaching a situation where they will no longer have positions available to internally accommodate their injured employees and is in need of an accelerated rehabilitation process that will expeditiously outplace injured employees in private sector employment positions.

Milestones
* National implementation of the Reassessment Initiative for identification of productive work assignments for rehabilitation, limited duty, and periodic roll category employees (2002).
* Identification of employees for private sector placement through an accelerated rehabilitation process with OWCP (2003).
Metrics
* Successfully implement, with the OWCP, an accelerated private sector placement program that reduces the amount of time necessary for an outplacement from up to two years to less than one year.
* Reduce the number of postal employees in nonproductive rehabilitation assignments by initiating action with the OWCP for private sector placement.

Interdependencies
Department of Labor – Office of Workers’ Compensation Programs
Substrategy 5: Interagency work cooperation to attain organizational objectives

Background
Often organizations have goals that conflict with each other. An example of such a conflict is the FECA
program objective for speed in processing compensation claims and medical bills. The Postal Service noted that in 1999, the OWCP changed the processing of compensation claims to meet new internal goals. The Postal Service needs to work with the OWCP to develop joint strategies to achieve both organization’s objectives, and not at each other’s expense.
Milestones
* Joint meetings to develop action plans that will not adversely impact each other’s organizational goals (2003).
* Attendance at national meetings to review strategies (2002).
Metrics
Claims are paid in a timely manner and quality checks are performed to prevent duplicate payments and unbundling of medical costs.