Tuesday, May 19, 2020

Medicaid Providers At The End Of The Line For Federal COVID Funding

By Julie Rovner
Kaiser Health News

Editor's Note: This article originally appeared on Kaiser Health News.

Casa de Salud, a nonprofit clinic in Albuquerque, New Mexico, provides primary medical care, opioid addiction services and non-Western therapies, including acupuncture and reiki, to a largely low-income population.

And, like so many other health care providers that serve as a safety net, its revenue — and its future — are threatened by the COVID-19 epidemic.

“I’ve been working for the past six weeks to figure out how to keep the doors open,” said the clinic’s executive director, Dr. Anjali Taneja. “We’ve seen probably an 80% drop in patient care, which has completely impacted our bottom line.”

In March, Congress authorized $100 billion for health care providers, both to compensate them for the extra costs associated with caring for patients with COVID-19 and for the revenue that’s not coming in from regular care. They have been required to stop providing most nonemergency services, and many patients are afraid to visit health care facilities.

But more than half that money has been allocated by the Department of Health and Human Services, and the majority of it so far has gone to hospitals, doctors and other facilities that serve Medicare patients. Officials said at the time that was an efficient way to get the money beginning to move to many providers. That, however, leaves out a large swath of the health system infrastructure that serves the low-income Medicaid population and children. Casa de Salud, for example, accepts Medicaid but not Medicare.

State Medicaid directors say that without immediate funding, many of the health facilities that serve Medicaid patients could close permanently. More than a month ago, bipartisan Medicaid chiefs wrote the federal government asking for immediate authority to make “retainer” payments — not related to specific care for patients — to keep their health providers in business.

“If we wait, core components of the Medicaid delivery system could fail during, or soon after, this pandemic,” wrote the National Association of Medicaid Directors.

So far, the Trump administration has not responded, although in early April it said it was “working rapidly on additional targeted distributions” for other providers, including those who predominately serve Medicaid patients.

In an email, the Centers for Medicare & Medicaid Services said officials there will “continue to work with states as they seek to ensure continued access to care for Medicaid beneficiaries through and beyond the public health emergency.”

CMS noted that states have several ways of boosting payments for Medicaid providers, but did not directly answer the question about the retainer payments that states are seeking the authority to make. Nor did it say when the funds would start to flow to Medicaid providers who do not also get funding from Medicare.

The delay is frustrating Medicaid advocates.

“This needs to be addressed urgently,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families in Washington, D.C. “We are concerned about the infrastructure and how quickly it could evaporate.”

In the administration’s explanation of how it is distributing the relief funds, Medicaid providers are included in a catchall category at the very bottom of the list, under the heading “additional allocations.”

“To not see anything substantive coming from the federal level just adds insult to injury,” said Todd Goodwin.

He runs the John F. Murphy Homes in Auburn, Maine, which provides residential and day services to hundreds of children and adults with developmental and intellectual disabilities. He said his organization — which has already furloughed almost 300 workers and spent more than $200,000 on COVID-related expenses including purchases of essential equipment such as masks and protective equipment that will not be reimbursable — has not been eligible for any of the various aid programs passed by Congress. It gets most of its funding from Medicaid and public school systems.

The organization has tapped a line of credit to stay afloat. “But if we’re not here providing these services, there’s no Plan B,” he said.

Even providers who largely serve privately insured patients are facing financial distress. Dr. Sandy Chung is CEO of Trusted Doctors, which has about 50 physicians in 13 offices in the Northern Virginia suburbs around Washington, D.C. She said about 15% of its funding comes from Medicaid, but the drop off in private and Medicaid patients has left the group “really struggling.”

“We’ve had to furlough staff, had to curtail hours, and we may have to close some locations,” she said.

Of special concern are children because Medicaid covers nearly 40% of them across the county. Chung, who also heads the Virginia chapter of the American Academy of Pediatrics, said that vaccination rates are off 30% for infants and 75% for adolescents, putting them and others at risk for preventable illnesses.

The biggest rub, she added, is that with the economy in free fall, more people will qualify for Medicaid coverage in the coming weeks and months.

“But if you don’t have providers around anymore, then you will have a significant mismatch,” she said.

Back in Albuquerque, Taneja is working to find whatever sources of funding she can to keep the clinic open. She secured a federal loan to help cover her payroll for a couple of months, but worries what will happen after that. “It would kill me if we’ve survived 15 years in this health care system, just to not make it through COVID,” she said.

KHN senior correspondent Phil Galewitz contributed to this story.

Wednesday, May 13, 2020

Are Pediatric Offices Open Amid the COVID-19 Pandemic? YES!

Gary W. Floyd, MD
Pediatrics and Pediatric Emergency Medicine, Keller
Chair, Texas Medical Association (TMA) Board of Trustees
Member, TMA

As a parent you might wonder, “Are pediatric offices open during this COVID-19 pandemic?”

Yes, most definitely, our pediatric offices are open to provide care during this time. As pediatricians, we believe it is very important to keep well-child visits to check growth and development, answer questions, discuss safety issues, check on patients’ emotional state during this stressful time, and give regular vaccinations. We realize shots are no fun, but they are far better than getting pertussis (whooping cough), polio, pneumonia, rotavirus, or measles. It’s important to keep up with measles vaccinations especially, after recent outbreaks in 2018 and 2019. In fact, more than 117 million kids are at risk of not getting a measles vaccine as a result of global vaccination programs on hold during the pandemic, according to a recent United Nations report. If the immunization rates begin falling, as soon as people start being around each other again, those outbreaks will start springing up and those can be devastating in and of themselves. The last thing we need is another outbreak of a preventable disease in the midst of this COVID-19 crisis. 

Just to remind you, children need regular well visits at ages 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 2.5 years, 3 years, and yearly after that through age 21. Your doctor administers important vaccinations at birth and at ages 2 months, 4 months, 6 months, 12 to 15 months, 18 months, 4-6 years, 9-12 years, and 16 to 18 years. The Centers for Disease Control and Prevention (CDC) updated the immunization schedule for children and adolescents during the COVID-19 pandemic.

It's important for children to be up-to-date with their vaccinations,
especially after recent outbreaks (measles) in 2018 and 2019.
Heather Hazzan, SELF Magazine
We realize many parents are hesitant to come to our offices, but please be assured that many physicians have changed how our offices work to help you and your children avoid needless contact with potentially sick patients. Some offices see well visits in the mornings and sick visits in the afternoon, while others close off certain exam rooms specifically for checkups and others exclusively for patients who are ill. Other pediatrics offices and clinics separate patients into a well visit waiting area and a sick visit waiting area. Many physicians even have parents and children wait in their car until they can be taken to an exam room. These are just a few of the many adjustments put in place to help ensure patient safety. Plus, all offices are disinfecting exam rooms after each visit.

We encourage parents to call their pediatrician to discuss how their office is working to cut down any chance of exposure and to schedule your child’s next regular well visit. We are here to keep all little Texans healthy and safe – from coronavirus AND everything else that could come their way.   

VIDEO: COVID-19: You're scared of coming in...we're scared of you NOT coming in

Austin pediatrician and Texas Medical Association physician leader Ari Brown, MD, is just one of many Texas physicians who have taken extra precautions for seeing child patients during the COVID-19. View the video below to get a sense of what she and similar practices are doing to make sure young Texans stay healthy and safe.

Tuesday, May 12, 2020

ROBERTS: Finding a new normal with coronavirus

Sid Roberts, MD
Lufkin Radiation Oncologist
Member, Texas Medical Association

Editor's Note: An earlier version of this article appeared in The Lufkin Daily News and Dr. Roberts' blog.

We have been self-distancing through the COVID-19 pandemic for a few months now. What a wild ride it has been! Despite the number infected — well over 1.25 million — and more than 75,000 deaths, many still question the legitimacy of the extraordinary measures that shut down our economy.

Uninformed proclamations comparing COVID-19 to the seasonal flu are an affront to anyone who has been sickened or died from this disease. The average length of stay of those hospitalized (especially those requiring ICU care and ventilator support), not to mention the number of deaths, is far greater than with the flu.

Still, should we have shut down the economy? Professors at the Kellogg School of Management at Northwestern University called it a “brutal trade-off: inducing massive economic suffering in order to save human lives.” Their research concludes that not closing the economy ultimately would be much costlier to society, potentially tens of trillions of dollars in addition to major loss of life. Consider it a “damned if you do; damned if you don’t” choice. I am grateful we chose to flatten the curve and save lives.

How do we recover from this mess? Many states, including Texas, are starting to loosen restrictive measures to reopen our economy. Trillions of dollars have been designated for businesses and individual taxpayers. That will help ease some of the financial suffering. But we have paid a collective price psychologically as well.

The unpredictable factor in this recovery is going to be people. What are we willing to do when we emerge from isolation? Some never really changed their behavior to begin with. For those who did take the pandemic seriously — and still do — it is not as easy as flipping a switch and going back to a pre-coronavirus routine. Predictions for a rapid economic boom assume we will all be hitting the malls and restaurants as if nothing ever happened.

Me? I think I have PCSD — Post Coronavirus Stress Disorder. My habits have changed. My sense of personal space and need for barriers is heightened. I avoid people. It will take me months or longer before I go back into a store and don’t wonder whose germy fingers have been on everything.

Interacting with strangers — or even friends I haven’t seen in a while — has a more dangerous feel to it. Consciously or not, we are figuring out what our personal risk tolerance is. Are there too many people in that store? Are the employees at that restaurant being careful enough? We decide with our feet and our pocketbooks.

Some will emerge sooner and more confidently than others. Peggy Noonan, columnist for the Wall Street Journal, called for patience and grace when other people are moving faster or slower in the recovery process than perhaps we think they should. “What will hurt us is secretly rooting for disaster for those who don’t share our priors.”

In the church, we refer in jest to some theological differences as “non-salvation issues” over which we can agree to disagree. As we emerge from our coronavirus self-isolation, we should respect that not everyone will be either as cautious or as cavalier as we may be. Extend grace.

The ideal conditions for me personally to feel truly comfortable again would be a) I have been infected (and recovered), and am proven immune, or b) I have been vaccinated. Only then will I regain my more nonchalant attitude toward life. Either of these conditions is imperfect assurance; only time and testing — and good science — will provide clarity on the true COVID-19 status of any of us.

In the meantime, I will continue my new habits (obsessions, really): self-distancing and cleanliness. I will avoid crowds for the foreseeable future. When I attend church services — at least in the beginning — I am at least going to mask myself on entering and exiting, if not the entire service. The last thing I want is to be an undiagnosed carrier who infects an elderly or at-risk fellow church member.

In public, I carry disinfectant wipes for use in the grocery store, at the gas pump, etc. Finally, I wash my hands. No, I really scrub them. Lots of bubbles all around. Often. (Admittedly, I still have trouble not touching my face.)

One more thing. Once we have a vaccine, we cannot let the anti-vaxxers and conspiracy theorists have their way. Legislators must remove conscientious and religious exemptions from vaccination requirements.

Eventually — hopefully next year sometime — enough of us will have recovered or been immunized and life truly can return to the pre-coronavirus routine ... at least until the next pandemic comes along. Please, can we wait another century for that?

Dr. Sid Roberts is a radiation oncologist at the Temple Cancer Center in Lufkin. Previous columns may be found at angelinaradiation.com/blog.

Thursday, May 7, 2020

Always The Bridesmaid, Public Health Rarely Spotlighted Until It’s Too Late

By Julie Rovner
Kaiser Health News

Editor's Note: This article originally appeared on Kaiser Health News.

The U.S. is in the midst of both a public health crisis and a health care crisis. Yet most people aren’t aware these are two distinct things. And the response for each is going to be crucial.

If you’re not a health professional of some stripe, you might not realize that the nation’s public health system operates in large part separately from the system that provides most people’s medical care.

Dr. Joshua Sharfstein, a former deputy commissioner for the Food and Drug Administration and now vice dean at the school of public health at Johns Hopkins in Baltimore, distinguishes the health care system from the public health system as “the difference between taking care of patients with COVID and preventing people from getting COVID in the first place.”

In general, the health care system cares for patients individually, while public health is about caring for an entire population. Public health includes many things a population takes for granted, like clean air, clean water, effective sanitation, food that is safe to eat, as well as injury prevention, vaccines and other methods of ensuring the control of contagious and environmental diseases.

In fact, it is public health, not advances in medical care, that has accounted for most of the increases in life expectancy during the past two centuries. Well before the advent of antibiotics and other 20th-century medical interventions, public health activities around clean water, food safety and safer housing led to enormous gains.

“It’s pretty invisible” if the public health system is working well, said Sharfstein, who also once served as Maryland’s state health secretary. “It’s the dog-that-doesn’t-bark agency.”

But while public health isn’t as flashy as a new drug or medical device or surgical procedure, it can simultaneously affect many more lives at once.

Dr. Arthur Kellermann, a former emergency room physician and public health researcher at Emory University in Atlanta, told me: “I’m sure I saved more lives keeping Georgia’s motorcycle law on the books than all the trauma resuscitations I did.”

Still, because the public health system mostly operates in the background, it rarely gets the attention or funding it deserves ― until there’s a crisis.

Public health is “a victim of its own success,” said Jonathan Oberlander, a health policy researcher and professor at the University of North Carolina-Chapel Hill.

“People can enjoy clean water and clean air but don’t always attribute it to public health,” he said. “We pay attention to public health when things go awry. But we tend to pay not a lot of attention in the normal course of events.”

Public health as a scientific field was created largely to address the sort of problem the world is facing today. Sharfstein noted that Baltimore established the nation’s first public health department in 1793 to address a yellow fever epidemic. But between emergencies, the public health domain is largely ignored.

“In the U.S., 97 cents of every health dollar goes to medical care,” he said. “Three cents goes to public health.”

It wasn’t that long ago when rebuilding the nation’s public health infrastructure was a top priority. In the wake of the Sept. 11, 2001, terrorist attacks and the anthrax attacks a month later, Congress devoted significant time, attention and dollars to public health.

Emerging from that flurry of activity from 2001 to 2004 was a bipartisan bill providing more than $4 billion to dramatically expand the nascent Strategic National Stockpile, to rebuild and modernize the capacity of state and local public health departments to deal with public health emergencies and to further protect the nation’s supply of drinking water from potential terrorist attacks. Also created during that period was Project Bioshield, a federal program to provide incentives to private industry to develop vaccines and countermeasures for biological terror agents as well as naturally occurring biological threats.

But as the threat of biological terrorism seemed to wane, so did public health funding from Congress and the states. After accounting for inflation, funding for the federal Centers for Disease Control and Prevention has decreased over the past decade, according to the Trust for America’s Health, a nonpartisan research and advocacy group.

And while the Affordable Care Act established a public health fund worth $15 billion over 10 years — the Prevention and Public Health Fund ― it has been repeatedly raided by both parties in Congress to pay for other, sometimes non-health items. For example, the fund was cut by more than $1 billion in 2018 to help cover the costs of a bipartisan budget bill.

Those choices on public health can come back to haunt us. Now, as the U.S. mourns the COVID-19 deaths of more than 63,000 people in less than two months, public health professionals again have the attention of policymakers. The question for them is, how best to seize the moment?

“The trick is to put in solutions that will work for a long time,” said Sharfstein. “It really matters how you handle a crisis because it might determine how you handle the next 50 or 60 years.”

The clock is ticking.

Friday, April 17, 2020

Want to Improve Your Health? Fill Out the Census!

Emily Dewar, MD
Emily Dewar, MD
Pediatric Resident at The University of Texas at Austin Dell Medical School 
Member, Texas Medical Association

Lauren Gambill, MD
Austin Pediatrician
Member, Texas Medical Association

There are many things that we should do to help protect our health: get a flu shot, exercise regularly, and eat fruits and vegetables. But this spring, there’s something else you can do. In fact, it may be the easiest, fastest, and most important task you complete this year to benefit the health and well-being of yourself and your fellow Texans: Fill out your census form.

Lauren Gambill, MD
Yes, you read that right. In addition to determining political representation and community infrastructure, the census helps determine funding for a wide array of critical health and human service programs. A few of the programs that rely on census data include: Medicaid, Children’s Health Insurance Program (CHIP), Supplemental Nutrition Assistance Program (SNAP), Title I, IDEA Special Education, Head Start, foster care, school lunches, and child care programs. Without accurate counts, we lose resources and funding, which directly harms the health and well-being of people in our communities.

Nationally, we are at risk for an undercount, as it is the first time the census is online. This is especially important because we can complete the form while social distancing because of COVID-19. While the U.S. Census Bureau hopes that the new online option will lead to more accurate counts, a new system opens itself up to potential glitches. Another reason we are at risk for an undercount is fear; while the information gathered is not linked to individuals, some may still not feel safe divulging personal information on a government questionnaire.

Texas is home to many people who are historically undercounted and are therefore considered “hard-to-count,” such as young children, people without a permanent address, immigrants, those who live in rural areas, and people of color. Twenty-five percent of Texans live in “hard-to-count” areas. Those vast areas have had low census response rates in the past.

There is often confusion as to who counts on the census. The short answer is that everyone counts, regardless of citizenship or age. This includes newborn babies still in the hospital, kids in foster care, undocumented immigrants, individuals experiencing homelessness, kids who live with non-related adults – everyone!

What’s on the line?

For every one percent of Texans who are not counted, Texas could lose $300 million in federal funding each year, for the next 10 years. This means less access to health care, food, and education, particularly in “hard-to-count” areas. Texans often wait months to see a physician or live in areas where hospitals and clinics are hours away; an undercount will only make these problems worse.

What can we do?

Take the census! Census Day was originally scheduled for April 1, 2020, but now operations are pushed back to protect the public and Census bureau employees from COVID-19. Census day is a mark in time where everyone is to report where they live or lived, on that particular day. It is not the deadline to complete the census. People began filling out the census online in March and can do so into August. The federal government encourages answering the census online above all other options (options to respond by phone or mail are also available). More than 70 million households have completed the Census as of April 13, which makes up more than 48% of American households.

So in-between all the other things you do to stay healthy, make sure you and everyone you know fills out the census. By doing so you’re not only being of service to you and your own health, but to the health of your fellow Texans.

Monday, April 13, 2020

Shinyribs Band and TMA Say, “Stay Home”

One of Austin’s best-known bands is adding its musical voice to the nationwide stay-at-home orders during the COVID-19 pandemic, backed by a new music video highlighting physicians.

Shinyribs, the award-winning eight member swamp-pop-supergroup, recently released “Stay Home,” a single written to encourage citizens to stay at home and practice social distancing to prevent the spread of COVID-19 (also known as the 2019 novel coronavirus). COVID-19, which causes flu-like symptoms like cough, fever, and difficulty breathing, is highly infectious and spreads upon person-to-person contact.

In addition to releasing the single, Shinyribs allowed the Texas Medical Association (TMA) to create a music video for the song. The video features nearly 50 physicians and health care workers photographed by TMA President David Fleeger, MD, as well as some cameo appearances by TMA staff.

VIDEO: Shinyribs Band and Texas Physicians Say "Stay Home!"

Shinyribs’ frontman Kevin Russell wrote “Stay Home” after the social distancing orders put a halt to the group’s tour in March. He said he wanted to share a lighthearted, yet important message with fans during this serious time.

“In situations like this, panic naturally ensues when daily routines are unprecedently interrupted,” Mr. Russell said. “You don’t need more toilet paper. You don’t need to hoard supplies and food. You just need to stay put.”

All in all, the band hopes audiences will abide by the overall message brought by “Stay Home” and do their part to “flatten the curve” – reduce the severity of the COVID-19 pandemic.

“This time is tough on all of us, but with everyone’s cooperation, we can slow the spread of this virus and get back to some normalcy,” Mr. Russell said. “In three months from now, if nothing has happened… well, isn’t that the point?”

“Stay Home” is now available on Bandcamp, Soundcloud, YouTube, and Facebook – with a widespread release to iTunes, Spotify, and all digital music services later this month. Proceeds from downloads of the song benefit Health Alliance for Austin Musicians (HAAM), an Austin nonprofit that assists Austin’s self-employed musicians access affordable healthcare.

“[I appreciate] this great opportunity to participate in the community; it really is what I had in mind when I wrote the song,” said Mr. Russell. “I thought, ‘Maybe people will like it and it will spread faster than the virus!’ It fills me with pride to be part of it.”

Editor’s note: TMA encourages MeAndMyDoctor readers to share the video on their social media channels.

Thursday, March 26, 2020

End-of-Life Implications of the Coronavirus Pandemic

Sid Roberts, MD
Lufkin Radiation Oncologist

Member, Texas Medical Association

We are early in this coronavirus game of social distancing and hand washing. We haven’t quite become weary of it. We joke about it. And yet, I am starting to see – among my friends – some very real concern about our elder parents and grandparents. But we don’t allow ourselves to linger on those thoughts much. We should.

The United States has been accused of being late to respond to the coronavirus pandemic, late to test our US population compared to other countries (South Korea, for example), and “doomed”  in our response. Even so, we are just beginning the initial rise of the now well-known bell curve of the Coronavirus Disease 2019 (COVID-19) pandemic. Known cases are doubling every day, it seems. Deaths are increasing as well.

As a cancer physician with additional hospice and palliative medicine (end-of-life care) certification, I view the coronavirus pandemic with increasingly darkened lenses. Coronavirus is a new and immediate threat to life, and we are not ready for what that means. If we don’t succeed in slowing the spread of coronavirus and suppressing new cases – now widely known as flattening the curve – 2.2 million people in the US could die.  We are not talking openly – publicly –about how we are going to handle this massive number of deaths with COVID-19.

If the coronavirus epidemic is as bad as some predict it will be, discussions about end-of-life care with this disease will soon become front and center. There may not be enough ventilators for everyone who “needs” ventilator support. Italy has been forced to triage sick coronavirus patients based on age, given that the death rate among the elderly is so high. Italian doctors have admitted that there were simply too many patients for each one of them to receive adequate care. They describe a “tsunami” of patients and a more than 7% death rate (though researchers have lowered the calculated death rate in Wuhan, where the pandemic started, to 1.4% ). Preliminary outcomes of patients with COVID-19 in the US show death is highest in persons aged greater than or equal to 85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years.

The Italian society of anesthesiologists issued fifteen recommendations of ethical and medical criteria to consider if ICU beds are exhausted, saying doctors may have to adopt more wartime triage criteria of gauging who has the best chance of survival versus “first come, first served.”   Those who are chronically ill with pre-existing lung disease, even if they survive a serious coronavirus infection, are likely to be left with even further reduced lung function and poorer quality of life.

Unlike a localized disaster – most memorably Hurricane Katrina, in New Orleans in 2005, where healthcare decision-making received intense scrutiny and prompted legal action  – we are experiencing a global, acute healthcare emergency that may require historic moral and ethical decisions that impact who lives and who dies. We will be rationing healthcare on the fly. Are we ready for that? As family members? As a community? As a nation? Are our hospices ready for the number of patients needing immediate, short-duration, and contagion-related end-of-life care?

Perhaps the most terrifying aspect of the coronavirus epidemic in countries where death has become frighteningly common is the loneliness of the death. Hospitals in the US are already limiting or even forbidding visitors. In Italy, seriously ill coronavirus patients are isolated from family and often die alone. Families are not allowed to have a proper burial, and not just due to restrictions on gathering – morgues have an enormous backlog to work through. That is certainly not what we would call a “good death” and not what those of us in the hospice care field want for any patient.

President Trump has labeled himself a wartime president, declaring we are at war with an invisible enemy. "Now it's our time. We must sacrifice together, because we are all in this together, and we will come through together," he said.  What is not stated – and what I am afraid will happen – is the wartime sacrifice analogy will extend to real lives lost. In an ironic twist of fate, it very well may be that the remnants of the Greatest Generation are once again on the front lines. Even down to the Baby Boomers, our nation’s elders will bear the brunt of the coronavirus disease, certainly, but likely the financial catastrophe surrounding the pandemic as well. (I wonder if the economic collapse will kill as many or more people than coronavirus does.)

The time is now to have discussions with our older/elderly parents and grandparents about the very real risk of serious illness and death from COVID-19. Wills need to be written and advance directives and durable powers of attorney completed now – before our loved ones hit the hospitals. This is not morbid; it is both pragmatic and necessary. If we emerge from this battle relatively unscathed, we are no worse off for having had the discussions and done the planning. Patients and families should be driving end-of-life care decisions. We owe it to our hospitals and healthcare workers not to overburden the system with trying to care for those who neither want nor would benefit from aggressive measures.

Dr. Sid Roberts is a radiation oncologist at the Temple Cancer Center in Lufkin and contributing columnist for The Lufkin Daily News. Previous columns can be found on Dr. Roberts' blog.
Related Posts Plugin for WordPress, Blogger...