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I am a paramedic currently working in Texas. I do not want to go to Medical School yet and give up my freedom, so I practice medicine in the EMS field for now. I love my Job and I love medicine. I invest in biotech stocks only and do thorough due diligence on all of my investments. I am not an... More
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  • Rockwell Medical (RMTI)- A Potential Sleeping Giant 3 comments
    Aug 29, 2013 2:11 AM | about stocks: RMTI

    Disclaimer: I am not a certified analyst, I cannot predict the future, I do not have insider information and no one should ever listen to some random guy on the internet like me. You should always consult a financial adviser, do your own due diligence and never place money into biotech stocks that you cannot afford to lose. Fortunes are made and lost everyday in biotech, play it safe and be smart. I am just a paramedic, my word means nothing. I have been long RMTI since before Cruise 1 data and holding through Cruise 2 data.

    FYI: Due to my incessantly overbearing OCD this article will be very long, in fact it may seem more like a research report. If you are not a fan of thorough research, there are plenty of articles to peak your interest by various authors who describe their picks succinctly. I am not one of those authors, in reality I am no author at all, I'm actually a major nerd. Enjoy the read.

    RMTI- Rockwell medical is a fully-integrated biopharmaceutical company targeting end-stage renal disease (ESRD) and chronic kidney disease (CKD) with innovative products and services for the treatment of iron deficiency, secondary hyperparathyroidism and hemodialysis.

    • According to the National Kidney Foundation in 1997, "approximately 20 million adults in the US are in various stages of CKD with more than 400,000 individuals with ESRD and more than 300,000 of those patients requiring maintenance dialysis".
    • According to the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) and National Institute of Health (NIH) at the End of 2009, 398,861 ESRD patients were being treated with some form of dialysis: 172,553 ESRD patients had a working transplanted kidney.
    • It has been projected, by the National Kidney Foundation that by the year 2030, more than 2 million patients will be in need of dialysis or transplantation for kidney failure due to an aging population and prevalence of Type 2 Diabetes in the US alone.
    • More than 10 times as many ESRD patients receive hemodialysis (HD) treatments at a clinic as those who do peritoneal dialysis (PD) and home HD combined.
    • At 85.5 percent, the 5-year survival rate for transplant patients is more than twice the 35.8 percent survival rate for dialysis patients.
    • Treating ESRD patients cost the United States over $40 billion in public and private funds in 2009. $29.03 billion was attributed to medicare costs and $13.47 billion in non-medicare costs.
    • Treating a patient with Hemodialysis costs THREE times as much as treating a transplant patient.

    According to the MOST recent statistics approximately 430,000 patients with End Stage Renal Disease that are on dialysis and need treatment for anemia. The number of dialysis patients that need treatment for anemia world wide is a staggering 2.2 million.

    Pathophysiology and some Definitions

    Your kidneys are by far two of the most important organs in your body. They help maintain your overall health, filter waste products in your blood stream and remove excess fluids from your body.

    Chronic Kidney Disease (CKD): reduced kidney function over a period of time caused by any condition . CKD is diagnosed when a patient's glomerular filtration rate remains below 60 milliliters per minute for greater than 3 months time or when the ratio of albumin-to-creatinine ratio is over 30 milligrams (MG) of albumin for each gram (G) of creatinine (30 mg/g) in the patients urine.

    Glomerular Filtration rate (GFR)-is a test used to check how well the kidneys are working. Specifically it estimates how much blood passes through the tiny filters in the kidneys called glomeruli each minute.

    According to the National Kidney Foundation, normal results range from 90-120 mL/min/1.73 m^2.

    Stages of CKD:

    • Stage 1- Kidney Disease noted in patients such as diabetes, high blood pressure, family history, older age and ethnicity (African Americans at higher risk). Patients with stage 1 CKD have some kidney damage, have protein in the urine and normal GFR. A normal GFR is defined as greater than 90.
    • Stage 2- Patients have kidney damage along with a mild decrease in GFR. GFR in these patients is typically between 60 to 89.
    • Stage 3- Kidney damage and Moderate decrease in GFR. GFR is noted to be 30-59.
    • Stage 4- Patients have significant kidney damage and have a Severe decrease in GFR. GFR in these patients is between 15 to 29.
    • Stage 5- Kidney Failure AKA End Stage Renal Disease. GFR is less than 15 and patients NEED dialysis or kidney transplant.

    End Stage Renal Disease (ESRD): total and permanent kidney failure caused by some disease, illness or injury. When the kidneys fail, the body retains excess fluid. Also, Harmful wastes build up in the body since the kidneys cannot filter out the toxins from the body. A person with ESRD needs treatment to replace the work of the failed kidneys, typically through hemodialysis.

    Some Causes of Renal Failure include:

    • diabetic glomerulopathy- caused by diabetes
    • Hypertension- Increased blood pressure over time damages the kidneys.
    • glomerulonephritides- immunologically mediated glomerular diseases, often inflammatory in nature with various known and unknown causes.
    • polycystic kidney disease- group of disorders that result from the formation and progressive enlargement of cysts in the kidneys without dysplasia. Affects both children and adults. Has genetic causes. Over 600,000 Americans are diagnosed with PKD
    • chronic pyelonephritis- Caused by chronic infections of the kidney resulting from vesiculourethral reflex or obstruction. Responsible for 15% of ESRD
    • lupus nephritis- inflammation of the kidneys caused by systemic lupus erythematosus (SLE), an auto immune disease.

    Vitamin D-

    is a hormone that can be obtained in the diet or synthesized by the action of ultraviolet radiation on cholesterol in the skin. That's right folks, a wee bit of sunlight is good for the body and soul (always wear sunscreen). However these forms of Vitamin D3 (cholecalciferol) are inactive and require two hydroxylations (organic chem term for a chemical process that introduces a hydroxyl (-OH) group into an organic compound) to establish a metabolically active form. The first step occurs in the liver and the second in the kidneys.

    Vitamin D is vital for the absorption of calcium and phophate by the small intestine. Vitamin D is an important modulator of immune, renal and cardiovascular system.

    The active hormone is called calcitriol. Disorders of Vitamin D metabolism have been linked to varied pathological conditions such as hypertension, congestive heart failure and hypertrophic cardiomyopathy, immune disease and cancer.

    Erythropoietin-

    EPO is produced by the kidneys in adults and is essential for normal erythropoiesis (erythro means red blood cell and poiesis means to make). Epo stimulates the bone marrow to produce red blood cells in response to tissue hypoxia (decreased oxygen levels). In patients with ESRD, the body lacks this essential hormone.

    Iron Deficiency Anemia-

    is the most common type of anemia worldwide. It is estimated that one fifth of the global population has iron deficiency. Iron is the essential component of hemoglobin (a red protein responsible for transporting oxygen in the blood. It is a molecule comprised of four subunits, each containing an iron bound to a heme group). Iron is also essential in the process of erythropoiesis (RBC production).

    Iron deficiency is also present when the demand for iron exceeds the supply, developing slowly through three overlapping stages:

    • Stage 1- body's iron stores are depleted but the erythropoiesis proceeds normally with the hemoglobin content of RBCs and remains normal.
    • Stage 2- the iron transportation to the bone marrow is diminished resulting in iron deficiency erythropoiesis (body is working on over drive with less materials)
    • Stage 3- begins when the small hemoglobin-deficient cells enter the circulation in appropriate numbers to replace the normal mature RBCs that have been removed from circulation. Manifestations of IDA appear in this stage, when iron stores are depleted and there is diminished hemoglobin production.
      • Early symptoms include fatigue, weakness, shortness of breath, pale earlobes, palms and conjuctivae (pull the skin at the bottom of your eyes and look to see if its nice and pink, if its pale go to your doctor)
      • Progression of IDA causes even more changes in the patients. The patients nail become brittle and thin due to impaired capillary circulation. The patients tongue may become sore, red and painful. Patients may experience dry mouth and difficulty swallowing.

    What does all this mumbo jumbo have to do with RMTI in simple words?

    RMTI- Rockwell medical is a fully-integrated biopharmaceutical company targeting end-stage renal disease (ESRD) and chronic kidney disease (CKD) with innovative products and services for the treatment of iron deficiency, secondary hyperparathyroidism and hemodialysis.

    There are approx 430,000 patients with End Stage Renal Disease (ESRD) being treated with dialysis in the U.S., and estimated 2.2 million ESRD patients worldwide, who require treatment for anemia. Anemia is a common occurrence in patients with ESRD due to the fact that the kidneys have become damaged and no longer produce and vital hormone called Erythropoietin.

    Currently patients with renal failure are treated with erythropoiesis-stimulating agents (ESA's) for anemia, primarily used in dialysis patients, most of whom have treatments MWF or TTHSAT. ESA's are used in conjunction with IV Iron Dextran to keep the patients hemoglobin levels elevated but can put them at risk for stroke or MI if their hemoglobin goes in the excess of 11g/dl (grams per deciliter). For normal healthy males the level is 14-18 g/dl, females 11-16 g/dl.

    The current standard of treatment is Erythropoietin (EPO), a synthetic form of the hormone that is produced mainly by the kidneys (before they were damaged). EPO shots are given quite frequently and it can take a month or two before a significant enough rise in hemoglobin/hematocrit levels (greater than 5%) for the patient to start feeling any better.

    When patients are administered ESA's during their dialysis visits it increases the bodies demand for iron, as it as precursor in the production of Red Blood Cells (RBC's). Also, the process of dialysis reduces the amount of iron in the blood stream (a patient loses an average of 5-7 mg during each dialysis treatment). To treat the low levels of iron in the blood stream, patients are given Intravascular (IV) Iron at the same time ESA's are given to start the production of RBC's. Since the levels of Iron are deficient, the clinicians have to administer higher doses of ESA's and this process is repeated several times throughout the month until Hemaglobin/Hematocrit levels increase and can sometime take several months.

    Unfortunately, this repeated use of giving ESA's along with IV Iron supplements can cause the body to react in an unfavorable manner for the patients. The bodies reticuloendothelial system isolates the IV iron in the liver and releases a chemical called hepcidin, which blocks the release of the iron that is bound to the liver. This buildup of iron in the liver is not a benign event, it can lead to toxicity and not to mention leads to hypoxia (decreased oxygen being delivered) to organs, tissues, and cells; due to the decreased production of RBC's. When the patient returns to the dialysis center, labs are redrawn, pt is given more ESA's along with IV Iron supplements and this cycle may continue until liver toxicity occurs, pt becomes hypoxic at the cellular level or the patients H/H might actually improve.

    RMTI is currently working on developing and marketing Soluble Ferric Pyrophosphate (SFP). SFP is the company's lead investigational product. The company has concluded Phase III cruise 1 and Crusie 2 studies just recently. The POSITIVE results of Cruise 1 were announced approximately 43 days after the announcement of completion of the study. SFP is an iron delivery therapy, designed to replace the current method of iron delivery to dialysis patients.

    Here is an excerpt from the companies website:

    "SFP has been designed to effectively address the current challenges in anemia management by:

    • Maintaining hemoglobin (Hgb) levels within a safe range using moderate ESA doses
    • Improving response to ESA therapy, while avoiding excessively high doses and potential risks
    • Preventing iron from being stored in the liver thereby avoiding liver toxicity
    • Reducing current drug administration costs

    SFP is intended to deliver iron directly to the bloodstream in small, continuous doses three times per week and is designed to replace the 5-7 mg of iron that is lost during every dialysis treatment. This mode of delivery maintains patient Hgb within a target range resulting in moderate ESA dose and improved ESA response. With current IV iron therapy, iron levels are not always adequate when ESA's are dosed and therefore greater ESA doses are needed; this is believed to contribute to Hgb variability and related adverse consequences.

    SFP's unique properties enable it to avoid storage in the liver upon dosing. Avoiding iron storage in the liver eliminates liver toxicity associated with current IV iron delivery. It is believed that approximately 50 percent of the IV iron that is dosed to a patient never leaves the liver and over time may cause adverse consequences. (Source: Coyne DW, Kapoian T, Suki W, et al. Ferric gluconate is highly efficacious in anemic hemodialysis patients with high serum ferritin and low transferrin saturation: results of dialysis patients' response to IV iron with elevated ferritin (DRIVE) study. JASN. 2007;18:975-984.)

    In addition to the potential to provide significant patient benefit and improved patient outcome, SFP is expected to reduce related healthcare costs considerably. Because SFP is delivered via dialysate, required supplies such as needles and syringes needed for current IV therapy are avoided and nursing time to deliver and manage IV iron is no longer needed. Furthermore, because SFP is designed to continously maintain iron balance, as opposed to IV iron which is dosed infrequently to replenish iron after Hgb has dropped below a certain threshold, ESA dose is expected to be significantly reduced, which should result in considerable savings to the dialysis provider.

    In the U.S. approximately $680M per year is spent on IV iron for ESRD patients; and $1.5B globally."

    I am not trying to get into a political discussion here but if you happen to be in the field of medicine at the current time, you may have noticed some changes recently. Obama care has made changes to the decades old traditions that hospitals followed. At this time if a patient with COPD (chronic obstructive pulmonary disease), Congestive Heart Failure (CHF) or Diabetes returns to the hospital within 30 days of treatment for the same problem, Medicare/Medicaid may choose to not pay the hospital.

    Dialysis patients are chronically sick and have a myriad of other medical problems such as heart failure, diabetes, hypertension, etc. These multiple health problems along with being on dialysis (increased risk of infections) keeps the dialysis patients going in and out of the hospital on a consistent basis. Our culture has shifted in medicine from a culture of care and compassion to a culture of cost basis. I am not implying you can't have one without the other but its been a difficult change but "yes we can" right?

    Here is the data from a meeting, prior to Cruise 1 data release, in which the company discussed their clinical data:

    "The primary objective of the study was to determine whether regular administration of SFP via dialysate reduced the requirement for ESA dose by maintaining iron balance and optimizing iron delivery. The primary endpoint was the percent change in ESA dose from baseline to end of treatment (final two weeks of treatment period). Baseline ESA dose was similar between SFP (9483 U/wk) and placebo (9205 U/wk). In the modified ITT population, at the end of the study, ESA dose in the SFP arm was 9871 U/wk and placebo was 12628 U/wk. After adjusting for differences in baseline hemoglobin, the SFP arm required 35% less prescribed ESA compared to placebo. The difference between the two groups was statistically significant (p=0.045). The ESA sparing effect from SFP was observed without any increase in serum ferritin or pre-dialysis transferrin saturation. The PRIME study demonstrated that regular administration of SFP-iron via dialysate reduced the usage of erythropoietin stimulating agents (ESAs) during hemodialysis by 35% while maintaining iron balance and maximizing iron delivery."

    If you consider the fact that the Market for ESA's in the US alone is approximately $2 billion and nearly $5 billion worldwide. Amgen recently paid $24.9 million dollars to settle some allegations for doing Pharmacy Kickbacks www.reuters.com/article/2013/04/16/us-us.... The company did not admit to being guilty, they just pleaded the fifth. Dialysis has been a very lucrative market for Big Pharma and especially AMGEN.

    On July 1st 2013, Centers for Medicare and Medicaid Services (CMS) proposed a 9.4% cut to the Dialysis payment system. Medicare covers dialysis for 85% of the nations dialysis patients. Amgen has had a monopoly on ESA market for decades now with competition around the corner next year. Due to the company being the only one with the drug that these patients needed, AMGEN has raised prices to their hearts content over the years.

    According to Blue Cross Blue Shield (www.bcbswny.com/content/bcbs_prov_guid_e...):

    • For patients with ESRD, the average cost of treatment over a 12 month period is between $7,371 to $14,742 for continuous treatment.
    • Amgen's revenue for Epogen sales have been between $2 billion to $2.5 billion and its only competitor (AFFYMAX) having their drug withdrawn from the market, increased sales of Epogen by an additional 15%.

    A 35% reduction in ESA use would save patients/insurance companies/CMS approximately 700 million dollars a year.

    A 35% reduction in the usage of ESA's is quite an achievement, IF THE RESULTS ARE REPRODUCED IN PHASE III; well they were certainly proven in cruise 1 results.

    Cruise 1 results

    The Cruise-1 study successfully met its pre-defined primary efficacy endpoint, which was a change in hemaglobin from baseline to end-of-treatment between the SFP and placebo group.

    The mean difference between the SFP and placebo was 3.6 g/dL, impressive statistical significance, P value of 0.011.

    At baseline the two groups had similar hemaglobin levels (109.6 g/L and 109.0 g/L placebo).

    Mean change after treatment for SFP group was 0.6 g/L

    Mean change in placebo group was negative 3.0 g/L

    That is a huge margin, clearly indicates that SFP works

    The company also reported that Cruise 1 met the secondary endpoints as well:

    "The key secondary endpoints at End-of-Treatment showed statistically significant differences between the SFP and placebo groups, including the pre-dialysis reticulocyte hemoglobin (CHR) and serum ferritin. CHr, an early index and the best marker of iron-delivery to the bone marrow, was maintained at baseline levels in the SFP group during the randomized treatment, compared to a significant decrease in the placebo group. At End-of-Treatment, the difference between groups was a statistically significant 2.1% difference in favor of SFP (p less than 0.001). Serum ferritin, a marker of tissue iron stores, declined by 14.7% from baseline in the SFP arm while the placebo group ferritin level declined by 28.2%. The difference between groups was statistically significant (p less than 0.001). These results indicate that hemodialysate containing 2 µM SFP iron delivers sufficient iron to maintain erythropoiesis and does not lead to tissue iron overload."

    In my opinion the most impressive thing from the results was that there were no significant adverse effects reported. In ESA use, OMONTYS being a recent example, pt experienced anaphylactic reactions leading to death. According to the FDA, IV Iron and ESA drug such as EPOGEN come with a black box warning. SFP will be the first drug use in these patients without such a risk. As a patient or a clinician, which would you prefer? A drug that might kill you within minutes or a safer alternative with proven clinical benefits?

    Here are some links for you to read up against the competition.

    www.medpagetoday.com/ProductAlert/Prescr.../5231

    www.fda.gov/Safety/MedWatch/SafetyInform....htm

    www.medpagetoday.com/ProductAlert/Prescr.../16473

    SFP does not eliminate the need for ESA drugs, only reduces it by approximately 35% ($700 million dollars in savings).

    Interesting facts to keep in Mind:

    • The company recently completed financing via classic biotech dilution. The first one was for $12.9 million on March 20th. The second for a total of $40.3 million in which the underwriters of the announced public offering exercised their over-allotment option to purchase an additional 1,721,311 shares of the companies common stock at $3.05.
    • On June 14, 2013 the company also took out a $20 million loan in straight debt financing from Hercules Technology Growth Capital Inc. The terms of the agreement are basically such that RMTI must meet the primary endpoints for both Cruise 1 and Cruise 2 data or the loan becomes immediately due. Hercules has committed $3.6 billion to over 230 companies are not exactly known for picking losers. However; the terms of the agreement are beyond absurd.
    1. 12.5% interest rate
    2. $0.2 million at closing and is required to pay a fee of $1.1 million upon any prepayment or at maturity.
    3. the company granted Hercules a security interest in virtually all of the assets of the company other than certain intellectual property, motor vehicles, real property and certain other interests.
    4. Loan agreement also contains covenants that, among other undisclosed things, limit the company's ability to incur additional indebtedness, transfer asset, acquire assets of or merge with another entity.

    So, either a really bone headed move by management or they are very confident.

    • In completed clinical trials to date, SFP has demonstrated that it can safely deliver iron to the bone marrow (where the production of Red Blood Cells takes place). SFP is currently in Phase 3 clinical study CRUISE-1 to address an estimated $600M U.S. and $1B global market.
    • Rockwell is preparing to launch its FDA approved generic drug called Calcitriol. Calcitriol is active vitamin D injection and indicated for the treatment of secondary hyperparathyroidism in dialysis patients. Rockwell intends to enter the vitamin D market in 2013, addressing an estimated $350M U.S. market. I do not believe that company will reach high market penetration but still will be able to generate positive income from this endeavor.
    • On March 8, 2013 RMTI announced that it has signed a contract with NxStage® Medical, Inc. to manufacture dialysate concentrate for the NxStage System One", the first and only truly portable hemodialysis system cleared for home use by the U.S. Food & Drug Administration. The contract term is for two years. You can research the company at www.nxstage.com/
    • Current revenue of RMTI stands at approximately $51 million and a market cap of $226 million, positive Phase III results could propel the stock to new highs. After the release of positive phase II data, the companies stock did surge to approx $8/share but being low on cash, that dissipated quickly.
    • According to the WSJ, this company is only being covered by two analysts with an average consensus price of $15.50 quotes.wsj.com/RMTI/research-ratings
    • The company has a short percentage of 16.77% (5.88 million shares) as of 08/15/13, a 31.54% increase from the previous report. If the company announced Vitamin D approval along with Positive Cruise data, this stock is a candidate for a serious short squeeze.
    • According to Finviz, Institutional Holding shows to be at 33.90%, an increase of 125.66% from last update and an impressive insider ownership of 5.70% (55.70% increase from last update)
    • The price movement as of late leading to data announcement has been from the high 4s to a recent high of $6.22.

    Conclusion

    In my opinion, I believe the stock will see a positive uptrend lead into data announcement and with positive data could propel the stock to new highs. KERX has been working on a similar drug that reduces ESA use by 25%. I can still recall the day that KERX announced their data, the stock jumped the first day, then the second and continued till the third to near 10 range before tapering off at approximately $8/share.

    Cruise 2 data is due in September and Calcitriol manufacturing approval is also around the corner (FDA is just slow).

    RMTI will be saving Medicare/Medicaid, patients and Insurance companies approximately 700 million dollars per year. SFP will the product of choice for these already low margin dialysis centers who are getting their funding slashed by CMS (center for medicare & medicaid services). If you also take into account that this drug has not killed a single patient due to anaphylaxis, compared to the black boxed drugs IV iron and Epogen, this product is going to be a game changer in the dialysis market. As a medical professional believe me when I say this, to the Healthcare Companies, saving money is just as important as saving patients lives and this drug (SPF) will certainly allow these vultures to find the morally correct balance; People over profit.

    RMTI is not a one tricky pony as you see with several small cap biotech firms. The company has multiple other products in the pipeline including Citrapure, hemodialysis concentrates, etc. I am confident in my investment decision in regards to this company and expect the stock price to rise significantly from current levels. Good luck to you all and please do your own due diligence. If I left something out please let me know and I will address it. Thank you.

    Sources:

    kidney.niddk.nih.gov/kudiseases/pubs/kustats/

    www.ncbi.nlm.nih.gov/pmc/articles/PMC2746982/

    www.nlm.nih.gov/medlineplus/ency/article....htm

    www.kidney.org/atoz/content/kidneydiscauses.cfm

    www.kidneyfund.org/kidney-health/kidney-....html

    faculty.stcc.edu/AandP/AP/AP2pages/Units....htm

    www.pathology.vcu.edu/education/PathLab/....html

    www.kidney.org/atoz/content/gfr.cfm

    ir.rockwellmed.com/releasedetail.cfm?ReleaseID=772067

    onlinelibrary.wiley.com/doi/10.1359/jbmr.../pdf

    www.renalbusiness.com/news/2013/07/akf-u....aspx

    secfilings.nasdaq.com/filingFrameset.asp...;FilePath=\2013\06\20\&CoName=ROCKWELL+MEDICAL%2C+INC.&FormType=8-K&RcvdDate=6%2F20%2F2013&pdf=

    www.rockwellmed.com/dialysis-products-he....htm

    secfilings.nasdaq.com/filingFrameset.asp...;FilePath=\2013\07\11\&CoName=ROCKWELL+MEDICAL%2C+INC.&FormType=8-K&RcvdDate=7%2F11%2F2013&pdf=

    U.S. Renal Data System 2003 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA.

    U.S. Renal Data System 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA

    Disclosure: I am long RMTI. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it. I have no business relationship with any company whose stock is mentioned in this article.

    Additional disclosure: I am long RMTI and do not plan on selling my shares within the next 72 hours. I am not being compensated by Seeking Alpha and I have no professional relationship with Rockwell Medical or any of its employees. My opinions are my own and I do not advise anyone to buy or sell upon my recommendation. Always do your own due diligence, consult with a financial adviser and invest according to your risk appetite.

    Themes: RMTI, long-ideas, AFFY, OMONTYS, AMGEN Stocks: RMTI
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Comments (3)
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  • Author’s reply » sorry guys/gals, I had to make some changes that I thought would better reflect the importance of SFP in regards to cost saving such as Centers of Medicare/Medicaid cutting funds, the rising cost of ESA's, etc.
    29 Aug 2013, 02:22 AM Reply Like
  • Good call, congratulations
    5 Sep 2013, 04:08 PM Reply Like
  • Author’s reply » thank you! GL2U in the future! :)
    7 Sep 2013, 08:33 PM Reply Like
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