House Bill 148 proposes expanding Medicaid eligibility in Alaska as well as making other changes to the state's Medicaid program. If expanded, Medicaid eligibility would include able-bodied adults up to 138% of the federal poverty level. The federal government would pay 90-100% of coverage costs for newly eligible individuals through 2020, though specifics beyond 2020 are unknown. However, the state would still be responsible for 50% of administrative expenses. In addition to Medicaid expansion, HB 148 would expand Denali KidCare and add new Medicaid programs and options, but it does not propose specific reforms to address the existing problems in Alaska's Medicaid system. There is uncertainty around how many newly eligible individuals would enroll and what the overall costs of expansion would be
Obamacare - The Patient Protection and Affordable Care Act - ACAAndrew F. Bennett
This short presentation will help bring you up to speed on the Affordable Healthcare act, eligibility requirements to buy in the online marketplace, and coverage that will be available.
Obamacare in Pictures: Visualizing the Effects of the Patient Protection and ...The Heritage Foundation
“Obamacare in Pictures: Visualizing the Effects of the Patient Protection and Affordable Care Act” shows in detail the impact of the sweeping health care law for Americans.
Did you have time to read the 1,990 page healthcare bill that was recently passed through Congress? Have you since wondered about the impact that massive bill will have on the average American, health insurance providers, business owners and YOU? If yes, then join the Young Professionals of Chicago as we host a panel of diverse health care professionals that will be discussing current healthcare reform and taking questions on the impact of the United States' new healthcare policy. The distinguished panelists will also provide some insight and clarity into what this massive bill means for individuals like you. There will also be an opportunity for open networking with other young professionals before and after the discussion.
Obamacare - The Patient Protection and Affordable Care Act - ACAAndrew F. Bennett
This short presentation will help bring you up to speed on the Affordable Healthcare act, eligibility requirements to buy in the online marketplace, and coverage that will be available.
Obamacare in Pictures: Visualizing the Effects of the Patient Protection and ...The Heritage Foundation
“Obamacare in Pictures: Visualizing the Effects of the Patient Protection and Affordable Care Act” shows in detail the impact of the sweeping health care law for Americans.
Did you have time to read the 1,990 page healthcare bill that was recently passed through Congress? Have you since wondered about the impact that massive bill will have on the average American, health insurance providers, business owners and YOU? If yes, then join the Young Professionals of Chicago as we host a panel of diverse health care professionals that will be discussing current healthcare reform and taking questions on the impact of the United States' new healthcare policy. The distinguished panelists will also provide some insight and clarity into what this massive bill means for individuals like you. There will also be an opportunity for open networking with other young professionals before and after the discussion.
This gives a good base knowledge of where the current insurance industry is, a timeline of when certain mandates go into effect and a simplified description of the mandats being launched on Sept 23, 2010.
1) Discuss what seems to be the current posture of the Trump Administration and Republican Party leadership relative to expected health care policy changes.
2) Identify key distinctions between the Affordable Care Act (ACA aka ObamaCare) and the American Health Care Act (AHCA aka TrumpCare).
3) Recognize key strategies for future success regardless of changes to US healthcare policy and law.
This gives a good base knowledge of where the current insurance industry is, a timeline of when certain mandates go into effect and a simplified description of the mandats being launched on Sept 23, 2010.
1) Discuss what seems to be the current posture of the Trump Administration and Republican Party leadership relative to expected health care policy changes.
2) Identify key distinctions between the Affordable Care Act (ACA aka ObamaCare) and the American Health Care Act (AHCA aka TrumpCare).
3) Recognize key strategies for future success regardless of changes to US healthcare policy and law.
The pending Healthy Ohio 1115 Medicaid waiver would require nearly all non-disabled adults on Ohio Medicaid to pay premiums. If approved by the federal government, the waiver would result in a greater number of uninsured Ohioans as well as increased Medicaid administrative costs and complexity.
Speakers include:
* Tara Britton, Public Policy Fellow, The Center for Community Solutions
* Nita Carter, Project Director, UHCAN Ohio
goes thru new healthcare law (PPACA) by section. all information is correct and factual to best of my research. gives great background education on economics of healthcare and covers how massachusetts and europe/canada are doing w/ "reforms". I am against this law, but most information is just plain fact.
FOCUS Health ReformonTHE HENRY J. KAISER FAMILY FOUNDATION.docxkeugene1
FOCUS Health Reformon
THE HENRY J. KAISER FAMILY FOUNDATION www.k�.org
Headquarters: 2400 Sand Hill Road Menlo Park, CA 94025 650.854.9400 Fax: 650.854.4800
Washington O�ces and Barbara Jordan Conference Center: 1330 G Street, NW Washington, DC 20005 202.347.5270 Fax: 202.347.5274
�e Kaiser Family Foundation, a leader in health policy analysis, health journalism and biggest health issues facing our nation and its people.
�e Foundation is a non-pro�t private operating foundation, based in Menlo Park, California.
July 2012
A Guide to the Supreme Court’s Affordable Care Act Decision
On the last day of the 2011-2012 Term, the United States Supreme Court issued its long-anticipated
opinion about the Affordable Care Act (ACA). In a case known as National Federation of Independent
Business v. Sebelius,1 the Court agreed to consider the constitutionality of two major provisions of the
ACA: the individual mandate and the Medicaid expansion. A majority of the Court upheld the
individual mandate. And, while the Court found the Medicaid expansion unconstitutionally coercive of
states, because states did not have adequate notice to voluntarily consent and the Secretary could
potentially withhold all of a state’s existing federal Medicaid funds for non-compliance, a majority of the
Court found that this issue was appropriately remedied by circumscribing the Secretary’s enforcement
authority, thus leaving the Medicaid expansion intact in the ACA. This policy brief describes the Court’s
decision and looks ahead to the implementation of health reform now that the constitutionality of the
ACA has been resolved.
Background
The Case Accepted by the Supreme Court
On March 23, 2010, the day that President Obama signed the ACA, the state of Florida filed a lawsuit in
federal district court challenging the constitutionality of the individual mandate and the Medicaid
expansion.2 Florida was joined by 25 other states: Alabama, Alaska, Arizona, Colorado, Georgia, Idaho,
Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Ohio,
Pennsylvania, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin, and Wyoming.3
Another group of plaintiffs, including the National Federation of Independent Businesses (NFIB) and
some individual plaintiffs who do not currently have health insurance, also filed a lawsuit in Florida.
Both cases were considered together by the Supreme Court.
Thirteen states, including California,
Connecticut, Delaware, Hawaii, Illinois,
Iowa, Maryland, Massachusetts, New
Mexico, New York, Oregon, Vermont, and
Washington filed amicus (“friend of the
court”) briefs in the Supreme Court
supporting the individual mandate and the
Medicaid expansion; the District of
Columbia also supported the ind.
Health Care Reform Proposals Including the President’s PlanTom Daly
Michael Bertaut, Senior Healthcare Intelligence Analyst for Blue Cross Blue Shield of Louisiana provides an update on Healthcare Reform efforts including a review of the President's Plan released on February 22nd.
ACA: A Step Toward Healthcare For All (Dr. John Cavacece, DO)Zach Jarou
Presented to the American Medical Student Association (www.AMSA.org) at Michigan State University's College of Human Medicine (MSU CHM) on Tuesday, March 20, 2012
The purpose of the webinar is to learn more about the value of the Medicaid expansion and how it could impact Ohio. We will also share resources to help you talk about the issue in your community.
Similar to Medicaid expansion issues to be considered (20)
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
1. 1
Medicaid Expansion and Beyond:
House Bill 148
Issues to be considered1
The present Medicaid program now covers the most vulnerable
populations:
The poor, elderly, blind, disabled, children, families with children
and pregnant women
The federal government generally pays 50% match for these
individuals2
Medicaid expansion as discussed in the media:
The addition of able-bodied individuals (ages 19-64) at or below
138% of the federal poverty level ($20,314 for single adults)
Throughout the following years – the match for expansion is:
2016 2017 2018 2019 2020 After 2020
100% 95% 94% 93% 90% ?
Throughout the above years, the State is still responsible for paying
generally 50% of the administrative expenses for administration of
Medicaid programs
HB 148 goes beyond Medicaid expansion
House Bill 148 also:
o Expands and grows Denali KidCare
1 Prepared by the Office of Representative Liz Vazquez
2Pregnant women and children who have family incomes that are too high to qualify for Medicaid who
qualify instead for Denali KidCare are reimbursed at 65%.
2. 2
o Expands the existing Medicaid by adding 3 new programs (the
1915 (i) and the 1915 (k) options and the 1115 demonstration
waiver).
o Reduces audits on providers - reducing accountability
o Instructs the Department of Health & Social Services (DHSS) to
propose tax even if providers do NOT treat Medicaid patients,
this can be expected to increase costs and drive away providers
Medicaid budget
Medicaid is the largest – and fastest growing – component of the state
operating budget
o It’s grown 250% -- from $200 million GF up to $700 million
general fund (GF) -- in just the past several years
o Alaska now spends $1.6 Billion each year on Medicaid
o FY14 Total Medicaid Recipients equal 165,7833 (22.5% of the
entire population of Alaska which totaled 736,732 for FY14)4
o By 2032 Medicaid without expansion is estimated to devour
the entire present budget and more, at over 6 billion dollars
Fiscal implications – enrollment is unknown
Unknown enrollment numbers – from 26,5355 to 40,2846
o Enrollment projections vary widely: disparity of at least 52%
o Experience of other states: enrollment greatly exceeds forecasts
3 According to data presented during the House Health & Social Services Committee on March 19, 2015 -
Medicaid 101 – slide 13.
4 According to U.S. Census estimates of the entire population of Alaska.
5 Department of Health & Social Services (DHSS) during a presentation on March 5, 2015 before the
House HSS Committee.
6 Lewin Group Final Report titled “An Analysis of the Impact of Medicaid Expansion in Alaska”, updated
April 12, 2013.
3. 3
Seventeen states that expanded Medicaid underestimated
enrollment an average of 91%7
o DHSS has a history of underestimating enrollment
When selling Denali KidCare to the legislature, DHSS’
enrollment exceeded their projected maximum by 92%
(1999-2002)8
Fiscal implications – costs are unknown
The spread between the various cumulative cost projections and
savings projections is nearly $417 million
Can Uncle Sam keep his promises?
The federal debt is $18 trillion -- $56,378 per each man, woman, and
child living in USA
Historically, once you expand Medicaid, costs go up
Can the federal government always pay the new matching
reimbursement for the expansion at 90% or above?
The federal government can reduce their match/reimbursement at
any time – and they have done so before
No promises were made after 2020
Uncle Sam is silent about what the federal match will be after 2020
Squeezing out existing vulnerable populations
With the federal government’s fiscal situation, decreased federal
funding is a real probability
o If that occurs, the state’s most effective cost-reduction strategy
will be to reduce services to the existing Medicaid beneficiaries
7 Arizona, Arkansas, California, Colorado, Connecticut, Illinois, Iowa, Kentucky, Maryland, Michigan,
Minnesota, Nevada, New Mexico, Ohio, Oregon, Washington, West Virginia (Arizona, Iowa and
Michigan expanded using 1115 demonstration waivers)
8 Using the only available information regarding enrollment of all children from Medicaid.gov
4. 4
first – impacting the most vulnerable (the elderly, disabled,
children and low-income families with children)
Most Medicaid services are matched at 50%; the State
Children’s Health Insurance Program is matched at 65%
o Alaska offers the most generous Medicaid program in the
nation with 27 additional optional services provided to present
enrollees
o When cuts to services are needed, the 27 optional services
Alaska provides will likely be the first to be cut
Providers will likely be penalized
o HB 148 calls for a proposal to tax up to all 19 provider types
that are allowed by federal law – regardless of whether the
provider accepts Medicaid
o Taxes will be passed on to consumers, resulting in higher
health care costs
Unintended consequences
Squeezes out Medicare seniors
o Will make it even harder for Medicare seniors to find providers
o Higher Medicaid reimbursement rates will lead providers to
prefer Medicaid over Medicare patients - which will hurt
seniors
Creates a serious equity issue
o Medicaid beneficiaries (including prisoners) will receive better
benefits than:
Seniors on Medicare
Veterans’ Administration beneficiaries
Military
5. 5
Most private insurance plans
State Fiscal Crisis
o Existing Medicaid eligible groups (with lower federal match
50% to 65%) likely will suffer more cuts because of the higher
matching reimbursement for the new expansion group (at least
90% through 2020)
o New expansion group is reimbursed at least 90% through 2020
o The State is still responsible for 50% of administrative costs
Once we expand, can we change our mind?
o DHSS is relying only on a letter9, not legal authority, not a
regulation or statute
o Binding law applies – Social Security Act, 42 U.S.C. Section
1396(c)
o The State Plan - is a legally binding agreement between the
state and federal government
o The courts will enforce legally binding laws and agreements
Studies of the University of Oregon’s expansion shows that Medicaid
expansion causes negative consequences
Results in overuse/abuse of the ER
o Increased emergency room visits – by 41%
o Undermines a key justification for expansion
o A lack of enrolled providers will increase ER use
Health outcomes mixed
o Medicaid expansion beneficiaries self-report better physical
and mental health
9 Letter dated March 6, 2015 addressed to Governor Walker from the United States DHHS Secretary
Burwell.
6. 6
However, no significant effects on measured health
outcomes such as hypertension, high cholesterol levels
and glycated hemoglobin (blood sugar)
System is broken – why expand a broken system?
Everyone admits the system is broken and needs reform
o Enterprise (formerly named MMIS) – payment system – had
numerous system defects affecting every area of operations
o Alaska has lost over 1,000 enrolled providers between 2010
and 2014
Old adage: If it ain’t broke don’t fix it
But if it is – fix it before you grow it and don’t throw more money at
it
Serious reforms NOT proposed
HB 148 goes beyond Medicaid expansion – but it doesn’t fix what is
broken
o Proposes only generalities, not specifics
o No measured standards or goals
o No deadlines
DHSS has not done enough due diligence
On the proposed 1115 demonstration waiver: DHSS personnel knew
of only one state trying expansion using a demonstration waiver –
Oregon
o Oregon however expanded its Medicaid program prior to the
Affordable Care Act – they were one of the first states to do so
o The following states implemented expansion through 1115
demonstration waivers/post the Affordable Care Act:
Arkansas, Indiana, Iowa, Michigan, New Hampshire, and
Pennsylvania
7. 7
o The following states have applied for demonstration waivers
but have had difficulties getting CMS approval: Arizona
California, Connecticut, Indiana, and Oklahoma
Uncle Sam denied changes in:
Arizona that sought cost-sharing increases
California that sought to increase co-payments
Connecticut that attempted to raise total asset tests
to limit eligibility
Indiana that sought to implement requirements that
would promote personal responsibility for failing to
meet co-pay obligations
Oklahoma because of enrollment caps
Possible alternatives to Medicaid expansion
Federally Qualified Health Centers such as Anchorage Neighborhood
Health Center
o Roughly $14 million budget including a $3.4 million federal
grant
o Provides discounted care to low-income patients (90% of their
patients) via a sliding fee schedule
o Getting the job done with less $: providing health care for the
community, including low-income and uninsured patients
Look Before We Leap
Imperative that we carefully weigh – and fully understand – both
fiscal and health care policy implications of both Medicaid
expansion and HB 148 – before we do it
o Arkansas stopped covering lifesaving drugs for Cystic Fibrosis
patients – forcing patients to sue
o Arizona hospitals see operating losses despite Medicaid
expansion
8. 8
o Massachusetts proposed to close a $1.8 billion state budget gap
by chopping benefits for the neediest and cutting rates of
reimbursements to providers
Printed May 20, 2015