lessons learned from aco/clinical integration … learned from aco/clinical integration...
TRANSCRIPT
Lessons Learned From ACO/Clinical Integration Implementation: 3 Successful Case Studies
October 31, 2012
Agenda
Introductions
Overview
Three Case Studies• Central Maine Medical Center
• The Reading Hospital and Medical Center
• Henry Ford Health System
Q & A
1
Why Change is Necessary
Problem
•
Fee for service is fading as dominant payment mechanism•
CMS and commercial payers instituting performance
benchmarks
•
Costs are squeezing employers and limiting enrollment•
Health status of many communities requires a different
paradigm
Opportunity
•
Redesign care around patients•
Produce better care for less •
Increase market share with better product•
Improve professional satisfaction through collaboration
2
The Cost of Not Changing
Decline in community health
status (diabesity)
Reduced physician income
Erosion of patient base
3
Value Defined
Value =
Cost is intrinsic to quality rather than separate from it
Total money spent
Health outcomes
4
Principles of Value‐Based Healthcare Delivery
5
Quality improvement is the most powerful driver of cost containment and value
improvement, where quality is health outcomes
• Prevention of illness• Early detection • Right diagnosis• Right treatment to the right patient• Rapid cycle time of diagnosis and
treatment
• Treatment earlier in the causal chain of
disease
• Less invasive treatment methods• Fewer complications
• Fewer mistakes and repeats in
treatment
• Faster recovery• More complete recovery• Greater functionality and less need for
long‐term care
• Fewer recurrences, relapses, flare ups,
or acute episodes
• Reduced need for ER visits• Slower disease progression• Less care‐induce illness
• Better health is the goal, not more treatment
• Better health is inherently less expensive than poor healthSource: Michael Porter, American Academy of Orthopedic Surgeons Conference, March 31, 2012
Getting from First Curve to Second Curve
Metrics to evaluate progress Self‐assessment questions
Source: “Hospitals and Care Systems of the Future,”
American Hospital Association, September 2011
Volume‐based first curve
Development of core competencies
• Fee‐for‐service reimbursement
segment
• High quality not rewarded• No shared financial risk• Acute inpatient hospital focus• IT investment incentives not seen by hospital• Stand‐alone care systems can thrive• Regulatory actions impede hospital physician
collaborations
• Payment rewards population value: quality
and efficiency
• Quality impacts reimbursement• Partnerships with shared risk• Increased patient severity• IT utilization essential for population health
management
• Scale increases in importance• Realigned incentives, encouraged
coordination
The gap
6
“Communication, Education,
Performance Incentives”
Transition to Enhanced Quality of Care
Current Ideal
Individuality Interdependence
Clinical autonomy Evidence‐based medicine
One‐on‐one patient carePatient‐centered
medical home
“Captain of my ship” Member of the team
Procedure‐driven Evidence‐based medicine
Fee for servicePerformance‐linked
payment
7
Seven Key Take Aways
Trust
Transparency
Leadership
Communications
Data
Flexibility
Patience
8
Medical Homes: Strong support and emerging evidence around impact; potential to leverage existing pilots and scale up rapidly
Centers of Excellence: Superior outcome and cost profile for selected high‐cost diseases and procedures; opportunity to explore providers outside NJ market (e.g., NYC, Philadelphia)
Disease/Procedure‐Based “Products”: Increasing adoption and evidence of potential impact on cost curve; may be selectively implemented with handful of providersAccountable Care Organizations: Increased popularity and visibility in reform proposals; potential for Horizon to facilitate coordination given fragmentationAdmin Integration: Potential to reduce back‐office complexity; will require technology and infrastructure to facilitate integration
Mature P4P: Various P4P programs implemented with limited impact; opportunity to optimize existing programs to generate more incremental savings and avoid excess administration Pay for Outcomes: Greater potential for cost savings than P4P however, difficulty in developing outcomes‐based measurement Bundled Case Rates: Some pilots being implemented with varying levels of impact; requires EBM, case rates and episodes of care, and underlying infrastructure/systems
Global Payments: Potential to deliver significant savings; raises concerns on capitation; relatively challenging given fragmented nature of NJ provider environment
eBay for Healthcare:Market sets the price for highly elective procedures; however, limited enabling infrastructure at present; may lead to reduced health plan role in the future
Uniform Hospital Pricing:May significantly cut delivery costs; however, potential policy issues from previous implementation; may also minimize Horizon provider discount advantage
Initial Hypotheses on Prioritization of Provider Engagement and Payment Models
Degree of Impact HigherLower
Lower
Higher
Degree of Difficulty
Medical
Homes
“Products” CI/ACO
Global
PaymentAdmin
Integration
Uniform
Hospital
Pricing
Centers of
Excellence
P4P
Bundled Case
RateseBay for
Healthcare
Pay for
Outcomes
6
4
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2
5
3
8
7
9
11
10
Degree of Impact: Potential effect on bending the cost curve in 3‐5 yearsDegree of Difficulty: Ability to implement based on provider environment, historical relationships, and Horizon’s existing capabilities
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11
Rationale ‐
Preliminary Hypotheses
Most Promising Models
Current Healthcare Delivery/Payment Models
9
Business Case for Clinical Integration/ACOs
The success of Clinical Integration/Accountable Care
Organizations will hinge on how well the case is made that
outcomes are improved and value is being delivered. To
date, the provider community has not been able to
adequately define, let alone deliver on, what quality means
and how it can be measured.
This appears to be a major stumbling block in the shift from
fee‐for‐service to fee‐for‐value. For those organizations
that can effectively make the case for improved quality
(along with cost management), they may be able to
capture a significant share of the employer market.
10
Growth of Government and Commercial ACOs/Clinical Integration
11
Accountable Care Organizations (ACOs)
ACOs –
an entity in which providers take responsibility for a
defined population , coordinate care across settings, and are held
to benchmark levels of quality and cost
ACOs seek to balance cost control with efforts to improve
outcomes and enhance people’s satisfaction
12
Clinical Integration
A Clinically Integrated Organization is an entity that emerges out of a
regulatory framework to allow physicians and hospitals to come together
and negotiate fees and bonuses with payers and employers as long
as
they can demonstrate quality improvements.
What does Clinical Integration accomplish? It aggregates and
integrates physician and hospital services to generate better care at less
cost and more favorable contracting with payers.
What must a Clinically Integrated organization do? The FTC/DoJ has
stated it would not pursue antitrust action (“safe harbor”) if they meet a
three‐part test:1.
Likely to achieve “real”
integration of providers;
2.
Program initiatives are designed to achieve likely improvements in healthcare cost, quality
and efficiency (e.g., evidence‐based protocols) and;
3.
Collective contracting with health plans is “reasonably necessary”
to achieve efficiencies
and clinical objectives of the program.
13
FTC “Clinically Integrated”
Requirement (1996)
Following conditions must be met
1.
Network of physicians willing to
demonstrate “a high degree of
interdependence and cooperation,”
through
2.
Program of initiatives designed to
“control costs and ensure quality,”
which
3.
Supported by an infrastructure
that
allows the physicians to “evaluate and
modify practice patterns.”
14
“A comparison of ACO
characteristics and those used
by the FTC to determine
whether the goal of clinical
integration has been met …
shows a high degree of
concordance.”
Burke & Rosenbaum, “Accountable
Care Organizations: Implications for
Antitrust Policy,”
BNA Health Law
Reports, March 11, 2010.
Source: Hogan Marren, Ltd.15
Clinical Integration (CI) vs Accountable Care Organizations (ACOs)
Characteristics CI ACO
Source of Patients Commercial Insurance & Employers Medicare
Basic Reimbursement Fee for Service Fee for Service with opportunity for
shared savings (Track 1) or shared
savings/losses (Track 2)
Number of Metrics 5 – 10 per specialty 33 measures (patient experience, care
coordinator, preventive health at‐risk
population)
Compliance Requirements Antitrust law Medicare Requirements & Antitrust
Physician participation Participation Agreement Participation Agreement
Legal Entity Not required for CI, but CI org can be
the service corporation
Separate legal entity with
independent board (75% ACO
participants)
Beneficiary alignment Not applicable on non‐risk
management
Alignment of beneficiaries based on
primary care codes
Physician Exclusivity Not required under CI Exclusivity of PCPs and specialists
providing primary care services
Source: Hogan Marren, Ltd.16
Key Foundation Capabilities for Clinical Integration/ACOs
• Develop infrastructure which collects and mines clinical and claims‐related information into a useful
database to support evidence based medicine
• Capture quality metrics to enable provider benchmarking and reporting
Informatics
Infrastructure
Medical Management
Product Development
Provider Selection/Contracting/ Funds Flow
• Infrastructure to support real‐time eligibility and claims, adjudication based on episodic care,
and billing/ payments integration
• Collaborative case management and utilization review based on clinical care guidelines (optimize case
management), with attention paid to appropriate transitions of care
• Create episodic product groupers and tie reimbursements to episodes of care (e.g., knee, hip)
• Identify provider risk/ cost share mechanisms to maximize P4P value
• Select providers based upon basic quality standards and commitment to the CI/ACO's philosophy and
delivery model
• Engage in joint contracting with providers based on gain share/ bundled payments modeling
Select Capabilities Description
• Active and ongoing program to evaluate and modify practice patterns by the network's physician
participants and create a high degree of interdependence and cooperation among the physiciansClinical Integration
• Develop analytical methods and tools to reduce physician variation across key cost & quality metrics
• Design and optimize care quality programsClinical Effectiveness
Strategic Communications
• Conduct perception research with physicians and patients to understand key motivations and resistance points
• Drive physician behavior and uptake of new processes through education
• External branding, and differentiation of CI/ ACOs and new product/services ‐‐
highlight benefits and drive
participation rates
17
The Road Ahead
Cultivate physician leadership
Align payment with expectations for performance
Develop transitions of care and care management capabilities, focused on the highest risk patients
Make time to allow for buy‐in from physicians
Develop the data model, IT infrastructure and tools for data modeling and analytics
Invest in population health solutions
Take an organizational change view and continually assess readiness for next steps. Communicate with all involved stakeholders.
18
Patient Care Is a Team Sport Now
19
Today Tomorrow
Going Forward
We can't solve problems by
using the same kind of
thinking we used when we
created them.
– Albert Einstein
20
Contact Information
Phil Polakoff MD
Chief Medical Executive
FTI Health Solutions
510‐508‐9216
21
3rd
National ACO CongressOctober 31, 2012
Edmund (Ned) Claxton, Jr., MDMedical Director, CMH ACO
22
Organization & Context
Central Maine Healthcare• CMMC –
225 beds, census ~ 125 (85 –
175)
• 2 Critical Access hospitals (25 beds each)
• 1 Managed hospital (50 beds)
3rd largest hospital in Maine (600, 400, 200)
Catchment area ~ 400,000 people, 100 miles
Maine• Same size as Indiana with 20% of the people
ACO is separate corporation under CMH• Limited resources
23
Integration
System• Common leadership and 1 board ‐
1990
• Major IT investments –
1998, 2006, 2011
Hospitals• Centralized administrative functions
• Integrated and shared staffing
Medical staffs• LAPA, 1986 PHO
• Separate staffs, common leadership
• Moving to common bylaws for medical staffs
24
Central Maine Medical Group
Employed providers:• 250 physicians
• 110 APS – CRNA, CNM, NP, PA
>80% of the hospital staffs• Started ~ 1991, added small practices since
New position of President ‐
2009
• New Bylaws 2010: Pres of CMMC Medical staff
Division/Chief structure• 3 hospitals + Hospital‐based, PCP, Surgery, Specialty
100,000 PCP + 40,000 Specialist patients
25
ACO Foundational Work
Business development• Employee health plan – “ACO‐like”
• Risk assessment, employee benefits structure, health coach
• “ACO”
regularly in discussions – March 2011
• Existing payers increasingly migrating to ACO efforts
• CMS/ACA
Readiness assessment• Premier – June 2011
26
ACO Foundational Work (cont’d)
Clinical• PCMH commitment – Maine PCMH multi‐payer pilot
• Provider quality incentives: +3%, +/‐
6%, +/‐
9%
• Population management –
Saving Lives Initiative
(Mining 12 years of Centricity history)
•AAA
Critical 3
Urgent 12
•Breast Cancer
Cat 5 8
Cancer 8
•Colon Cancer
Pre‐cancer 645
Cancer 15
• Medical staff bylaws revisions ‐
2010
27
ACO Status
Employees ~ 3000 covered lives• Expenses decreased 4% YTD
Private insurers ~ 8,000
CMS MSSP ~ 16,000 (July 1 start)• Success: Readmission rates, advanced imaging, LOS
• Challenges: ED visits, Amb Care Sensitive conditions
Resources• Registries –
Centricity (Meridios)
• Case (Care) Managers
• Health coaches, LCSW’s28
Lessons Being Learned
Patients• Earlier and greater involvement (Board, Steering, Ops)
• Communication ‐
Social media?
• Mental Health integration
Providers and Administration• Communication
• Champions
• Cultural sensitivity and change management
• Transparent and shared decision‐making
• PCP burden
• Aligned incentives
29
ACO Concepts
30
3rd
National ACO CongressOctober 31, 2012
Clint MatthewsPresident & Chief Executive Officer
31
Organization & Context
The Reading Hospital & Medical Center• Licensed Beds‐
775, Staffed Beds ~ 660, 29,000 annual admissions
• Over 800 physicians on medical staff, about 300 of whom are employed
• Post‐acute facility
Berkshire Health Partners (BHP)• Non‐profit PPO servicing Berks and surrounding counties
• 50/50 ownership with physicians
• Contains Medicus Resource Management, a care management subsidiary
• Reading Hospital Medical Group & Reading Professional Services
• Over 300 employed physicians in two corporate structures providing both primary
care and specialty services.
32
Why Pursue Clinical Integration?
•
Align our medical staff (both employed and independent)
around common goals of quality and efficiency
•
Improve community health
•
Respond to employer and payer demands for better healthcare
value
•
Prepare for changing reimbursement structures
•
Complement other health system strategies, most notably
Reading HealthConnect (Epic)
33
The Reading Path to Clinical Integration
34
• Plan for
implementation• Finalize
communication
materials• Obtain necessary
approvals
• Answer key
questions• Inventory assets• Create functional
models• Create Business Case
and Budget• Develop early
consensus• Engage hospital and
physician leadership
• Detailed design• Build key elements• Launch organization• Hire redeploy
executives• Deploy assets• Deliver proof of
concept• Obtain FTC/DOJ
anti‐trust guidance,
if necessary• Initiate Learning
Laboratory
• TBD
Phase 1:
Conceptual Design
Phase 2: Hypothesis
Testing &
Implementation
Planning
Phase 3: Detailed
Design and Year One
Build & Deploy
Ongoing Phases:
Future Capability
Deployment
12 weeks 8‐10 weeks 12‐16 months Ongoing
Readiness
Assessment
4 weeks
• Inventory existing
quality improvement
programs• Understand
leadership
perspectives• Assess levels of
understanding• Understand business
drivers• Assess physician
alignment level(s)• Build list of
participants for design
TRH CLIO is here
63 Physicians
Engaged in
Design
Clinical Integration Design Effort
35
DESIGN SUMMIT
Outputs: Finalize Straw Models, Determine Interdependencies
and Obtain Senior Leadership Validation
Clinical Integration Design Engagement
36
15 Design Sessions (30 Total Design Hours)
62 Physician Participants
36 Employed and 26 Independent Physicians
75% attendance at meetings
25 Specialties represented
Clinical Integration Governance
37
Coordinated, Physician‐Led
Governance Structures
BHP enters into CI
contracts with
payers
Physicians
can elect to
participate in the CI
Program
Physicians continue to receive FFS
payments under BHP’s CI payer
contracts
P4P bonuses,
“shared savings”
payments, etc.
Reading Physician Organization (RPO)
Clinical Integration
Operations Company
RPO nominates Physician
members
FTE(
s)
2012 CLIO FTEs support existing care management initiatives including East Penn and the new Heart Failure protocols. Salary expenses for
these 7 FTEs was annualized in 2012 to reflect .5 year expense.
Note: variance in timing of FTEs attributed to the Fiscal Year (FY) versus Calendar Year (CY).
Over the next 4 years, the staffing component of BHP will
transition to focus on Clinical Integration initiatives
38
Clinical Integration will Change our Contracting Approach
39
Payers
Employers
Provider Contracting
Non‐negotiated FFS Rates
Reading
Physician
Organization
Berkshire HealthPartners
The Reading
Hospital and
Medical Center
Hospital Contracting
Negotiated FFS
Rates
The Reading
Hospital and
Medical Center
Reading
Physician
Organization
BerkshireHealthPartners
CI Operating
Company
(hospital owned,
physician led)
Payers
EmployersCollective Negotiation
Negotiated FFS Rates, P4P,
Shared Savings
• Non‐
negotiated
FFS rates
• Separate
contracting
activities
• Messenger
Model at BHP
Toda
y
• Collective
Negotiation
• Performance
IncentivesTo
morrow
Contracted
Services
Our Foundation to Build Upon
Heart Failure Pilot Results (25 Patients Enrolled)• Admissions Decreased by 74%
• 73% Patient‐Reported Improvement in Quality of Life, per survey
• Readmissions Decreased by 37.5%
Branded the Heart Partners Program• 128 patients currently enrolled
Team has now started on Chronic Obstructive Pulmonary Disease
(COPD)
Goals are to grow and maintain these programs while rewarding
providers who meet quality and efficiency thresholds
40
Procedure
Center
Acute Care
Center
How Care Changes…The New Reading Model
41
Communication
Coordination
Transitions of Care
Measurement
Post Acute
Care Center
Physician
Office
Home Health
Center
Diagnostic
Center
Key Success Factors
•
Physician, governance, leadership and participation
•
Consistent and ongoing leadership commitment through the
full implementation of a Clinically Integrated Organization
(CLIO)
•
Collaboration and coordination across The Reading Hospital &
Medical Center and its physicians
•
Adherence to a disciplined plan for development and excellent
execution
•
Strategic awareness of the changing healthcare reform
environment and an entrepreneurial mindset to react quickly
in response
42
Key Learnings
•
Obtaining widespread consensus among both physicians and
executives is critical to proceeding, but Board members must
also be engaged along the journey.
•
Technology is critical, difficult and expensive.
•
Converting from FFS reimbursement to value‐based
contracting is inevitable but a much more difficult transition
for many health systems “in the heartland”
than in
environments that have a significant penetration of managed
care.
•
Employers are “changing the game”
even more quickly than
payers in some environments. CI must enable us to respond to
employer demands for reduced costs and higher value.
43
3rd
National ACO CongressOctober 31, 2012
Dr. Charles Kelly President & Chief Executive Officer
44
Where does the HFPN fit in?
45
The Henry Ford Physician Network (HFPN) is a subsidiary of HFHS
Ownership
Operating Division
HENRY FORD
HEALTH SYSTEM
HENRY FORD
HEALTH SYSTEM
HENRY FORD
CONTINUINGCARECORP.
HENRY FORD
CONTINUINGCARECORP.
HENRY FORD
WYANDOTTEHOSPITAL
HENRY FORD
WYANDOTTEHOSPITAL
HENRY
FORD HOSPITAL
HENRY
FORD HOSPITAL
HENRY
FORD MEDICAL
GROUP
HENRY
FORD MEDICAL
GROUP
BEHAVIORAL
HEALTH(IncludesKingswood Hospital
& MaplegroveCenter)
BEHAVIORAL
HEALTH(IncludesKingswood Hospital
& MaplegroveCenter)
HFHS
FOUNDATION
HFHS FOUNDATION
P‐COR
L.L.C.(OptimEyes)
P‐COR
L.L.C.(OptimEyes)
FAIRLANE
HEALTHSERVICESCORP.
FAIRLANE
HEALTHSERVICESCORP.
HENRY FORD
PHYSICIANNETWORK
HENRY FORD
PHYSICIANNETWORK
HEALTH
ALLIANCE
PLAN
HEALTH
ALLIANCE
PLANCOMMUNITY
CARE
COMMUNITY
CARE
DOWNRIVER
CENTERFORONCOLOGY
DOWNRIVER
CENTERFORONCOLOGY
HENRY FORD
WESTBLOOMFIELD
HOSPITAL
HENRY FORD
WESTBLOOMFIELD
HOSPITAL
HENRY FORD
MACOMBHOSPITALCORPORATION
HENRY FORD
MACOMBHOSPITALCORPORATION
PREFERRED
HEALTHPLAN, INC.
PREFERRED
HEALTHPLAN, INC.
HORIZON
PROPERTIES
INC.
HORIZON
PROPERTIES
INC.
ALLIANCE
HEALTHAND LIFEINSURANCE
COMPANY
ALLIANCE
HEALTHAND LIFEINSURANCE
COMPANY
SHA REALTY
SHA REALTY
FAIRLANE
PHARMACYSERVICESCORP.
FAIRLANE
PHARMACYSERVICESCORP.
ONIKA
INSURANCE
COMPANYLIMITED
ONIKA
INSURANCE
COMPANYLIMITED
Current Recruitment Status
46
Summary by Affiliation
Affiliation Category Signed PCPs %PCP
HFMG 1133 258 23%
Employed 82 52 63%
Private Practice 571 134 23%
Contracted 14 0 0%
Total (goal 2011) 1800 444 25%
Summary by Region
Region Signed PCPs
Private
Practice HFMG* Employed Contracted Total Total %
Macomb 296 1 56 8 361 76 21%
Oakland 77 0 0 0 77 54 70%
Downriver 198 0 26 2 226 56 25%
Detroit 0 1132 0 4 1136 258 23%
Total (goal 2011) 571 1133 82 14 1800 444 25%
HFPN Board Composition and Committee Structure
47
50% Private Practice50% Henry Ford Medical Group
President/CEO HFPNCEO, HFHS or designeeCEO, HFMG or designeeCFO, HFHSPrivate Practice Physician Trustee, HFHS Board
Why did we do this?
•
System transition from AMC and HFMG reliance on feeder
source referrals to an IDS with more Community Beds and
more independent than employed physicians
•
Physician alignment strategy‐become the preferred health
system partnership
•
Began late 2008 (18 months pre‐
PPACA)
•
Prepare for “reform”
regardless of how it might look
48
Critical Goals and Objectives
•
Be first to market and recruit private docs into our network
with aligned vision and financial incentives
•
Reduce internal concerns of HFMG
•
Deploy IT connectivity on shared EMR
•
Educate, deploy and support true clinical integration
•
Negotiate contracts rewarding docs for doing the right thing
49
Clinical Integration
HFPN
Program Development Timeline
50
13
Jul2009
Jan2011
Apr 2009
Jan2009
New Business Entity
Incorporated &
Physician‐led Board
of Trustees Launched
Strategy Retreat to
Confirm New
Business
Entity
Commitment to Vision –
Clinically
Integrated network
Private Practice &
HFMG Physicians
Commit to Lead
Program
Development
Year 1 Clinical &
Efficiency Metrics
Defined & First
Physician Par
Agreement Signed
InitialData flowing
via Crimson
from source
systems
2 4 6
91 3 5 7
8Jan 2010
Jul2010
Dec2010
Oct2009
Apr 2010
Site Visit to
Advocate Health
System
Strategy
Retreat
Prompted
by
Employer
Interest
Program review
with the Federal
Trade
Commission
(FTC)
PPACA
Passed
10
March2011
1st
HFPN
Portal User
11
1st
Clinical
Program
Live
Sept2011 12
1st
ContractEffective
Jan2012
April2012
Crimson Full
Access
Rollout to
connected
physicians
Results to Date
Clinical Supportive Initiatives• Diabetic education, anticoagulation clinic, Medication Therapy Management (harm
and readmission reductions), biomechanical approach to chronic pain and stress
classes, and developing mobile case management
Educational and IT deployments• Epic transition with well priced ambulatory offering
• data driven CME focused on ED utilization and COPD/advanced CHF
• Telemedicine pilot with medication dispensing unit
• Communication pilot with mobile Application for Smart phones
51
Results to Date
Contracting success• HFHS Employee “learning lab”
• Upside P4P
• CMMI Bundled Payment Application• Gainsharing
• Commercial Bundled Offerings• Shared savings
• Narrow network discussions• Commercial self‐funded employer• Individual offering with HAP
• Ambulatory intensivist
pilot• Population management/case management
• CMMI SNF/ dual eligible LTC grant• Model organizing a new clinical and shared risk relationship
52
Key Learnings
•
The leading message on the benefits of CI is quality and
efficiency outcomes for the patient‐
what you ultimately need
are contracts
•
The ultimate goal should be opportunity to focus on
meaningful measures for all payers‐
don’t start with 104 of
your own
•
There is as much internal resistance and misunderstanding as
you encounter externally
•
CI leadership requires much passion and integrity
53
Questions
54