Insight, analysis & opinion from Joe Paduda

Jul
26

Wildly off topic #7, do our part.

Time to check in on how our Ukrainian friends are doing…

Last time we focused on strategy vs tactics…today we’ll cover why the Russians continue to do stupid stuff while the Ukrainians take full advantage of technology.

How who follow this closely know that the Russians are relying almost entirely on massive artillery barrages to level towns, cities, and villages before trying to push troops in. That was working, and Ukrainian forces were hard-pressed to withstand the bombardment.

From the Kyiv Independent: “artillery dominance compensates for the weak performance of Russia’s infantry.” 

That was then.

It’s quite different now, mostly because A) NATO countries have sent hundreds of artillery tubes (think cannons) and dozens of rocket systems to Ukraine and B) Russian logistics are awful.

A – These NATO weapons are much more accurate and have greater range than most of the stuff the Russians are using.

This allows the Ukrainians to shoot from further away, reducing the risk from Russian “counter-battery fire” (radar can identify where the outgoing shells and rockets are coming from so the enemy can shoot back). The new weapons systems are also much more mobile; our HIMARS rocket systems can shoot and be gone in 2 minutes. (thank you American taxpayers!)

Since mid-June, Ukrainian artillery has become increasingly lethal and extremely effective. This from the Kyiv Independent.

On June 15, a massive explosion occurred near the city of Khrustalniy (formerly Krasniy Luch) in occupied Luhansk Oblast. Explosions continued for days. According to satellite images, the blasts created a destruction zone spanning some 500 meters around the epicenter. The site was one of Russia’s largest ammunition depots

July 2, Ukraine’s military published a video showing an enormous explosion at another large depot in the city of Popasna…Two days later, another devastating blast destroyed a large depot in the city of Snizhne. Three more depots were also hit in Donetsk.

Which leads us to B – Russian logistics.

Faithful readers will know Russian logistics – in English the process of supplying troops with fuel, munitions, water, spare parts, and equipment – is awful. They don’t use forklifts to move heavy stuff, but rely on manpower. They don’t have pallets, but rely on manpower. They don’t have enough trucks, so they rely on trains.

That’s why the Ukrainians have been able to destroy thousands of tons of Russian artillery shells and other munitions; the Russians move those munitions to giant storage depots, where people offload the shells and trucks transport the shells to the artillery locations.

It’s pretty easy to identify where trains are off-loading, and even easier to use a few artillery rounds to set off giant, days-long fireworks shows.

 

reportedly a large Russian ammo depot; actual video is here.

So, the Russians move the depots further from the front lines  – out of range of most artillery.

Enter HIMARS – which has a range of almost 50 miles with current rockets – can hit pretty much any target inside Ukraine.

From Igal Levin, a Ukraine-born Israeli defense expert.

“…if all those forwarded bases, depots, repair facilities, all of the logistics chains are destroyed — [Russians] will have to deal with the need to bring supplies from beyond the Ural Mountains, then be thinking how to store and distribute them, how to bring munitions to artillery.”

The takeaway.

Russia has a far larger army, exponentially more artillery weapons, and enough artillery rounds in storage to fight for decades.

They also have a wildly corrupt economy, where kleptocrats stole billions of rubles intended to feed, clothe, and equip soldiers.

Ukraine has a much smaller military – and had a history of corruption, albeit one that pales in comparison to Russia’s. Their troops – men and women – are way more motivated, fighting for their families and  land, and increasingly well-supplied.

They are also very well led by commanders who have years of experience fighting the Russians in Crimea and the Donbas and are taking full advantage of Russia’s limitations and NATO largesse.

What do we need to do.

Keep the faith, people.  Russia’s invasion of Ukraine is a major contributor to inflation, driving up fuel and food costs around the world. Yes this sucks, but our sacrifices are nothing compared to what Ukrainians are doing every minute of every day.

This too shall pass. When it does Putin and Russia will be far less dangerous, food and fuel prices will be much lower, and the world will be a way better place.

If you can, please help Ukrainians suffering from hunger, homelessness, injury and disease by donating to Care.


Jul
25

A creative way to generate work comp PBM revenue.

The work comp Pharmacy Benefit Management business has become hyper-competitive; total drug spend has dropped 6 of the last 7 years, there’s been massive consolidation of PBMs, margins are declining…all signs of a very mature industry.

Sounds like a not-very-attractive-business…right?

Well, due to accounting rules, PBMs are still wildly popular among work comp service companies.

They love PBMs because the companies get to count the cost of the drugs as well as their margins as top-line revenues – which makes those service companies look bigger than they really are.

The problem is…once you buy a PBM, you get a big one-time increase in revenue. But – and it’s a BIG but, unless you figure out how to grow that PBM revenue in a business that is declining, your top line flat-lines.

If you’re looking to sell your work comp service company, or otherwise tout strong financial performance, that is not a good look. Which brings me to a creative way a PBM is generating script volume without adding new payer customers.

Occ med clinic giant Concentra’s providers are writing scripts that direct the pharmacy filling the script to send it to Mitchell Pharmacy Solutions for administration.  (I looked for a company link, but couldn’t locate any mention of Concentra’s OccuScript program on their website)

According to Concentra, the OccuScript program:

  • has been in place for quite some time;
  • is mostly – but by no means exclusively – used in states where physician dispensing is not allowed (e.g. Texas);
  • appears to primarily address initial prescription fills which are mostly generics prescribed for a limited time;
  • about one of every nine scripts written in the company’s 520 clinics and 120 onsite centers flows through the program. Mitchell is the current administrator, providing network access and the claim adjudication platform. To be clear, Mitchell does not use its own pharmacy network…they contract with Script Care.

Injured workers treated at this clinic may be – or more likely are not – covered by a payer that contracts with Mitchell. (Mitchell is one of several work comp PBMs  – and far from the largest.) If it’s a Mitchell-contracted payer this form/process is helpful indeed.

In an email conversation with Concentra, the company noted “OccuScript supports medication compliance which is fundamental to evidence-based care delivery and positive patient outcomes.”  (note Concentra stated in an email “We have national employer customers whose injured workers are never processed through the OccuScript program…(some payers instruct Concentra on how to process scripts for their injured workers.))

Medication compliance is important indeed, but there are several potential issues/concerns/problems if the injured worker is NOT covered by a Mitchell-contracted payer.

  1. The payer gets a bill from a non-contracted billing entity which adds a lot of work for claims adjusters who have to figure out what to do with it.
  2. Unlike scripts processed by the PBM contracted by the injured worker’s employer/insurer/TPA, the payer finds out about the script AFTER it is dispensed. The drug(s) actually dispensed may – or may not – be:
    1. duplicates of other scripts,
    2. contra-indicated due to other drugs prescribed for the injured worker (while prescribers are supposed to ask about other meds, many patients aren’t able to recall drugs they are taking), and/or
    3. an expensive version of the prescribed drug (there are literally dozens of companies making ibuprofen, many at different prices for the same pill; contracted PBMs control for this with MAC lists.)
  3. The injured worker’s payer/employer/insurer is usually billed at a rate that is higher than their contracted PBM price – sometimes MUCH higher…driving up the employer’s/insurer’s/taxpayer’s work comp costs.
  4. Concentra’s OccuScript contracts with Mitchell who in turn contracts with Script Care…
    1. all of whom have to get paid,
    2. and adding communication challenges as issues have to pass through several entities.

So what to do?

Concentra avers it is ready and willing to work with payers and employers to route scripts to their PBM. It is also interested in working with PBMs. Sure, most “first fills” are “one and done”…but many are not. Getting on the claim as quickly as possible is an industry-wide best practice.

Note – Concentra execs were quite responsive to my queries about the program; kudos to CEO Keith Newton and Charles Bavier – who runs Concentra’s OccuScript program – for jumping on this.

What does this mean for you?

If you aren’t a Mitchell Pharmacy Solutions customer, get with Concentra ASAP to get those scripts routed to your PBM.

For those unfamiliar with this space…Insurers and TPAs hire Pharmacy Benefit Managers (PBMs) to ensure injured workers get the medications they need to recover and return to work. PBMs contract with pharmacies, operate call centers and employ pharmacists – all in an effort to deliver the right drug at the lowest possible price.


Jul
21

California’s Med-Legal Mess

In the esoteric world of workers’ comp, California’s “med-legal” issues rank near the top of issues bound to frustrate/infuriate.

Med-legal (analogous to physician review or independent medical exam) may have even moved up a notch or two, as expenses have zoomed after a change in the med-legal fee schedule that went into effect in April of 2021.

The change was intended to:

  • simplify the payment structure by replacing several variations with one flat-fee
  • increase the number of QMEs – Qualified Medical Examiners
  • and increase the number of oncologists and toxicologists,
  • reduce overuse of “supplemental” reports
  • do this all without more than a 25% increase in aggregate med-legal fees.

CWCI’s research indicated that results appear to be far less than intended…

  • the number of QMEs increased slightly – up 134 – with most ortho surgeons – NOT oncologists and toxicologists
  • there was no decrease in supplemental report services (e.g. billing for more pages reviewed)
  • and the average paid per month for comprehensive evaluations went up more than 50%.

Thanks to CWCI for sharing the details…need more details?

Sign up for CWCI’s webinar on Wednesday, July 27 at 10 a.m. (Pacific). Senior Research Associate Stacy Jones, who authored the study, and CWCI General Counsel Sara Widener-Brightwell, will review those changes and discuss the results of the study.  The program will be followed by a live Q&A session.

What does this mean for you?

As if we needed it, another entry in the Hall of Unintended Consequences tells us – YET AGAIN – regs have to be carefully thought through, responses anticipated and planned for, profiteer strategies gamed out, and then – AND ONLY THEN – finalized.


Jul
19

Healthcare costs are…

heading up.

First, a bit of background.

Big health insurers that sell insurance via the Exchanges have to file their rates with the Feds now. While they don’t insure a lot of people, their filings are detailed, public, and cover 13 states – Georgia, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, New York, Oregon, Rhode Island, Texas, Vermont, and Washington DC.

The fine folks at the Kaiser Family Foundation did a lot of analysis, here are the key takeaways.

  • many insurers are projecting a medical cost trend of 4-8%.
  • “A substantial share of the increase in premiums is from rising health prices and utilization of health care”
  • one insurer said “Medical Care Services CPI in March 2020 (pre-pandemic) was 5.5% and as of March 2022 is 2.9%. This data suggests a correction is imminent as labor and supply cost increases directly impact hospitals and physician offices.” [emphasis added]

Oh, and that COVID thing? “many insurers are projecting the pandemic will have a net neutral or only slight impact on health costs and premiums.”

So…what does this all mean?

My view.

  • for this year, increased utilization and prices will drive trend north of 5%
  • we’ll see a bump in Q3/Q4 as increased labor costs work their way thru the system
  • 2023 trend will likely settle around 5% as inflation in other sectors eases off.

The wild card is – brace yourself – politics.

Sen Manchin – the mercurial-I-can’t-make-up-my-mind-and-it-sure-is-fun-being-the-center-of-attention Senator from West Virginia will determine if 13 million Americans can no longer afford health insurance.

If legislation doesn’t pass, health systems will have to care for more people without health insurance; some systems and hospitals will raise prices to cover their losses.

What does this mean for you?

Higher healthcare costs for the privately insured, workers’ comp insurers, employers, and taxpayers.


Jul
18

(Perhaps) unintended consequences of abortion bans

With all the attention paid to abortion these days, I thought it worthwhile to dig into the financial and health impact of abortion and childbirth.

First, the cost.

Women who give birth incur about $19,000 in additional healthcare costs compared to women who don’t.

And that’s for women covered by large employers’ health plans.

Second, medical debt.

Lower-income adults in the South and/or in states that have not expanded Medicaid are much more likely to have medical debt than the rest of us.

Third, coverage.

About 13 million of us will see their health insurance premiums jump in January unless Congress acts. The issue is subsidies for lower-income folks who get their insurance via the Exchanges will expire at the end of this year unless they are extended. So far, the chances for an extension don’t look promising.

Fourth, societal costs.

  • Almost half of the women receiving abortions have incomes below the poverty line.
  • Lives will be hugely impacted, as “the expansion of abortion access … reduced teen motherhood by 34% and teen marriage by 20%”
  • Women who are denied abortions are three times more likely to be unemployed than women who were able to receive one, according to a 2018 study.
  • Women who were not allowed to access abortion services had nearly a four times greater chance of living below the federal poverty line.
  • And…”research shows that in 2010 the public paid just under $13,000 on “prenatal care, labor and delivery, postpartum care and 12 months of infant care.” per birth.”

Connecting the dots.

States that have or are likely to ban abortion are:

  • unlikely to have expanded Medicaid,
  • have much more restrictions on Medicaid coverage so far fewer people qualify for Medicaid, and
  • therefore many more poor women who are forced to have children will have higher medical debt,
  • will not escape living in poverty, and their child will grow up poor.

What does this mean for you?

If one is going to force people to do things, one should understand and be responsible for the consequences.


Jul
11

Healthcare Sharing Ministries and the brutal reality of medical debt

Last week I posted on Health Care Sharing Ministries, noting I’d been reaching out to the PR firm that works with theAlliance of Health Care Sharing Ministries, the PR people put out a release touting their new accreditation standards.

As I noted last week the accreditation process/requirements don’t appear to require minimum cash reserves, specific expense ratios or meet other financial adequacy minimums and the accreditation board doesn’t include individuals with actuarial or financial credentials.

In English, this is a very big deal. Unlike real health insurers, HCSMs aren’t required to have enough cash to pay your medical bills. Also unlike health insurers, members don’t have any recourse if their “ministry” decides your care isn’t worthy of their support.

This comes on the heels of a recent study that found almost a third of all Americans have medical debt; in their efforts to pay off debt respondents made a number of sacrifices and suffered substantial financial consequences: (actual study and responses from KFF)

  • cutting back on household spending
  • more than four in ten say they or a household member have used up all or most of their savings
  • respondents reported skipping payment on other bills,
  • and delaying college or buying a home, or changing their housing situation, while
  • half of adults with health care debt say they have made what they feel to be a difficult sacrifice in order to pay down their debt
  • One in seven adults with health care debt say they have been denied care by a provider due to unpaid bills

Here’s the truly awful thing…the least fortunate among us are in the worst shape.

I get that some people have had good experiences with HCSMs. I also know others have not, and are now among those with crippling, life-changing medical debt.

What does this mean for you?

HCSMs are no silver bullet…rather they are a “send the check in and hope you are covered if you get hurt or sick” non-solution.

It’s a measure of just how dysfunctional our healthcare system is that HCSMs even exist.

Ed note – I’ve been holding off on this post for days, hoping to hear something from AHCSM. I’ve repeatedly asked the PR firm for more details; evidently the right folks haven’t been able to respond.

I first reached out to the PR contact on June 21, 2022…three weeks ago.

 


Jul
6

Healthcare Sharing Ministries – the latest

Healthcare costs are about to jump again, driven by exploding staffing expenses, continued healthcare provider consolidation, and the brilliant profiteering by some of the largest (mostly for-profit) healthcare systems.

So, what’s a family to do?

A few have turned to Healthcare Sharing Ministries, a thing that looks like health insurance but isn’t. HCSMs purport to “share” health care costs among members in what might best be described as a risk-pooling framework. Almost all claim to be “Christian”, they are largely unregulated (except as charities), don’t comply with insurance regulations or laws in most states, and most have requirements that members:

  • are in good health,
  • make a statement of Christian belief, attend church regularly, don’t use tobacco or have sex outside of marriage and
  • commit to taking care of their own health.

note there are ministries focused on other religious denominations.

So…sounds good right? cheaper healthcare is better…well, HCSMs also:

  • are not legally required to pay your medical bills,
  • require enrollees to do much of the groundwork to get bills paid (negotiate upfront with the provider, get all the paperwork and documentation, pay upfront then seek reimbursement)
  • medically underwrite – meaning they require disclosures of pre-existing conditions and can reject applicants for medical reasons,
  • can refuse coverage to anyone for any reason,
  • have limits on what they’ll pay for healthcare,
  • can’t guarantee healthcare providers will accept sharing ministry coverage, and
  • have appeals processes that aren’t subject to regulatory oversight.

Enrollment is a bit hard to nail down; the Alliance of Health Care Sharing Ministries claims 1.5 million enrollees although it doesn’t specify the year. Other reports indicate AHCSM reported membership was “over 1 million” in February of 2019. Other sources report membership closer to that 1 million figure.

HCSMs tend to be significantly cheaper than health insurance plans, making them increasingly attractive. However, most families that buy health insurance through the exchanges get major subsidies that significantly reduce their premiums.

There have been multiple reports of individuals and families stuck with huge bills after their “Ministry” refused to pay for care. Aliera Healthcare Inc. and Trinity Healthshares, Inc are the most visible example of what can happen without tight regulation. Regulators in multiple states issued cease and desist orders after concluding the companies violated laws; Aliera was found guilty of fraud and filed for bankruptcy late last year.

Tops among concerns is this – HCSMs are NOT required to have enough cash on hand to pay medical bills. Even more concerning, they don’t have to report their finances, cash reserves, expense ratios or other data.

There’s an effort underway to “accredit” HCSMs; the process/requirements don’t appear to address this critical issue and the accreditation board doesn’t include individuals with actuarial or financial credentials.

I’ve asked the lobbying outfit that purports to represent HCSMs for details on the financial portion of that accreditation process. So far they’ve been less than forthcoming.

What does this mean for you?

be very careful.

 


Jun
29

Mob rule.

How could anyone think a riot would overturn an election and keep an unelected person in office?

That more than two centuries of carefully nurtured democracy could be trashed in a few hours?

18 months ago we watched in stunned disbelief as our Capitol was attacked, police officers were brutalized and beaten, and bizarre characters wandered the halls, stole mementos and put their feet up on desks, ascended to the podium and eerily called for the heads of the Speaker of the House and Vice President.

For me, yesterday’s January 6 hearing made the insanity of it all stunningly clear. The testimony of a very young staffer crystallized how far we’d gone off track, and why.

Cassidy Hutchinson’s placid, calm recounting stood in stark contrast to the events she was describing, none more jarring than her description of then-President Trump’s furious and frantic effort to get his Secret Service detail to open up the Capitol, remove magnetic detectors and thereby allow his “wonderful people” to bring guns, knives, automatic weapons, pistols, bear spray, and spears to wreak mayhem on Congress’ certification of the 2020 election.

Trump’s megalomania, narcissism and bloody-minded pursuit of power at any price was on full display yesterday. Hutchinson’s recounting of agents describing Trump as irate because the agent wouldn’t drive him to the Capitol so he could “let his people in” says it all.

Five police officers died as a result of the insurrection.

Dozens more may well have been killed if the Secret Service had bowed to Trump’s  insane demands.

For what?

What made Trump think that he could stay in office, prevent Biden from assuming the Presidency, reject the will of the American people?

How could Trump possibly think he could stay in office?  That a bunch of weirdos, military fetishists, tinfoil-hat-wearing simpletons and assorted other nutjobs could turn the United States into a banana republic, one where a strongman could keep power because a few thousand criminally-stupid idiots wanted him to?

Did Trump actually think our entire government, our military, our law enforcement and security and intelligence operations, all of us would stand by and let him stay in the White House? Because a moron wearing a buffalo headdress says so?

Hutchinson’s testimony made it clear Trump is completely detached from reality.

Trump wants power at any price – up to and including killing police officers, destroying our Capitol, and ending the United States of America as we know it.

What does this mean for us?

We are each individually responsible. Ensuring our kids and grandkids live in a free country is up to each of us.

 

 


Jun
27

Wildly off topic #6…Strategy, not tactics

After what was a really awful/crappy/despair-inducing week, we divert into the most important story of the year – Russia’s invasion of Ukraine.

Because the news there is actually kinda good. The dominant story line in the popular press is Ukraine is getting hammered, Russia is taking territory, and Ukraine’s allies aren’t doing enough.

Well…yes and no.

Briefly…

Ukraine is getting hammered – but Russia is expending huge quantities of munitions and soldiers which it cannot replace.

Russia is taking tiny bits of territory – at huge ^ cost.

Ukraine’s allies are doing waaaaay more than the popular press would have you think. Examples…

  • monitoring Russian naval activity in the Black Sea (south of Ukraine) (the picture below shows an airborne surveillance plane circling just south of Ukraine)
  • those fancy artillery and rocket systems we are sending are having an impact – which will only increase.  Russian generals 40 mile behind the front lines are waking up dead, surrounded by destroyed equipment, fuel, and supplies.
  • Thanks to the Dutch and (FINALLY!) the Germans for their support
  • The super-capable and highly advanced rocket systems the US has provided are taking out critical Russian ammo dumps.
  • And other prime targets…

As a result, the Russians are facing a huge logistical problem – they’ve used up millions of artillery rounds/missiles/bombs, some of their remaining supplies are being destroyed, they can’t get what’s left from storage depots to the front lines, and they can’t set up storage depots far enough away from those front lines to avoid the missiles and advanced artillery rounds we are supplying (HIMARS).

More important – yet rarely reported – is the strategy behind combatants’ tactics. Think of strategy as the long game – what the combatants want to achieve at the end of the war; tactics are supposed to be (but often aren’t) the moves you make to achieve your strategic goals.

Example – Russia is using its vaunted artillery (cannons and rockets and missiles plus bombs) to pulverize Ukrainian positions, forcing Ukrainian troops to retreat or be destroyed. That’s “working”; Ukraine recently evacuated its troops from Severodonetsk allowing Putin to claim a “victory”…

“The loss of Severodonetsk is a loss for Ukraine in the sense that any terrain captured by Russian forces is a loss — but the battle of Severodonetsk will not be a decisive Russian victory,” said the Institute for War.

In fact, the Ukrainians forced the Russians to expend huge quantities of shells, missiles, rockets and bombs – and likely incur thousands of casualties – to capture what is now a bunch of rubble.

Reports indicate Russian morale is awful, drunkenness among troops is widespread, medical care is non-existent and food scarce,

History is replete with tactical decisions that cost a strategic victory; Napoleon’s invasion of Russia is a prime example.  In 1812, Napoleon marched his half a million-strong Grand Armee’ to Moscow, trying to force Russia to stand and fight. Russia refused battle and Napoleon had to march back through the Russian winter, in the process losing 9 out of every 10 soldiers.

Russia’s strategic goal was to increase Russian power and weaken the West (that’s us and Europe). Putin figured his invasion would:

  • divide the West,
  • disrupt and weaken NATO,
  • capture territory including really valuable energy and agricultural assets; and
  • make Ukraine a Russian territory.

What does this mean?

Despite murdering tens of thousands of kids, grandparents, moms and dads, Putin’s idiotic war has been an abject strategic failure. And that isn’t going to change.

Russia is:

  • much weaker than it was before the invasion,
  • its economy is in a shambles,
  • the territory it has “captured” is a hellscape of rubble from which Ukrainian guerrillas pop up to shoot Russian generals, destroy supplies and vehicles, and
  • the West is united as never before.

While Putin’s tactics are just stupid, his strategy was even dumber.


Jun
17

Things work comp can/should learn

In addition to my focus on work comp medical management I’m deeply involved in governmental programs (Medicare/Medicaid/dual eligibles) and related businesses.

Here’s a few things work comp would do well to understand/explore/pursue.

  1. Auto-adjudication of medical bills – the standard target for auto-adjudication of medical bills is 90%.  That’s far higher than any workers’ comp bill process, and about twice as high as the average.
  2. Medical bill turn-around time (TAT) – average is at or below 20 days from receipt of complete “claim” (defined as a medical bill and needed documentation)
  3. Administrative expense ratio – <10%. yes, I understand work comp is a lot more litigious, blah blah blah. But seriously – 28-35%??
  4. Value-based care – is taking over the big governmental programs and corporate plans as well. Yes there have been a ton of misjudgments, errors, problems and failures, but make no mistake – in the near future VBC will be the dominant form of contracting and basis for reimbursement. (those who declare VBC isn’t going to happen in work comp may want to look outside their bubble)
  5. The impact of provider consolidation – this is one area where recent articles/briefs/research are starting to scratch the surface – but only just. Reality is consolidated markets are much more expensive and WC payers have way less ability to “manage” care in those markets. WC needs to get a whole lot smarter and more agile.

Whether this actually happens is up in the air. We veterans with decades in this business recall all too well what happens to claim counts/claimdurations when recessions hit.

What does this mean for you?

This is rarely helpful.


Joe Paduda is the principal of Health Strategy Associates

SUBSCRIBE BY EMAIL

SEARCH THIS SITE

A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.

 

DISCLAIMER

© Joe Paduda 2022. We encourage links to any material on this page. Fair use excerpts of material written by Joe Paduda may be used with attribution to Joe Paduda, Managed Care Matters.

Note: Some material on this page may be excerpted from other sources. In such cases, copyright is retained by the respective authors of those sources.

ARCHIVES

Archives