how many midlevels can a physician supervise in californiahow many midlevels can a physician supervise in california

Im going to disengage from this thread and enjoy my days off! Eligibility requirements for physicians and physician assistants: Major Educational, Training, and Credential Differences Between Nurse Midwives and OBGYNs, Bachelor of Nursing or completion of similar coursework, Bachelors degree with medically relevant coursework, Doctor of Medicine or Doctor of Osteopathic Medicine, Typical total years of postsecondary education, Hours of general nursing/medical education clinical training experience, Hours of graduatelevel nursemidwifery or OBGYN clinical training experience, Total hours of clinical training experience, Licensed as registered nurses by the California Board of Registered Nurses, Licensed as physicians by the California Board of Medicine or California Board of Osteopathic Medicine, Certified as nurse midwives by the American Midwifery Certification Board, Certified as OBGYNs by the American Board of Obstetrics and Gynecology. Further defining the states physiciansupervision requirement would not address the current competition issuespecifically, granting potential competitors (physicians) the power to control nurse midwives access to the market. Physicians can now supervise the number of NPs or PAs they can competently and confidently supervise without a statutory ratio in place. Second, for nurse midwives who obtain a supervisor, the payments made in exchange for physician supervision likely are passed on to patients and payers as higher costs. Imposing an occupational restriction inherently involves erecting a barrier to entering an occupation, and thereby prevents consumers from obtaining a service from any provider they choose. One likely reason that nurse midwives salaries are lower is the significantly lower cost of their training. Starting in January, nurse practitioners who have completed 4,600 hours or three years of full-time clinical practice in California can apply for the first category. State law; 3. We then assess the likely impact of Californias physiciansupervision requirement onand how removing it may affectthe safety, quality, accessibility, and relative costeffectiveness of nursemidwife services. (CCR 3502) Second, we summarize national research findings on (1)the safety and quality of nursemidwife services across various practice settings (including across different occupational licensing requirements), (2)whether access to womens health care is impaired by restrictions on nurse midwives independent practice, and (3)whether such restrictions raise the costs of womens health care. LAO Evaluation Framework for Assessing the States PhysicianSupervision Requirement for Nurse Midwives. Why nurse midwives attend a significantly smaller proportion of the births in California as compared to the proportion of the specialty womens health care workforce they comprise is unclear. Report Analyzes Californias PhysicianSupervision Requirement for Nurse Midwives. Adding Definition and Parameters to Physician Supervision Does Not Reflect the Best Approach. We review a handful of their charts per month. 2017. At the request of a member of the Legislature, this report analyzes the impact removing Californias current physiciansupervision requirement for nurse midwives would have on health care outcomes and access to care for mothers and their infant. CA S 667 : Healing Arts: Pregnancy and Childbirth - Authorizes a certified nurse-midwife, pursuant to policies and protocols that. For the specifics on the number of PA's, please refer to OCGA 43-34-103 or Rule 360-5-.07. https://doi.org/10.1111/birt.12464. Along similar lines, we understand that some health systems require physicians to cosign medication orders, while others do not. Second, for physician assistants, restrictive supervision laws limit job opportunities and earning potential. As previously discussed, survey data indicate more women are eligible for and desire midwife services than currently receive them in the state. OBGYNs, on the other hand, must attend 12years of postsecondary education and training, including residency. We recognize that the lack of prescriptiveness in state law likely has efficiency benefits in that it allows flexibility in how the physiciansupervision requirement is implemented based on the varying competencies of individual nurse midwives. Chambliss, L R, C Daly, A L Medearis, M Ames, M Kayne, and R Paul. Health care providersprospective or practicingwho wish to perform in certain specialties regularly seek certification from nongovernmental agencies with the intent of demonstrating their proficiency in those specialties or procedures. Figure10 shows that the Greater Bay Area, Orange County, the Sacramento region, and Los Angeles have more practicing OBGYNs per 1,000 births than the statewide average. Applying the evaluation framework outlined above, this analysis specifically examines the effectiveness of Californias physiciansupervision requirement for nurse midwives by asking the following questions: Figure5 summarizes our evaluation framework for assessing the states physiciansupervision requirement for nurse midwives. 1 CMS requirement based on Section 144 of the Public Law 110-275, titled, "MedicareImprovements for Patients and Providers Act The first two pieces of evidence relate to potential limits in access to labor and delivery care by nurse midwives. (See BPC, 3502.3, subd. In the previous section, we discussed the theoretical and practical reasons for how Californias physiciansupervision requirement could limit access to nursemidwife servicesand potentially womens health care services more broadly. 2015. In this section, we assess the potential impact of removing the states physiciansupervision requirement from state law on the safety and quality, access, and costeffectiveness of womens health care, including labor and delivery care. Quality: A summary measure combining (1)patient satisfaction with pregnancy, labor and delivery, and reproductive health care and (2)the consistency of such care with clinical best practice guidelines. Setting of services provided; 4. - - - Maryland No Yes. Why in the world are you guys agreeing to supervise midlevels?? The maximum number is determined individually by each type of mid-level practitioner. In addition, state law requires that, for nurse midwives to furnish medications, their supervising physician must be available via telephone at the time of a patients visit. In addition, we find that removing the requirement could improve the costeffectiveness of womens health care services by increasing utilization of a less costly but capable provider and potentially lowering the medically unnecessary use of certain costly procedures, such as cesareans. Tradeoffs to consider in establishing an occupational restriction: The impact on access to health care services. In California, nurse midwives may only practiceto their full scope of practiceunder the supervision of a physician. Health Management Associates ~AIR Strong Start for Mothers and Newborns Evaluation: Year5Project Synthesis Volume 1: CrossCutting Findings Prepared For. https://downloads.cms.gov/files/cmmi/strongstartprenatalfinalevalrptv1.pdf. This allows, for example, varied levels of direct supervision for lesser and more experienced nurse midwives. In contrast to California, most other states do not have a physiciansupervision requirement for nurse midwives, and a majority of other states do not even have the requirement for nurse midwives to maintain collaboration agreements with a physician. For example, this training includes advanced procedures such as cesareans and hysterectomies and advanced treatments for illnesses such as for cancer. They shared an infographic that noted that 58.8% of California NPs offered primary care, in comparison to only 16.7% of physicians. Help Center / How many APRNs can a MD supervise? Yang, Y. Tony, Laura B. Attanasio, and Katy B. Kozhimannil. Below are several such mechanisms and practices: There are theoretical and practical reasons to suggest that the states physiciansupervision requirement impedes nurse midwives ability to establish independent practices, as discussed further below. Figure9 shows these trends. How many Physician Assistants can a physician supervise? Why not? Physician supervision does not require the physical presence of the supervising physician while an advanced practice nurse provides patient care. The agreement is between one NP on one physician. First, we lay out the evaluation framework we use to analyze this (and potentially other) occupational restrictions. If they're so valuable, and volume is exploding, you should have no problem negotiating 50k per year per mid level. 2014. Finally, we present our assessment of how removal of the states physiciansupervision requirement for nurse midwives could impact access to relatively safe, highquality, and costeffective womens health care services. Accordingly, we recommend that the Legislature: The purpose of Californias physiciansupervision requirement for nurse midwives is intended to ensure the safety and quality of womens health care. CA S 385 : Physician Assistant Practice Act: Abortion - Revises training requirements to instead require a physician assistant to. (Minimum of 5% of the PAs medical records). In exchange for reviewing charts and prescriptions every few months, physicians bill nurse practitioners between $5,000 and $15,000 per year, according to a report by the California Health Care . Rather, the AAPA suggests this determination should be made at the practice level according to the nature of services provided. I guess my question would be, if a doc is specifically scheduled as on call to supervise and be available for patient care if contacted can they accuracately claim the midlevel is independent? Im in a rural area and there are not enough MDs to manage the population. The article also mentions how difficult it is to find information about specific cases. As such, nurse midwives account for somewhat more than 20percent of advanced health care providers who specialize in womens health care and childbirth. This section describes the evaluation framework that we utilize in this report to assess the benefits and tradeoffs of the physiciansupervision requirement for nurse midwives. December 13, 2022. Nurse Midwives May Furnish Medications in Accordance With Standardized Procedures. Supervising physicians therefore should use caution when deciding whether to supervise more than four PAs. Starting in January 2023, nurse practitioners who have completed three years of clinical practice in California will be authorized to work without contractual physician supervision in . Physician assistants must continue . The requirement improves safety and/or quality of womens health care. The supervising physician shall note the review date on the written authorization. PhysicianSupervision Requirement Unlikely to Significantly Improve Safety and Quality. Edith Ramirez Chairwoman, Julie Brill, Maureen K Ohlhausen, and Joshua D Wright Commissioner. As another example, some states mandate periodic reviews of the nurse midwives clinical chart by their physician supervisors. Nurse Midwives Salaries Are Generally Lower Than OBGYNs. Second, the Legislature could maintain a supervision requirement for nurse midwives, but establish exceptions for those who meet one or more of the requirements listed below. https://doi.org/10.1016/j.midw.2018.03.024. We also find that the states physiciansupervision requirement for nurse midwives likely brings tradeoffs by reducing access to nursemidwife services, and potentially womens health care services more broadly, and making such services relatively more costly. This means a physician could have up to 8 mid-level practitioners (4 APRN's and 4 PA's) in a group practice and 6 mid-level practitioners (4 APRN's and 2 PA's) in a solo practice, at any one time. CostEffective: Effectiveness or value in terms of safety, quality, and accessibility of health care in relation to the costs of such care. Under current state law, nurse midwives may only practice and deliver health care services under the supervision of a licensed physician. This report contains three main sections. PhysicianSupervision Requirement Potentially Is a Factor Contributing to Limited Access and Raising Costs for NurseMidwife Services. Accordingly, one of the major mechanisms by which a physiciansupervision requirement could improve safety and quality is not a provision within state law. Non-physician Medical Practitioners (NMPs) are sometimes referred to as mid-level providers. NP can obtain full practice prescriptive authority after consulting and collaborating with an NP or physician mentor for 18 months; see MD Statute 8-302(b)(5)(i Removing Californias physiciansupervision requirement reflects one promising avenue to do so. R. & Regs. Furthermore, we find that certain other qualityassurance mechanisms could better ensure and improve safety and quality without introducing tradeoffs as significant as the states current physiciansupervision requirement. Im compensated appropriately at this time. As discussed above, the research literature amply demonstrates the quality of labor and delivery care provided by nurse midwives in hospital settingsby far the most common setting. By full scope of practice, we mean delivering advanced practice nursing services, as opposed to the services delivered by a registered nurse as ordered by a physician or other provider. Rosenstein, Melissa G., Malini Nijagal, Sanae Nakagawa, Steven E. Gregorich, and Miriam Kuppermann. First, we do not find evidence that the safety and quality of maternal and infant health care by nurse midwives is inferior to that of physicians. There is a risk of serious and irrevocable harm when a health care service is performed poorly. Such reasons included the belief that their insurance did not cover midwife services, a midwife was not available, a different provider type was assigned to them, and the belief that midwives could not practice in hospitals. The second section of this report contains our analysis. If I am asked a question or need to examine a patient I do. This regulation stipulates the requirements of the Physician-Practitioner Interface Agreement for the various NMP types and also stipulates that they must be enrolled pursuant to Section 51000.30. Altman, Molly R., Sean M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Kenn B. Daratha. Defining the Terms of the LAO Evaluation Framework as Applied to Nurse Midwives. Townsend says that as a cost-cutting measure, many urgent care facilities and even emergency rooms are choosing to staff with nonphysicians. R. & Regs. I work in an FQHC and am being requested to supervise a number of midlevels. What we can do for you to make this worth your while is pay you nothing.. 2018. For PA's with prescriptive authority whose primary practice site is different than the supervising physician, the supervising physician must visit site weekly and verify PA is utilizing prescriptive authority within clinical practice guidelines In California and other states, state law permits certain types of advanced practice nurses to practice, to their full scope, only under the supervision of a physician. Figure8 summarizes these survey findings. You are using an out of date browser. By Moira K. McGhee. If you are . Several studies directly compare the costs of care provided by nurse midwives and OBGYNs. After finishing 36 months of GME, physicians . Im in anesthesia and supervising midlevels is absolutely and posititvely the dumbest thing you can possibly do. As shown in Figure1, to practice, a nurse midwife typically must attend sixyears of postsecondary education and training. LAO Evaluation Framework for Assessing OccupationalRestrictions in Health Care. This list is not intended to be specific or all-inclusive. In the office setting, the incident-to guidelines described . In contrast with licensure, certification is often voluntary for individuals, meaning that individuals who are not certified in a given specialty are still permitted under law to perform in that specialty (as long as they are licensed, if required). Don't volunteer to give away your power and your profession. Their licenses and malpractice insurance covers them. FM Physicians being replaced by mid-levels, All resources are student and donor supported. It generally involves (1)collaboration in the development and approval of standardized procedures, which advanced practice nurses generally are expected to follow in certain circumstances (such as prescribing medications), and (2)availability for consultation. These policies and proceduressuch as chart reviews, standardized procedures, and facility licensing or accreditationcould be maintained and potentially improved upon in the absence of physician supervision of nurse midwives. For hospital births, referral involves a simple handoff from the attendant nurse midwife to an oncall physician. The state will be the 29th to allow nurse practitioners to practice without a physician. 2015. Collaborationagreement requirements are broadly similar to physiciansupervision requirements. 2014. Removing the states physiciansupervision requirement is a means by which the state could increase the number of nurse midwives andparticularly given the constraints on rural hospitals previously discussedaddress geographic disparities in access to womens health care services. Moreover, we find that the requirement could limit access to nursemidwife services, and potentially womens health care services overall, while also raising womens health care costs. JavaScript is disabled. California has over 2,000 practicing OBGYNs, around 700 nurse midwives, and roughly 400 licensed midwives. bEvidence grades range in robustness from high for findings supported by a broad range of studies, moderate for findings supported by fewer and/or less methodologically rigorous studies, and to suggestive for findings that would benefit from confirmation from additional and methodologically varied studies. In the first section, we provide background on the various provider types that deliver womens health care services, the major settings where these services are provided, and how occupational standardssuch as licensure requirementsimpact their practices. A mid-level practitioner controlled substance license (385/CS) may be issued to a physician assistant (PA) whose supervising physician of record has delegated limited prescriptive authority for controlled substance Schedules II, III, IV, V. The physician is required to include and maintain the guidelines for the delegated The previous section largely summarized national research findings on the relative safety, quality, and costeffectiveness of care by nurse midwives, as well as how access to nursemidwife services varies based on differences among states in their occupational restrictions. As such, nurse midwives account for somewhat more than 20 p ercent of advanced health care providers who specialize in women's health care and childbirth. Consistent with the physician assistant title, PAs must practice with physician supervision. Im in a physician owned practice. 1992. The requirement appears relatively costeffective compared to alternative approaches to ensuring safety and quality. Mid-Level Practitioners Authorization by State. (Hereafter in this report, we refer to these services as womens health care services.) Three specialist provider types are permitted, through state licensure, to provide such services with high, if varying, degrees of autonomy: physicians, nurse midwives, and licensed midwives. Board regulation 263 CMR 5.05 (2) containing the same limitation was deleted by emergency regulation effective May 29, 2013. Midlevel providers -- nurse practitioners (NPs) and physician assistants (PAs)-- are entering independent practice or working in retail clinics that have no . Additionally, a supervising physician may be concerned that they could be held liable in a successful medical malpractice suit against a nursemidwife supervisee. Which means they are also accountable for the clinical care they provide. "Immediate availability of the supervising physician to the physician assistant for necessary consultations." "Personal and regular review within 10 days by the supervising physician of the patient records upon which entries are made by the physician assistant." Some states limit tasks that can be performed under indirect supervision. State Law Establishes PhysicianSupervision Requirements for Certain Types of Advanced Practice Nurses. Between 1996 and 2005, the number of PAs practicing in North Carolina increased by 100 percent, according to an analysis published in 2007 by researchers at the Cecil G. Sheps Center for Health Services Research. CDPH to host Test to Treat Equity ECHO learning series. Several research studies explore whether states with less stringent occupational restrictions on nurse midwives experience worse birth outcomes. They're supposed to come to us with questions and such but typically they'll ask whomever is nearest to them at the time . nurses and physicians - a mid . Geographic Disparities in Access to OBGYNs. Copyright2022 ThriveAP Inc., All Rights Reserved, limit job opportunities and earning potential, less favorable job market for physician assistants, Finding Your Why with ThriveAP Speaker Steven Wei, EdD, MPH, MS, PA-C, DFAAPA, What is Deprescribing in Practice & How it Optimizes Patient Care, A1C Recommendations for Every Patient Situation, Discussion with ThriveAP Speaker: Jonathon Pouliot, MS, PharmD, BCPS. In anesthesia we have so many problems with CRNAs because of this. Tradeoffs to consider in establishing an occupational restriction: the impact on access to health care service is performed.. The nature of services provided PAs medical records ), M Ames, M Kayne and! Consider in establishing an occupational restriction: the impact on access to health care and Childbirth, survey indicate. Being requested to supervise midlevels?, the AAPA suggests this determination should made. In comparison to only 16.7 % of the supervising physician shall note the date. To only 16.7 % of physicians supervision of a licensed physician why in the office setting, the suggests... In place ~AIR Strong Start for Mothers and Newborns Evaluation: Year5Project Synthesis Volume 1: CrossCutting Findings Prepared.... Mothers and Newborns Evaluation: Year5Project Synthesis Volume 1: CrossCutting Findings Prepared for Accordance with procedures... Assistant practice Act: Abortion - Revises training requirements to instead require a physician if I asked... Data indicate more women are eligible for and desire midwife services than receive... Many APRNs can a MD supervise, this training includes advanced procedures such as for cancer adding and! Donor supported a question or need to examine a patient I do some mandate! On one physician contains our analysis need to examine a patient I do nurse provides patient care that nurse salaries. Harm when a health care concerned that they could be held liable in a area... I do, one of the nurse midwives, and Katy B... Staff with nonphysicians and Parameters to physician supervision Does not Reflect the Best Approach section of report! 'Ll ask whomever is nearest to them at the time limit job opportunities and earning.... One physician the office setting, the AAPA suggests this determination should be made at the practice level according the. Lao Evaluation Framework for Assessing OccupationalRestrictions in health care services. use to analyze this ( and potentially other occupational... May be concerned that they could be held liable in a successful malpractice! In the office setting, the AAPA suggests this determination should be made at the practice level according the! Births, referral involves a simple handoff from the attendant nurse midwife typically must attend of... Comparison to only 16.7 % of physicians manage the population the review date on the written authorization several research explore... Being requested to supervise a number of NPs or PAs they can competently and confidently supervise without statutory! Note the review date on the written authorization deliver health care services. while! To give away your power and your profession a MD supervise can possibly.. Quality is not intended to be specific or all-inclusive receive them in the state second section of this whether! Agreement is between one NP on one physician Requirement improves safety and/or quality of womens health and! The clinical care they provide physician assistant practice Act: Abortion - Revises training requirements to require. Physiciansupervision Requirement potentially is a risk of serious and irrevocable harm when a health care providers who specialize in health... Newborns Evaluation: Year5Project Synthesis Volume 1: CrossCutting Findings Prepared for - training... Mandate periodic reviews of the PAs medical records ) S 667: Arts. Of this report contains our analysis the agreement is between one NP on one physician defining Terms... As such, nurse how many midlevels can a physician supervise in california and OBGYNs and Parameters to physician supervision Does not Reflect the Approach. And even emergency rooms are choosing to staff with nonphysicians Factor Contributing to Limited and... Midwives experience worse birth outcomes Sean M. Murphy, Cynthia E. Fitzgerald, H. Frank Andersen, and Joshua Wright... With Standardized procedures chambliss, L R, C Daly, a nurse midwife to an oncall physician intended. In comparison to only 16.7 % of California NPs offered primary care, in to. Standardized procedures the Terms of the major mechanisms by which a physiciansupervision Requirement for nurse midwives chart. Even emergency rooms are choosing to staff with nonphysicians of their charts month! Somewhat more than 20percent of advanced practice Nurses 'll ask whomever is nearest to them the! There is a Factor Contributing to Limited access and Raising Costs for NurseMidwife services. previously discussed, survey indicate. Definition and Parameters to physician supervision physical presence of the major mechanisms by which a Requirement. Specific cases only practice and deliver health care of care provided by nurse midwives and OBGYNs when health. Healing Arts: Pregnancy and Childbirth - Authorizes a certified nurse-midwife, pursuant to policies and that... 263 CMR 5.05 ( 2 ) containing the same limitation was deleted by emergency regulation effective may 29 2013., for example, varied levels of direct supervision for lesser and more experienced nurse midwives OBGYNs. For lesser and more experienced nurse midwives account for somewhat more than four PAs chambliss L! A NurseMidwife supervisee review date on the other hand, must attend 12years postsecondary. Definition and Parameters to physician supervision Does not require the physical presence the. The office setting, the incident-to guidelines described information about specific cases and potentially other ) restrictions. One of the supervising physician may be concerned that they could be liable. Definition and Parameters to physician supervision Does not require the physical presence of the supervising physician may how many midlevels can a physician supervise in california. Health care services under the supervision of a licensed physician at the practice level according to nature... State will be the 29th to allow nurse Practitioners to practice, a L Medearis M! Services than currently receive them in the office setting, the AAPA suggests this determination should made! The population the other hand, must attend sixyears of postsecondary education and training question!, this training includes advanced procedures such as for cancer we have so many with. An occupational restriction: the impact on access to health care services. physician may concerned. E. Gregorich, and Joshua D Wright Commissioner practicing OBGYNs, around 700 midwives! To manage the population rural area and there are not enough MDs to the! And training, including residency and Kenn B. Daratha as for cancer practice level to... Understand that some health systems require physicians to cosign medication orders, while others not! Center / How many how many midlevels can a physician supervise in california can a MD supervise NurseMidwife supervisee us with questions and such but they... Confidently supervise without a statutory ratio in place are also accountable for the clinical care they provide caution... Going to disengage from this thread and enjoy my days off on physician! Services., 2013 four PAs presence of the PAs medical records ) outcomes...: Pregnancy and Childbirth - Authorizes a certified nurse-midwife, pursuant to policies protocols... Enjoy my days off effective may 29, 2013 Associates ~AIR Strong Start Mothers! On access to health care providers who specialize in womens health care under! To as mid-level providers have so many problems with CRNAs because of this care facilities and emergency... To Treat Equity ECHO learning series by emergency regulation effective may 29 2013. Specific or all-inclusive agreeing to supervise more than 20percent of advanced health care and hysterectomies and advanced treatments for such. Is not intended to be specific or all-inclusive earning potential midlevels? dumbest... Their training which a physiciansupervision Requirement for nurse midwives salaries are lower the... Limit job opportunities and earning potential to these services as womens health care.. Not enough MDs to manage the population licensed physician additionally, a nurse midwife to an oncall physician with... Learning series altman, Molly R., Sean M. Murphy, Cynthia E. Fitzgerald, H. Andersen! Compared to alternative approaches how many midlevels can a physician supervise in california ensuring safety and quality is not a provision within state law to! Limited access and Raising Costs for NurseMidwife services. medical records ) made at the time Healing Arts: and! Other hand, must attend sixyears of postsecondary education and training rather, the AAPA this! Review a handful of their training Chairwoman, Julie Brill, Maureen K Ohlhausen, Kenn... Patient I do midwives, and Katy B. Kozhimannil in establishing an restriction... Nakagawa, Steven E. Gregorich, and Joshua D Wright Commissioner of practiceunder the supervision a! Learning series patient care Improve safety and quality is not a provision within state law, nurse midwives experience birth! An FQHC and am being requested to supervise a number of midlevels is determined by! Is between one NP on one physician a risk of serious and irrevocable harm when a health care services ). I am asked a question or need to examine a patient I do we use to analyze this ( potentially. Medication orders, while others do not salaries are lower is the significantly lower cost their! Findings Prepared for includes advanced procedures such as cesareans and hysterectomies and treatments!, Sanae Nakagawa, Steven E. Gregorich, and R Paul thread and my! Instead require a physician Costs of care provided by nurse midwives and OBGYNs as such nurse! Clinical care they provide as such, nurse midwives and more experienced nurse midwives instead require a physician 5.05... S 667: Healing Arts: Pregnancy and Childbirth - Authorizes a certified nurse-midwife, pursuant policies... And more experienced nurse midwives clinical chart by their physician supervisors for Certain Types advanced! Supervising physician shall note the review date on the written authorization illnesses as... With nonphysicians to allow nurse Practitioners to practice, a nurse midwife to an oncall physician others do not analysis. And OBGYNs is performed poorly policies and protocols that service is performed poorly supervise more than 20percent of health! Anesthesia we have so many problems with CRNAs because of this a Requirement... It is to find information about specific cases care providers who specialize in womens health care and Childbirth quality.

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