February 2012  -  NAI PRESENTS TO THE COUNCIL FOR VALUE IN SPINE CARE ON ACOs

Rita E. Numerof, Ph.D., President of Numerof & Associates, Inc. (NAI), will join other healthcare experts including David Nash, Professor of Health Policy and Medicine at Jefferson Medical College, as a speaker at the Council for Value in Spine Care on February 25, 2012.

Drawing on her 30 years of experience working with major providers, payers, and manufacturers, Dr. Numerof’s session, The Accountable Care Organization (ACO): What Is It and Is It a Viable Solution? will offer her perspective on this new organizational structure, and discuss the opportunities and pitfalls of this approach to care delivery.

January 2012  -  NAI PUBLISHED IN HFM MAGAZINE ON BUNDLED PRICING

Bundled pricing represents a significant departure from the current fee-for-service model -- a model that has been widely criticized as motivating providers to drive up utilization, rather than focusing on healthcare quality. By changing utilization incentives and shifting some financial risk from payers to providers, bundled payment presents an opportunity for providers and physicians to work together to drive better, more efficient care

In theory, the development of a bundled price is simple, but in reality, healthcare finance professionals seeking to prepare their organizations for bundled pricing must overcome several key hurdles. In their article, Bundled Pricing: Overcoming the First Hurdles, published in this month’s hfm Magazine, NAI Managing Partner Michael Abrams, M.A., and Research Analyst Simone Cummings, Ph.D. describe what these challenges will be, and the steps providers can take to manage them.

January 2012  -  NAI PUBLISHED IN LES INSIGHTS ON CHANGES TO THE 510(K) PROCESS

Tension in the medical device industry is building as the industry continues to speculate about what the FDA will unveil regarding changes to its premarket notification submission process, otherwise known as the 510(k) process. For years, the 510(k) process has been under intense scrutiny by the Senate and House, as well as by critics within the FDA, and last summer’s recommendation from the Institute of Medicine to simply scrap the process altogether sent shockwaves through the industry.

One thing is certain: changes are coming. In her article, Medical Device Regulations: The Shape of Things to Come, published by LES Insights, NAI Senior Consultant Jill Sackman, D.V.M., Ph.D., offers a preview of what these changes are likely to entail, and what their implications will be for medical device companies.

January 2012  -  NAI PUBLISHED IN BECKER’S HOSPITAL REVIEW ON SERVICE LINE STRATEGY

Regardless of the way in which legal challenges to recent legislation are resolved, healthcare is an industry confronting dramatic change. Delivery organizations face growing pressure to raise quality, reduce costs and increase revenues. Survivors in this market will need to adapt and implement new care models … models that provide evidence-based economic and clinical value and can serve as strategic growth platforms of the future. This is what service lines need to do.

In What Service Lines Are Really Supposed to Do, published by Becker’s Hospital Review, NAI President Rita Numerof, Ph.D. explains how to get the most value from your service lines -- and what the consequences of poorly defined service lines can be.

January 2012  -  UPCOMING WEBINAR: BUNDLED PRICING: GETTING STARTED

Based on the enthusiastic response to our last offering, we’ve scheduled another live, one-hour webinar on Bundled Pricing. It brings the latest guidance on this current topic.

• Date: Thursday, April 26, 2012
• Time: 11:00am - 12:00pm CT
• Register online now! We will contact you to arrange payment.

Healthcare delivery organizations face a growing list of demands -- for reduced cost, improved quality, and more transparency. Bundled pricing is an innovation being implemented by market leaders to satisfy these new requirements. Deceptively simple sounding, this radically different approach to pricing and risk can be challenging to implement. It also carries the risk of an important side-effect --commoditization.Is bundled pricing right for your organization? Are you ready for bundled pricing?

Attend this webinar and learn what you need to know about developing a bundled price approach -- the critical steps you need to take, and the challenges and pitfalls you'll want to avoid.

Learn More >>

January 2012  -  UPCOMING WEBINAR: ENSURING A DEFENSIBLE FMV FRAMEWORK

• Date: Thursday, March 29, 2012
• Time: 11:00am - 12:00pm CT
• Register online now! We will contact you to arrange payment.

Pharmaceutical and medical device companies’ financial relationships with physicians remain a large and growing focus of OIG and DOJ enforcement activity. That makes it more important than ever to ensure that these arrangements can withstand critical examination.

Compliance concerns increasingly focus on consistency of practice across business and functional groups, ensuring transparency, and the broader framework for handling commercial relationships with providers. Building a defensible valuation approach and a comprehensive framework to document compliance is the only way to insure your organization against compliance risk.

Learn More >>

December 2011  -  NAI PUBLISHED IN MEDTECH EXECUTIVE ON CHANGES TO THE 510(K) PROCESS

The Institute of Medicine’s recent recommendation that the FDA should scrap the 510(k) process earlier this year sent shockwaves through the medical device industry. While the FDA has announced that it does not intend to end this approval process, device companies must expect additional, significant changes to the 510(k) process and post-market safety requirements.

In 510(k) Clearance -- Change Is in the Wind, published by MX: Medtech Executive, NAI Consultant Stephen Rothenberg, J.D. and Senior Consultant Jill Sackman, Ph.D., D.V.M. explain what these changes are likely to entail, and how medical device companies should prepare.

November 2011  -  NAI PUBLISHED IN PM360 ON MARKET ACCESS

Recent legislation and growing anxiety about debt have put healthcare in the spotlight, where it’s likely to stay for an indefinite period. Payers and providers are under enormous pressure to reduce costs and improve quality.

As reimbursement rates for hospitals decrease, the way decisions about care are made is changing as well. Administrators' influence on purchase and even clinical decisions is growing at the expense of that wielded by physicians. And physicians themselves are exerting price pressure on manufacturers as they become more aligned with new reimbursement incentives.

In, Impact of the Changing Reimbursement Landscape on Healthcare Marketers, which appeared in PM360 this month, NAI Managing Partner Michael Abrams, M.A. and Consultant Kim White, M.B.A. describe what the tumultuous reimbursement environment will mean for medical product marketers, and how they can increase their odds of success.

November 2011  -  NAI PUBLISHED IN H&HN DAILY ON PHYSICIAN ENGAGEMENT

Reform is driving an industry redefinition of "value" that challenges traditional healthcare business models. Several solutions to move healthcare delivery organizations toward evidence-based value orientations have been proposed, including accountable care organizations and new payment models like bundled pricing.

Any new business model that acknowledges the critical role of clinical decision making in determining cost and quality requires the creation and use of predictive care paths to define the sequence of actions and options in treatment. Given the complexity of clinical practice, physician input is central to any of these efforts, both to ensure buy-in and to leverage their expertise. In their article Engaging Physicians to Improve Quality and Lower Costs, published by H&HN Daily, NAI Managing Partner Michael Abrams, M.A., Business Analyst Dana Hage, M.P.H., and Consultant Eric Abrams, M.B.A. describe the steps that healthcare leaders should take to secure physician buy-in to care paths, and to the broader goal of improved quality and lower costs.

November 2011  -  NAI PUBLISHED IN PHARMACEUTICAL COMMERCE ON ACOS

CMS’s release of the final regulations for accountable care organizations in October created a buzz across the healthcare sector. Industry organizations, policy specialists, and other stakeholders were quick to note that the regulations were much less onerous than expected, and projections for participation in the Shared Savings Program grew.

The final regulations did little to improve the likelihood that the Shared Savings Program will actually improve healthcare cost or quality, however. In an editorial for Pharmaceutical Commerce, ACOs and Their Impact on Pharma, NAI President Rita E. Numerof, Ph.D. explains how the final rules failed to address the fundamental flaws of the ACO model, and outlines implications of ACOs for pharmaceutical companies’ commercial and product development strategies going forward.

November 2011  -  NAI PUBLISHED IN BECKER’S HOSPITAL REVIEW ON BUNDLED PRICING

Most hospitals have learned to manage financially with the discounted fee-for-service model that’s been in place, but that’s history. In light of reform and demands for better health outcomes at lower cost, alternative payment models -- specifically bundled payment -- are gaining momentum.

In, Bundled Pricing: Strategies for Success, published by Becker’s Hospital Review, Eric R. Abrams, M.B.A., consultant for NAI, explores the main drivers of bundled pricing and describes five steps providers need to take to move to this new payment model.

November 2011  -  NUMEROF PRESENTS ON MARKET-BASED HEALTHCARE

NAI President, Rita E. Numerof, Ph.D. joins Steve Bonner, President and CEO, Cancer Treatment Centers of America, in a panel discussing the future of the U.S. healthcare system, in St. Louis on Wednesday, November 16.

Produced by the St. Louis Business Journal, the session is entitled Healthcare Renaissance: Moving Toward a Market-Driven Model of Healthcare. Presenters will discuss the need for a patient-centered, value-based approach to healthcare delivery, what such a model looks like in practice, and how business can help to move this fundamentally different business model forward.

October 2011  -  NAI PRESENTS TO THE SOCIETY FOR HEALTHCARE STRATEGY AND MARKET DEVELOPMENT ON ACCOUNTABLE CARE

NAI Consultant Stephen Rothenberg, J.D. will present a webinar on ACOs, titled The Essence of Accountable Care, to the Society for Healthcare Strategy and Market Development on October 12, 2011.

In theory, the ACO model will provide financial incentives to health care organizations to reduce costs and improve quality. In reality, given the dynamics and complexity of the structure required, ACOs are unlikely to solve these issues. This webinar will outline the challenges to the ACO model, and offer alternative strategies achieving better health outcomes at lower cost. The session will include information on other alternative payment models and steps providers can take to improve clinical integration and cost management -- without the complexity of creating a new organization.

October 2011  -  UPCOMING WEBINAR: BUNDLED PRICING: GETTING STARTED

• Date: Thursday, October 27, 2011
• Time: 11:00 a.m. - 12:00 p.m. CT
• Pre-Register online now! We will call you to arrange payment.

Healthcare delivery organizations face a growing list of demands -- for reduced cost, improved quality, and more transparency. Bundled pricing is an innovation being implemented by market leaders to satisfy these new requirements. Deceptively simple sounding, this radically different approach to pricing and risk can be challenging to implement. It also carries the risk of an important side-effect -- commoditization. Is bundled pricing right for your organization? Are you ready for bundled pricing?

Attend this webinar and learn what you need to know about developing a bundled price approach -- the critical steps you need to take, and the challenges and pitfalls you'll want to avoid.

Learn More >>

September 2011  -  NAI PUBLISHED BY EYEFORPHARMA

NAI announces the first of a series of monthly columns on the pharmaceutical industry written by Rita E. Numerof, Ph.D., President, and published by eyeforpharma starting September 25, 2011.

In her ongoing column -- called In the Eye of the Storm -- Rita will examine the multitude of critical issues the pharma industry currently faces, and offer insights and solutions based on NAI’s extensive industry consulting experience.

Her first column, titled Pharma marketing and comparative effectiveness research, Rita explores the impact of healthcare reform, and how comparative effectiveness research will require pharmaceutical and medical device manufacturers to rethink key business decision-making processes.

September 2011  -  NAI PUBLISHED IN TRUSTEE MAGAZINE ON BUNDLED PRICING

In light of reform and demands for better health outcomes at lower cost, strategies that have sustained margin for healthcare organizations in the past are no longer viable. Alternative business models like bundled pricing are gaining momentum, but as hospitals begin implementing these new strategies, they face significant cultural barriers.

In this month’s issue of Trustee Magazine, NAI Managing Partner Michael Abrams, M.A. and Research Analyst Simone Cummings, Ph.D. examine the cultural barriers to implementing bundled pricing, and walk through the steps healthcare leaders can take to address them. Their article, Cultural Challenges of Bundled Pricing, provides experience-based insights into the challenges of managing significant business model change that impacts clinical and administrative roles across healthcare delivery.

September 2011  -  NAI PUBLISHED IN BECKER’S HOSPITAL REVIEW ON ACCOUNTABILITY FOR CARE

One consequence of reform is that it has shown a spotlight on what’s missing in the current business model of healthcare: accountability -- for care coordination, outcomes, and decision-making -- in short, accountability for better care at lower cost.

In their article, 7 Ways to Improve Accountability for Care, recently published by Becker’s Hospital Review, NAI Business Analyst Dana Hage, M.P.H. and Consultant Eric Abrams, M.B.A. describe how providers can address the need for greater accountability for care, and offer actionable strategies they can use to achieve the objective of better outcomes at lower cost.

September 2011  -  UPCOMING WEBINAR: MANAGING COST AND QUALITY WITH PREDICTIVE CARE PATHS

• Date: Thursday, September 15, 2011
• Time: 11:00 a.m. - 12:00 p.m. CST
• Register online now! We will call you to arrange payment.

As debate swirls around the future of the healthcare industry, there’s one prediction virtually all stakeholders can agree on: reimbursement will decline. To succeed in this increasingly demanding environment, healthcare executives will need to take cost and quality management to a whole new level. Predictive care paths are the essential starting point for such an effort.

Attend this webinar and learn what you need to know about developing predictive care paths -- the critical steps you need to take, and the pitfalls you’ll want to avoid.

Learn More >>

September 2011  -  NAI PRESENTS AT THE 4TH ANNUAL ORPHAN DRUG CONFERENCE

NAI President Rita E. Numerof, Ph.D., and Senior Consultant Jill Sackman, Ph.D., D.V.M. will join industry leaders in a panel at the 4th Annual Ultra Orphan Drug Conference on September 19th, 2011, sponsored by Centric Health Resources.

Drawing on their extensive industry experience, Drs. Numerof and Sackman will join the session titled Addressing the Needs of Ultra Orphan Patient Populations by Creating and Measuring Value Strategies for Delivering Outcomes and Value for Patients, Physicians, Payers, and Manufacturers. They will discuss what really constitutes value, and how pharmaceutical companies can develop the value case they need to make their products successful. For more information about the session, check out Centric Health Resources’ website.

August 2011  -  NAI PUBLISHED BY HFMA ON BUNDLED PRICING

Spiraling cost inflation and lagging quality outcomes have fueled reforms that are rewriting the rules for the entire healthcare sector. As a result, concepts like bundled pricing are gaining momentum -- but these efforts require physician input and buy-in to succeed.

In NAI’s article Engaging Physicians in Bundled Pricing, published by HFMA’s Strategic Financial Planning, August 2011, Managing Partner Michael N. Abrams, M.A. and President, Rita E. Numerof, Ph.D. discuss the steps that hospital executives should take to build the physician support required for innovations like bundled pricing to succeed.

August 2011  -  NAI PUBLISHED BY H&HN DAILY ON BUNDLED PRICING

The healthcare industry is in the midst of a revolutionary upheaval reflecting the concerns of patients, payers, providers, and policymakers over spiraling costs, lagging quality, and a lack of transparency. Healthcare providers are experimenting with a variety of approaches to address these issues, including offering "bundled prices" for episodes of care. This approach realigns provider incentives to deliver better care at lower cost, but it has a hidden side effect -- commoditization.

In NAI’s article ECV: The Antidote to Commoditization Under Bundled Pricing, published by H&HN Daily, August 2011, Managing Partner Michael N. Abrams, M.A., and Research Analyst Simone Cummings, Ph.D., describe why a strong economic and clinical value case is necessary, and how to build one.

July 2011  -  NAI PRESENTS AT THE AHA/HEALTH FORUM ANNUAL LEADERSHIP SUMMIT ON BUNDLED PAYMENT

Rita E. Numerof, Ph.D., President of Numerof & Associates Inc., will present to healthcare industry leaders at the annual AHA/Health Forum Annual Leadership Summit in San Diego, July 19, 2011

Drawing on her 30 years of experience working with major providers, payers, and manufacturers, Dr. Numerof’s session, Bundled Payment: The Next Step in Improving Quality and Reducing Cost, will describe the steps necessary to develop a bundled payment offering. Committing to deliver a standardized set of services for a fixed price calls for new ways of doing business that depart significantly from the current model. Dr. Numerof will discuss key considerations that providers will need to address to make this innovation successful.

June 2011  -  NUMEROF PRESENTS ON ACOS FOR THE HERITAGE FOUNDATION

Rita E. Numerof, Ph.D., President of Numerof & Associates, Inc. (NAI) joined other healthcare experts in a panel discussion on ACOs titled Accountable Care Organizations: More Bureaucracy or Real Health Care Solutions? On June 22. The session on Capitol Hill was moderated by Bob Moffit, Ph.D., Senior Fellow with the Heritage Foundation.

The session was a follow up to the Heritage Foundation's Congressional policy paper on ACOs authored by Dr. Numerof, Why Accountable Care Organizations Won’t Deliver Better Health Care - and Market Innovation Will. Panel members discussed ACOs and alternative solutions to achieving better health outcomes at lower cost.

June 2011  -  NAI PUBLISHED BY H&HN DAILY ON BUNDLED PRICING

Spiraling cost increases, coupled with lagging quality outcomes and a chronic lack of transparency have gotten the attention of payers, patients, and policymakers. Healthcare delivery organizations face growing pressure to address these issues. Bundled pricing is an innovation being implemented by market leaders that promises to do so. Deceptively simple sounding, this radically different approach to pricing and risk brings its own challenges.

In his article Laying the Foundation for Success in Bundled Pricing, published by H&HN Daily, June 2011, NAI Managing Partner Michael N. Abrams describes in detail the steps needed to successfully implement bundled pricing. He describes the administrative, clinical and financial challenges that organizations will face in developing bundles of care -- and how to overcome them.

April 2011  -  NAI PUBLISHED BY THE HERITAGE FOUNDATION ON ACOs

The Heritage Foundation has released its policy guidance for Congress on ACOs, titled Why Accountable Care Organizations Won't Deliver Better Health Care - and Market Innovation Will, authored by Rita E. Numerof, Ph.D., President of Numerof & Associates, Inc.

In theory, ACOs provide financial incentives to health care organizations to reduce costs and improve quality. In reality, given the complexity of the existing system, ACOs will most likely exacerbate the very problems they set out to fix.

This white paper describes how ACOs will concentrate more and more power in fewer and fewer organizations, allowing them to become "too large to fail." It outlines the reasons why this approach will be unlikely to reduce costs or improve quality of care, and offers alternative strategies on how to achieve better health outcomes at lower cost.

April 2011  -  NUMEROF PRESENTS TO MOHEG ON ACOs

Rita E. Numerof, Ph.D., President of Numerof & Associates, Inc. (NAI) will join David Knocke, President, BJC Medical Group in a panel discussion on Accountable Care Organizations for the Missouri Healthcare Executives Group (MOHEG) at their meeting on April 19th.

Speaking as head of a management consulting firm specializing in the strategic and operational challenges of healthcare reform, Dr. Numerof will offer her perspective on this new organizational structure. Drawing on her extensive client experience, Dr. Numerof will discuss opportunities and pitfalls of this new approach to care delivery.

March 2011  -  UPCOMING WEBINAR: FAIR MARKET VALUE: ESTABLISHING A DEFENSIBLE FRAMEWORK

• Date: Thursday, May 5, 2011
• Time: 11:00 a.m. - 12:00 p.m. CST
• Pre-Register online now! We will call you to arrange payment.

Pharmaceutical and medical device companies' financial relationships with physicians are a large and growing focus of OIG and DOJ enforcement activity. That makes it more important than ever to ensure that these arrangements can withstand critical examination. Determining fair market value (FMV) fees is difficult, and little practical guidance is available. Old ways of valuing professional services -- surveys of historical data, opportunity cost, etc. -- won't be good enough. Building a defensible valuation approach and a broader framework to document compliance is the only way to insure your organization against compliance risk.

Learn More >>

March 2011  -  NAI PUBLISHED IN H&HN DAILY ON ACOs

For all the debate, virtually all stakeholders agree with the overall objective of healthcare reform ... achieving better health outcomes at lower cost. Different views have emerged as to how best achieve this objective. One model appearing in reform legislation is the Accountable Care Organization (ACO).

In their March 10, 2011 article, The Essence of Accountable Care, authors Rita E. Numerof, Ph.D., President, and Stephen Rothenberg, J.D., Business Analyst, set important context by distinguishing between accountable care (the goal) and accountable care organizations (how to get there). Accountable care (the goal) means restructuring incentives so that providers are directly impacted by the consequences of their decisions on quality and cost. ACOs are just one model for achieving this end -- one whose broad effectiveness has yet to be proven. Whether or not your organization ultimately decides to use this particular vehicle, there is nothing stopping you from embedding more accountability throughout your organization now. This article provides a framework for meeting this goal.

March 2011  -  NAI AND THE CENTER FOR HEALTH TRANSFORMATION RELEASE RECOMMENDATIONS FOR PAYMENT REFORM

The historical fee-for-service payment model in healthcare does not provide incentives to support progress toward the reform goals of better care at lower cost. An unintended consequence of the model is that it doesn't reward physicians and hospitals for improving quality or lowering costs. In fact, it often encourages the maximum use of resources and fails to reinforce prevention and wellness. A new payment model which incents better health outcomes at lower cost must be developed -- but ideas differ on how to achieve this goal.

The Center for Healthcare Transformation (CHT) convened a series of work sessions to discuss alternative payment models and develop non-partisan recommendations to meet this challenge. These sessions included various stakeholders across the healthcare industry, and were led by Rita E. Numerof, Ph.D., President of Numerof & Associates, Inc., Julia Eckstein, Vice President of State Government Affairs for CHT, Former Speaker of the House Newt Gingrich, and former Senate Majority Leader Tom Daschle. On February 8, CHT released a white paper authored by Dr. Numerof, describing in detail the six key recommendations for payment reform that were developed in these sessions. Click here to read Transforming Healthcare: Recommendations for Payment Reform.

February 2011  -  NAI AND AHA COLLABORATE ON ACTION GUIDE FOR MANAGING COST & QUALITY VARIATION

Sometimes patients with the same medical needs receive different courses of treatment, with different outcomes. Why? Because even within the same hospital, lack of appropriate metrics and analytics allow variation in treatment decisions and resulting unpredictability in cost and quality outcomes. If hospital administrators hope to deliver better quality at lower cost, they will need to manage healthcare delivery as a process -- including both administrative and clinical decision making.

To help hospital administrators with this challenge, the American Hospital Association's Hospital Research & Educational Trust (HRET) worked with NAI to create a new publication titled Health Care Leader Action Guide: Understanding and Managing Variation. This important and timely resource provides best-in-class guidance for understanding and managing variation in inputs and outcomes, steps to consider when launching improvement initiatives, and an extensive list of case studies and sources of best practices. Click here. to learn more and to download the Guide from the Hospital Research & Educational Trust website.

February 2011  -  UPCOMING WEBINAR: BUNDLED PRICING: ARE YOU READY?

• Date: Wednesday, April 13, 2011
• Time: 11:00 a.m. - 12:00 p.m. CST
• Pre-Register online now! We will call you to arrange payment.

Healthcare delivery organizations face a growing list of demands -- for reduced cost, improved quality, and more transparency. Bundled pricing is an innovation being implemented by market leaders to satisfy these new requirements. Deceptively simple sounding, this radically different approach to pricing and risk can be challenging to implement. It also carries the risk of an important side-effect -- commoditization. Is bundled pricing right for your organization? Are you ready for bundled pricing?

Attend this webinar and learn what you need to know about developing a bundled price approach -- the critical steps you need to take, and the challenges and pitfalls you'll want to avoid.

Learn More >>

February 2011  -  UPCOMING WEBINAR: HEALTHCARE INSURANCE AND THE ROADMAP TO 2014

• Date: Wednesday, February 23, 2011
• Time: 11:00 a.m. - 12:00 p.m. CST
• Pre-Register online now! We will call you to arrange payment.

As central players in U.S. healthcare reform, insurers find themselves in the midst of a radical transformation. New regulatory requirements present significant challenges, including the essential benefits package, medical loss ratio requirements, and insurance exchanges - - and all by 2014!

Join this webinar and hear what Dr. Rita Numerof, healthcare strategy consultant, author, and Congressional advisor, has to share about the coming changes to the healthcare insurance landscape, and how insurers should prepare for radical change to their business model.

Learn More >>

December 2010  -  NAI PUBLISHED IN PM360 ON ADVISORY BOARDS

Physician advisory boards are being scrutinized more and more closely by regulatory agencies. OIG enforcement of anti-kickback statues has set new records over the last 18 months and the Patient Protection and Affordable Care Act signed into law in 2010 has made it easier for prosecutors to impose liability on medical product company management. But these advisory boards provide valuable insight into marketing and clinical issues for manufacturers -- so management must figure out how to use them without risking running afoul of regulatory requirements.

In their December 2010 article, Developing Effective and Compliant Advisory Boards, published in PM360, authors Michael N. Abrams, M.A., Managing Partner, and Stephen E. Rothenberg, J.D., Business Analyst, describe what challenges manufacturers will face in convening advisory boards. The authors outline a comprehensive framework to engage physicians as advisory board consultants that will provide demonstrable value and comply with regulatory enforcement agencies anti-kickback statutes.