September 15, 2014

 
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Board of Licensure in Medicine Clarifies New Telemedicine Guidelines

The Maine Board of Licensure in Medicine made important changes in its Telemedicine policy first adopted in June.  Most significantly, the policy was changed to a guideline and the prohibition against prescribing scheduled drugs through telemedicine was repealed in favor of a more permissive provision.  The changes were effective immediately.  MMA had advocated for changes in the previously announced policy.

The new language on Prescribing (in section H. of the Guidelines), reads as follows:

"Telemedicine technologies, where prescribing may be contemplated, must implement measures to uphold patient safety in the absence of traditional physical examination.  Such measures should guarantee that the identity of the patient and provider is clearly established and that detailed documentation for the clinical evaluation and resulting prescription is both enforced and independently kept.   Measures to assure informed, accurate and error prevention prescribing practices (e.g. integration with e-Prescription systems) are encouraged.

Prescribing medications, in-person or via telemedicine, is at the professional discretion of the physician.  The physician prescribing via telemedicine must ensure that the clinical evaluation, indication, appropriateness, and safety considerations for the resulting prescription are appropriately documented and meet the same standard of care as that of a traditional patient-physician interaction.  Consequently, prescriptions via telemedicine carry the same accountability as prescriptions delivered during an encounter in person.   However, where such measures are upheld, and the appropriate clinical consideration is carried out and documented, physicians may exercise their judgment and prescribe medications as part of telemedicine encounters."

This amended policy is now consistent with the final product of the work group formed by the Federation of State Medical Boards to review telemedicine and to make recommendations to the state medical licensing boards.

During the discussion at the meeting on Tuesday, Board members did express concern about some of the potential applications for telemedicine being discussed nationally and MMA members implementing new services utilizing telemedicine technology should follow the national trends and potentially consult with the Board or MMA.

The Board Guidelines can be found on the MMA website at www.mainemed.com (spotlight section).

On September 9th, the American Telemedicine Association (ATA) issued two reports grading states on their telemedicine policies.  No state received high marks for easing licensing restrictions, but seven states, including Maine, received "A" grades for having insurance coverage policies that encourage telemedicine adoption.

Next MMA Listening Session to be held Thursday, October 23rd in Lewiston

MMA will hold its next member "Listening Session" in Auburn on Thursday evening, October 23rd from 5:30 to 7:30 pm at the Hilton Garden Inn.  These sessions are informal and are intended to give MMA members an opportunity to meet MMA officers and to share what thoughts they may have about the value of MMA and about what MMA needs to be doing to be an effective voice for Maine's physicians.

This particular event will also serve as a reception recognizing the new President, Lisa Ryan, D.O.  Dr. Ryan practices pediatrics in Bridgton with Central Maine Medical Group and is the Association's first President with an osteopathic medicine degree.

All MMA members will receive an invitation but anyone wishing to RSVP may communicate with Ashley Bernier at MMA via e-mail to abernier @mainemed.com.

 
 
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MMA Payment Reform Committee to Meet Wednesday Evening, Sept. 17th

MMA's Payment Reform Committee will meet on this coming Wednesday evening, Sept. 17 from 6:00 to 8:00 p.m.  Dinner will be available and the meeting will be held at the Association offices in Manchester.  The Committee is chaired by President-elect Brian Pierce, M.D. and is charged with following the trends in payment reform and in educating Maine physicians about those trends and their impact on medical practice in the state. Jennifer Reck, MA staffs the committee and provides it with consultation services.

On Wednesday evening, Committee members will hear from representatives of Maine Community Health Options and from attorney Ben Townsend of Kozak & Gayer.  Mr. Townsend will present his report, entitled, Payment Reform Update:  Current Context and Emerging Issues.

Any MMA member or interested practice manager or corporate affiliate is welcome to attend, but please communicate with Jennifer Reck via e-mail to jreck@mainemed.com for meal planning purposes.

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Health Insurance Marketplace Update: Open Enrollment for 2015 Begins Two Months From Today on November 15

The next open enrollment for the Health Insurance Marketplace starts on November 15, 2014 and closes February 15, 2015.  The Health Insurance Marketplace provides options for more affordable health insurance. Depending on household income, many people may be able to get lower costs on monthly Marketplace health insurance premiums and out-of-pocket costs.

The benefit year for 2014 Marketplace plans ends December 31, 2014. Individuals who are now enrolled and get financial assistance through the Marketplace should review their options and either renew the current plan or choose a new health plan by December 15 to continue health coverage on January 1, 2015.  Some people may want to switch plans or make changes for 2015, and many will need the help of Assisters to make changes and understand options.
 
Some people can sign up outside of Open Enrollment, and may be eligible for a Special Enrollment Period if they have a qualifying life event such as: having a baby, adopting a child, getting married, having a change in immigration status, moving to a new area or losing health insurance.
 
A Navigator or Certified Application Counselor can help review coverage options and apply for an insurance plan.  Go to www.enroll207.com to find a local Assister or call the Maine HelpLine at 800-965-7476. 
 
To request brochures for your patients and waiting room, resources and updates for office staff, or information about where your patients can get enrollment assistance, contact Susan Kring, ACA Outreach Coordinator, at 662-2364 skring@mainemed.com. [return to top]

Payment Reform Update: Current Context and Emerging Issues

The MMA’s payment reform webpage now offers a new report on payment reform entitled “Payment Reform Update: Current Context and Emerging Issues.

This publication was authored by Benjamin Townsend, Esq. of Kozak & Gayer to serve as an educational resource for Maine physicians and includes an update on payment reform in the context of the implementation of the Affordable Care Act including specific examples and discussions of ongoing payment reform efforts in Maine. Please visit the Payment Reform Resources webpage on the MMA site to access this report and more.

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Medicare Payments for Chronic Care Coordination Coming January 2015

In January of 2015, Medicare will begin paying doctors to coordinate care for patients with two or more chronic conditions.  Though doctors have coordinated such care for Medicare patients in the past, they were previously ineligible for reimbursement. The care coordination payments will be $42 a month per patient, with patients paying approximately 20% of the fee. 

Care coordination entails the following elements:

  • Obtaining patient agreement in writing
  • Drafting and implementing a comprehensive care plan
  • Psychological and social needs assessment
  • Medication management
  • Coordination with other doctors caring for the patient
  • Coordination of transitions of care, e.g. from hospital to home
  • Effective use of electronic health records
  • 24/7 access to a doctor or other staff for urgent chronic care needs

The care coordination payments represent a significant policy shift toward improving the care of Medicare patients with two or more chronic conditions, a group that accounts for two-thirds of all beneficiaries but 93% of all Medicare spending. The investment in care coordination should result in better care and lower costs.  [return to top]

MMA Members Get Free Access to DocBookMD Through MMA Endorsement

Recently, MMA successfully concluded an agreement with DocBookMD, a "physician-centric" smart phone application that enables users to exchange patient information through a HIPAA-secure network.  With DocBook, MD, using your desktop, or iPhone, iPad, and Android devices, you can:

  • Send messages that meet HIPAA requirements for encryption and security.

  • Share patient information at the point-of-care with the ability to attach high-resolution images (e.g., EKGs, X-rays, photos) and other content (e.g., discharge summaries, test results, medical history) to any message.

  • Build a "Care Team" in order to communicate with non-physicians (e.g., nurses, PAs) at your practice and at your discretion.

  • Access a directory of your MMA colleagues as a member-only network.

Hundreds of physicians in New Hampshire, Massachusetts and many other states have found the application to be of great value in their practice and MMA is pleased to become one of the states to provide free access to the product exclusively through MMA membership.

Watch for information later this month in Weekly Update to learn how to register on-line for the product.

 

 

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DEA Issues Final Rule Permitting Pharmacies and Others to Take Back Unused Drugs

On September 8th, Attorney General Eric Holder announced that the Drug Enforcement Administration (DEA) has issued a final rule authorizing pharmacies, long-term care facilities, hospitals, and other health care entities to take back unused prescription drugs.  The final rule is effective October 9th and was published in the Federal Register on September 9th.  This rule implements the Secure and Responsible Drug Disposal Act of 2010 by expanding the options for disposal of unwanted, unused prescription drugs, including take-back events, mail-back programs, and collection receptacle locations.

The DEA's next take-back event is scheduled for September 27th.   [return to top]

Footing Bill For Insurers' Pay Methods Shouldn't Fall on Doctors

An increasingly common payment method among health insurers offers these companies significant financial rewards while sticking physicians with all the associated fees and extra work. But physicians are fighting back as the AMA and other health care associations take the issue to the federal government.

Many insurers are choosing to use virtual credit cards for claims payments to physicians, instead of sending paper checks or paying via the electronic funds transfer (EFT) standard transaction. When paying via virtual credit card, insurers send single-use credit card payment information and instructions to physicians via mail, fax or email. The physician's office staff then processes the payment as they would a patient's credit card.

For each of these payments, physicians are charged fees that typically amount to 3-5 percent of the total payment, the AMA explained in recent testimony (log in) to the National Committee on Vital and Health Statistics, an advisory board to the secretary of the U.S. Department of Health and Human Services (HHS).

That adds up. If a physician contractually is owed $5,000, for instance, he or she could have to shell out up to $250 in fees.

In addition, physicians' practices are forced to devote more time to processing these payments, having to manually enter information, correct any entry errors and manually reconcile the payment with the separate claims remittance advice.

Insurers, on the other hand, often receive cash-back incentives for making virtual card payments, including a portion of the fees the physician paid.

The AMA is urging HHS to issue additional guidance on this issue. In a letter (log in) sent last week to HHS Secretary Sylvia Burwell, the AMA and three other leading organizations called on the agency to prohibit insurers from forcing physicians to accept this payment method. They also urged the agency to require insurers to give full upfront disclosures of associated fees, obtain physician authorization before implementing virtual card payments and ensure an easy opt-out process if a physician later chooses not to accept this form of payment.

Physicians instead can request insurers to pay via the EFT standard transaction, which works like direct deposit and can cut down the time spent on processing paper checks. The AMA offers two educational opportunities for physicians who are interested in pursuing the EFT payment method:

  • A free continuing medical education webinar, "Stop paying to get paid: Effective electronic payments," will take place at noon Eastern time Sept. 16. Registration now is open.
  • An EFT toolkit offers guidance about physicians' rights regarding electronic payments, the effects of virtual credit card payments, and the ins and outs of EFT payments.

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Law Limiting Physician Speech Upheld; Doctors Call For Rehearing

Physician groups recently filed a brief in support of a formal petition for the rehearing of a precedent-setting case.  A federal appellate court earlier this summer issued a split-decision upholding a controversial Florida law that could restrict what physicians can talk about with their patients in the exam room.

The state law bars physicians from freely discussing firearm safety with their patients, putting political agendas before public health and the patient-physician relationship.  While one of the judges on the three-person panel sided strongly with physicians in opposing the law, the two other judges ruled in favor of the state.

"[T]he panel decision … denigrates the practice of medicine," the AMA and eight medical specialty societies wrote in the filing. "To be effective, [medicine] requires a special bond of trust between patient and physician, which depends for its existence on the ability to communicate freely."

"Patients must believe in their physicians' absolute honesty and fidelity when relying on their physicians' advice," the filing said.  Furthermore, "if physicians must tailor their communications to meet a legislative agenda, they cannot fully respect their patients' needs."

The medical associations are pointing to the "exceptional importance of this case."  The ruling not only has direct negative consequences on the practice of medicine in Florida but also sets a precedent that could encourage other state lawmakers to proceed with legislation that similarly would restrict physicians' conversations with their patients about health and safety.

 

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Upcoming Events


Health Care (HC4ME) For Maine

2nd Annual Health Care for Maine Conference

"Successfully Implementing the ACA in Maine"

Keynote Speaker:  Ron Pollack, Founding Executive Director of Families USA

Tuesday, September 16, 2014 from 8:30 a.m. to 4:00 p.m.

Augusta Civic Center

Agenda and registration available on the Consumers for Affordable Healthcare website

***  

13th Annual Downeast Ophthalmology Symposium

Presented by the Maine Society of Eye Physicians and Surgeons
September 19-21, 2014 - Bar Harbor, Maine
Topics include:  Glaucoma, Neuro-ophthalmology, and Cataract/Refractive.
Open to ophthalmologiststs across the country, so spread the word!   For more information and registration materials, visit http://www.maineeyemds.com.  Questions can be addressed to Shirley Goggin at sgoggin@mainemed.com or 207-445-2260.

***  

Direct Primary Care (DPC) Workshop

with Dr. Brian Forest, Founder, Access Healthcare Direct & AAFP DPC Workgroup Leader

& Maine physicians developing an integrated Maine Direct Care Network for existing practices

 Calling Doctors & Consumers: Come explore the options.

September 26, 1-5pm and September 27, 8:30-12:30pm,  2014

Maine Medical Association, Manchester

For further information email MaineDPCProject@yahoo.com.

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Prenatal Education-Strategies that Work 

Join us for a webinar featuring the Geisel School of Medicine Faculty developed for all Physicians, Nurses, Nurse Practitioners, Physician Assistants, Certified Nurse Midwives and all other members of the Perinatal Team.  Be sure to join us live to get any questions you may have answered and to learn from your peers around the state!

Learning Objective:  After this webinar the participant will able to institute evidence-based, effective, and timely breastfeeding education for pregnant women.

How to JoinWebinar 
Conference line 1-877-455-0244 
Passcode 207-287-4064
http://stateofmaine.adobeconnect.com/bfwebinar3/

To join the live meeting on October 2nd click on the adobe connect link above, click on the “Guest” button and enter your name.  You may call in to the meeting conference # before or after you do this.  If you have a direct phone line # to your office you can enter that number when prompted and the meeting will call you.  Press #1 to connect your audio to the meeting and you are in!  See you all there.

Earlier 6 for ME Recorded Webinars can be found here: 
Recording of Webinar 1 The Epidemiological Evidence for the Benefits of Exclusive Breastfeeding- Alison Holmes, MDhttp://vimeo.com/letsgo5210/review/103911028/ee3fa490c9

Recording of Webinar 2 Why Provider Education Matters & the Expanding Evidence of the “Ten Steps to Succesful Breastfeeding”http://stateofmaine.adobeconnect.com/bfwebinar/

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Psychopharmacology for Medical & Behavioral Health Professionals

Focus:  Individuals with Autism or Intellectual Disabilities

Thursday, October 2, 2014

10 a.m. to noon

Woodfords Training & Resource Center, 100 Larrabee Road, Westbrook

Cost is $25, but register before 9/26/14 & the fee is $20

The presenters are Katherine Ray, M.D., Psychiatrist, and David Payne, PA-C.  The course is intended to enhance understanding of the appropriate use of psychotropic medications with children and adults with developmental disabilities, such as autism spectrum disorder.  Drug interactions, dosage, side-effects, and the need for alternative or adjunctive methods, such as behavioral interventions and counseling will be discussed.  Participants will have the opportunity to discuss actual cases.

This course is appropriate for direct care providers such as primary care physicians, nurses, physician assistants, licensed clinical social workers, and licensed clinical professional counselors.

Seating may be limited.  Advance registration is recommended.  FMI or to register, contact Training Coordinator Maria Romano, 207-878-9663, ext. 4131, or mromano@woodfords.org.

This training is supported in part by a grant from the Maine Developmental Disabilities Council

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The Maine Public Health Association’s (MPHA) 

30th Annual Fall Conference

October 7, 2014

Augusta Civic Center

Keynote speakers include: Erik N. Steele, D.O., FAAFP, Senior Vice President, Chief Medical Officer, Summa Health System and Paul Kuehnert, DNP, RN Team Director for the Bridging Health and Health Care Portfolio, Robert Wood Johnson Foundation

For more information or to register, click here.

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Maine Health Management Coalition 2014 Annual Symposium:

"Finding Value: How to Lower Cost & Improve Health"

Wednesday, October 15th, 8 am to 2:45 pm

at the Abromson Center on the University of Southern Maine campus 

MMA members are entitled to a special registration fee of $75 (instead of $100).

The Symposium is shaping up to be a truly enlivening event for all those engaged in the challenging work of improving health care delivery and controlling costs.  Highlights of the day will include:

  • Keynote speaker Ron Sims, Board Chair of Washington Healthplanfinder, Washington State’s insurance exchange.  A community health innovator, Sims is well-known for the award-winning employee wellness program he instituted to reduce rising healthcare costs.  Within the program’s first year, 75% of employees at moderate or high risk for developing a chronic disease eliminated at least one risk factor.
  • Other outstanding speakers include Neel Shah, MD, MPP, Founder and Executive Director of CostofCare.org, a national nonprofit that helps caregivers engage in controlling medical costs, and Richard Wexler, MD, Chief Integration Officer of Healthwise, which merged with the Informed Medical Decisions Foundation in April 2014 and now uses expertise in shared medical decision making to help people make better health decisions.

A full agenda with links to all of the Symposium details is available at http://www.mehmc.org/news-events/2014-symposium/agenda/. To register, go to https://webapp.usm.maine.edu/DCPEOnline/addRegCONFPage1.do?offeringId=100075926.

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Maine Concussion Management Initiative Training

October 21, 2014 in Portland in conjunction with the Maine Brain Injury Conference

7:30 a.m. - 12:00 p.m. 

Includes An Introduction to Concussions and Concussion Management & Interpreting Neurocognitive Testing (including using ImPACT)

$100 for Health Care Professionals  (CEUs/CME available); $40 for school personnel and all other attendees

For more information or to register, contact Jan Salis, jsalis@aol.com, (207) 577-2018

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Job Openings

FAMILY PRACTICE PHYSICIAN Sought In Central Maine!

A progressive 25-bed critical access hospital in central Maine is seeking a FP to join their employed primary care group.  This is a full time opportunity which consists of 32 patient contact hours per week, allowing time to enjoy what this region of Maine has to offer! 

Sebasticook Valley Health (SVH) in Pittsfield, Maine is an integral member of the communities it serves. SVH takes a proactive approach in helping people in the Sebasticook Valley improve the quality of their lives.  SVH serves an area of approximately 30,000 people and has a wide range of outpatient services, including over 20 specialty services.  SVH is a proud member of the Eastern Maine Healthcare Systems which ensures access to high quality care to Maine residents and visitors.

For Further Information, please contact:

Sherry Tardy, Director Business Development/Provider Recruitment
Sebasticook Valley Hospital
447 North Main Street
Pittsfield, ME  04967

By email at: stardy@emh.org or by phone at: 207-487-4085

9/29/14

Gastroenterologist Jobs in Central Maine!

Challenging, Lucrative, Gastroenterologist jobs in central Maine - honoring and serving Veterans. Gastroenterologists are needed in Augusta. Must-have an unrestricted medical license (from any U.S. state), and current ACLS certification. This is your opportunity to use and develop your skills of diagnosing, treating, and managing patients according to standard, usual, and acceptable methods and techniques.

B/C or B/E specializing in Gastroenterology by the appropriate accrediting agencies required.

This is the opportunity for you to receive a competitive salary, a generous leave package, excellent health & life insurance benefits, and retirement benefits. You'd be eligible to participate in a pension program as well as a matching Thrift Savings Plan which is similar to a 401K. If you are a veteran, you may be able to combine accrued military retirement credit with VA pension benefits.

Your salary will be determined by local Physician/Dentist Compensation Panel (commensurate with education, experience and qualifications). By law, U.S. Citizens will be given 1st preference but non-citizens will be considered in the absence of qualified citizens. A signing bonus may be available.  Equal Opportunity Employer. Disabled persons and/or veterans are encouraged to apply.

https://www.usajobs.gov/GetJob/PrintPreview/366611500

9/29/14

Department of Psychiatry Faculty Position

The Geisel School of Medicine at Dartmouth, Department of Psychiatry, in a productive collaboration with the State of Maine, is seeking psychiatrists to join our faculty for inpatient responsibilities at the Riverview Psychiatric Center.

Riverview Psychiatric Center is a 92-bed acute psychiatric facility located in Augusta, ME and is the flagship inpatient treatment center for Maine’s public mental health system.  Psychiatrists with expertise in general inpatient psychiatry or forensic psychiatry are encouraged to apply.

Academic duties can include teaching and supervision of medical students and residents. Research opportunities available and encouraged.

Candidates should be board certified or eligible in Psychiatry. This position will include a faculty appointment at The Geisel School of Medicine at Dartmouth at a rank and salary commensurate with experience. Curriculum vitae and three letters of reference, addressed to Dr. William Torrey, Search Chair, should be e-mailed to psychiatry.jobs@dartmouth.edu.  Please reference search number PS0314D.

Dartmouth College/Dartmouth Hitchcock Clinic/Geisel School of Medicine is an equal opportunity/ affirmative action employer with a strong commitment to diversity. In that spirit, we are particularly interested in receiving applications from a broad spectrum of people, including women, persons of color, persons with disabilities, veterans or any other legally protected group.

9/29/14

Physician Reviewers Sought

Maine Community Health Options (MCHO) is seeking physician reviewers to assist with 2nd level Medical Necessity Appeal requests.  This is a contracted position and physicians will be paid for their time involved in reviewing and participating in the Appeal. 

The physician reviewer must hold an active, unrestricted license to practice medicine and be board certified (if applicable) by:

  1. A specialty board approved by the American Board of Medical Specialties (doctors of medicine); or
  2. The Advisory Board of Osteopathic Specialist from the major areas of clinical services (doctors of osteopathic medicine)

In addition, in order to meet State mandated timeframes for Appeal decisions, the physician reviewer must be available to:

  1. Review the Appeal request within 5 business days of MCHO receipt of the Appeal.
  2. Participate in an Appeal panel with MCHO staff as well as the member or their provider within 10-15 business days from receipt of the Appeal request.
  3. Provide a written summary opinion of the Appeal determination within 5 business days from convening the panel.

Please contact Trish Ward at 207-402-3771 or PWard@maineoptions.org for more information.

9/29/14 

Family Physician - Potential income of $430,000.00 plus

We are recruiting for a full-time primary care physician with emergency/urgent care experience for a client in Nova Scotia, Canada.

The position is at a small community hospital near the town of Antigonish, Nova Scotia.  Antigonish is a vibrant, welcoming community and home to one of Canada’s top undergraduate schools, St. Francis Xavier University. 

The physician will be expected to maintain a primary care clinic at a community hospital and participate in after hours call for the level 1 ER at the facility.  The emergency room sees approximately 30-40 patients per day. 

This is an ideal position for a new physician with a sense of adventure, or an experienced physician looking for more work-life balance.  

Income is from an Alternative Payment Plan (APP) and fee-for-service.  Income of $236,000.00 for APP for daytime work, and $140/hour for out of hours emergency room coverage (expected 1400 hours of emergency room coverage, per physician, per year; 1 in 4 call.)

You will have access to a wide range of outdoor/indoor activities, including hiking, golf, boating, skating and, of course, hockey. (It’s Canada, after all.)  

Please Contact:

David Nurse

CanAm Physician Recruiting Inc.

Office: 1-902-719-7309

Fax: 1-902-640-3118

dnurse@canamrecruiting.com

10/6/14

Industrial Physician - Salaried Job Opportunity

Job Description:

  • Provides routine and emergency medical services to BIW employees
  • Performs physical examinations to support regulatory driven medical surveillance programs such as asbestos, lead, cadmium, respirator and hearing conservation
  • Performs pre-placement and return-to-work examinations
  • Performs patient examinations to support the company's Probable Cause policy
  • Provides medical support for sea trials
  • Determines work capacity and assigns work restrictions for new or chronic injuries and illnesses
  • Interfaces with Workers' Compensation to assist case management
  • Participates in quality assurance audits
  • Provides consultation to management on ADA and job accommodations
  • Participates in updating clinic protocols and standards of practice

Required Education/Training:

  • Allopathic/osteopathic physician with Maine license
  • Board certified or board eligible in occupational medicine
  • ACLS certified

Experience (type and number of years):  Four years’ experience in ambulatory care preferred

Unique/Additional Requirements:  DOT/CDL examiner certification desirable

Thank you for your interest in Bath Iron Works.  For a link to this listing and other career opportunities, please visit our web site at: https://www.gdbiw.com/careers

10/6/14

Family Practice Physicians

Katahdin Valley Health Center is recruiting dedicated Family Practice Physicians that are committed to providing quality health care services to the people in Central/Northern Maine.  Join our practice in one of the newly expanded facilities.  We are seeking physicians for our Millinocket, Ashland and Houlton locations.  KVHC is a fully electronic medical record site and offers a competitive salary ($170,000 to $190,000 annual) and benefit package which includes: a 10% of first year salary sign on bonus, generous amounts of paid time off, $2500 annually toward CME as well as a completely outpatient site.  The call schedule is 1 in 8 with additional coverage from the Open Access Clinic.  Physicians who join KVHC are eligible to apply for NHSC Loan Repayment.

To learn more about KVHC and Practitioner Opportunities, please contact Michelle LeFay at mlefay@kvhc.org or visit our website at www.kvhc.org.  KVHC is an equal opportunity employer.

11/24/14

 

 

 

 

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