Trying to reason increase in stipend to hospital...

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neuroride

neuroride

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We are 4 doc/13 CRNA PP group with a stipend for call which now is incredibly low for the given times with CRNA salaries and rembursements/ payor mix. We lose alot of money each month at the hospital covering 5 ORs and paying our CRNAs. Fortunately, we also cover a surgery center that we are owners at that has been keeping us going up until the last year or so. We have been pushing for a doubling of our stipend but are getting nowhere thus far. We are losing about 4x our stipend each month from the hospital side of the street. We are hoping to go to the method where they reimburse us the monthly cost of doing business (assuming a loss) and if we make money, then no payment to us. Anyone have wisdom in this route or how to really show the admin how to do this? Also we have already gone down 1 OR to 4 and also put in our letter of termination given the 180 day notice (up in july)?
 
neuroride said:
We are 4 doc/13 CRNA PP group with a stipend for call which now is incredibly low for the given times with CRNA salaries and rembursements/ payor mix. We lose alot of money each month at the hospital covering 5 ORs and paying our CRNAs. Fortunately, we also cover a surgery center that we are owners at that has been keeping us going up until the last year or so. We have been pushing for a doubling of our stipend but are getting nowhere thus far. We are losing about 4x our stipend each month from the hospital side of the street. We are hoping to go to the method where they reimburse us the monthly cost of doing business (assuming a loss) and if we make money, then no payment to us. Anyone have wisdom in this route or how to really show the admin how to do this? Also we have already gone down 1 OR to 4 and also put in our letter of termination given the 180 day notice (up in july)?
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Quit and come back as 1099 making more money.

That’s the play.

Keep the surgery center if it’s profitable. Easier to deal with 4 docs dividing up work load and new schedule
 
Stay PP at surgery center and 1099 at the hospital? Also the hospital is 50% partner with us in this surgery center. Worst case we retreat to the surgery center and then we locums back to the hospital for embarrassing rate per hour is what we are thinking.
I always thought I would never convert us over to employees of the hospital but our payor mix and surgeon roster is not doing us any favors. Also trying to recruit CRNAs these days is a nightmare.
 
Gotta agree with @aneftp on this one. In any business if you are on the path of losing more and more money you need to cut your losses at some point. In this case the only way to cut the losses is to no longer manage the increasing labor cost all by yourselves. Because the hospital hasn’t really felt the pain & burden of the losses they have had no reason to contribute to mitigation steps.

It will be interesting to see what happens in 180 days…
 
They have done an FMV but do not want to share the results so I assume they know they could be giving way more money to us. I haven't seen the bylaws in some time but its language says that we are around for them. They always could in theory go CRNA only but our L& D physicians would freak out as we do all the epidurals.
 
neuroride said:
They have done an FMV but do not want to share the results so I assume they know they could be giving way more money to us. I haven't seen the bylaws in some time but its language says that we are around for them. They always could in theory go CRNA only but our L& D physicians would freak out as we do all the epidurals.
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FMV analysis is a load of bs fed by administration. I had this hospital feed the full time w2 staff the email they were the highest paid anesthesiologists in the area per hour worked.

5 docs have now left in a matter of 4 months. The market has spoken. Coincidence they managed to hire 5 new crnas (all with combined 2 years experience) due to 6 figure sign on bonus for 3 years bringing their average compensation over 300k for a 40 hr work week no nights and no weekends. Plus 11 weeks off for the crnas

They will have to come up with something quick for the docs or it’s gonna to snowball but tons of overtime available now. So the docs who want the overtime can take in 900k if they want. So maybe they will try to keep it short staff md wise
 
When you say you are 50% owners with hospital of surgery center you as a group don’t own 50% I assume? That’s all the physician owners who own 50%?
 
When you say you are 50% owners with hospital of surgery center you as a group don’t own 50% I assume? That’s all the physician owners who own 50%
 
Best solution is to let the hospital fund the CRNAs, like the rest of the medium to large hospitals in the region. You continue to contract with your group for medical direction and OB coverage. This is a stipend without having to call it a stipend. Paying money straight to you is viewed very different from paying a cadre of CRNA/locums. They get perceived control, you maintain independence.
 
Agree with Ethernet as thars best option

Any large amcs near you? Good for you but it’s extremely rare for surgery centers to offer anesthesia ownership anymore as anesthesia doesn’t bring any patients. Reason I ask is hospital can rfp. AMC will claim they can do it cheaper but will say surgery center has to be included. Depends on the surgery center bylaws but if hospital owns 50% likely they can find way to term you at surgery center. Then they’l have grounds to buy back your shares of surgery center.

I understand what you’re doing and need. Just one surgery center to fall back on risky
 
neuroride said:
They have done an FMV but do not want to share the results so I assume they know they could be giving way more money to us. I haven't seen the bylaws in some time but its language says that we are around for them. They always could in theory go CRNA only but our L& D physicians would freak out as we do all the epidurals.
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Incredibly bad business not to share with you. I’d ask for the moon.

Glad you put your notice in.
 
We have a separate contract for the surgery center saying only my company can provide anesthesia and also all our CRNAs have a noncompete with the hospital unless we say.
AMCs non existent round here thank god. Right now a RFP sounds like the best bet. If hospital takes over the CRNAs, I would worry they could try to get rid of us docs bc we are op out state.
 
Iso4ane said:
How much do you need/want? If they put out a request for proposals, I’d be happy to supply one that is 2x whatever you need, so they realize what a ‘bargain’ they’re getting.
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Ha ha. It’s like me asking for 50k for the week locums. My friend goes in at 40k for the week.

They counter for 25k for week. We both reject it and ask for 60k beeper coverage for the weeks. Just a cat and mouse game.

I just think every thing is a game with negotiations these days.
 
You made a smart move giving notice but that should have happened July 2024. RFP will be your friend as all the AMCs will ask for a larger stipend than you are getting now. Unfortunately, You may need to enforce that non compete for the CRNAs as the hospital needs to feel the pain of their error when they decide to go with the AMC. The AMC will cost them millions per year as locums costs will mount and you all will want a fair wage (at least $300 per hour plus call pay). Once the AMC thinks they have a deal with your administration you can have 1 last meeting with the CEO/CFO and explain the reality of this market. The AMC will be unable to hire or recruit in this market at their supposed wages and instead will dump the massive locums cost on the hospital. You should also maker sure there is no non compete in your contract for the area and a buyout clause like $30,000 for the hospital. After 2 years of facing millions in excess anesthesia costs the administration will be ready to talk terms. In the meantime you will earn a fair wage.
 
Be prepared to walk away. If the hospital can do it better than you guys can, then good for them (but I don’t think they can). Walk away, and let the hospital come to you, begging for labor, and you can charge very high Locums rates (which frustratingly ends up being much more than what the hospital could’ve given you with the stipend that you guys want and deserve).
 
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Opt-out state is not going to change anything. They might consider CRNA only and that's what a consultant will push down their throat. Hopefully you have support from the surgeons and the executive suit is physician run. I've been through this with some success. They will certainly push to the extreme in some way, but hopefully its only a negotiating tactic to get you to meet in the middle.
 
You're not in business to lose money. The ASC is an entirely separate issue and should not be considered as part of the hospital stipend problem. Someone's gonna have to be the hard-ass and say "this is the deal, this is what it costs, this is when we're available and how many staff will be available to cover it". Even before we became hospital employed (and even now) we work closely with the OR scheduling office. We have a "grid" telling them what is available each day. They want to open more rooms at hospital #2 that day? Fine - close rooms at hospital #1. We limit the number of rooms after 3pm, 5pm, and 7pm. We have people in-house 24-7 but we will not keep an excess of people around after hours. Our shift people go home when their shift is done. They do not start more cases than what can be finished by a certain time. If the limit is 2 rooms after 7pm, including emergencies, they do not start a case at 6:30 that will run until 7:30. It will have to follow.
 
I have to ask how many out of OR anesthesia sites are there and how many at the center?
Right now you have 17 providers for 5 ORs.
I am sure there is more information
 
Our hospital was resistant to significantly increase our stipend for other than the stuff they agreed was required and not self sustaining (trauma, Transplant call, etc.) that they always paid for. Historically we did very well, but the post covid wage increases and peds anesthesia and CRNA market shortages finally caught up to us. We limped along for a couple years on money from a few folks that left and some left over profit in the system. Then we couldn’t effectively hire CRNAs and were losing staff so couldn’t cover all the rooms and they finally woke up. We were not going to be able to pay physicians at our current expected established percentile and they were going to be looking at a mass exodus. They still dragged their feet and apparently didn’t understand that losing $1M/mo for each room we can’t staff would be several times more costly than the annual stipend we needed. So we let them do the math the hard way. The market is what it is.
They tried to bridge the gap with Locums, but - surprise! There aren’t a lot of experienced peds fellowship trained folks on the market that want to work at a major Children’s hospital doing high acuity complex peds cases. Rooms closed, surgeons raged, no flucks were given. They did it to themselves. We even lost a couple more faculty while they “figured out a plan to move forward.” Shockingly, some people want guarantees and stability and are willing to move to get it. That stung them hard and hopefully they remember it for a long time. Oh well. They actually paid a consultant 6 figures to tell them the market is what it is, and losing 4x what we were asking on closed rooms makes good financial sense, oh and more people will leave if they don’t keep up with the market. Do you need a fancy consultant for that? Apparently, yes.
 
It’s been a few years already and the market has been “set,” yet they still don’t have the balls to pull the trigger and need to pay a consultant to justify it.
No better feeling than screwing over physicians I guess.

IlDestriero said:
Our hospital was resistant to significantly increase our stipend for other than the stuff they agreed was required and not self sustaining (trauma, Transplant call, etc.) that they always paid for. Historically we did very well, but the post covid wage increases and peds anesthesia and CRNA market shortages finally caught up to us. We limped along for a couple years on money from a few folks that left and some left over profit in the system. Then we couldn’t effectively hire CRNAs and were losing staff so couldn’t cover all the rooms and they finally woke up. We were not going to be able to pay physicians at our current expected established percentile and they were going to be looking at a mass exodus. They still dragged their feet and apparently didn’t understand that losing $1M/mo for each room we can’t staff would be several times more costly than the annual stipend we needed. So we let them do the math the hard way. The market is what it is.
They tried to bridge the gap with Locums, but - surprise! There aren’t a lot of experienced peds fellowship trained folks on the market that want to work at a major Children’s hospital doing high acuity complex peds cases. Rooms closed, surgeons raged, no flucks were given. They did it to themselves. We even lost a couple more faculty while they “figured out a plan to move forward.” Shockingly, some people want guarantees and stability and are willing to move to get it. That stung them hard and hopefully they remember it for a long time. Oh well. They actually paid a consultant 6 figures to tell them the market is what it is, and losing 4x what we were asking on closed rooms makes good financial sense, oh and more people will leave if they don’t keep up with the market. Do you need a fancy consultant for that? Apparently, yes.
Click to expand...
 
crna2006 said:
I have to ask how many out of OR anesthesia sites are there and how many at the center?
Right now you have 17 providers for 5 ORs.
I am sure there is more information
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We usually have the 5 ORs but work in out of dept stuff usually with gaps in the OR schedule
 
Sorry 17 providers 5 OR'S. Either people are .3 fte or ....i don't know, standing by full time for trauma?
 
crna2006 said:
Sorry 17 providers 5 OR'S. Either people are .3 fte or ....i don't know, standing by full time for trauma?
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Probably 5 in main OR, 2-3 in non-OR areas, 1 on OB, a couple across the street at the ASC, 2 post-call, and 3-4 on vacation. It can add up.

The real question is how efficient is scheduling and are all these locations generating a full FTE of income.
 
thinkorswim said:
Probably 5 in main OR, 2-3 in non-OR areas, 1 on OB, a couple across the street at the ASC, 2 post-call, and 3-4 on vacation. It can add up.

The real question is how efficient is scheduling and are all these locations generating a full FTE of income.
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Like I asked how many out of OR sites, unless they are super busy they do not need a full time OB provider. The numbers make no sense.
 
Only 1 CRNA on call at night 2 possible vacation spot per week and then the post 48 hr weekend person is off the next week
 
neuroride said:
We are 4 doc/13 CRNA PP group with a stipend for call which now is incredibly low for the given times with CRNA salaries and rembursements/ payor mix. We lose alot of money each month at the hospital covering 5 ORs and paying our CRNAs. Fortunately, we also cover a surgery center that we are owners at that has been keeping us going up until the last year or so. We have been pushing for a doubling of our stipend but are getting nowhere thus far. We are losing about 4x our stipend each month from the hospital side of the street. We are hoping to go to the method where they reimburse us the monthly cost of doing business (assuming a loss) and if we make money, then no payment to us. Anyone have wisdom in this route or how to really show the admin how to do this? Also we have already gone down 1 OR to 4 and also put in our letter of termination given the 180 day notice (up in july)?
Click to expand...
there are consultant companies that make projections and interface with the hospital with you/for you.. they usually work with bigger groups than your describing but thats the way its done on a large scale
 
Ok update, the hospital is slowly coming to their senses that they need us. The newest idea floated has been employment with the hospital but they obviously need to pay us appropriately. I am throwing it out there for some brainstorming on ideas, safe vs crazy on what to do. One option would be to be fully employed with the CRNAs fully employed as well and cover the OB and 5ish ORs at the main hospital and then 5-6 locations at the surgery center across the street. If the salary is high enough, this might be great to not have to hire CRNAs/deal with that drama but then we would likely have to sell our shares in the surgery center at that point and not get distributions from the ASC.

They also hinted that there is a new ortho group coming in to take over and hopefully pump our volume but they have said that multiple times in the past but this would make sense why more of the urgency to get us nailed down with a contract so they can have anes coverage for this new possible ortho business.

Option 2 could be that we keep our small practice at the surgery center with 5-6 CRNAs, no call and then possilbly locums and/or charge the hospital as a 1099 to provide full time doc coverage with call shifts and let them employ their own 'hospital' CRNAs that we would supervise. We could keep our shares at the surgery center also that way.
Thoughts on this or any other ideas how you would approach this. I feel a shift now like they know we have them up against a wall so maybe we ask for the moon as far as salary or as hourly shifts at the hospital?
 
Have you tried analyzing your schedule and coverage sites, formalizing coverage times for areas, and determining the amount of FTEs that are needed to cover the sites?
After FTE determination, you could contractually have an “income guarantee” with the hospital.
I know one group that does this.

Essentially, if you need 15 FTEs, have 12 FTEs of individuals, and make through billing 10.25 FTEs because insurance sucks and gaps in the OR schedules, than the hospital owes your group 4.75 FTEs of money.
This avoids the “stipend” word and puts accountability back at the hospital to fix their inefficiencies and payor mix.

The hardest part is negotiating how much income and vacation an FTE should make.
 
neuroride said:
They have done an FMV but do not want to share the results so I assume they know they could be giving way more money to us. I haven't seen the bylaws in some time but its language says that we are around for them. They always could in theory go CRNA only but our L& D physicians would freak out as we do all the epidurals.
Click to expand...
you could ask for a revenue guarantee. Make more and they dont need to cover, make less and they have to make you whole.
 
Yeah a guarantee is definitely on our radar also, I feel like it would be the most fair for both parties
 
neuroride said:
Ok update, the hospital is slowly coming to their senses that they need us. The newest idea floated has been employment with the hospital but they obviously need to pay us appropriately. I am throwing it out there for some brainstorming on ideas, safe vs crazy on what to do. One option would be to be fully employed with the CRNAs fully employed as well and cover the OB and 5ish ORs at the main hospital and then 5-6 locations at the surgery center across the street. If the salary is high enough, this might be great to not have to hire CRNAs/deal with that drama but then we would likely have to sell our shares in the surgery center at that point and not get distributions from the ASC.

They also hinted that there is a new ortho group coming in to take over and hopefully pump our volume but they have said that multiple times in the past but this would make sense why more of the urgency to get us nailed down with a contract so they can have anes coverage for this new possible ortho business.

Option 2 could be that we keep our small practice at the surgery center with 5-6 CRNAs, no call and then possilbly locums and/or charge the hospital as a 1099 to provide full time doc coverage with call shifts and let them employ their own 'hospital' CRNAs that we would supervise. We could keep our shares at the surgery center also that way.
Thoughts on this or any other ideas how you would approach this. I feel a shift now like they know we have them up against a wall so maybe we ask for the moon as far as salary or as hourly shifts at the hospital?
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5 ORs in the Hospital and 5 ORs at the ASC is a very inefficient set up. How do you do it with 4 docs? I would think you need 4 docs every day to cover 5 rooms at each place.

I would definitely try to keep the ASC, and get some kind of guarantee from the hospital side or let the hospital employ the hospital side of it.

I would go with straight up hourly rate for the hospital over income guarantee, too messy with sharing books.

We keep the ASC.

300/hr for Anesthesia Doc Coverage at the hospital. 350/hr after 3pm. You guarantee doc coverage. They deal with the CRNAs
 
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neuroride said:
Ok update, the hospital is slowly coming to their senses that they need us. The newest idea floated has been employment with the hospital but they obviously need to pay us appropriately. I am throwing it out there for some brainstorming on ideas, safe vs crazy on what to do. One option would be to be fully employed with the CRNAs fully employed as well and cover the OB and 5ish ORs at the main hospital and then 5-6 locations at the surgery center across the street. If the salary is high enough, this might be great to not have to hire CRNAs/deal with that drama but then we would likely have to sell our shares in the surgery center at that point and not get distributions from the ASC.

They also hinted that there is a new ortho group coming in to take over and hopefully pump our volume but they have said that multiple times in the past but this would make sense why more of the urgency to get us nailed down with a contract so they can have anes coverage for this new possible ortho business.

Option 2 could be that we keep our small practice at the surgery center with 5-6 CRNAs, no call and then possilbly locums and/or charge the hospital as a 1099 to provide full time doc coverage with call shifts and let them employ their own 'hospital' CRNAs that we would supervise. We could keep our shares at the surgery center also that way.
Thoughts on this or any other ideas how you would approach this. I feel a shift now like they know we have them up against a wall so maybe we ask for the moon as far as salary or as hourly shifts at the hospital?
Click to expand...
Option 2.
 
Make sure if you’re doing some kind of revenue guarantee that you’re keeping hospital business separate from ASC business. I.e. when you “share your books”, make sure it’s just the hospital portion. Otherwise, the hospital will be happy to let your ASC work subsidize your commitment to the hospital.

Even if the hospital is a partner in the ASC, your collections there don’t really have any bearing on the losses you’re taking at the hospital. Unless the hospital is the one contracting you to work at the ASC, those are separate accounts.

I agree with others that if the hospital refuses to open their eyes, you retreat to the ASC and let the hospital bleed out paying locums rates until they come to their senses.
 
Yes up to this point we have only shown them the hospital revenue we generate.

Our system works well, we direct the CRNAs when we need to per insurance and just supervise and help out when needed on the others. We do work alot but up to a couple years ago was pretty lucrative.

The hospital was saying that we should just eat the losses bc we have the surgery center and our distributions from the ASC but that was the dumbest comment from them, no one is in business to lose money regardless of what type of business it is. Just bc we are doctors doesn't mean we should just be happy with losing tons of money.
 
neuroride said:
Yes up to this point we have only shown them the hospital revenue we generate.

Our system works well, we direct the CRNAs when we need to per insurance and just supervise and help out when needed on the others. We do work alot but up to a couple years ago was pretty lucrative.

The hospital was saying that we should just eat the losses bc we have the surgery center and our distributions from the ASC but that was the dumbest comment from them, no one is in business to lose money regardless of what type of business it is. Just bc we are doctors doesn't mean we should just be happy with losing tons of money.
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Up until recently, many groups did in fact have to rely on ASC work to subsidize hospital work/call. It wasn’t necessarily the case that they were losing money at the hospital, but without the ASCs, the pay would be so low as to be unsustainable.

If the group didn’t like it, there were AMCs waiting at the gates, promising to make it work with their better insurance reimbursement.

It’s only recently that that anesthesia groups can tell the hospital to pay up or we’re out of here. Good luck finding a replacement. We can help you out at locums rates in the meantime.
 
aneftp said:
Option 2.
Click to expand...
Yup. The hospital needs to be paying you for every minute you are “covering” their hospital. There are simply too many “inefficiencies” in the way hospital OR’s are run these days, especially considering that you lose money on every Medicare/Medicaid/“self pay” case you do.

I would have a lawyer review your contract and “ownership stake” in the ASC. Make sure the hospital can’t toss you out of there. They can obviously give “exclusive contracts” to another group, for the hospital, but this may not be the case at the ASC, as long as it is being staffed appropriately.

“Hospital employment” is not something I’d consider, unless no other option exists (and, again, there are stipulations that you have a “minimum” salary AND are paid for every minute you’re there, for anything beyond, say, 40 hours). You’ll end up with some hospital “practice manager” telling you what to do, and they’ll work you like dogs, covering all kinds of call/evenings for NO pay and taking over rooms for their “hourly” CRNA’s at 3pm, if you agree to a “straight salary”.
 
DirtDocMD said:
Yup. The hospital needs to be paying you for every minute you are “covering” their hospital. There are simply too many “inefficiencies” in the way hospital OR’s are run these days, especially considering that you lose money on every Medicare/Medicaid/“self pay” case you do.

I would have a lawyer review your contract and “ownership stake” in the ASC. Make sure the hospital can’t toss you out of there. They can obviously give “exclusive contracts” to another group, for the hospital, but this may not be the case at the ASC, as long as it is being staffed appropriately.

“Hospital employment” is not something I’d consider, unless no other option exists (and, again, there are stipulations that you have a “minimum” salary AND are paid for every minute you’re there, for anything beyond, say, 40 hours). You’ll end up with some hospital “practice manager” telling you what to do, and they’ll work you like dogs, covering all kinds of call/evenings for NO pay and taking over rooms for their “hourly” CRNA’s at 3pm, if you agree to a “straight salary”.
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Yes employment is off the table now after some thought, I can't trust they wouldn't **** us over in a year or so. We also have a separate contract that gives us exclusive access to the ASC.
 
Update: We connected with EHC consultants and have presented our proposal to our hospital. We are still waiting to hear what they have to say but found out its likely that we are competing against Sound anesthesia AMC i guess and one of the rumored proposals is to go with them and switch over to all CRNA model. It seems far fetched but we have some questionable leadership as well. Considering we do all the labor epidurals and all the regional blocks, they would have to bring in alot of new CRNAs even if they managed to hire some from our existing group.
 
exactly what I stated. Know your competition. Never trust your relationship with the hospital. They will go with sound. It will likely fail. Youll
Lose the surgery center probably in the process. You’ll be correct but without your job or it won’t be the same job. Hope I’m wrong but all admins see are the $
 
Just a reminder - If they go with an AMC, be strong and enforce your non-compete!

BLADEMDA said:
You made a smart move giving notice but that should have happened July 2024. RFP will be your friend as all the AMCs will ask for a larger stipend than you are getting now. Unfortunately, You may need to enforce that non compete for the CRNAs as the hospital needs to feel the pain of their error when they decide to go with the AMC. The AMC will cost them millions per year as locums costs will mount and you all will want a fair wage (at least $300 per hour plus call pay). Once the AMC thinks they have a deal with your administration you can have 1 last meeting with the CEO/CFO and explain the reality of this market. The AMC will be unable to hire or recruit in this market at their supposed wages and instead will dump the massive locums cost on the hospital. You should also maker sure there is no non compete in your contract for the area and a buyout clause like $30,000 for the hospital. After 2 years of facing millions in excess anesthesia costs the administration will be ready to talk terms. In the meantime you will earn a fair wage.
Click to expand...
 
neuroride said:
Update: We connected with EHC consultants and have presented our proposal to our hospital. We are still waiting to hear what they have to say but found out its likely that we are competing against Sound anesthesia AMC i guess and one of the rumored proposals is to go with them and switch over to all CRNA model. It seems far fetched but we have some questionable leadership as well. Considering we do all the labor epidurals and all the regional blocks, they would have to bring in alot of new CRNAs even if they managed to hire some from our existing group.
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They WILL go with the AMC. 100% predictable.
 
NicholasPavona said:
They WILL go with the AMC. 100% predictable.
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Met crna from broward health (ft Lauderdale Florida ) some of you may have gotten bombarded with emails from locums companies. who worked for the previous anesthesia private practice.

It’s pretty much a crap show broward health and Envison. So she left to do locums.

But it’s south Florida so they are finding takers for lower locums rates from both crna and docs.

People just don’t want to move or commute far. So take what they can get.
 
neuroride said:
Update: We connected with EHC consultants and have presented our proposal to our hospital. We are still waiting to hear what they have to say but found out its likely that we are competing against Sound anesthesia AMC i guess and one of the rumored proposals is to go with them and switch over to all CRNA model. It seems far fetched but we have some questionable leadership as well. Considering we do all the labor epidurals and all the regional blocks, they would have to bring in alot of new CRNAs even if they managed to hire some from our existing group.
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Did you drive the Koenigsegg to work?
 
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