FP Report -- August 1998

American Academy of Family Physicians

August 1998

Patients' rights top AAFP priority list

AAFP President Neil Brooks, M.D., of Rockville, Conn., spent time in Washington recently, talking to national media representatives about patient protection legislation.

"Our patients tell us that they are sometimes unhappy with their health plans. As family physicians, we sometimes encounter problems with health plans that make it harder for us to provide high- quality, effective health services," said Brooks.

"Actual decisions about health care ultimately must be made by physicians and patients."

-- Neil Brooks, M.D.

Patient protection legislation, also known as patient rights or health care quality guarantees, is considered the most important pre-election issue facing Congress.

Patients and physicians want more protection; managed care companies want less. And everyone seems to have his or her own definition of "quality" health care.

"Quality health care is the care that results from doctors and patients working together to achieve the most effective, medically appropriate care in the most appropriate settings," Brooks said. "Quality health care improves the patients' health status and respects patients' values and preferences."

Brooks told media representatives that certain protections must be legislated to alleviate concerns with getting and providing quality health care:

First of all, patients should feel confident that primary care physicians in their health plans have the training and experience to provide preventive care, diagnosis, treatment and referral.

"Physicians who provide primary care need to have breadth and depth of knowledge as well as training in all organ systems of the body," Brooks said. "If doctors don't have that knowledge and training, then they are not primary care physicians."

And patients should be able to get complete information about their health care options.

Health plans should provide adequate information about participating physicians to enrollees who request it, including board certification status, credentials availability, specialty focus, affiliation arrangements, consumer satisfaction and methods for compensating participating health professionals.

"Also, any patient protection legislation needs to ban gag clauses," Brooks said.

Second, health plans should work for health.

"The ER is no place to worry about whether you have the right health card in your pocket," the AAFP president said. "The Academy supports the prudent layperson standard that requires health plans to pay for emergency room services."

Health plans should have an internal and external appeals process, and physicians should not be penalized if they act as patients' advocates. "I compare the external appeals process to a crossing guard," said Brooks. "You want to think your child knows how to cross the street safely. You want to believe drivers know how to watch for children. But the guard will be there to help if things don't go right. And that's what the independent outside review is all about."

Third, any legislation should include means for measuring and improving quality. The AAFP doesn't want to create a new bureaucracy when it comes to health care, Brooks said. "Instead, Congress should provide adequate funding to the Agency for Health Care Policy and Research," he said. "This would ensure that the necessary primary care research would be conducted and published, enabling physicians to translate the breakthroughs in medical knowledge into effective treatments."

However, patients' rights legislation should never interfere with clinical decision making. "No matter what the legislation finally says, actual decisions about health care ultimately must be made by physicians and patients," Brooks said. "Americans trust their physicians with their lives. They need to know that government regulations will enhance this trust, not diminish it."

AMA acts on E/M codes, collective negotiation

The AMA House of Delegates took action on many issues June 14-18 in Chicago. Some areas the AMA house addressed:

Delegates discussed their objections to Medicare guidelines for coding evaluation and management services. Past AAFP President Douglas Henley, M.D., of Fayetteville, N.C., said some quantitative formulas were necessary: "We need objective criteria to determine what level of service we code for our E/M visit." Henley was one of AAFP's eight delegates and a member of the AMA Current Procedural Terminology Editorial Panel.

When delegates considered opposing any documentation system that relied on quantitative formulas, Henley suggested a compromise opposing any system that relied solely on quantitative formulas. Delegates quashed his idea and voted against any quantification of medical care.

Incoming AMA President Nancy Dickey, M.D., said, "Our experience with the Health Care Financing Administra-tion tells us that the likelihood is, there's going to be some form of quantification."

Delegates labeled obesity a major public health problem and called for reimbursement for evaluating and managing it.

The house asked the AMA to form a negotiating unit by December. It would allow physicians to negotiate collectively without antitrust constraints and without joining national trade unions.

During the meeting, the Chicago Bulls became national basketball champions, and the Bulls chairman was televised passing out victory cigars to players. In protest, delegates asked the TV industry not to show athletes using cigars or other tobacco products and asked players to join anti-tobacco campaigns.

Delegates passed a report on the Sunbeam fiasco, in which the AMA last year lent its name and logo to Sunbeam home health products and, after a firestorm of protest, broke the contract. Saying staff had not alerted the board to the arrangement, the report recommended steps to heighten communication and the board's fiscal responsibility.

Delegates changed the AMA policy on hospitalists to include the patient's consent, as well as the consent of the patient's physician, before the patient would come under a hospitalist's care.

1998 Assembly Preregistration ends August 12

Assembly may seem like it's just around the corner, but the advance registration cutoff date is even closer.

Take advantage of this chance to save money and to attend the CME features of your choice by registering before Aug. 12. Advance registration also will save you some time in San Francisco. After Aug. 12, you'll have to register on-site.

This year, there are three ways to register: mail, fax and online. To register by fax or mail, simply fill out your registration form and fax it to (816) 333-0066 or mail it to AAFP Housing and Registration Dept., 8880 Ward Parkway, Kansas City, MO 64114-2797.

For online registration, access http://www.aafp.org/assembly on the Internet, open the registration area and select items from three different categories. Use your Visa or MasterCard and submit your materials electronically. After the Academy processes your general registration form and request for extra-fee sessions, you'll receive final confirmation by mail for the courses you selected that aren't already full.

Physicians With Heart airlift set for Siberia

The dates are set, and organizers are seeking contributions and volunteers for the sixth annual Physicians With Heart aid effort for the former Soviet Union.

In its first "dual airlift," Physicians With Heart -- a joint effort of the Academy, AAFP Foundation and the humanitarian organization Heart to Heart International -- will deliver medical supplies and pharmaceuticals Oct. 3-13 to Siberia and in spring 1999 to Uzbekistan. The October airlift will target hospitals in eight Siberian cities.

You can participate in two ways:

Serve on the delegation that will travel to Siberia with the airlift. Delegation members will get hands-on experience distributing humanitarian aid. They will tour recipient hospitals to document the safe arrival of supplies and conduct pharmaceutical updates. They also will discuss family practice as a specialty and provide an overview of family practice throughout the world to Siberian doctors. For more information, contact Kirsten Harrison, Heart to Heart project coordinator, at (619) 687-0343.

Plans for the Uzbekistan airlift are still being developed.

Contribute supplies, such as stethoscopes, otoscopes, blood pressure cuffs, and new or nearly new Physicians' Desk Reference books. These basic tools are urgently needed at many Siberian hospitals. Make sure your donation is part of the 1998 shipment by sending it to Heart to Heart. Call Barb Nielson, Heart to Heart procurement coordinator, at (913) 764-5200 for more details.

Since 1993, Physicians With Heart has distributed more than $40 million worth of medicines and supplies in the former Soviet republics of Armenia, Kazakstan, Kyrgyzstan and Georgia.

AAFP proposes law to fix GME funding problems

Congress will soon consider a proposal AAFP developed.

It zeroes in on a topic crucial to the specialty: technical problems with funding for graduate medical education.

In late June, two senators introduced AAFP's proposal, in effect cloning it. AAFP Board Chair Patrick Harr, M.D., of Maryville, Mo., wrote all senators July 8 about the bills.

"We ask for your support and cosponsorship of the bills, each titled the Graduate Medical Education Technical Amendments of 1998," said Harr.

S. 2216 was introduced by Sen. Susan Collins, R-Maine, and S. 2259 (identical to S. 2216) was introduced by Sen. Frank Murkowski, R-Ark.

The Collins/Murkowski bills would correct problems stemming from the Balanced Budget Act of 1997. Namely:

The BBA sets hospital-by-hospital caps on residency slots to receive Medicare funding, based on the number of residents trained in the hospitals in 1996. The new bills would expand the caps to include residents training in community settings in 1996. Most of those residents were FPs.

The new bills would allow urban residencies that sponsor rural training tracks to gain an exception to BBA funding caps (for rural tracks only).

The new bills would grant single-residency hospitals an exception to BBA caps so the hospitals may meet community needs for primary care physicians. By contrast, multiple-residency hospitals can shift their residency slots from less-needed specialties to those in higher demand, such as family practice. Among the 300 single-residency hospitals, 191 have family practice residencies.

Over the years, the AAFP has drafted many bills, including proposals to appropriate and authorize funds for family practice training.

Help your patients head back to school

The Academy has several items available to help members talk with their adolescent patients.

The Stand Up and Speak Out to Teens speaker's kit includes speeches about alcohol abuse, tobacco, STDs and mental health, plus two slide shows about preventing STDs and alcohol abuse. The price is $50 for members and $75 for nonmembers. To order, call the AAFP order department at (800) 944-0000 and ask for item #R047.

Members can get a free speech about alcohol abuse for presenting to teens by using AAFP Express (see box above). This speech emphasizes the dangers of alcohol abuse and the importance of getting help for alcohol-related problems.

A new brochure series from the AAFP about common health problems is geared specifically for teens. You can get a free set of 30 brochures about STDs, alcohol and stress by calling Barb Decker or Helen Worthley at (800) 274-2237, Ext. 4234.

Card sales benefits AAFP Foundation

The AAFP Foundation, in conjunction with the Texas AFP Foundation, has developed a series of holiday and all-occasion cards. The cards feature paintings by Yoakum, Texas, family physician A. Earl Mgebroff, M.D. Cards cost $20 for a box of 15, with discounts for purchases of 10 boxes or more. Cards can include messages or may be purchased blank.

Funds from the sale of the holiday and all-occasion cards will go toward foundation programs and initiatives that benefit family medicine.

To order, call (800) 274-2237, Ext. 4462, or fax your request to "Foundation cards" at (816) 822-0907.

AAFP urges persistence on tobacco bills

In July, Board Chair Patrick Harr, M.D., of Maryville, Mo., wrote three key figures in the fight to control the tobacco industry by law.

"The current opposition of the industry to the (recently defeated) legislation should make Congress and the administration even more determined to pass a comprehensive bill," Harr wrote to President Bill Clinton; Sen. John McCain, R-Ariz.; and Senate Majority Leader Trent Lott, R-Miss. McCain had introduced S. 1415, the National Tobacco Policy and Youth Smoking Reduction Act. It failed June 13 in procedural votes, including a 57-43 vote for cloture (60 votes for cloture were necessary to stop debate and have a vote on the bill itself).

"The Academy was dismayed that Senate Republicans were responsible for defeating S. 1415 in the narrow cloture vote," Harr wrote Lott. "As members of both parties, family physicians strongly believe that public health measures must have bipartisan backing."

1998 Candidates for Academy offices, Board seats

Eight Academy chapters have announced candidates for the following AAFP officer or director positions. All of the candidates either are or were delegates or alternates to the AAFP Congress of Delegates. Also, all are Academy Fellows and are certified by the American Board of Family Practice.

The Congress of Delegates will elect officers and three new directors Sept. 17 in San Francisco.

President-elect

Bruce Bagley, M.D., Albany, N.Y.: in group practice; clinical assistant professor; AAFP director; serves on Executive Committee; chairs Commission on Health Care Services and Task Force on Hospitalists; chaired commissions on Quality and Scope of Practice and on Public Health; chaired task forces on Quality in Family Medicine and Obstetrics in Family Medicine; chaired the (then) National Conference of Family Practice Residents; served on Commission on Membership and Member Services and committees on Members' AAFP Insurance and Financial Services and on Resident and Student Affairs; past chapter president.

Joseph Scherger, M.D., M.P.H., San Diego: in university medical group practice; associate dean; chair of family medicine department; AAFP director; chairs Commission on Finance and Insurance and Task Force to Enhance Family Practice Research; chaired Commission on Education; served on commissions on Legislation and Government Affairs and on Clinical Policies and Research; past national Family Physician of the Year; past chapter president.

Speaker

Richard Roberts, M.D., J.D., Verona, Wis.: in rural family practice; professor; speaker of AAFP Congress; serves on Executive Committee; chairs Committee on Resident and Student Affairs; chaired Commission on Clinical Policies, Research and Scientific Affairs and Task Force on Clinical Policies for Patient Care; served on commissions on Legislation and Governmental Affairs and on Health Care Services and committees on Finance and on Professional Liability; past chapter president.

Vice speaker

Michael Fleming, M.D., Shreveport, La.: in group family practice; clinical assistant professor; vice speaker of AAFP Congress; serves on Task Force on Governance and Member Participation; chaired Task Force on AAFP/Chapter Relations and then Committee on Public Relations and Marketing; served on committees on Health Education and on Finance and Insurance and on Task Force on Relationships with Proprietary Entities; past chapter president.

Board of Directors

Ross Black II, M.D., Cuyahoga Falls, Ohio: in group family practice; clinical assistant professor; serves on Committee on Communications; chaired Committee on Scientific Program; served on Committee on Resident and Student Affairs and on Commission on Quality and Scope of Practice; past chapter president.

James Martin, M.D., San Antonio: residency director; clinical professor; chaired Committee on Health Education and Parke-Davis Teacher Development Awards; served on Commission on Legislation and Governmental Affairs; past chapter president.

Robert Pallay, M.D., Belle Mead, N.J.: medical director of university primary care center; clinical associate professor; served on Committee on Finance and Insurance; served on Task Force on AAFP/Chapter Relations; past chapter president.

Jerry Rogers, M.D., Moorhead, Minn.: in private practice; clinical assistant professor; served on Commission on Education; past chapter president.

1998 Congress of Delegates to consider changes in AAFP Bylaws

Notice has previously been given of the 50th Annual Scientific Assembly of the American Academy of Family Physicians to be held in the city of San Francisco, September 16-20, 1998, at the Moscone Convention Center. The Congress of Delegates will convene at the San Francisco Marriott on Sept. 15.

Pursuant to Chapter XVII of the Bylaws, the following amendments to the Bylaws are submitted to the Congress of Delegates by the standing Committee on Bylaws. The Committee on Bylaws has considered all proposed amendments and thoroughly reviewed the Bylaws on a section-by-section basis. The recommendations and comments of the standing committee regarding the respective proposed amendments are indicated.

PROPOSED AMENDMENT NO. 1

To Amend Section 8 of Chapter III of the Bylaws

Proposed by the Commission on Membership and Member Services

TO PROVIDE ELIGIBILITY FOR INTERNATIONAL MEMBERSHIP FOR PHYSICIANS IN TRAINING (Proposed Amendment No. 1 would expand eligibility for international membership to include physicians in training.)

RESOLVED, That Section 8 of Chapter III of the Bylaws shall be and hereby is amended in Line 4 by adding the following new sentence after the word "membership."

"Additionally, physicians in training in countries or territories outside the United States in which no constituent chapter exists and who are not eligible for membership in the uniformed services chapter may be elected to international membership."

Comment: The Committee on Bylaws agrees philosophically with the expansion of eligibility for international medical students and residents. It was observed that there is no formal family practice movement in many countries, so information provided by the Academy may be the only way by which individuals undergoing medical training are educated and informed on family practice issues. In addition, it appears that the annual dues required of international members covers the cost of providing the benefits of membership.

The Committee on Bylaws, however, believes that the term "physicians in training" as shown in Proposed Amendment No. 1 is ambiguous, as it could be interpreted either as applying to those who are in training to be physicians or as those who are already physicians and are still in training. The proposed wording could result in limiting eligibility to residents or others who already have medical degrees, although it was the intention of the Commission on Membership and Member Services to include international medical students in this category of eligibility. Therefore, the Committee on Bylaws believes that the intention of Proposed Amendment No. 1 can be more effectively carried out if the substitute language set forth in Proposed Amendment No. 1A is adopted.

Recommendation of the committee: AGAINST

PROPOSED AMENDMENT NO. 1A

To Amend Section 8 of Chapter III of the Bylaws

Proposed by the Committee on Bylaws

TO PROVIDE ELIGIBILITY FOR INTERNATIONAL MEMBERSHIP FOR MEDICAL STUDENTS AND PHYSICIANS IN TRAINING (Proposed Amendment No. 1A would expand eligibility for international membership to include students and physicians in training.)

RESOLVED, That Section 8 of Chapter III of the Bylaws shall be and hereby is amended in Line 4 by adding the following new sentence after the word "membership."

"Additionally, medical students and physicians in training in countries or territories outside the United States in which no constituent chapter exists and who are not eligible for membership in the uniformed services chapter may be elected to international membership."

Comment: The Committee on Bylaws is proposing Proposed Amendment No. 1A for the reasons set forth in the Comment to Proposed Amendment No. 1 above. The substitute language set forth in Proposed Amendment No. 1A simply makes explicit that medical students (in addition to physicians who are still in training) are eligible for international membership.

Recommendation of the committee: FOR

PROPOSED AMENDMENT NO. 2

To Amend Section 2 of Chapter XI of the Bylaws

Proposed by the Board of Directors

TO PROVIDE THAT INDIVIDUALS REPRESENTING NEW PHYSICIANS MAY SERVE ONLY ONE YEAR AS ALTERNATE AND ONE YEAR AS DELEGATE (Proposed Amendment No. 2 would amend the Bylaws to provide that those elected to represent new physicians in the Congress of Delegates could only serve one year as alternate and one year as delegate and could not be elected to a second term in that same capacity.)

RESOLVED, That Section 2 of Chapter XI of the Bylaws shall be and hereby is amended by deleting the two sentences beginning in Line 22 and ending in Line 25 and by inserting in lieu thereof the following:

"An individual elected to serve a term as alternate and delegate for the new physicians may not be elected to a second term in that same capacity but may be elected to a second term by one of the other constituency groups. An individual elected to serve a term as alternate and delegate for the women or minority constituency groups may be elected to a second term by either the constituency group which initially elected the individual or another constituency group which the individual is qualified to represent. No individual may serve a cumulative total of more than four years as alternate and delegate for one or more of the three constituency groups."

Comment: There was considerable discussion by the Committee on Bylaws regarding this proposed amendment. Initial comments were largely in opposition. It was observed that the new physicians constituency already has the ability to limit terms by simply not electing someone for a second term. Another concern expressed was that Proposed Amendment No. 2 would, if adopted, result in inconsistent standards for special constituency delegations, which was perceived as undesirable. A view also was expressed that more experienced delegates tend to be more comfortable in openly expressing their thoughts before the Congress of Delegates, thus potentially increasing the effectiveness of new physician representation in the Congress.

Several members of the Committee on Bylaws spoke in support of the proposed amendment. One committee member felt that considerable weight should be given to the fact that Proposed Amendment No. 2 resulted from a resolution introduced by the New Physicians Caucus, which represents the affected constituency. In response to the possible inconsistent standards for term limits among special constituency delegations, it was pointed out that women and minorities have no limit on the length of time they can seek to represent those specific constituencies, whereas new physicians have only seven years during which they are eligible to represent that constituency.

Comments by committee members on both sides of the issue expressed a concern that the resolution reflected in Proposed Amendment No. 2 had not been considered by the Committee on Special Constituencies. In addition, in light of the fact that the issue of term limits is largely political, there may be merit in considering whether it is even appropriate for the Bylaws to address term limits for special constituencies, or whether a preferred approach would be for the Bylaws to be silent on this issue and thereby allow each special constituency to address delegate term limits through its own rules.

In light of the diverse views and possible alternatives presented at its meeting, the Committee on Bylaws is recommending that Proposed Amendment No. 2 not be adopted at this time and that the issue raised in Proposed Amendment No. 2 be referred to the Committee on Special Constituencies for further consideration.

Recommendation of the committee: AGAINST

PROPOSED AMENDMENT NO. 3

To Amend Section 2 of Chapter XI of the Bylaws

Proposed by: Ben Oteyza, M.D.
Roberto Quizon, M.D.
Lydia Camanga, M.D.
Pat Marquez, M.D.
Rano Bofill, M.D.
Roberto Villasenor, M.D.
Benito Rosero, M.D.

TO ESTABLISH DELEGATE AND ALTERNATE DELEGATE SEATS FOR INTERNATIONAL MEDICAL GRADUATES (Proposed Amendment No. 3 would amend the Bylaws to provide that international medical graduates shall be entitled to two delegates and two alternate delegates in the Congress of Delegates through 2003.)

RESOLVED, That Section 2 of Chapter XI of the Bylaws shall be and hereby is amended in Lines 11, 20 and 25 by deleting the word "three" and by substituting in lieu thereof the word "four"; in Line 12 by inserting, "international medical graduates" immediately following the words,"minority physicians"; and in Line 19 by inserting after the words "Congress of Delegates" a new sentence to read as follows: "Representation of international medical graduates shall be discontinued at the conclusion of the 2003 annual meeting of the Congress of Delegates.", and be it further

RESOLVED, That the Philippine American Association of Family Physicians be considered favorably at this time as a source of delegates and alternate delegates, should this amendment be adopted.

Comment: A similar amendment to Proposed Amendment No. 3 was presented to the 1997 Congress of Delegates and the Congress referred that amendment to the Board of Directors with the suggestion that it be considered by the Task Force on Governance and Member Participation. That task force surveyed all delegates and alternates concerning the desirability of creating additional seats in the Congress of Delegates for special constituencies not currently represented. One hundred percent of the delegates responding and ninety-six percent of the alternate delegates responding were opposed to creating additional special constituency seats in the Congress. As a result of its discussions and a review of these survey results, the Task Force on Governance and Member Participation recommended to the Board that the current special constituency representation in the Congress of Delegates be maintained. The Board approved this recommendation.

The Committee on Bylaws agrees with the conclusion of the task force and the Board of Directors and is recommending that Proposed Amendment No. 3 not be adopted. The committee believes that it would be extremely difficult to develop a mechanism for electing international medical graduate delegates who are representative of the diverse interests that various groups of international medical graduates have. Moreover, the committee believes that efforts should be made to more fully integrate this very important group of Academy members in the mainstream process rather than isolate them as a separate and distinct group. This integration will occur only through the active involvement of international medical graduates in constituent chapter and AAFP affairs and through the commitment of constituent chapters and the AAFP to provide the opportunity for Academy members of diverse backgrounds to fully participate in shaping this organization.

The committee would suggest to the Congress of Delegates that if it supports adoption of Proposed Amendment No. 3, the second resolved clause be removed from the amendment and dealt with separately as a recommendation to the Congress of Delegates. Technically, the language in the second resolved clause is not phrased in terms of an amendment to the Bylaws but is a suggestion as to how the first resolved clause could be implemented. Recommendation of the committee: AGAINST

PROPOSED AMENDMENT NO. 4

To Amend Section 2 of Chapter XI of the Bylaws

Proposed by the 1997 Congress of Delegates

TO EXTEND THE TIME OF REPRESENTATION IN THE CONGRESS OF DELEGATES FOR MINORITY PHYSICIANS (Proposed Amendment No. 4 will amend the Bylaws to provide that minority physicians will be seated in the Congress of Delegates through the 2010 annual meeting of the Congress of Delegates rather than through the 2002 annual meeting.)

RESOLVED, That Section 2 of Chapter XI of the Bylaws shall be and hereby is amended in Line 18 by deleting "2002" and by inserting in lieu thereof, "2010."

Comment: Proposed Amendment No. 4 was developed pursuant to a resolution adopted by the Congress of Delegates in 1997. Discussion by the Committee on Bylaws on Proposed Amendment No. 4 was largely favorable. However, concern was expressed over the fact that adoption would result in extending the current sunset provision by eight years. A committee member explained that the date set forth in Proposed Amendment No. 4 was based on current projections of when minority representation in the Congress of Delegates is expected to more closely reflect the proportion of minority membership in the Academy. While it was recognized that the current projections could significantly change before 2010, on balance it was felt that there is merit to the proposed extension.

Recommendation of the committee: FOR

Note: I hereby certify that the above proposed amendments were received by the executive vice president of the American Academy of Family Physicians in accordance with the requirements set forth in Chapter XVII of the Bylaws.

Signed: Robert Graham, M.D., Executive Vice President

Respectfully submitted

Ronald C. Van Buren, M.D., Chair
Ann R. Berlage, M.D.
Alessandro Bertoni, M.D.
Cora L.E. Christian, M.D.
Raymond K. Weber, M.D.
Thomas J. Weida, M.D.
Richard G. Roberts, M.D., ex-officio

Mr. R. Michael Miller, Staff Executive

FP Report * August 1998 * Volume 4/Number 8

The official news publication of the American Academy of Family Physicians. Published monthly by the News Department, Communications Division, for distribution to all AAFP members. Opinions expressed in the FP Report do not necessarily reflect the policies of the AAFP.

Paula Haas Binder, Editor, News Department
Leigh Anne Bathke, Managing Editor>Todd Simchuk, Associate Editor
Jane Stoever, Associate Editor
Sharon Dickinson Dent, Associate Editor
Renee Campbell, Production/Circulation

Address comments and inquiries to FP Report, 8880 Ward Parkway, Kansas City, MO 64114-2797; fax them to (816) 822-8857; call (800) 274-2237, Ext. 4230; or send them to pbinder@aafp.org via electronic mail.

Copyright © 1998 American Academy of Family Physicians. All rights reserved.

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