While I watched most of the Health Care Summit hosted by President Obama on Feb. 25th,  I was aware of not one but THREE 800 lb. gorillas in the room at Blair House.

Gorilla #1 Both Medicare and Medicaid are broke and are not sustainable.

Gorilla #2  Insurance overhead costs consume 26% of all private health insurance dollars

Gorilla #3  The number of doctors/other providers is a constant and will not change if we add 30 million additional insureds.

Democrat Sen. Kent Conrad and the Republicans acknowledged Gorilla #1, but Gorillas #2 & 3 went ignored while only the 2% profit margin of insurance companies was cited.

The only way to have the same number of docs see 15% more patients is to take some non-clinical load off their backs!  Like insurance intrusion, paperwork, approvals, coding, clerical staff hiring and supervision!

My Two Party Plan is the only one I have seen that provides care for all while disengaging docs from the third party reimbursement monster.

Uncategorized No Comments February 28th, 2010

Proposal for a Two Party Health Care System:  MDs/Therapists Take Charge

By  Maryann M. Knag—paythedoctor.com

Contents:

I  The Core Value of a Health Care System

II.  Goals of a Viable and Economically Sustainable Health Care System

III.  The Alarming Facts of the Present System in Relation to the National Economy

IV.  The Short History of Third Party Payment for Health Care in the U.S

V.  False Premises of the Current Debate On Reform of Health Care

VI.  The Two Party Plan: MDs/Therapists Take Charge

VII.  Four Hard Case Examples

VIII.  Comprehensive Benefits of the Two Party Plan:

MDs/Therapists Take Charge

IX.  What About Tort Reform and Insurance?

X.  Still Doubting?   Try This!

XI.  Footnotes

I.   The Core Value of a Health Care System:

The core value of a health care system is a trusting relationship, the relationship between the professional care-giver and the patient.  It is reciprocal. The MD/therapist gives care and the patient pays the MD/therapist to the best of his/her ability to pay.

The primary level of the relationship represents care and the secondary level represents the medical economy.

Any system which ignores the primacy of this core relationship will break down.

****************

II.   Goals of a Viable and Economically Sustainable Healthcare System:

A. Provision of care according to “best practice” standards

B.    Availability to all

C.   Provision of  preventive care as well as sick care

D.   Cost of  care for all borne by employed members of  a region/nation.

E.  Agreement of health providers to provide some free care.

F.  Establishment of medical economy independent of government subsidies.

G.  Decentralization or localization of healthcare administration

H.   Continuous attraction of more dedicated MDs/therapists to the profession.

******************

III.   The Alarming Facts of the Present System in Relation to the National Economy:

A.  National Economic Figures:

1.  US population is 300,000,000+[i]

2.  The Gross Domestic Product (GDP) of US is $14.4 trillion per year. [ii]

3.  Public sector is 1/3 of GDP.

4.  Healthcare represents 16% of the GDP of the US. [iii]

5.  Therefore, healthcare is $2.3 trillion per year.

6.  The 2009 National Budget Deficit stands at $1.4 trillion as of November 15^th. [iv]

7.  The National Debt is $11.9 trillion. [v]

8.  The nation faces unfunded mandates for Social Security and Medicare of $106.4 trillion. [vi]

B.  Health Care Sector Figures:

1.  US has the second highest health care cost per capita in the world. [vii]

2.  Breakdown of Health Care Industry by Sector:

a)  Medicaid + CHIP (2007)……………….$331.8 billion [viii]

b)  Medicare (2008)………………………….$468.0 billion [ix]

c)  Private Health Insurance Industry:

paid by employers…….$850 billion

individual & family……$326 billion[x]

Total Private Insurance………$1.176 trillion

d)  Pharmaceuticals (2004)…………………$235.4  billion[xi]

3.  One quarter of  Medicare dollars are for the last year of life. [xii]

4.  75 % of all health care dollars due to diabetes, obesity, heart disease, lung disease, high blood pressure and cancer.  Many of these diseases can be prevented or controlled by healthier life styles. [xiii]

C.  Non-clinical Costs:  Insurance Industry, Doctor/Hospital Clerical, Fraud and Abuse

1.  One dollar out of every four paid for private health care insurance goes for administration. [xiv]

2.  14 % of MD/therapist income goes to insurance claims processing. [xv]

3.  Total health care Insurance Fraud: Estimates range between $68 billion to $150 billion.

It is very difficult to obtain accurate figures on health insurance fraud.  I offer three estimates by fraud experts who have testified before congressional committees:

a)   $68 billion  Louis Saccoccio, Ex. Dir. Health Care Anti-Fraud Ass’n

b)  $85 billion  Malcolm Sparrow,  Harvard Sch. Of Gov’t, former fraud investigator

c)   $45-150 billion Richard J. Pro, SAS Health and Life Sciences Global Practice

*****************

IV.   The Short History of Third Party Payment for Health Care in the US:

A.  Prior to 1966, health care for poor and aged was paid for through public assistance programs in the states.

B.  Medicare and Medicaid began July 1, 1966.[xvi]

C.  Health insurance as an industry grew enormously in the 1960s and 70s.

D.  Prior to the 1960’s there was very little health insurance.  Patients paid the MD/therapist or went to free/low cost hospital clinics.  Untold unpaid work was done for patients in private practices.

****************

V.   False Premises of the Current Debate On Reform of  Healthcare:

A.   “Coverage” equals healthcare.  “There are 45 million uninsured Americans”, was a sound-bite of the 2008 campaigns.

Correction:  “Coverage” is an insurance industry term.  Insurance companies occasionally deny care to patients (“managed care”), as well as delay or fail to pay claims to hospitals and MDs/therapists. The correct questions are:  How many Americans are without care?  What are the best ways for all Americans to get care?

B.  The discrepancy between high cost and poor outcomes, eg.  incidence of infant mortality, diabetes, obesity, heart disease, emphysema, high blood pressure and cancer, is indicative of healthcare system failure.

Correction:  We have the best medical care in the world.  People come here from all over the world.  It is the system for payment for  healthcare which has failed.  The four leading diseases which sop up healthcare dollars are related to patient behaviors  (smoking, diet, lack of exercise and obesity) not poor healthcare.

C.  Insurance policies can ease the burden of and distribute the risk of the cost of healthcare in the same way that auto, fire, homeowner and life insurance does.

Correction:   Auto accidents, fires, thefts and loss of life are seldom to one-time occurrences for families.   Whereas the dates of service for medical/dental/therapeutic care as well as preventive care over just one year on average are numerous per person, creating mountains of EOBs by thousands of buildings full of insurance workers.

D.  Healthcare providers, patients and insurers can function in a three party relationship.

Correction: General:  Triangles in relationships are troublesome.

Specific:  Medicine is an old profession.  Insurance is a new industry. The two fields of employment have different values and different goals.  The triangulation blurs these values and goals and creates conflicts of interest.

1)  Healthcare providers dedicate themselves to and “profess”  certain altruistic ideals (as do teachers, lawyers, firemen, police and soldiers).  Their primary concern is for the common good (health, education, justice, safety, peace).  Their concern for remuneration is secondary to these goals.  Healthcare as a profession, like law and education, has a history going back to antiquity (eg. Imhotep in ancient Egypt –b. 2667 BC, and Hippocrates in ancient Greece — b. 460 BC).[xvii] Traditionally doctors have often been paid with potatoes or chickens, or worked without pay.

2)  Insurance is an industry whose goal is to distribute financial risk while reserving a percentage of premium income for operating expenses (mutual insurance companies) and profit.  The company/client relationship in the health care sector of the insurance industry is 99% faceless, involving unknown third party individuals and lots of paper.  Insurance companies deny care.  MDs/therapists do not.

The merging of the medical profession and the insurance industry into the three party triangle has invaded both the clarity of the doctor/patient relationship, as well as the trust and longevity of that relationship, leading to:  denials of care, interference with medical decisions, massive fraud expense, administrative expense in the medical office and hospital as well as in the insurance offices, appeal battles and a huge increase in frivolous malpractice law suits.

E.  Government can and should fund the health care cost of non-working populations , eg.  at-risk children, disabled, unemployed and elderly, eg. Medicare, Medicaid, SSI-medical.

This was a commendable premise and a worthy experiment.  Sometimes good legislation has unintended consequences.

Flaw: No one counted on nor even imagined  the massive outright fraud we are experiencing (see part III above).  Nor did anyone anticipate that people and advisors would develop ways to legally “game the system”.  One example:  There is a new subspecialty of the legal profession dignified by the name Elder Law.  Elder lawyers  instruct adult children of elderly parents how to distribute the real and liquid assets of the parents, five years before the projected need for a nursing home or special services so as to make them eligible for Title 19 (Medicaid) funding.  In this way children enjoy their elderly parents’ lifetime equity at the expense of the taxpayer. This was never the intent of the Title 19 (Medicaid) legislation.  The temptation to do this is overwhelming.  David Goldhill calls this effect the “moral hazard”. [xviii]

After 44 years of Medicare and Medicaid, we are left at the national level with a giant, unfunded Ponzi scheme.

F.  MDs/therapists/labs need to be paid for every service to make a good living.

Correction:  Physicians and other health care providers  have provided some free care from the dawn of the medical arts.  While they don’t advertise it, they are doing it to this day.  What has undermined their earnings severely are medical malpractice costs, and the in-office clerical staff necessary to the third-party reimbursement system.

****************

VI.   The Two Party Plan:  MDs/Therapists Take Charge

A.  All care is local and available to all regardless of ability to pay or legal status

All payment is local and due to MD/therapist at time of service.

All third party payment systems, eg. managed care insurance plans, Medicare and Medicaid, are phased out ( with government checks sent to ‘baby-boomers’ to fuel their HSAs) leaving MDs/therapists free of paperwork, coding, phone calls and third party interference in the delivery of care. Medicare and Medicaid need to phased out gradually over a generation.

MDs/therapists have more time to deliver more care.

All employers are relieved of the burden of providing health benefits and are free to create more jobs.  They are NOT relieved of OSHA regulations, nor of the obligation to carry disability insurance to cover work-related injuries.

B.  Emphasis on the responsibility of the patient in managing his/her own healthcare:

In lieu of existing third party payment systems, all employed persons, as well as persons with unearned income, must maintain Health Savings Accounts in which they deposit

$8,000 per adult and $3,000 per child per family, per year, pre-state and federal income tax dollars.  These HSA checking accounts are used to pay the MD/therapist/hospital/pharmacy at the time of service.  Unused HSA balances roll over into the following year, accumulating over a life-time, incentivizing healthy behaviors and hopefully providing a large “rainy day fund”.  If an employed person does not establish and contribute to an HSA, these dollars are subject to income tax.  As part of the “medical economy”, HSA tax-exempt dollars could be donated by the account holder to another person’s HSA.

C.  Care is available to all regardless of ability to pay:

Clinics are available to the unemployed and the working poor.  Clinic patients are encouraged to pay according to a sliding scale or receive free care.

Clinics are organized voluntarily by MDs through their medical societies and hospital medical staffs.

Two kinds of clinics are provided:  sick care and preventive care.

In the urban setting, the clinics are located in the hospitals and staffed for free by attending MDs and residents.  MDs/therapists perform clinic service three half days per month.

Example:  An OB-GYN serves for free 2 half days at the hospital OB-GYN sick clinic and 1 half day at the GYN prevention clinic.

In the rural setting, the clinics, both sick and preventive, are located in community centers, granges, schools or big box pharmacies as a community service.  The rural clinics are staffed and administered voluntarily by the family practice and internal medicine MD/therapist members of the Medical Societies, city, county or state, as the case may be, in coordination with the nearest hospitals.  MDs/therapists volunteer three half days/month for free.

D.  Care is available regardless of legal status:

MD/therapists provide care even if they suspect the patient is an illegal alien.  They can report their suspicions to an administrator who informs the appropriate authorities, as is done in the public school systems, when a teacher suspects a student is residing out of district or is an illegal alien.  MDs/therapists never deny care.  MDs/therapists are not investigators.

E.  Inpatient hospital care and surgical care is available to all regardless of ability to pay:

Hospitals organize care on three levels, private, semi-private and ward.  Private and semi-private patients are private payers.  Ward patients pay on a sliding scale, negotiate an extended payment plan or receive free care.  The private payers and partial payers fund the hospital budget.  Hospital clinicians and administrators are relieved of the clerical, administrative and legal burden of applications, regulations and coding required by insurance and government third party payers.  This greatly reduces clinical work loads as well as the need for administrative and clerical staff, resulting in great savings for hospitals.

F.  City, County or State Medical Societies establish “Medical Resource & Economic Regions”.

In order to evenly distribute doctors and specialties, Medical Resource Regions are established to achieve a balance between medical resources and population distribution.

Equally, in order to distribute the economic burden on hospitals with a high percentage of clinic patients, Medical Economic Regions are established, so that all hospitals participate in the in-hospital care of  patients without HSA funds.

G.  There is no need for rationing:

MDs/therapists alone make the decision who needs care, what care and when.  The only limitation on care is the limit of the energies and schedules of the MDs/therapists.

H.  End of Life or Long Term Care is a matter of healthy living and within the reach of all:

Tax-exempt earnings, accumulated in a HSA over a lifetime of healthy living mount up high to pay for care in a long term care facility.  If unused they can be donated to another long term care patient. HSA dollars must stay in the medical economy.

I. Conclusion:     This plan  puts MDs/therapists in the driver seat.

This plan relies on MDs/therapists taking charge through their

Hospitals and Medical Societies.

This plan relies on MDs and therapists doing some free work.

Why will MDs/therapists do this?  They will do it…….

1) because the experiment of third party payer systems of the last 40+

years has become very burdensome for MD/therapists.

2) because they are professionals, ie. they profess ideals.

3) because it is a good deal.  They exchange the onerous intrusion of  the

insurance industry and government into the practice of medicine

for some free work and service to the community.

4) because they regain autonomy in their own profession.

VII.  Four Hard Case Examples:

A.  Two year old child diagnosed with a brain tumor, requires two years of hospitalizations, testing and chemo-therapy.  Cost: $1 million

Options:

1)  Parents have $40,000 in HSA.  This is exhausted.

2)  Negotiated Fees:  Parents ask MDs/therapist and hospital to treat for free, on extended payment plan or for reduced fee.  Doctors and hospital work out a plan.  Care is never denied.

3)  Safety Net: Parents and child always have the out-patient clinic and in-patient ward status at their disposal.  This may be free, depending on their financial status.  Care is never denied.

4)  The HSA economy:   In the face of tragedy, friends, neighbors and relatives with high HSA balances may donate from their HSAs to the HSA of the stricken family.  The tax-exempt dollars stay in the medical economy.

B.  Fifty-five year old woman is attacked by chimpanzee with disfiguration of face and loss of hands, requires multiple surgeries, prostheses,  rehabilitation and occupational therapy.

Options:

1)  Woman submits  bills to owner of chimp.

2)  If payment is not forthcoming from owner of chimp, woman sues owner.

3)  Woman exhausts her own HSA.  Further,  as a disabled person, she can participate in a family member’s HSA if the latter claims her as a dependent.

4)  Negotiated Fees:  Woman asks MDs/therapists/hospital for reduced or free care in the interim.  Care is never denied.

5)  Safety Net:  Woman always has access to clinic care and reduced or free hospital ward care.  Care is never denied.

6)  The HSA economy:   In the face of tragedy, friends, neighbors and relatives with high HSA balances may donate from their HSAs to the HSA of the stricken woman.  The tax-exempt dollars stay in the medical economy.

C.  Firefighter falls from roof and is permanently disabled.  He requires hospitalization, rehabilitation, physical therapy, occupational therapy, medical devices and modification to his car and home.

Options:

1)  He has $20,000 in his HSA.  He exhausts this.   Further,  as a disabled person, he can participate in a family member’s HSA if the latter claims him as a dependent.

2)  He has access to disability insurance medical benefits through the fire department.

3)  Negotiated Fees:  If he runs through the disability funds,  he can ask the treating MDs/therapists to provide reduced or free care  (No doubt they would offer to do this under the circumstances)  Care is never denied.

4) Safety Net:   Disabled firefighter always has access to clinic care and reduced or free hospital ward care.  Care is never denied.

5)  The HSA economy:   In the face of tragedy, friends, neighbors and relatives with high HSA balances may donate from their HSAs to the HSA of the disabled firefighter.  The tax-exempt dollars stay in the medical economy.

D.  Young soldier steps on IED in Iraq and loses leg, requires surgeries, prosthesis, physical and occupational therapy.

Options:

1)  The VA: The Two Party Plan would not affect military healthcare, military hospitals and clinics or the Veterans Administration System.  All these services would stand as is.

2)  In addition,  if employed after discharge he would begin setting tax-free dollars in an HSA to use for the private MD/therapist of his choice.

3)  If unemployed, and unhappy with the VA, he can ask treating MD/therapist for free or reduced care in the interim.  Care is never denied.

4)  Safety Net:   If unemployed, the out-patient clinics would be available to him at reduced or no cost as a back up.  Surgeries and hospitalization in private sector hospitals would be available to him at reduced or no cost.  Care is never denied.

5)  The HSA economy:   In the face of tragedy, friends, neighbors and relatives with high HSA balances may donate from their HSAs to the HSA of the disabled veteran.  The tax-exempt dollars stay in the medical economy.

***********************

VIII.   Comprehensive Benefits of the Two Party Plan—MDs/Therapists Take Charge

A.  For Patients:

1.  Provides care to all

2.  Direct relationship with MD/therapist

3.  Patient-centered care replaces insurance, government or mal-practice-centered care.

4.  Restores patient choice of MD/therapist  (except in clinics)

5. Outcome-based care:  Patient has incentive to adopt healthy behaviors leading to

life time savings in his/her HSA

B.  For MDs/therapists:

1.  Restores clinical autonomy to MDs/therapists

2.  MDs/therapists unburdened of non-medical chores.

3.  MDs/therapists gain time to provide more care.

4.  Reduces malpractice lawsuits due to clarity and longevity of MD-patient relationship, as well as choice.  (see Part IX)

5.  Happy, empowered MDs/therapists

C.  For taxpayer:

1.  Vastly reduces cost by elimination of insurance costs:   in federal and state government bureaucracies, in the private healthcare insurance industry, in hospital clerical costs and in physician office clerical costs—estimated ¼ to 1/3 of total health care sector costs (total sector=$2.3 trillion)

2.  Vastly reduces cost by elimination of Medicare, Medicaid and private insurance fraud and abuse—estimated $60,000,000,000 to 150,000,000,000.  How does one commit fraud in a two party system?

D.  For  All:

1.  Restores financial accountability and awareness of costs to both MDs/therapists and patients

2.  Restores medical market forces to lower costs:

a.) MDs/therapists compete to attract patients

b.) Patients pay the MDs/therapists.  Hence they know and compare the price of

each service.

c.)  Uniformity in pricing of services in a given hospital, office or clinic.

3.  Eliminates duplication of testing.  Patients won’t pay for the same test twice.

4.  Requires no oversight from Washington

5.  Community based

E.  For employers:

1.  Detaches healthcare from employers

F.  For the National-International Economy:

1.  Takes the federal government out of the healthcare sector except for Military Medicine and the VA!

2.  More job creation by employers freed from the burden of the costs of benefits.  This will make up for the jobs lost in the government, insurance and clerical sectors of the economy.

3. Two party system more attractive to aspiring MDs/therapists

4.  Simplicity

IX.   What About Tort Reform and Insurance?

A.  Tort Reform:

1)  Courts require Medical Peer Review session  prior to patient filing suit.

2)  Courts require losing plaintiff to assume all costs.

3)  Wait and see if malpractice suits lessen as the Two Party Plan is implemented. I project that as the MD-patient relationship is strengthened and restored, the tendency to sue will abate.

Historically, as the third party payer system arose, so did the incidence of medical malpractice suits.

This stands to reason.  Indeed, I suggest that malpractice suits and high tort judgments are a direct result of the breakdown of the trusting MD-patient relationship which is the core value of healthcare.  The triangulation of the healthcare relationship introduced conflicts of interests in treatment, frequent changes of clinicians as plans and employment shifted and decreased face time given to patients. Third party payer systems put greater stress on clinicians leading to less understanding and loyalty on the part of patients.

4)  Accountability is necessary in all professions.  There are unethical or sloppy MDs/therapists.  We do not want to tie the hands of the legal system in the event of real malpractice.

B.  Insurance:

1)  Insurance companies would still be free to offer healthcare insurance to individuals and groups in keeping with the free enterprise system.  It simply would not be required and employers would not need to offer it as a benefit.

2)  Also, insurance “coverage” would be limited to a two party relationship between the company and the subscriber, as it is with auto, home and life insurance.  The subscriber is the customer.  The subscriber pays the premium, the subscriber submits paid receipts from the MD/therapist to the insurance company, and the insurance company reimburses the subscriber.  The insurance company would not be in contact with the MD/therapist, nor would the company make any demands upon the MD/therapist.

No more triangulation where the insurance company is not accountable to the insured and the MD/therapist has to deliver the bad news that the insurance company is denying care.!!!

3)  Individuals and heads of household might decide to take some of their HSA funds to purchase catastrophic insurance and pay ordinary medical expenses from their HSAs

4)  Or, individuals and heads of household might choose to use their HSA monies to purchase  individual or family health insurance “coverage”.

***************************

X.   Still Doubting?   Try the Following:

Mindset Reform and Attitude Adjustment

A.  MDs/Therapists/all medical providers:

–Questions for Interior Reflection:

1)  Why did I become a MD/therapist/medical provider?

2)  What do I profess?

3)  Am I willing to serve non-payers?

4)  Am I willing to work together with other MDs/therapists/medical providers?

B.  Medical Societies and Professional Groups:

–Questions for Group Consideration and Discussion:

1)  What do we profess?

2)  Are we ready to profess again as a group?

3)  Are we ready to reclaim leadership and control of healthcare?

4)  Are we ready to problem solve at the local level rather than leaving problem solving to politicians and lobbyists in Washington?

5)  Are we ready to designate members of our groups to administrate the sick and preventive care clinics?

6)  Do we have the courage to Just Say No to insurance and Government?

C.  Health Care Recipients—Everyone:

–Questions for Interior Reflection:

1)  Am I willing to renounce Dependency on Government?

2)  Am I willing to accept responsibility for being my own healthcare advocate?

3)  Am I willing to take on a healthy attitude toward my own body?

4)  Am I ready to eliminate unhealthy behaviors?

5)  Am I ready to begin saving for my healthcare now?

6)  Am I ready to begin saving now for End of Life or Long Term Care?

7) Am I ready to accept the  benefits of a two party relationship with my MD/therapist?  (See  Part VIII)

D.  Lawmakers Role in the Two Party Plan—MDs/Therapists Take Charge

1)  Incentivize individual and family saving for present and future healthcare needs by adjusting the Internal Revenue Code to allow for Health Savings Accounts equal to  specifications in Part VI.

2)  Phase out the Centers for Medicare and Medicaid of HHS.

3)  Eliminate unnecessary federal and state regulations and controls pertinent to third party payers, eg. Stark, Medicaid, Title 19 and Federally Qualified Healthcare Clinics.

4)  Continue to provide healthcare for military and veterans through the Veterans Administration.

5)  Transition payments to HSA accounts for current Medicare and Title 19 patients.

6)  Provide oversight and licensure services at state level.

7)  Provide research and statistical services through the National Institutes of Health.

8)  Pass legislation to require Medical Peer Review Boards prior to filing medical tort law suits, and require losing plaintiffs to pay all costs.

*******************

XI.  Footnotes:

---

[i] December 31, 2008 www.census.gov

[ii] Bureau of Economic Analysis 2008, US Dept. of Commerce

[iii] WHO (May 2009) “World Health Statistics 2009”, World Health Organization

[iv] Treasurydirect.com

[v] Treasurydirect.com (9/30/2009)   Historical Debt Outstanding, annual 2000-2009

[vi] Bruce Bartlett, Forbes Magazine.  5/14/2009,  www.forbes.com/2009/05/14/taxes-social-security-opinions-columnists-medicare.html

[vii] WHO 2009 “World Health Statistics 2009, World Health Organization

[viii] Urban Institute and Kaiser Commission

[ix] CMS Dept. of HHS

[x] National Coalition on Health Care, ,Wash. DC

[xi] York University Study, Jan. 3, 2008, PLoS Medicare, Gagnon, Marc

[xii] Healthaffairs.org, Hogan, Gabel, Lanny  & Lynn, abstract 20/4/180

[xiii] Centers for Disease Control and Prevention

[xiv] Journal of American Medicine 2007

[xv] AMA.org “Hear the Claims Process Campaign”, National Health Care Exchange Service, 2008

[xvi] www.cms.hhs.gov/Medicare/Medicaid Stat.Supp.

[xvii] KNH Centre for Biomedical Egyptology, U. of Manchester, UK, Dr. Jackie Campbell

[xviii] “How American Health Care Killed My Father”, Atlantic Magazine, September 2009

Click here for PDF of the latest version.

Uncategorized No Comments February 25th, 2010