OFFICE of GOVERNOR EDWARD G. RENDELL HEALTH CARE REFORM Pennsylvania s Chronic Care Commission Transforming Primary Care Practice: The Southeast Pennsylvania Rollout Status as of May 21, 2008 WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS The State of Primary Care in the USA Research shows patients with PCPs have lower costs, but Primary care practitioners declining in numbers failure to attract new graduates Low reimbursement compared to non-pcp peers Low satisfaction Current primary care practice is reactive, often responding to acute episodes, resulting from poor selfmanagement by patients with chronic illness Access is inadequate Emphasis is on issuing referrals and not on coordinating care Minimal focus on patient education and no support staff for patients Slow to adopt evidence-based medicine Generally lower level of sophistication (EMR, support staff, etc.) Minimal communication between providers WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 2 1
Chronic Care Commission Origins Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission created by Governor Rendell s Executive Order, May 2007. First requirement was to develop a strategic plan for implementing the Chronic Care Model to improve the quality of care while reducing avoidable illnesses and their attendant costs. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS Chronic Care Commission Strategic Direction The Commission developed and delivered a strategic plan to the Governor and Legislature in February 2008 to: Begin regional rollouts using learning collaboratives, practice coaches and provider and consumer incentive alignment beginning with Southeast PA in May 2008 The model is an integration of Chronic Care Model and the Patient- Centered Medical Home concepts. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 4 2
The Chronic Care Model Team-based coordinated care, with a focus on patients with chronic illness Origin: Ed Wagner, McColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound Improved care coordination Cost reductions from averted admissions Improved quality of care Several existing state and national collaboratives, e.g., Vermont s Blueprint for Health WA state - based on the IHI Breakthrough Series Model HRSA implementation through Federally Qualified Health Centers across the U.S., including 16 in PA WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 5 What is the Chronic Care Model? Community Resources and Policies Self- Management Support Health System Health Care Organization Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 6
The Patient-Centered Medical Home (PCMH) Origin: American Academy of Pediatrics Now embraced by American Academy of Family Physicians, American College of Physicians and American Osteopathic Association Several pilots in place and emerging around the country (NY, CO) Features Open access scheduling Use of a registry or EMR to manage a population Use of a team: Physician, CRNPs, case managers, health educators Improved communication (telephonic, e-mail) Decision support WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 7 Pennsylvania s Chronic Care Commission Organization: 45 Commission members Provider, insurer, state government agency, organized labor, academic and consumer representatives Four subcommittees include Commission members, plus additional representatives from stakeholder organizations Practice Redesign Consumer Engagement Incentive Alignment Performance Measurement Fifth subcommittee in 6-08: Pooled Claims Database Staffed and facilitated by the Governor s Office of Health Care Reform WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 8 4
Pennsylvania s Chronic Care Commission February 2008 strategic plan created a framework to guide rollout activities in the Commonwealth s six regions Each regional rollout must adhere to the framework, but has room to vary its approach A Southeast PA Regional Rollout Steering Committee crafted the following specific model. Other regions of the state need not use this exact model. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 9 Requirements: Funding faculty and expenses for a year-long learning collaborative for participating primary care practices Coordinating the flow of data and funds to practices Providing ongoing project management support Funding cost of registry (first rollout excluded due to lack of appropriations) Funding data collection, evaluation and reporting activities through a contracted rd party WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 10 5
Requirements: Primary Care Practices Participate in seven days of learning collaborative meetings in year 1: initial focus on diabetes and pediatric asthma Work with an assigned practice coach between learning collaborative sessions to transform practice Use a patient registry to track patients with chronic illness Achieve Level 1 NCQA PPC-PCMH Recognition within 12 months Report data from the patient registry and other sources required for evaluation purposes Reinvest funds into the practice site, including for case management in those instances where the practice does not already have that resource in place Three-year commitment WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 11 Requirements: Primary Care Practices Most importantly, implement fundamental redesign of the practice for all patients, including, for example: Using the registry to send patient reminders Conducting planned visits to address all aspects of the patients conditions Providing team-based care, using non-physician personnel to support the patient (education, care coordination, etc.) Providing self-management support, involving the patient in goal setting, action planning, problem-solving and follow-up Providing enhanced access to the care team Performing population-based data analysis WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 12 6
What is NCQA PPC-PCMH Recognition? Standard 1: Access and Communication A.Has written standards for patient access and patient communication** B.Uses data to show it meets its standards for patient access and communication** Standard 2: Patient Tracking and Registry Functions A.Uses data system for basic patient information (mostly nonclinical data) B.Has clinical data system with clinical data in searchable data fields C.Uses the clinical data system D.Uses paper or electronic-based charting tools to organize clinical information** E.Uses data to identify important diagnoses and conditions in practice** F.Generates lists of patients and reminds patients and clinicians of services needed (population management) Standard : Care Management A.Adopts and implements evidence-based guidelines for three conditions ** B.Generates reminders about preventive services for clinicians C.Uses non-physician staff to manage patient care D.Conducts care management, including care plans, assessing progress, addressing barriers E.Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Pts 4 5 9 Pts 2 6 4 21 Pts 4 5 5 Standard 5: Electronic Prescribing A.Uses electronic system to write prescriptions B.Has electronic prescription writer with safety checks C.Has electronic prescription writer with cost checks Standard 6: Test Tracking A.Tracks tests and identifies abnormal results systematically** B.Uses electronic systems to order and retrieve tests and flag duplicate tests Standard 7: Referral Tracking A.Tracks referrals using paper-based or electronic system** Standard 8: Performance Reporting and Improvement A.Measures clinical and/or service performance by physician or across the practice** B.Survey of patients care experience C.Reports performance across the practice or by physician ** D.Sets goals and takes action to improve performance E.Produces reports using standardized measures F.Transmits reports with standardized measures electronically to external entities Pts 2 8 Pts 7 6 1 PT 4 4 Pts 2 1 15 Standard 4: Patient Self-Management Support A.Assesses language preference and other communication barriers B.Actively supports patient self-management** 20 Pts 2 4 6 Standard 9: Advanced Electronic Communications A.Availability of Interactive Website B.Electronic Patient Identification C.Electronic Care Management Support **Must Pass Elements WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 1 Pts 1 2 1 4 Requirements: Payers Three-year commitment Financial support design follows Commission framework, but specific to the Southeast rollout. Payments proportional to the revenues paid to each practice by each of the payers Payment to IPIP (Improving Performance in Practice) for Practice Coaches (1 for every 15 practices) @$10K per coach per year Three-part provider payment model: Infrastructure development Enhancement to existing FFS or capitation payments Pay-for-performance WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 14 7
Requirements: Payers Infrastructure development payments Licensing fee for registry, support for data entry to registry, cost of NCQA survey tool, NCQA application fee, and lost revenue for time to attend 7 days of learning collaborative meetings in the first year Enhanced payments to FFS/capitation For initial three years, lump sum payments aligned with stepwise achievement of the three levels of NCQA PPC-PCMH recognition Pay-for-performance Maintenance of existing program common measures across insurers by 2010 WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 15 Requirements: Payers Derivation of infrastructure development payments: Infrastructure Costs to Practice During the First Year NCQA PPC-PCMH survey tool $80/practice Data entry to registry $800/practice Office assistant $8,000/practice NCQA application fee $60/clinician Registry license fee $275/clinician Time to attend learning collab (7 days/year) $11,655/clinician WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 16 8
Requirements: Payers Derivation of enhancement of FFS/capitation: Informed by analysis of limited available estimates of practice costs to implement CCM/PCMH ($4-$9PMPM range excluding EMR) and of existing CCM/PCMH programs and pilots Commission recognized that it is likely that costs would vary based on practice size and configuration. Some existing modeling assumes a solo PCP practice, while RI assumes a small group practice. Southeast PA model provides up to approximately $4PMPM for NCQA PPC-PCMH recognition, less Medicare FFS share of practice Per clinician amount decreases as practice size increases WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 17 Source Estimated Practice Costs Enhancement in PMPM terms What s included for the payment Comments Deloitte Center for Health Solutions [1] $8.66 PMPM PCP added annual $100K payment for care coordination Health coach salary plus fringe Health coach tools (data collection, telephones, IT) Data manager (. FTE with salary of $65K and fringe) EMR purchase cost of $80-120K, with $20K for installation, and then $5K annually. Also, $20K at risk for annual perf. bonus. Rhode Island Chronic Care Sustainability Initiative (a) $4.78 PMPM Case manager salary plus fringe Office staff (.5 FTE with annual salary plus fringe) Office space (case mgr, office staff, co-located specialists) Assumes a threephysician practice with one NP. Office equipment (case manager, office staff, co-located specialists) Patient educational collateral materials Rhode Island Chronic Care Sustainability Initiative (b) $7.4 PMPM All of the above, plus: PCP added annual payment for alt. communication (optional) PCP added payment is for e-mail and telephone calls, including after hours and on weekends. Rhode Island Chronic Care Sustainability Initiative (c) $.00 PMPM Not yet decided. The $.00 limit was set when one insurer stated that it would pay no more than $.00. [1] "The Medical Home: Disruptive Innovation for a New Primary Care Model", Deloitte Center for Health Solutions, 2008. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 18 9
Estimated Practice Costs Source Enhancement in PMPM terms What s included Comments Richard Baron for SEPA Project, 9-07 $.78 - $5.04 PMPM PCP added annual payment for lost revenue Nurse Practitioner (. FTE) Medical assistant (. FTE) Health educator (.1 FTE) EMR purchase cost of $78K. Lost revenue due to PCP time on project management. Social worker (.1 FTE) Allan Goroll et. al. [1] $5.8-$9.8 PMPM Nurse Practitioner (.5 to 1 FTE) Data manager (.85 to 1 FTE) Nutritionist (0 to.5 FTE) Social worker (0 to.5 FTE) The latter two would be excluded in smaller practices. EMR and quality monitoring system: $5K annually. Also, $5-$50K annual bonus for meeting mutually est. goals. Miscellaneous Notes: Bridges to Excellence s new medical home program estimates annual savings of $245 savings per patient from a medical home, and has capped award payments to providers at $100,000 per year. United HealthCare estimates the additional reimbursement to a primary care practice for implementing a Patient-Centered Medical Home at 20% above baseline reimbursement. [1] Allan Goroll et. al. "Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care", Journal of General Internal Medicine. 22(): 410 415, March 2007. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 19 Examples of Other CCM/PCMH Programs Source Enhancement PMPM What s required Comments Community Care of North Carolina $5.50 PMPM The payment is not based on an assessment of practice costs. Requirements include: 1.Create a medical home. 2.Give data to the state..address four quality improvement program areas: disease management; high-risk and high cost patients; pharmacy management; and emergency department utilization. 4.Use local network funds to support local case and disease management activities and staff for putting resources into the community (e.g., initially case managers, then clinical pharmacists). $2.50 is paid to the PCP, while $.00 goes to the network. Blue Cross Blue Shield of Michigan $0.17 PMPM The payment is not based on an assessment of practice costs. The payment is made to local physician organizations or networks and is used to purchase shared resources. "A meaningful amount was estimated to be $000 per physician, under the assumption that this would be enough catalyze commitment, leadership and change. Our experience to date has proved this calculus to be correct." BCBSMI will move to a fee schedule enhancement in 2009. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 20 10
Examples of Other CCM/PCMH Programs Source Enhancement in PMPM terms What s required Comments Blue Cross Blue Shield of Vermont 6% fee enhancement The payment is not based on an assessment of practice costs. BCBSVT expects the following in return for the added payment: 1. Patient registry and reminder system. 2. Use of evidence-based clinical guidelines.. Evidence that the practice team is prepared for the patient visit Care Plan. 4. On-site nurse educators or easy access to nurse educators. 5. Patient access to self-management tools. 6. Tracking and reporting of outcomes. 7. Patient satisfaction survey/measures. 8. Evidence of office staff training on the scheduling and coding implications of chronic disease management. We weren t necessarily aiming to offset the costs and we didn t have an anticipated ROI. We landed on 6% as a starting point. Our anticipated ceiling is 12%. Health Disparities Collaboratives of the Health Resources and Services Administration (HRSA) $0 However, health centers routinely experienced financial losses. [1] Participation in collaboratives to improve the care of patients with diabetes, asthma, or cardiovascular disease There were significant improvements in the measures of prevention and screening. There was no improvement, however, in any of the intermediate outcomes assessed. [2] [1] Elbert Huang et. al. The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified Community Health Centers, Health Services Research, 2007. [2] Bruce E. Landon et. al. Improving the Management of Chronic Disease at Community Health Centers, New England Journal of Medicine, 56;9, March 1, 2007. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 21 Payment Triggered by NCQA PPC PCMH Recognition Annualized revenue per full-time-equivalent practitioner from all sources for implementing the features of the PCMH recognizes economies of scale and the incremental resources to achieve full transformation of the practice to include all features, discounted by the % of practice revenue derived by Medicare FFS and insurers with low market share. NCQA PCMH Recognition Level Practice 1 FTE Practice 2-4 FTEs Practice 5-9 FTEs Practice 10-20 FTEs Level 1 $40,000 $6,000 $2,000 $28,000 Level 2 $60,000 $54,000 $48,000 $42,000 Level $95,000 $85,500 $76,000 $66,500 WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 22 11
Requirements: Payers Commission is still working on recommendations for payer strategies to better engage consumers in self-management. Currently considering piloting consumer incentives. Also looking at benefit design changes. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 2 1 practices Participants representing 148 clinician FTEs internal medicine, family practice, pediatrics and NP-led practices combination of independent practices and those affiliated with one of three academic systems almost half have or are implementing an EMR size of practice sites: practices of 1 physician 16 practices of 2-4 physicians 10 practices of 5-8 physicians practices of 10-20 physicians WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 24 12
Participating Practices Buckingham Family Practice Children s Health Center (VNA Community Services) CHOP Primary Care @ South Phila. Crozer-Keystone Center for Family Health Crozer Medical Associates Eagle Family Medicine Center Edward S. Cooper Practice Family Medicine, Geriatrics & Wellness Family Practice & Counseling Network Founders Medical Practice Greenhouse Internists Holland Medical Associates Jefferson Family Medicine Associates Kids First Chestnut Hill Kids First HighPoint Lower Bucks Pediatrics Mary Howard Health Center Medical Group at Marple Commons Mt. Airy Family Practice Ninth Street Internal Medicine Assoc. North Willow Grove Family Practice North Willow Grove Pediatrics Penn-Care Bala Cynwyd Pennsbury Medical Practice PHMC Health Connection Project Salud Quality Community Health Care, Inc Rising Sun Health Center Sayre Health Center Temple Pediatric Care Penn Medicine at Radnor WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 25 6 payers Participants Aetna, AmeriChoice (Medicaid), CIGNA Healthcare, Health Partners (Medicaid), Independence Blue Cross, Keystone Mercy Health Plan (Medicaid) UnitedHealthcare may still join as the 7 th insurer Insurers including commercial (insured and self-insured), Medicaid and Medicare Advantage business, no Medicare FFS WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 26 1
Supporting Coalition The Primary Care Coalition The PA Academy of Family Physicians, the PA Chapter of the AAP, and the PA Chapter of the ACP. Together they are the RWJF IPIP grantee in PA. IPIP practice coaches will assist with: transforming the practice data collection and reporting linking practices to community resources WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 27 Evaluation The Commission has approved an evaluation design utilized matched pairs of practices as a control group. The initiative will be evaluated using the following measurement domains: 1. engaged providers 2. patient self-care knowledge and skills. patient function and health status 4. primary care practice satisfaction 5. appropriate and efficient utilization of services 6. clinical care quality 7. cost WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 28 14
Evaluation As part of the evaluation, the Commission will utilize standardized measure sets and performance goals for diabetes, asthma and hypertension adopted by IPIP. These measures are based on national measures as defined by AQA/NQF and NCQA/HEDIS. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 29 Diabetes Goal Endorsements A1C A1C documented >90% AQA, NCQA, NQF Most recent A1C level greater than 9.0% <20% AQA, NCQA, NQF Most recent A1C level less than 7.0% >40 NCQA Blood Pressure BP documented in the last year <140/90 >65% AQA, NCQA, NQF BP documented in the last year <10/80 >5% NCQA Cholesterol At least one LDL >85% AQA, NCQA, NQF LDL Control <10 mg/dl >6% NCQA, NQF LDL Control <100 mg/dl >6% NCQA, NQF Eye Exam Received a dilated eye exam >60% AQA, NCQA, NQF Foot Exam Foot exam >80% NCQA, NQF Smoking Status Counseled to stop tobacco use >80 AQA, NCQA, NQF Nephropathy Tested for nephropathy or already under treatment >80% NCQA, NQF Prevention Influenza vaccination >60% AQA, NCQA, NQF WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 0 15
Asthma Goal Endorsements Utilization ED visit <0.% Hospitalization <0.1% Classification Severity classified >90% NQF, Physicians Consortium Anti-inflammatory Persistent asthma on anti-inflammatory medication >90% AQA, NQF Prevention Influenza vaccination >90% AQA, NQF Composite Measure Receive all key strategies for asthma care (classification, anti-inflammatory, influenza vaccination) >75% WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 1 Hypertension (still under development) Goal Endorsements Blood Pressure Most recent blood pressure below 140/90 NCQA, CMS, NQF WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 2 16
Performance Reporting System The Commission require practices to submit monthly performance data on these measures through IPIP. The measures apply to the entire practice population (e.g., population management). Easy to report data from Colorado registry system. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS Anticipated Gains Improved quality of care within 1 year Reduced admissions and cost in years Improved access to care and member satisfaction Support for the vulnerable and essential primary care professional community A robust demonstration of the impact of a farreaching, multi-payer strategy to transform care delivery Lessons learned to hopefully apply to a broader system-wide model application WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 4 17
Next Steps Finalizing contract with evaluation contractor, and then completing work on evaluation design. Beginning planning for next regional rollout in South Central Pennsylvania in the fall of 2008. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 5 Contacts for Additional Information Phil Magistro, PA pmagistro@state.pa.us Michael Bailit, consultant to PA mbailit@bailit-health.com WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 6 18