http://www.youtube.com/watch?feature=player_embedded&v=JZkk6ueZt-U

Majority are still negative about ACA but want it improved

Views of the law overall remained more negative than positive in January 2014, with 50 percent saying they have an unfavorable view & 34 percent favorable, almost identical to the split in opinion since November 2013. Still, more than half the public overall, including three in ten of those who view the law unfavorably, say opponents should accept that it’s the law of the land and work to improve it, while fewer than four in ten want opponents to keep up the repeal fight. 

• replace private insurance, Medicare or Medicaid
• regulate health care

• Regulate health insurance & some of the worst practices of the for-profit health care industry

How are seniors affected by the ACA?

Seniors greatly benefit from the $716 billion of wasteful spending cut from Medicare & closing of the donut hole

Money saved is being reinvested in Medicare & ACA to improve coverage & insure tens of millions of more seniors. Medicare parts A, B, C and D have all been changed almost all for the better

State Health Insurance Exchanges and the Federal Marketplaces

ACA exchanges are state or federal run (depends on the state) online marketplaces where health insurance companies compete to be people’s providers.

Getting insurance through the marketplace is done by applying for a plan, finding out if one qualifies for subsidies & then comparing competing health plans

A State's "Exchange" is commonly referred to as "Health Insurance Marketplace“

10 Essential Health Benefits Guaranteed by ACA

1. Ambulatory Patient Care
2. Emergency Care
3. Hospitalization
4. Prescription Drugs
5. Maternity & Newborn Care
6. Mental Health Services & Addiction Treatment
7. Rehabilitative Services & Devices
8. Laboratory Services
9. Preventive services, wellness services & Chronic  Disease Treatment
10. Pediatric Services

Essential Health Benefits Guaranteed by ACA & Behavioral Medicine will be on Parity with Physical Medicine

The 2008 Mental Health Parity and Addictions Equity Act applies to individual plans as well as small group plans 

This provision was inserted into the ACA law as an amendment by Senator Debbie Stabenow (D-MI) during the health reform debate and was implemented in Spring 2014

Adult Prevention Services Guaranteed by the ACA

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
2. *Alcohol Misuse screening and counseling
3. Aspirin use to prevent cardiovascular disease for men and women of certain ages
4. *Blood Pressure screening for all adults
5. Cholesterol screening for adults of certain ages or at higher risk
6. *Colorectal Cancer screening for adults over 50
7. *Depression screening for adults
8. *Diabetes (Type 2) screening for adults with high blood pressure
9. *Diet counseling for adults at higher risk for chronic disease
10. *HIV screening for everyone ages 15 to 65, and other ages at increased risk
11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:Hepatitis A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis & Varicella
12. *Obesity screening and counseling for all adults
13. *Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
14. *Syphilis screening for all adults at higher risk
15. *Tobacco Use screening for all adults and cessation interventions for tobacco users

*Opportunities for Mental Health Practitioners to provide behavioral medicine interventions

Women’s Preventative Services Guaranteed by the ACA

1. Anemia screening on a routine basis for pregnant women
2. *Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer
3. *Breast Cancer Mammography screenings every 1 to 2 years for women over 40
4. *Breast Cancer Chemoprevention counseling for women at higher risk
5. *Breastfeeding comprehensive support and counseling from trained providers, and access to breast feeding supplies, for pregnant and nursing women
6. *Cervical Cancer screening for sexually active women
7. *Chlamydia Infection screening for younger women and other women at higher risk
8. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs).
9. This does not apply to health plans sponsored by certain exempt “religious employers.”
10. *Domestic and interpersonal violence screening and counseling for all women
11. Folic Acid supplements for women who may become pregnant
12. *Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
13. *Gonorrhea screening for all women at higher risk
14. *Hepatitis B screening for pregnant women at their first prenatal visit
15. *HIV screening and counseling for sexually active women
16. *Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older
17. Osteoporosis screening for women over age 60 depending on risk factors
18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
19. *Sexually Transmitted Infections counseling for sexually active women
20. Syphilis screening for all pregnant women or other women at increased risk
21. *Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
22. Urinary tract or other infection screening for pregnant women
23. Well-woman visits to get recommended services for women under 65

*Opportunities for Mental Health Practitioners to provide behavioral medicine interventions

Implications of the ACA for Mental Health Practitioners

The emerging health needs of Americans is changing and as a result the roles and function of mental health practitioners will be changing as well due to the Affordable Care Act

The Implications of the Affordable Care Behavioral Medicine Interventions

1. ACA calls for the coordination and integration of medical services through the primary care provider for a “whole person orientation” to medical treatment - model currently implemented at some level in VA & Federally Qualified Health Centers (FQHC’s)

2. The ACA calls for creation of Affordable Care Organizations (ACO’s) to provide comprehensive services to Medicare recipients with a strong primary care basis

3. The ACA model includes integration of mental & behavioral health services into the Patient-centered medical home (PCMH) which can enhance patient outcomes

4. The ACA model integrates mental, behavioral and medical services under one roof with potential of controlling the costs for patients

5. The ACA integrated behavioral medical approach opens a massive opportunity for clinical mental health practitioners

6. To be prepared to fill this evolving behavioral medicine role, it is imperative that clinical mental health counseling training    programs establish training for future practitioners in these integrated medical settings.

7. Beginning 2014 ACA increased access to quality health care including coverage for mental health & substance use disorder services

8. All new small group & individual private market plans are required to cover mental health & substance use disorder services as part of the health care law's “Essential Health Benefits” categories

9. Behavioral health benefits are covered at parity with medical & surgical benefits

10. Insurers will no longer be able to deny anyone coverage because of a pre-existing medical or behavioral health condition

11. ACA ensures that new health plans cover recommended preventive benefits without cost sharing, including depression screening for adults & adolescents as well as behavioral assessments for children

Additional Results of the ACA

1. Primary care providers receive 10% Medicare bonus payment for primary care services

2. A new Medicaid state option was created to permit certain Medicaid enrollees to designate a provider as a health home & states taking up the option receive 90% federal matching payments for two years for health home-related services. [Unfortunately Florida did not accept this Medicaid State Option]

3. Small employers receive grants for up to five years to establish wellness programs

4. The Center for Medicare & Medicaid Innovation launches the Accountable Care Organization (ACO) Model & Advance Payment ACO Model, which offers shared savings & other payment incentives for selected organizations that provide efficient, coordinated, patient-centered care

5. Some States established American Health Benefit Exchanges & Small Business Health Options Program Exchanges to facilitate purchase of insurance by individuals & small employers

6. Teaching Health Centers are established to provide payments for primary care residency programs in community-based ambulatory patient care centers

Two Healthcare Organizational Models which are Driving Change

Two New Medicare/Medicaid models are driving a change in healthcare delivery:

1. Patient Centered Medical Homes (PCMH)
2. Accountable Care Organizations (ACO’s)

History of the Patient Centered Medical Home Model

The patient-centered medical home is not a new concept it has evolved to define a model of primary care excellence

1967: “Medical Home” first use in 1967 by the American Academy of Pediatrics

1978: The World Health Organization support principle of primary care

1996: The Institute of Medicine (IOM) redefined primary care close to PCMH model

2002: Family Medicine promotes Medical Homes

2005: Research on Primary Care promotes PCMH concepts

2006: (A) American College of Physicians adopts Patient Center Physician Guided model of health care (B) Patient Centered Primary Care Collaboration (PCPCC) is founded

2007: Major Primary Care Physician Associations endorse joint Principles of Patient-Centered Medical Home

2008: Medical Home accreditation began and 65 community health centers in five state transform into PCMH

2010: ACA includes numerous provisions for enhancing primary care and medical homes

2011: (A) Primary care providers receive a 10% Medicare bonus payment for primary care services. (B) new Medicaid state option is created to permit certain Medicaid enrollees to designate a provider as a health home (C) Small employers receive grants for up to five years to establish wellness programs. (D)The CMHO launches the Pioneer Accountable Care Organization (ACO) Model and Advance Payment ACO Model (E) States begin establishing of American Health Benefit Exchanges and Small Business Health Options Program Exchanges, which facilitate the purchase of insurance by individuals and small employers. (F) Teaching Health Centers are established to provide payments for primary care residency programs in community-based ambulatory patient care centers.

2012: 47 states had adopted policies and programs to advance the medical home

2013: Thanks to ACA (A) some states now operate their own health insurance marketplaces(B) Providers receive 1% point increase in federal matching payments for preventive services (C) Essential Health Benefits in health insurance marketplaces include prevention, wellness and chronic disease management

Patient Centered Medical Homes Objectives are

1. Patient Centered - Empowers patients with Information and Understanding

2. Comprehensive - Co-location of care providers in physical and behavioral health

3. Coordinated Care - Through Health Information Technology all providers are kept in touch

4. Accessible – same day appointment & 24/7 availability through technology online

5. Committed to Quality & Safety – Quality Improvement Goals which are tracked

Benefits of Patient Centered Medical Homes

1. Patients seek out the right care which is needed-which is often behavioral vs. physical

2. Less use of ER’s or delays in seeking care

3. Less duplication of tests, labs & procedures

4. Better control of chronic diseases & other illnesses improving health outcomes

5. Focus on wellness & prevention – reduce incidence & severity of chronic disease or illnesses

6. Cost savings less use of ER’s & Hospitals

What is moving the Patient Centered Home Health Model

In April 2013 the Patient-Centered Primary Care Collaborative Pointed out on it website these factors driving the Home Health Model

1. Unsustainable cost increases in health care delivery

2. Growing availability of data

3. Vast change in the way we communicate

Example: In Denmark, more than 80 percent of health-care encounters & transactions are electronically based & vastly different method of communicating is coming online and it is coming fast, driven by younger generations of patients and physicians.

Accountable Care Organizations

Have a look at the CMS video which overviews the ACO model at:

https://www.youtube.com/watch?v=MZaa1QROQAU

Goal of an ACO

The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

What are ACO’s

1. ACO assumes financial risk rather than 3^rd party payers (government, business or insurance companies) for group of patients assigned to it

2. Consists of more than one hospital & number of primary care clinics with full array of medical & health specialists-who self-refer to their own specialists

3. Control costs by being responsible for full care of patients

4. Integration of mental & behavioral health services into Patient-centered medical homes

5. Enhance patient outcomes through emphasis on prevention, compliance, and immediate 24/7 attention

6. Utilize an integrated behavioral medical approach

Implications of ACA for Clinical Mental Health Counselors

Potential Roles for Mental Health Practitioners thanks to ACA

1. Conduct Depression, Anxiety & MH Assessments

2. Address the stressors which lead folks to seek out medical attention in the first place

3. Assist in increasing compliance of patients with the medical directives given them by primary care staff

4. Wellness educational programming to help ward off chronic or severe illnesses

5. Assisting clients to cope with the medical conditions for which they are receiving medical attention

AMHCA’s 2011 Expanded Clinical Standards for Training of CMHC’s include these ACA related Factors

1. Evidenced-Based Practices

Diagnosis and Treatment Planning using EBP’s

Diagnosis of Co-Occurring Disorders & Trauma

2. Biological Basis of Behaviors

Knowledge of Central Nervous System

Lifespan Plasticity of the Brain

3. Psychopharmacology

4. Behavioral Medicine

Neurobiology of Thinking, Emotion & Memory

Neurobiology of mental health disorders (mood, anxiety, psychosis) over life span

Promotion of optimal mental health over the lifespan

What Competencies Do Mental Health Professionals Need to Become Members of Integrated Medical Teams under the Affordable Care Act (ACA) Guidelines?

What is needed to improve an integrated Primary Care Model with Behavioral Care?

The American Hospital Association (AHA) recommendations for Workforce Roles in a Redesigned Primary Care Model in 2013 on their website.

Their overall recommendations for all health care professional workforce is:

Their overall recommendation a Primary Care Delivery Model is:

1. Primary health care should be centered around the patient and family in a user-driven design, in all aspects of practice.
2. Hospitals should evolve from traditional “hospitals” to “health systems,” partnering with community organizations and patients in order to advance the community’s wellness and health needs.
3. Hospitals, or health systems, can serve as catalysts for linking and integrating the various components of health and wellness together for patients in a way that provides a sustainable infrastructure of health care for patients and the community.
4. In order to mitigate rising health care costs, a fundamental shift in reimbursement will need to occur

You can read their entire report at: http://www.aha.org/content/13/13-0110-wf-primary-care.pdf

Need to integrate Behavioral Care into Primary Health Care

In 2012, the American Hospital Association (AHA) in its TrendWatch posted this article: Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes. In this article they pointed out that many providers already are working with private payers to meet the goals of integration of behavioral health care services into the broader health care continuum to obtain a positive impact on quality, costs and outcomes. These initiatives span value-based purchasing, accountable care organizations, patient-centered medical homes, and efforts to reduce readmissions.

These initiatives the ACH believes will have important implications for the delivery of behavioral health care. They state that as the demand for behavioral health services is likely to continue to outstrip capacity, improving care integration can help to better manage this need.

You can read this entire article on the AHA website at: http://www.aha.org/research/reports/tw/12jan-tw-behavhealth.pdf

What is the Federal Standard for Integrated Medical Care?

SAMHSA put out these guideline for integrated medical care: A Standard Framework for Levels of Integrated Healthcare in April 2013.

They point out that there are three distinct levels of integrated care:

Coordinated Care

Level 1 – Minimal Collaboration

Behavioral health and primary care providers work at separate facilities and have separate systems. Providers communicate rarely about cases. When communication occurs, it is usually based on a particular provider’s need for specific information about a mutual patient.

Level 2- Basic Collaboration at a Distance

Behavioral health and primary care providers maintain separate facilities and separate systems. Providers view each other as resources and communicate periodically about shared patients. These communications are typically driven by specific issues. For example, a primary care physician may request copy of a psychiatric evaluation to know if there is a confirmed psychiatric diagnosis. Behavioral health is most often viewed as specialty care.

Co-Located Care

Level 3 – Basic Collaboration Onsite

Behavioral health and primary care providers co-located in the same facility, but may or may not share the same practice space. Providers still use separate systems, but communication becomes more regular due to close proximity, especially by phone or email, with an occasional meeting to discuss shared patients. Movement of patients between practices ismost often through a referral process that has a higher likelihood of success because the practices are in the same location. Providers may feel like they are part of a larger team, but the team and how it operates are not clearly defined, leaving most decisions about patient care to be done independently by individual providers.

Level 4 — Close Collaboration with Some System Integration

There is closer collaboration among primary care and behavioral healthcare providers due to colocation in the same practice space, and there is the beginning of integration in care through some shared systems. A typical model may involve a primary care setting embedding a behavioral health provider. In an embedded practice, the primary care front desk schedules all appointments and the behavioral health provider has access and enters notes in the medical record. Often, complex patients with multiple healthcare issues drive the need for consultation, which is done through personal communication. As professionals have more opportunity to share patients, they have a better basic understanding of each other’s roles.

Integrated Care

Level 5 — Close Collaboration Approaching an Integrated Practice

There are high levels of collaboration and integration between behavioral and primary care providers. The providers begin to function as a true team, with frequent personal communication. The team actively seeks system solutions as they recognize barriers to care integration for a broader range of patients. However, some issues, like the availability of an integrated medical record, may not be readily resolved. Providers understand the different roles team members need to play and they have started to change their practice and the structure of care to better achieve patient goals.

Level 6 — Full Collaboration in a Transformed/Merged Practice

The highest level of integration involves the greatest amount of practice change. Fuller collaboration between providers has allowed antecedent system cultures (whether from two separate systems or from one evolving system) to blur into a single transformed or merged practice. Providers and patients view the operation as a single health system treating the whole person. The principle of treating the whole person is applied to all patients, not just targeted groups.

SAMHSA implies that the level 6 model is the ultimate goal of the ACA and other reforms in the Medicare-Medicaid Health Delivery Systems. However they stated: Even if health outcomes improve as levels of integration increase, it is not practical to believe that every healthcare setting will be able, at least in the near term, to implement increasing levels of integration. Many integrated implementations will be constrained by community politics, trust between organizational systems, financing, and/or differing service values.

You can read the entire manual on the SAMHSA website at: http://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf 

which is located on their webpage on integrated health care models at:: http://www.integration.samhsa.gov/integrated-care-models

Self-Assessment of Your Personal Competencies to Function in an Integrated Medicine Setting

BI-CAT (Robinson, 2013) Downloadable at: http://cabhp.asu.edu/presentations/other-center-hosted-presentations/media-and-pdfs/robinson-handouts

This self-assessment helps you to determine your functioning in the following areas:

1. Practice Context

2. Intervention Design

3. Intervention Delivery

4. Outcome-Based Practice

Primary Care Behavioral Health Toolkit (Mountainview Consulting Group, 2013)

This manual provides both institutional and individual practitioner self-assesments as to their readiness for integrated primary care behavioral health. You can download this kit at: http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf

What is the Role of a Behavioral Health Care Provider?

You will learn about what competencies are needed by Behavioral Care Professionals within an Integrated Primary Care Program by use of the Primary Care Behavioral Health Toolkit available at: http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf  This is a must document for those who intend on working within an integrated health system.

This manual presents the keep Principles of an Integrated Model

Principle #1:

The Behavioral Health Consultant’s role is to identify, treat, triage, and manage primary care patients with medical and/or behavioral health problems.

Principle #2:

The Behavioral Health Consultant functions as a core member of the primary care team, providing consultative services.

Principle #3:

The Primary Care Behavioral Health Model is grounded in a population-based care philosophy.

Principle #4:

The Behavioral Health Consultant seeks to enhance delivery of behavioral health services at the primary care level and works to support a smooth interface between primary care and specialty services (Mental Health and Substance Abuse Treatment).

Responsibilities of Behavioral Health Consultants

The Behavioral Health Consultant in the Primary Care Behavioral Health (PCBH) has the following role. The BHC role is a behavioral health provider who:

1) Operates in a consultative role within a primary care team utilizing the PCBH Model

2) Provides recommendations regarding behavioral interventions to the referring Primary Care Clinician (PCC)

3) Conducts brief interventions with referred patients on behalf of the referring Primary Care Clinician PCC.

The Toolkit identifies the responsibilities of Behavioral Health Consultants as:

The BHC responsibilities include the following:

1. Maintains a visible presence to the PCCs during clinic operating hours.

2. Is available for “curbside” consultation (a brief interaction between the PCB

and a PCC) by being in the clinic or available by phone or pager.

3. Is available for same day and scheduled initial consultations with patients referred by PCCs.

4. Performs brief, limited follow-up visits for selected patients

5. Provides a range of services including screening for common conditions, assessments, and interventions related to chronic disease management programs.

6. Conducts risk assessments, as indicated.

7. Provides psycho-education for patients during individual and group visits.

8. Assists in the development of clinical pathway programs, group medical appointments, classes, and behavior focused practice protocols.

9. Maintains an up-to-date library of patient education materials for commonly seen problems.

10. Identifies, reviews, and modifies educational materials for literacy level and cultural appropriateness under the supervision of the PCBH Supervisor.

11. Provides brief behavioral and cognitive behavioral interventions for patients

12. Triages patients with severe or high-risk behavioral problems to CBHS or other community resources for specialty MH services consistent with Step-up/Step-down criteria.

13. Provides PCCs with same-day verbal feedback on client encounters either in person or by phone.

14. Facilitates and oversees referrals to specialty MH / SA services, and when appropriate, support a smooth transition from specialty MH / SA services to primary care.

15. Presents the PCBH model to private and public programs and agencies, in order to establish effective linkages and resources.

16. Prepares brief consultant notes for the medical chart that explain assessment findings, interventions delivered, and recommendations made to the PCC.

17. Maintains clinical records and other necessary paperwork in a timely manner to comply with all administrative regulations.

18. Educates PCCs in the basic principles of brief behavioral and cognitive behavioral interventions and reinforce their use in the medical visit.

19. Supports collaboration of PCCs and psychiatrists concerning medication protocols.

20. Provides assistance in capturing program evaluation and fidelity measures.

21. Attends clinic meetings, including all staff, PCC, Clinic Leadership, and Clinic

PCBH Committee meetings as requested by Clinic Site Director and or PCBH

Program Supervisor.

22. In primary care clinics with two or more BHCs, one BHC may be designated as the BHC Lead. The Clinic Site Director may appoint the lead; otherwise it will be based on seniority. A small amount of the BHC Lead’s time may be shifted from clinical activities to administrative activities and attending meetings.

Read more about within the Primary Care Behavioral Health Toolkit available at: http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf

Assessments for Behavioral Medical use by Mental Health Practitioners

Patient Health Care Questionnaires Screeners

They screen for most common types of mental disorders presenting in medical populations:

Depressive

Anxiety

Somatoform

Alcohol

Eating disorders

Concise, self-administered screening, Quick & user-friendly. PHCQ forms are available at: http://www.phqscreeners.com/

DSM-5 Assessments

Available at: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures

1. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult, 11-17, Parent Report for Children

2. Level 2: Adult Scale by PROMIS: anger, depression, mania, repetitive thoughts, sleep disturbance, substance use

3. Level 2: Children Scale by PROMIS (Parent Report) & 11-17: anger, anxiety, depression, inattention, irritability, mania, sleep disturbance, substance use

4. Disorder-Specific Severity Measures (Agoraphobia, Generalized Anxiety, Panic Disorder, Separation Anxiety, Specific Phobia, Acute Stress, PTSD)

5. Disability Measures (World Health Organization Disability Assessment Schedule)

6. Personality Inventories (The Personality Inventory for DSM-5 - Adult & Children)

7. Early Development and Home Background (Clinician and Parent/Guardian)

8. Cultural Formulation Interviews 

Are there any Red Flags Here for CMHC’s who are licensed?

Currently Psychologists and Social Workers are the only licensed non-medical mental health providers recognized as Medicare Providers. For that reason in states like Massachusetts which has had a long history of “ACA like” coverage, the PCMH’s and ACO’s in that state only hire Psychologist and Social Workers since they do not want to “triage” their patients as to their 3^rd party payers and they would need to do this if they had LMHC’s on their staff. So they avoid this by not hiring LMHC’s in Massachusetts. For this reason it is imperative that LMHC’s get Congress to approve them as Medicare Providers and they need work with AMHCA on the national level in their lobbying efforts to get this done.

“Incident to” is Alternative for now!

“Incident to” are services supervised by physicians (Psychiatrists included) or certain non-physician practitioners such as physician assistants, nurse practitioners or clinical psychologists

“Incident to services” are reimbursed at 85% of physician fee schedule

To qualify as “incident to,” services must be part of patient’s normal course of treatment, during which a physician personally performed an initial service & remains actively involved in course of treatment

Physician or non-physician does not have to be physically present in patient’s treatment room while services are provided, but must provide direct supervision, by being present in office suite to render assistance, if necessary. Patient record should document essential requirements for “incident to” service.

More information related to “incident to” is available at:

Medicare Benefit Policy Manual: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

“Incident to” Services Guidelines: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0441.pdf