Developing a Medicaid Rebate Processing Strategy for your Organization

Christopher C. BiddleAll programs and calculations which are detailed within this presentation Have been directly derived from CMS guidelines

Medicaid Drug Rebate Program (MDRP): Medicaid Drug Rebate Program (MDRP): BackgroundBackground

• Program was sponsored by David Pryor (D-AR)Program was sponsored by David Pryor (D-AR)

• Program was enacted on November 5, under Section Program was enacted on November 5, under Section 4401 of the Omnibus Reconciliation Act (OBRA) of 19904401 of the Omnibus Reconciliation Act (OBRA) of 1990

• Program was effective January 1, 1991Program was effective January 1, 1991

• Program is administered at the federal level by the Program is administered at the federal level by the Centers for Medicare and Medicaid Services (CMS)Centers for Medicare and Medicaid Services (CMS)

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: RequirementsRequirements

• Manufacturers must provide rebates to states Manufacturers must provide rebates to states on a quarterly basis for products dispensed by on a quarterly basis for products dispensed by prescription to Medicaid patientsprescription to Medicaid patients

• Manufacturers must give the federal Manufacturers must give the federal government unrestricted audit access government unrestricted audit access

• Manufacturers must pay significant monetary Manufacturers must pay significant monetary penalties for any late, incomplete or penalties for any late, incomplete or “knowingly” false pricing submissions“knowingly” false pricing submissions

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: AmendmentsAmendments

Veterans Health Care Act of 1992Veterans Health Care Act of 1992 Requires pricing agreement with PHS & VA Requires pricing agreement with PHS & VA

(in order to participate in MDRP)(in order to participate in MDRP) Prevents double discountsPrevents double discounts Changes rebate percentageChanges rebate percentage Excludes prices charged to certain entities from Excludes prices charged to certain entities from

Best Price (BP)Best Price (BP)

OBRA 1993OBRA 1993 Changes parameters for calculating rebates for Changes parameters for calculating rebates for

products approved by FDA after 10/1/90products approved by FDA after 10/1/90

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: Reporting RequirementsReporting Requirements

• Manufacturers Manufacturers mustmust report Baseline Data for all eligible report Baseline Data for all eligible NDCs within 30 days of end of quarter in which rebate NDCs within 30 days of end of quarter in which rebate agreement signedagreement signed

• Manufacturers Manufacturers mustmust report Average Manufacturer Price report Average Manufacturer Price (AMP) and Best Price (BP, for S and I drugs only) to CMS (AMP) and Best Price (BP, for S and I drugs only) to CMS within 30 days after the end of each quarter for all covered within 30 days after the end of each quarter for all covered NDCsNDCs

• Manufacturers Manufacturers mustmust report Baseline and AMP/BP data for report Baseline and AMP/BP data for all new products as well as pricing adjustments for prior all new products as well as pricing adjustments for prior quarters with quarterly submissionsquarters with quarterly submissions

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: Baseline DataBaseline Data

•NDC NumberNDC Number •Product NameProduct Name•Units Per Units Per Package Size Package Size (UPPS)(UPPS)

•Therapeutic Therapeutic Equivalency Equivalency CodeCode

•Unit TypeUnit Type •DESI IndicatorDESI Indicator•Drug CategoryDrug Category •FDA Approval FDA Approval

DateDate•Date Entered Date Entered MarketMarket

•Drug TypeDrug Type

•Correction FlagCorrection Flag •Termination Termination DateDate

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: AMP/BP DefinitionsAMP/BP Definitions

• AMPAMP – – “average unit price charged to wholesalers or “average unit price charged to wholesalers or distributors for sale to the retail class of trade. distributors for sale to the retail class of trade. Manufacturer must apply cash discounts and all other Manufacturer must apply cash discounts and all other price reductions which reduce the ‘actual’ price paid”price reductions which reduce the ‘actual’ price paid”

• BPBP – – “lowest effective price the manufacturer sells the “lowest effective price the manufacturer sells the covered outpatient Single Source or Innovator Multi-covered outpatient Single Source or Innovator Multi-source drug to any purchaser, including wholesalers, source drug to any purchaser, including wholesalers, retailers, providers, HMOs, non-profit agencies and state retailers, providers, HMOs, non-profit agencies and state government agencies”government agencies”

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: AMP Exclusions AMP Exclusions (page P1 of CMS guide)(page P1 of CMS guide)

The AMP calculation excludes:The AMP calculation excludes:

Direct sales to hospitalsDirect sales to hospitals

Direct sales to HMOsDirect sales to HMOs

Direct sales to wholesalers where the drug Direct sales to wholesalers where the drug is relabeled under the distributor’s NDCis relabeled under the distributor’s NDC

Federal Supply Schedule pricesFederal Supply Schedule prices

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: BP ExclusionsBP Exclusions

(page P2 of CMS guide)(page P2 of CMS guide)

Best Price excludes prices charged to:Best Price excludes prices charged to: The Indian Health Service (IHS)The Indian Health Service (IHS) The Department of Veterans Affairs (VA) The Department of Veterans Affairs (VA) State homes receiving funds under section 1741 State homes receiving funds under section 1741

of title 38, United States codeof title 38, United States code The Department of Defense (DOD)The Department of Defense (DOD) The Public Health Service (PHS) or any entities The Public Health Service (PHS) or any entities

described in section 340B(a)(4) of the PHS Actdescribed in section 340B(a)(4) of the PHS Act The Federal Supply Schedule The Federal Supply Schedule State pharmaceutical assistance programsState pharmaceutical assistance programs Nominal Sales (prices < 10% of AMP)Nominal Sales (prices < 10% of AMP)

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: Rebate CalculationRebate Calculation

• For N drugsFor N drugs, Unit Rebate Amount (URA) = 11% of AMP, Unit Rebate Amount (URA) = 11% of AMP

• For S or I drugsFor S or I drugs, URA = Basic Rebate + Additional Rebate, URA = Basic Rebate + Additional Rebate

Basic Rebate = the greater of 15.1% of AMP Basic Rebate = the greater of 15.1% of AMP oror AMP – BP AMP – BP Additional Rebate (CPI-U “creep” calculation) = Inflation Additional Rebate (CPI-U “creep” calculation) = Inflation

“adjustment” used if the product’s price increase has exceeded “adjustment” used if the product’s price increase has exceeded the rate of inflation, measured against the Consumer Price Index the rate of inflation, measured against the Consumer Price Index (CPI-U)(CPI-U)

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: CPI-U “Creep” Calculation CPI-U “Creep” Calculation

• ““Creep” calculation is designed to compensate for a rise in product price that outpaces Creep” calculation is designed to compensate for a rise in product price that outpaces inflationinflation

• Value of additional rebate depends on how baseline (BL) values used in calculation are Value of additional rebate depends on how baseline (BL) values used in calculation are defined, which has changed throughout the history of the MDRPdefined, which has changed throughout the history of the MDRP

• Additional Rebate =Additional Rebate =

Current AMP – ((BL AMP/BL CPI-U)*Current CPI-U)Current AMP – ((BL AMP/BL CPI-U)*Current CPI-U)

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: URA Baseline ValuesURA Baseline Values

Rebate Quarter Market Date Baseline AMP Baseline CPI-U

4Q1993 - present

Greater than 9/30/93

AMP for 1st Qtr. After Market Date

CPI-U for month prior to 1st Qtr.

after Market Date

4Q1993 - present

Greater than 9/30/90; less than

10/1/93AMP for 1st Qtr.

After Market Date

CPI-U for month prior to 1st Qtr.

after Market Date

1Q1991 - 3Q1993

Greater than 9/30/90; less than

10/1/93

AMP for 1st day of 1st full month on the

market

CPI-U for the month before 1st

full month

1Q1991 - present

Equal or less than 09/30/90

3Q1990 AMP132.7 (value for

9/90)

URA Calculation Example (S or I Drug):URA Calculation Example (S or I Drug):

Basic URABasic URA:: 0.357911 * 15.1% = 0.0540450.357911 * 15.1% = 0.0540450.357911 – 0.299563 (BP) = 0.357911 – 0.299563 (BP) = 0.0583480.058348

Additional URAAdditional URA::0.244795/153.5 = 0.0015950.244795/153.5 = 0.0015950.001595*174.00 = 0.2774870.001595*174.00 = 0.2774870.357911 – 0.277487 = 0.080424 (additional URA)0.357911 – 0.277487 = 0.080424 (additional URA)

Total URATotal URA = 0.058348 + 0.080424 = = 0.058348 + 0.080424 = 0.1388000.138800

Baseline Baseline AMPAMP

Baseline Baseline CPI-UCPI-U

Current Current AMPAMP

QuarterlQuarterly CPI-Uy CPI-U

0.2447950.244795 153.5153.5 0.3579110.357911 174.00174.00

Medicaid Drug Rebate Program: ClaimsMedicaid Drug Rebate Program: Claims

• Program requires that manufacturers submit payment to Program requires that manufacturers submit payment to the states based on all undisputed invoice entries within the states based on all undisputed invoice entries within 30 days of receipt of invoice or 38 days from invoice 30 days of receipt of invoice or 38 days from invoice postmark datepostmark date

• Interest on rebate is payable to the state beginning on the Interest on rebate is payable to the state beginning on the 3838thth day after the postmark date day after the postmark date

• Interest is also due the state on disputed units if resolved Interest is also due the state on disputed units if resolved in the state’s favor, if manufacturer does not pay resolved in the state’s favor, if manufacturer does not pay resolved dispute within 38 days of notifying state of disputedispute within 38 days of notifying state of dispute

Medicaid Drug Rebate Program: Key Medicaid Drug Rebate Program: Key DatesDates

Termination Date for Covered DrugTermination Date for Covered Drug If product is pulled from shelf by FDA or manufacturer, the If product is pulled from shelf by FDA or manufacturer, the

termination date is the “removal date” of the producttermination date is the “removal date” of the product If product is discontinued by manufacturer, the termination date If product is discontinued by manufacturer, the termination date

is last lot expiration dateis last lot expiration date

Expiration Date for Covered DrugExpiration Date for Covered Drug 1 year past Termination Date1 year past Termination Date The expiration date is the the date on which the product is The expiration date is the the date on which the product is no no

longerlonger eligible for a Medicaid Rebate eligible for a Medicaid Rebate

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: ReportsReports

Reconciliation of State Invoice (ROSI)Reconciliation of State Invoice (ROSI) Used by manufacturers to explain adjusted rebate Used by manufacturers to explain adjusted rebate

payments to states for the payments to states for the current quarter onlycurrent quarter only Must accompany rebate payment within 38 days of Must accompany rebate payment within 38 days of

postmark date on state’s current quarter invoicepostmark date on state’s current quarter invoice

Prior Quarter Adjustment Statement (PQAS)Prior Quarter Adjustment Statement (PQAS) Used by manufacturers to reconcile and explain prior Used by manufacturers to reconcile and explain prior

quarter actions, payments or credits to statesquarter actions, payments or credits to states

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: TimelineTimeline

Manufacturer submit pricing and new product baseline Information to CMS for previous quarter

CMS: validates manufacturers data, calculates URA and generates data for States

States generate invoices and send to manufacturers

States send utilization data to CMS

Manufactures must submit rebates to States within 38 days of postmark date

Day 30 Day 45 Day 60 Day 90End of Quarter Day 90 + 38

Medicaid Drug Rebate Program: Medicaid Drug Rebate Program: Fines and PenaltiesFines and Penalties

• $10,000 per $10,000 per dayday per per itemitem for failure to provide timely AMP for failure to provide timely AMP and BP reporting to CMSand BP reporting to CMS

• $100,000 for $100,000 for eacheach item item of false information reported to CMS of false information reported to CMS

• $100,000 for $100,000 for eacheach item item if manufacturer refuses a CMS if manufacturer refuses a CMS “request for information”“request for information”

• CMS may terminate the manufacturer’s rebate agreement for CMS may terminate the manufacturer’s rebate agreement for failure to submit quarterly pricing data, nonpayment of failure to submit quarterly pricing data, nonpayment of rebates or for other “good cause”rebates or for other “good cause”

PHS Drug Discount Program/340B PHS Drug Discount Program/340B Program: BackgroundProgram: Background

• Genesis in rising prices for “non-Medicaid” federal & Genesis in rising prices for “non-Medicaid” federal & state payors of drugs after MDRP was enactedstate payors of drugs after MDRP was enacted

• Program enacted under Section 602 of the Veterans Program enacted under Section 602 of the Veterans Health Care Act of 1992, Public Law No. 102-585 & Health Care Act of 1992, Public Law No. 102-585 & Section 340B of the Public Health Service ActSection 340B of the Public Health Service Act

• Administered by the Office of Pharmacy Affairs (OPA)Administered by the Office of Pharmacy Affairs (OPA)

PHS Drug Discount Program/340B PHS Drug Discount Program/340B Program:Program:

RequirementsRequirements

• Manufacturers cannot participate in the 340B Program Manufacturers cannot participate in the 340B Program unless their drugs are covered by the Medicaid Programunless their drugs are covered by the Medicaid Program

• Manufacturers agree to provide discounts on drugs Manufacturers agree to provide discounts on drugs purchased by PHS covered entities purchased by PHS covered entities

• Discount is calculated using MDRP formula Discount is calculated using MDRP formula

• Covered entities are free to negotiate discounts greater Covered entities are free to negotiate discounts greater than than the Medicaid rebate amountthan than the Medicaid rebate amount

PHS Drug Discount Program/340B PHS Drug Discount Program/340B Program:Program:PricingPricing

• Manufacturer sells at a discounted price to covered Manufacturer sells at a discounted price to covered entities, rather than paying a rebate to statesentities, rather than paying a rebate to states

For S & I drugs, price = (AMP - URA) * UPPSFor S & I drugs, price = (AMP - URA) * UPPS For N & OTC drugs, price = AMP - (11% * AMP)For N & OTC drugs, price = AMP - (11% * AMP)

• Prices calculated & reported quarterlyPrices calculated & reported quarterly

• Manufacturers responsible for verifying eligibility of Manufacturers responsible for verifying eligibility of covered entities each quartercovered entities each quarter

PHS Drug Discount Program/340B PHS Drug Discount Program/340B Program:Program:

Covered EntitiesCovered Entities

• Certain non-profit disproportionate share hospitalsCertain non-profit disproportionate share hospitals owned by (or under contract owned by (or under contract with) state & local governmentswith) state & local governments

• Specified PHS GranteesSpecified PHS Grantees, such as:, such as: Certain Federally Qualified Health CentersCertain Federally Qualified Health Centers State operated AIDS drug assistance programsState operated AIDS drug assistance programs Tuberculosis, black lung, family planning,STD clinicsTuberculosis, black lung, family planning,STD clinics Hemophilia treatment centersHemophilia treatment centers Public housing primary care clinics & homeless clinicsPublic housing primary care clinics & homeless clinics Urban Indian clinics & Native Hawaiian health centersUrban Indian clinics & Native Hawaiian health centers

PHS Drug Discount Program/340B PHS Drug Discount Program/340B Program:Program:Key FactsKey Facts

• Drugs purchased by a covered entity cannot be resold or Drugs purchased by a covered entity cannot be resold or transferred, except to patients of the covered entitytransferred, except to patients of the covered entity

• Drugs purchased through the 340B Program are not Drugs purchased through the 340B Program are not subject to a Medicaid rebate (prevents double discounts)subject to a Medicaid rebate (prevents double discounts)

• Covers outpatient prescriptions onlyCovers outpatient prescriptions only

Federal Supply Schedule (FSS): Federal Supply Schedule (FSS): BackgroundBackground

• Schedule of contracts & prices for frequently used supplies & Schedule of contracts & prices for frequently used supplies & services available to federal governmentservices available to federal government

• Contracts for medical-related schedules awarded by Department Contracts for medical-related schedules awarded by Department of Veterans Affairs (VA)of Veterans Affairs (VA)

• Individual FSS prices set by negotiations between manufacturer Individual FSS prices set by negotiations between manufacturer & VA (no statutory ceiling price)& VA (no statutory ceiling price)

• Government wants “most favored customer price” (or below)Government wants “most favored customer price” (or below)

• VA has substantial audit rightsVA has substantial audit rights

Federal Supply Schedule (FSS): Federal Supply Schedule (FSS): Industrial Funding Fee (IFF)Industrial Funding Fee (IFF)

• IFF = 0.5% fee on all FSS SalesIFF = 0.5% fee on all FSS Sales

• VA requires manufacturers to collect and remit the IFF VA requires manufacturers to collect and remit the IFF each quartereach quarter

• Manufacturers must decide whetherManufacturers must decide whether to include the IFF in to include the IFF in their pricing to government entities purchasing on the FSStheir pricing to government entities purchasing on the FSS

• A report of sales data and payment is due within 60 days A report of sales data and payment is due within 60 days after the end of each quarterafter the end of each quarter

Federal Supply Schedule (FSS): Federal Supply Schedule (FSS): IFF Numerical Example IFF Numerical Example

• FSS Final Price = 9.01FSS Final Price = 9.01

IFF = 9.01 * 0.005 = 0.045IFF = 9.01 * 0.005 = 0.045

• FSS Final Price with IFF = 9.06FSS Final Price with IFF = 9.06

• The FSS Final Price with IFF is published in the The FSS Final Price with IFF is published in the FSS Price ListFSS Price List

Big 4 Federal Ceiling Prices (FCP): Big 4 Federal Ceiling Prices (FCP): BackgroundBackground

• Like PHS, genesis in rising prices for “non-Medicaid” federal & Like PHS, genesis in rising prices for “non-Medicaid” federal & state payors of drugs after MDRP beganstate payors of drugs after MDRP began

• Enacted under Section 603 of the Veterans Health Care Act of Enacted under Section 603 of the Veterans Health Care Act of 1992, Public Law No. 102-585 1992, Public Law No. 102-585

• Establishes separate drug discount program for 4 largest Establishes separate drug discount program for 4 largest federal purchasers of drugs: VA, DOD, PHS (including IHS) federal purchasers of drugs: VA, DOD, PHS (including IHS) and Coast Guard and Coast Guard

• Places a ceiling price (federal ceiling price, or FCP) on brand Places a ceiling price (federal ceiling price, or FCP) on brand name (S or I) drugs purchased by the Big 4name (S or I) drugs purchased by the Big 4

Big 4 Federal Ceiling Prices (FCP): Big 4 Federal Ceiling Prices (FCP): RequirementsRequirements

• Manufacturer must enter into “master agreement” with Manufacturer must enter into “master agreement” with VA in order to be paid for drugs under Medicaid, the VA in order to be paid for drugs under Medicaid, the 340B Program or by the Big 4340B Program or by the Big 4

• ““Master agreement” requires a Master agreement” requires a minimumminimum discount of discount of 24% off nonfederal average manufacturer price 24% off nonfederal average manufacturer price (NFAMP) on brand name drugs sold to the Big 4(NFAMP) on brand name drugs sold to the Big 4

• Additional discount required if a drug’s price rises Additional discount required if a drug’s price rises faster than inflationfaster than inflation

Big 4 Federal Ceiling Prices (FCP): Big 4 Federal Ceiling Prices (FCP): Dual PricingDual Pricing

• FCP discount formula is only available to the Big 4FCP discount formula is only available to the Big 4

• Other federal agencies must pay “normal” FSS pricesOther federal agencies must pay “normal” FSS prices

• Manufacturers have the option of maintaining 1 or 2 FSS Manufacturers have the option of maintaining 1 or 2 FSS schedules (of charging single or dual prices to the Big 4 schedules (of charging single or dual prices to the Big 4 and other FSS purchasers for the same covered drug)and other FSS purchasers for the same covered drug)

• Under dual pricing, FSS prices are generally higher than Under dual pricing, FSS prices are generally higher than FCP prices for the same drugFCP prices for the same drug

Big 4 Federal Ceiling Prices (FCP): Big 4 Federal Ceiling Prices (FCP): NFAMPNFAMP

• NFAMP = NFAMP = The average price paid by wholesalers to The average price paid by wholesalers to manufacturers, including any cash discounts, similar manufacturers, including any cash discounts, similar price reductions and chargebacks paid on price reductions and chargebacks paid on non-federal/non-nominal salesnon-federal/non-nominal sales

• Quarterly NFAMPQuarterly NFAMP reported to VA within 45 days after reported to VA within 45 days after the end of each quarterthe end of each quarter

• Annual NFAMPAnnual NFAMP reported to VA on November 15 reported to VA on November 15thth of of each year each year

Big 4 Federal Ceiling Prices (FCP): Big 4 Federal Ceiling Prices (FCP): FCP CalculationFCP Calculation

• FCP = 0.76 * (Annual NFAMP) FCP = 0.76 * (Annual NFAMP) in the 1in the 1stst year of a year of a multi-year contractmulti-year contract

• In the 2In the 2ndnd & subsequent years, & subsequent years, FCP will be the lower FCP will be the lower ofof::

1.1. FSS price charged during preceding 12 months FSS price charged during preceding 12 months (adjusted for inflation) (adjusted for inflation) OR…OR…

2.2. Reported annual NFAMP multiplied by 0.76 (minus Reported annual NFAMP multiplied by 0.76 (minus any inflation adjustment)any inflation adjustment)

Big 4 Federal Ceiling Prices (FCP): Big 4 Federal Ceiling Prices (FCP): Multiple Year FCP CalculationMultiple Year FCP Calculation

Prior Year FSS Price

AllowableCPI-U

Increase

(annual).76*NFAMP

CPI-UAdditionalDiscount

+

-

=

=

New YearFSS-InflatedPrice Option

New YearNFAMP-Based

Price Option

Lower Of FCP

Big 4 Federal Ceiling Prices (FCP): Big 4 Federal Ceiling Prices (FCP): Differences from MDRP and 340BDifferences from MDRP and 340B

• FCP discounts for Big 4 only apply to brand name drugs (S & FCP discounts for Big 4 only apply to brand name drugs (S & I) drugs, whereas the MDRP and 340B Program also impose I) drugs, whereas the MDRP and 340B Program also impose discounts on generic drugsdiscounts on generic drugs

• FCP pricing calculation does not involve any type of best FCP pricing calculation does not involve any type of best price formulaprice formula

• Additional discount calculation for price increases that Additional discount calculation for price increases that outpace inflation is not identicaloutpace inflation is not identical

• Though nominal prices are excluded from NFAMP, VA Though nominal prices are excluded from NFAMP, VA interprets “nominal” more narrowly than CMS interprets “nominal” more narrowly than CMS

What are the risks ?What are the risks ?

• FinesFines

• Significant increase in Federal ScrutinySignificant increase in Federal Scrutiny

• Public damage to reputationPublic damage to reputation

What steps can we take ?What steps can we take ?

• Data AuditData Audit

• Internal Legal Department ReviewInternal Legal Department Review

• Proactively “partner” with State and Federal Proactively “partner” with State and Federal

AgenciesAgencies

Pricing/Sales DataPricing/Sales Data

• Direct and Indirect SalesDirect and Indirect Sales

• Rebates and ChargebacksRebates and Chargebacks

• MedicaidMedicaid

Systems and ControlsSystems and Controls

• Where and when possible, use proven data Where and when possible, use proven data processing systems and technologiesprocessing systems and technologies

• Carefully design Filter mechanisms and place Carefully design Filter mechanisms and place them in exclusively in the hands of Users.them in exclusively in the hands of Users.

• Dedicate IS resources to support this functional Dedicate IS resources to support this functional area as their primary responsibilityarea as their primary responsibility

Your Internal Legal DepartmentYour Internal Legal Department

• Ensure full review and blessing of All Ensure full review and blessing of All pricing/discount strategies by your Legal pricing/discount strategies by your Legal DepartmentDepartment

• Target high exposure areas such as Nominal Target high exposure areas such as Nominal

PricingPricing

• Examine and enhance standard Legal clauses Examine and enhance standard Legal clauses within all contracts going forwardwithin all contracts going forward

Work with Federal and State AgenciesWork with Federal and State Agencies

• Appoint full time representative(s) to Government Appoint full time representative(s) to Government EntitiesEntities

• In addition to Government Mandated reports, In addition to Government Mandated reports, provide the availability of additional detailed provide the availability of additional detailed reportsreports

• Strive for a positive, open dialogue at all times.Strive for a positive, open dialogue at all times.

Conclusions…Conclusions…