Health policy in play as Coalition licks wounds

AMA President Dr Michael Gannon has intensified his calls on the Government to dump its Medicare rebate freeze policy and reverse other health cuts amid mounting pressure within the Coalition for changes to health policy following the narrow Federal election result.

Seizing on admissions from Prime Minister Malcolm Turnbull that health policy concerns swayed many voters away from his party, Dr Gannon has called on the Coalition to change course and treat health as an investment, rather than a cost.

“The Prime Minister, the Coalition, have had the scare of their life,” Dr Gannon said. “It’s very clear that Australians value their health, and many of them voted on the grounds that they were worried about their health care.”

Last week the Coalition secured the 76 seats needed to form Government in its own right after suffering a national swing of 3.4 per cent against it. The narrow victory (the ABC predicts Labor will hold 68 seats, the Greens and Xenophon Team one each, and three independents) prompted a wave of finger-pointing and recriminations within conservative party ranks, including calls to revisit health cuts made in the 2014 and 2016 budgets.

Rancour over the close election result extended to include speculation that Health Minister Sussan Ley would be dumped amid complaints she had not done enough to counter Labor’s attack lines on the Government over Medicare. Her supporters, though, revealed that she had been muzzled from speaking out during the campaign by Liberal strategists, and Dr Gannon said that, from afar, it seemed “that the Coalition didn’t want to talk about health in the campaign, and that they had silenced Minister Ley”.

Dr Gannon said the big lesson for the Government from the election was that the public valued the health system highly, and in post-election talks with the Prime Minister he had reinforced the need to invest in general practice, increase public hospital funding and reverse cuts to bulk billing incentives for pathology and diagnostic imaging services.

The AMA President said Mr Turnbull understood the AMA’s concerns.

“I think that in an ideal world he would unravel the freeze tomorrow,” he told ABC radio. “What we have seen in the past, going back to the 2014 Budget, was a desire by the Coalition to introduce a co-payment to try and work out ways that those who can afford it can contribute more to the cost of their health care.

“Now, the reason that proposal failed so badly is because it didn’t give the opportunity for individual GPs to make a judgement, knowing their patients well, who can and can’t afford even a modest amount of money.”

Asked if he would re-visit the idea of a patient co-payment, Dr Gannon said he was not seeking “a re-energisation” of the co-payment debate, but instead wanted a serious discussion about the future funding of Medicare.

“My comments…are about being able to have conversations about why those two [co-payment] proposals from two years ago were not good policy, being able to have a conversation about how we fund Medicare, 15, 20 years in advance,” he said on radio station 2GB.

“We’re not far off the balance in Australia, it just needs some tinkering around the edges. And I’m really keen to, in this next Parliament, with a knife-edge result in the Lower House and a very interesting Senate…I’m just hopeful we can have these conversations that make sure that Medicare is there to protect people in 20 years’ time, and have more than that two- or three-year view of it.”

The Government appears receptive to calls to re-visit its health policies.

As the Coalition took stock of the extremely tight Federal election result, Mr Turnbull said it was clear that Labor’s message that the Coalition posed a threat to Medicare had fallen on “some fertile ground”.

“What we have to recognise is that many Australians were troubled by it. They believed it, or at least had anxieties raised with it. It is very clear – it is very, very clear – that [Deputy Prime Minister] Barnaby [Joyce] and I and our colleagues have to work harder to rebuild or strengthen the trust of the Australian people in our side of politics when it comes to health. There is no question about that,” Mr Turnbull said.

“We have to recognise that there is a real issue for us if people voted Labor because they genuinely believed or they feared that we were not committed to Medicare, because that is not the case. So that is why Barnaby and I, as we reflect on this and our colleagues reflect on this, that is something that is an issue we have to address,” Mr Turnbull said.

Dr Gannon told ABC radio the election result had shown just how important health policy was for voters, and it was clear that the Medicare rebate freeze, combined with earlier polices such as the GP co-payment, meant Labor’s scare campaign on Medicare had resonated with voters.

“If we go back to the first co-payment model in 2014, which came out of the much-maligned Budget that year, if we look at Co-payment Mark II which came out later that year, it possibly showed that health policy was being run out of Treasury,” Dr Gannon said. “The Coalition has realised maybe too late…that people do worry about their health, they do vote on it, they do regard it as one of the major issues when they decide how to vote.”

Adrian Rollins

More resources, faster internet the key for rural health

Rural doctors have overwhelmingly identified the need for improved public hospital funding and better internet access as the most important solutions for rural health care.

In the first AMA survey of rural doctors since 2007, GPs, other specialists, salaried doctors and doctors in training were asked to rank in importance 20 proposed solutions to improve the health of rural Australians.

Almost 600 doctors took part in the 2016 AMA Rural Health Issues Survey in April.

And, as they did in 2007, they nominated “provide extra funding and resources to support improved staffing levels, including core visiting medical officers, to allow workable rosters” as their top priority.

In a sign of the growing use of internet-based communications and data, access to high-speed broadband was not a survey option nine years ago, but was ranked as second-most important in this year’s survey.

Ensuring that rural hospitals have modern facilities and equipment rose one space to third, and encouraging medical colleges to include rotations for trainees to rural areas rose from sixth to fourth.

Related: Rural doctors want support

AMA President Dr Michael Gannon said the survey results showed that rural Australia needs more resources to recruit and retain doctors and other health professionals.

“We have record numbers of medical school places and, with sufficient numbers of medical graduates coming through, the focus must now be in how we can get them to work in the places they are needed the most,” Dr Gannon said.

As one respondent said: “I cannot stress enough the importance of rotating specialist/vocational trainees into rural posts. The RACS and RACP have done so for years with great exposure and training of prospective doctors for a rural practice. Other colleges must follow suit, especially psychiatry, radiology, pathology, O&G, and emergency medicine, to name a few key deficiencies in rural placement or training.”

The survey found that rural doctors enjoy their careers but struggle with the workload and lack of support.

“It’s very hard to find locum support to take holidays/attend conferences, and as the only specialist in my field in all rural WA, extra support to maintain CPD and be able to go on holidays would be nice,” one respondent said.

But the response from the community makes the job rewarding, doctors said.

“Small towns often appreciate what little I could do for them,” one doctor said.

The survey results build on the AMA’s Plan for Better Health Care for Regional, Remote, and Rural Australia, released in May.

The Plan proposes a focus on four key areas – rebuilding country hospital infrastructure; supporting recruitment and retention of doctors; encouraging more young doctors to work in rural areas; and supporting rural practices.

“Addressing and investing in these measures will make a long-term difference to the health of Australians living in rural communities,” Dr Gannon said.

Maria Hawthorne

Photo credit: Nils Versemann / Shutterstock.com

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More funding needed for Health Care Homes trial

GPs are still waiting for clarity on whether appropriate funding will be offered for services to patients under the Government’s $21 million Health Care Homes trial.

Under the model, also known as the Medical Home, patients suffering from complex and chronic health problems will be able to voluntarily enrol with a preferred general practice, with a particular GP to coordinate all care delivered.

The Government announced the model in March, with $21 million to allow about 65,000 Australians to participate in initial two-year trials in up to 200 medical practices from 1 July 2017.

The trial was one of the recommendations of the report of the 2015 Primary Health Care Advisory Group, headed by former AMA President Dr Steve Hambleton.

It was hailed as a step in the right direction for chronic disease management, with the Labor Opposition announcing plans for a similar trial.

However, the Labor proposal came with $100 million of funding, while under the Government model, the funding is not directed at services for patients, but rather on clinical need.

Professor Jane Gunn, the head of the General Practice Department at the University of Melbourne’s medical school, said the outcomes of similar trials, such as the 1994 coordinated care trials and the more recent diabetes care project, highlighted the difficulty in driving health delivery reform.

“The coordinated care trials showed some promise but were costly to implement and too costly to scale up,” Professor Gunn wrote on The Conversation website.

“They were difficult to replicate and few were sustained outside the trial environment.

“The impact of the diabetes care project was also disappointing. The diabetes care project included many of the elements of [the advisory group’s] report, such as bundled payments, yet only small gains were made in health outcomes and the cost-effectiveness of the model was not proven.

“The bundled payment used in the diabetes care project was viewed as inadequate.”

Making improvements in chronic disease management would require strong buy-in from all stakeholders, but it would be a challenge to get eligible practices and patients to sign on for the trial, she said.

“One of the biggest challenges will be to work out exactly how much the Government should pay a practice for providing a person with all their chronic disease care in a year,” Professor Gunn said.

“Working out how an individual GP will get their fair share of the chronic disease payment is likely to make for interesting negotiations and new ways of working for practice managers.

“Female GPs will be vulnerable to further pay inequities as they are less likely to be practice owners and more likely to work part-time.

“It is also not clear whether the recommended ‘bundled payment’ would include more radical models where the practice has to fund payment for pathology, imaging and medications from the ‘bundled payment’.”

AMA President, Dr Michael Gannon, said the AMA was keen to work with the Government to make the trial a success, but appropriate funding would be a critical test.

“The Medical Home is fundamental to the concept of the family doctor who can provide holistic and longitudinal care and, in leading the multidisciplinary care team, safeguard the appropriateness and continuity of care,” Dr Gannon said.

“BEACH data shows that GPs are managing more chronic disease. But they are under substantial financial pressure due to the Medicare freeze and a range of other funding cuts.

“GPs cannot afford to deliver enhanced care to patients with no extra support. If the funding model is not right, GPs will not engage with the trial and the model will struggle to succeed.”

With the right support, GPs can provide more preventive care services and greater management and coordination of care, keeping patients healthier and out of hospital, he said.

“Health played a major part in the Federal Election and the Government must now demonstrate that it has heard the people’s concern regarding the ongoing affordability of their health care,” Dr Gannon said.

“The Medical Home must be appropriately funded to succeed.”

Maria Hawthorne

Family doctors: invaluable to health

As the new Chair of the AMA Council of General Practice, I am honoured to follow on from my predecessor, Dr Brian Morton, and wish to acknowledge him for his six years of leadership and service to the Council and to general practitioners.

It is certain that as a profession we will have some interesting times ahead of us as the dust from the Federal Election settles. If there is one thing we know for sure from the last few weeks, it is that putting health on the backburner is risky business. The Government must be in no doubt now that health is a priority, and that it will have to do more than it has to date to ensure vulnerable patients do not have to worry about whether or not they can afford to see their GP when required, and to have pathology and radiology investigations when requested.

Next week we will be celebrating general practice and the primary role played by Australia’s GPs, our family doctors, as frontline and holistic health care providers. Throughout Family Doctor Week (24-30 July), the AMA will be highlighting how invaluable the family doctor is to patient health, and to the health system more broadly.

We know from international comparisons that countries with a strong GP-led primary care system have lower rates of ill health, better access to care, reduced rates of hospital admissions, fewer referrals to other specialists, less use of emergency services, and better detection of adverse effects of medication.

The comprehensive care provided by our nation’s family doctors needs to be seen by Government as an investment rather than as an expense. With only 6 per cent of Australia’s total health expenditure on general practice, our family doctors have proven the value of their care. Ending the freeze on Medicare rebates, raising the rebates and lifting rates of indexation to cover the true costs of care must be at the top of the Government’s to-do list.

For most patients, our general practices are their medical home. If appropriately funded, rather than struggling for viability, we know we can do more to help our patients live the healthiest life they can. We can do this though appropriate health screening and life-stage assessments, through structured care that is patient-centred and planned, through greater use of innovative technology that not only empowers patients in managing their conditions, but enables us to monitor their progress, through better use of medicines, and through care that is streamlined and coordinated within our multidisciplinary health care team.

Family Doctor Week will highlight that, properly funded, the medical home has the potential to both improve the care patients receive, and to save on more costly downstream health costs.

Supporting general practices to bring non-dispensing pharmacists into the health care team is but one way Government can invest to deliver better patient outcomes and minimise avoidable hospital admissions. The AMA’s Pharmacist in General Practice Program would deliver $1.56 in savings for every $1 invested by ensuring the quality use of medicines, medication optimisation and increased medication compliance, reducing adverse drug events and hospitalisations as a result.

In rural and remote areas, Government needs to assist general practices with appropriately designed and implemented infrastructure grants to expand their facilities to better meet the complex health needs of people in these communities.

You can support us in supporting you by visiting the website family-doctor-week-2016 and downloading and displaying the poster and your Family Doctor Logo, and by using #amafdw16 if tweeting or sharing FDW content on social media.

[Case Report] Bilateral lower limb weakness in acute severe ulcerative colitis

An obese 49-year-old man with no medical history of note presented in August, 2014, with a 5-week history of bloody diarrhoea, anorexia, and unintentional weight loss. He reported passing 20 bloody stools per day, with nocturnal disturbance, and on admission had pyrexia, tachycardia, anaemia, and a robust inflammatory response. Flexible sigmoidoscopy showed severe confluent colitis, and histopathology confirmed a first presentation of active ulcerative colitis (figure). In view of these findings we started intravenous methylprednisolone 30 mg twice daily for 7 days followed by a standard reducing course of oral prednisolone (40 mg daily, decreasing by 5 mg per week).

Health policy in play as Coalition licks wounds

AMA President Dr Michael Gannon has intensified the pressure on the Coalition to dump its Medicare rebate freeze policy following an admission from Prime Minister Malcolm Turnbull that health policy concerns swayed many voters away from his party.

“The Prime Minister, the Coalition, have had the scare of their life,” Dr Gannon said. “If they do survive, it’s time for them to listen about how elements of their health policy could be improved and let’s start with number one – unfreezing the rebate.”

As the shockwaves from the extremely tight Federal election result continue to reverberate, Mr Turnbull said it was clear that Labor’s message that the Coalition posed a threat to Medicare had fallen on “some fertile ground”.

“What we have to recognise is that many Australians were troubled by it. They believed it, or at least had anxieties raised with it. It is very clear – it is very, very clear – that Barnaby [Joyce] and I and our colleagues have to work harder to rebuild or strengthen the trust of the Australian people in our side of politics when it comes to health. There is no question about that,” Mr Turnbull said.

“Barnaby [Joyce] and I and my colleagues are as committed to Medicare as any other Member in the Parliament. That’s a fact.

“However, there was some fertile ground in which that grotesque lie could be sown. There is no doubt about that. It was a grotesque lie. Very cynical, very dishonest, but very effective.”

In comments that raise the prospect the Coalition will re-visit its health policies, the Prime Minister flagged that he and his colleagues would need to address perceptions they were not committed to Medicare.

Dr Gannon said the AMA had been campaigning hard on convincing the Coalition to join Labor and the Greens in committing to reinstate Medicare rebate indexation: “That was number one in the AMA’s campaign. We repeatedly asked the Coalition to unwind the freeze. Other elements of Coalition policy leant themselves to the scare and I think they’ve paid for it at the polling booth”.

Health has been a highly politically charged area of policy since the Coalition, led at the time by Tony Abbott, twice attempted to introduce a co-payment for GP visits. A backlash led by the AMA forced it to abandon the idea, and instead the Coalition reinstated a freeze of Medicare rebates first initiated by Labor, and has sought to make savings in other areas of health, including big cuts to public hospital funding and the abolition and reduction of bulk billing incentives for pathology and diagnostic imaging services.

During the election, Labor campaigned heavily on health care, and claimed that a proposal to outsource Medicare payments to the private sector was part of a broader but hidden agenda of the Coalition to privatise Medicare.

At the time, Dr Gannon publicly rebutted the claim, arguing that there was “never any suggestion that anyone was even remotely looking at privatising Medicare”, and Mr Turnbull tried to shut the issue down by declaring the Coalition would not look to outsource the Medicare payments system.

Reflecting on the election, Mr Turnbull blamed the issue for much of the plunge in Coalition support at the ballot box.

“This was a shocking lie,” Mr Turnbull said. “But the fact that significant numbers of people believed it or at least believed it enough to change their vote, tells us that we have work to do…That is a very clear lesson.

“We have to do more to reaffirm the faith of the Australian people in our commitment to health and to Medicare. Now, that commitment is there, but plainly there were concerns.”

Dr Gannon said that, whatever the outcome of the election, the AMA stood ready to work with all sides of politics to deliver better health policy.

“The Prime Minister has had the scare of his life and, if he is returned, I think he’ll be looking to hear ways that he can come up with an improved health policy. The Australian people have shown how dearly they hold it,” he told ABC News Radio. “The AMA is prepared to work with the Coalition, with the Labor Party, with the crossbench, to try and come up with health policy that’s good over the next three years. And we’re particularly determined to come up with health policy that will serve this nation for 10, 15 years into the future.”

Adrian Rollins

Health must be focus whoever wins Government: Gannon

The tight Federal election result was “compelling evidence” that voters want a strong Medicare and health system that supports general practice and public hospitals, AMA President Dr Michael Gannon said.

As the outcome of the election remains in the balance two days after voting day, Dr Gannon said the clear message from the poll was that health policy was a vote changer.

“The exit polls confirmed what the AMA had been hearing from its members in the lead-up to the election: people want confidence that they can see their doctor or get to a hospital when they or their loved ones need health advice or care,” Dr Gannon said.

The Turnbull-led Coalition is facing the very real prospect of minority government, having to negotiate deals with independent and minority party MPs if it is to return to office.

The latest tally from the Australian Electoral Commission gives the Coalition 67 seats, Labor 71 seats, two to the Nick Xenophon Team, one each to the Greens and Katter’s Australian Party and two independents. The Commission reports that six seats remain too close to call.

Health issues figured prominently in the campaign. The AMA campaigned strongly on lifting the Medicare rebate freeze, funding public hospitals, and reversing cuts to pathology and diagnostic imaging bulk billing incentives – all issues seized on by Labor and the Greens in their own campaigns.

The Coalition also found itself on the back foot over accusations by Labor – discredited by Dr Gannon – that it had a secret plan to privatise Medicare.

During the campaign, the AMA President rubbished Labor’s attempts to portray the possible outsourcing of the Medicare payments system as amounting to its privatisation, but said the Coalition’s refusal to change key policies allowed the Opposition to spread such misinformation.

He said that, rather than scare campaigns, voters were swayed by the genuine concerns expressed by their family doctors.

“We believe that people who voted because of health policy were influenced by credible information from trusted doctors and other health professionals who campaigned against the Medicare freeze,” Dr Gannon said. “Grassroots doctors across the country shared their concerns with their patients. Local family doctors had genuine fears about the livelihoods of their practices.”

It is expected to be days, or maybe even weeks, before the final result of the election is known, but Dr Gannon said the AMA stood ready to work cooperatively with whoever formed Government.

Either way, he said, health needed to be at the centre of the national policy agenda.

“The election result is compelling evidence that people want a strong Medicare and a health system that promotes quality primary care, supports general practice, and properly funds public hospitals,” Dr Gannon said.

Adrian Rollins

[Perspectives] Malaria

In 1866 a newly qualified Aberdonian doctor, Patrick Manson, followed his older brother into the Chinese Imperial Maritime Customs Service. After a decade in the service Manson retired to Scotland, but in the early 1890s he was forced back into practice by a currency crash that wiped out his Chinese pension. Drawing on his experiences in east Asia, he began to concentrate on the study of tropical diseases, developing an ecological approach in which bacteriology and pathology were combined with entomology and geography.

Radiologists abandon campaign on promise of Govt review

The Coalition has convinced the diagnostic imaging industry to drop its campaign against cuts to bulk billing incentives in exchange for a review of the commercial pressures the sector is working under.

After last month striking a peace deal with pathologists to end a damaging campaign over the axing of bulk billing incentives for pathology services, the Government has headed off similar action by the nation’s radiology providers.

Health Minister Sussan Ley announced on 5 June that the Coalition, if re-elected, would commission an “independent evaluation…of the commercial pressures facing diagnostic imaging providers”.

Ms Ley said the evaluation would also be used to help identify ways to make Government spending more targeted and efficient.

“Advancing technology in many areas of the health system creates a much more efficient and automated service, leading to decreased costs,” the Minister said. “However, this is not the case for most diagnostic imaging services, which need specialist doctors to supervise the examination and analyse the results, not machines.

“This independent evaluation will ensure we can work together with the diagnostic imaging sector to pinpoint exactly where possible improvements can be made in the broader system, and ensure this significant additional investment is targeted where it will have the most benefit for patients.”

Ms Ley up to $50 million a year could be saved through greater efficiencies in Government spending.

The Minister’s announcement came just days before the Australian Diagnostic Imaging Association planned to launch a public campaign warning that cuts to bulk billing incentives, coming on top of an 18-year freeze on patient rebates, would force the cost of crucial of crucial diagnostic and treatment services beyond the reach of many patients, including those with cancer.

The Association had said that average out-of-pocket costs for x-rays, ultrasounds, CTs and MRIs had reached $100, and practices were “extremely concerned” that the freeze on rebates would “continue to drive more patients away from essential diagnosis and treatment”.

But, following Ms Ley’s announcement, Association Chief Executive Officer Pattie Beerens said she was confident the Coalition’s plan, which includes maintaining the bulk billing incentive for concession card holders and children, a three-year moratorium on changes to Diagnostic Imaging Services Table and a resumption of rebate indexation in 2020, would “show a path” to adequate Medicare rebates.

“We had to fight the case for patients and we are really pleased that our advocacy has resulted in the diagnostic imaging sector and the Government working constructively to achieve a positive outcome for patients, providers and taxpayers,” Ms Beerens said.

Adrian Rollins

Medibank actions ‘unconscionable’: ACCC

The consumer watchdog is taking the nation’s largest health insurer to court alleging it engaged in misleading and unconscionable conduct after it reduced benefits without informing policyholders.

In damning accusations that reflect widespread public discontent over the conduct of private health funds, the Australian Competition and Consumer Commission has launched legal action against Medibank Private claiming it deliberately withheld information about a cut in benefits for in-hospital radiology and pathology services to make money and avoid hurting its image ahead of its public float.

“We think these are very serious allegations, and we think the behaviour we’re alleging should change right across the industry,” ACCC Chairman Rod Sims told The Australian.

In a strongly-worded statement, the ACCC claimed Medibank made a calculated decision to keep communications about the change “contained and reactive” for fear that if it was disclosed members might leave the fund, and the bad publicity could damage its reputation and “have a negative impact on its planned initial public offering of securities”.

The issue arose when, in September 2014, Medibank terminated and phased out agreements with pathology and radiology providers to pay the gap for in-hospital services. As a result, the ACCC said, policyholders were left with average out-of-pocket expenses of $151 for pathology services, and $83 for radiology services.

The ACCC alleges Medibank failed to give members with advance notice of the changes despite previously committing to do so, and that representations it made that members would not face out-of-pocket expenses for in-hospital pathology and pathology services were, from 1 September 2014, false and misleading.

“Consumers are entitled to expect that they will be informed in advance of important changes to their private health insurance cover, as these changes can have significant financial consequences at a time when consumers may be vulnerable,” Mr Sims said. “Private health insurers must ensure their disclosure practices comply with the Australian Consumer Law.”

Medibank has rejected the ACCC’s allegations.

“Medibank take sits obligations under the Australian Consumer Law seriously, and has appropriate processes in place to ensure compliance,” a spokesman for the health fund said. “We have been working cooperatively with the ACCC throughout its investigation.”

AMA President Dr Michael Gannon welcomed the ACCC’s action.

Dr Gannon said the AMA has long been highly critical of the actions of insurers making changes to their health cover without informing policy holders, and it was pleasing to see that at least one was now being held to account.

“It has become a distressingly common experience for patients to think they are covered for the cost of medical treatment, only to find that they are lumbered with unexpected out-of-pocket costs,” Dr Gannon said.

“It is completely unacceptable for insurers to make changes to the cover they provide without informing policyholders, and it is very important that this type of behaviour is now being called out.”

The ACCC’s action follows the release earlier this year of the AMA Private Health Insurance Report Card, which showed that many policies offered by health insurers were no better than junk, while others did not provide the cover expected.

The AMA’s analysis of the 40,000 policies offered by the nation’s 33 private health funds has found that Medibank Private, NIB, HCF, HBF, which together account for more than 55 per cent of the health insurance market, are marketing products that, because of multiple exclusions, provide barely more cover than Medicare or, in many instances, provide no additional entitlement at all.

The ACCC last year launched a report highly critical of the quality and accuracy of information provided by the health funds, which the watchdog said served to confuse consumers about what they were covered for and hampered their ability to make informed choices.

Health Minister Sussan Ley has commissioned a review of the private health insurance industry amid widespread discontent about rising premiums and shrinking cover, and the Coalition has promised that if it is re-elected it will institute a rating system for health cover and “weed out” junk policies by mandating a minimum level of cover.

Dr Gannon said it was time insurers were held accountable for their actions, which often caused great financial and emotional distress for patients caught unaware by surprise out-of-pocket expenses.

“Policyholders need to know exactly what they are covered for and are entitled to, rather than being hit with shock bills when they are ill or at their most vulnerable,” he said.

The AMA Private Health Insurance Report Card 2016 is at ama-private-health-insurance-report-card-2016

Adrian Rollins