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As part of the Patients over Paperwork initiative, beginning in March the Centers for Medicare & Medicaid Services (CMS) will streamline its survey and certification process for psychiatric hospitals. Cutting the Red Tape Since launching the Patients over Paperwork initiative in fall 2017, CMS has streamlined regulations to reduce clerical and administrative burdens that weigh […]
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CMS needs to evaluate, clarify, and modify sections of the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, according to public comments made by the American Hospital Association (AHA). The NOTICE Act was signed into law August 2015 and will take effect August 2016. CMS is currently preparing rulemaking to implement the law. The AHA supports the NOTICE Act’s goals of providing patients and their families with timely notification, both written and oral, about their status in the hospital, what inpatient observation is, and the reasons for and implications of that status, such as cost-sharing requirements and eligibility for skilled nursing facility coverage. However, the AHA also raises concerns about the implementation of the act and conflicts and confusion that may arise due to overlapping state laws. The AHA recommends revisions and clarifications be made on the following points:
Hospitals will need to change existing policies and procedures, update information systems, and provide education to staff. A six-month implementation period beginning after the law takes effect would allow hospitals the necessary time to make these changes, the AHA recommends. This would also allow CMS to provide clarification and detailed guidance to hospitals and MACs.
The act’s current notification requirements will include informing the patient of specific cost-sharing and coverage information. However, hospitals often do not know the exact cost-sharing and coverage information until after the patient has been discharged and the claim submitted, the AHA says. CMS should permit and make clear in the final rule that hospitals are allowed to use standard language about applicable Medicare outpatient policies regarding cost-sharing, the prohibition on coverage of self-administered drugs, and other relevant Medicare policies. Additionally, CMS should develop standard written templates for these notifications in simplified language, the AHA says.
The act currently states that if a patient refuses to sign the notification it must be signed and dated by the staff member who presented the written notification. This process should also be explicitly applied in other cases in which the patient is unable to sign due to their mental or medical condition, the AHA says.
On May 18, 2012, CMS initiated the Patient Safety Initiative which included surveyor worksheets for assessing compliance with three hospital Conditions of Participation (CoP): Quality Assessment and Performance Improvement, Infection Control, and Discharge Planning.
The goal of these was to reduce hospital-acquired conditions, including healthcare infections and preventable readmissions.
Maria Del Pilar Messner, corporate director of accreditation, regulations, and licensing at Adventist Health says that this a huge gift for accreditors. If CMS was sharing the surveyor worksheets, why not use them?
Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models
by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called SHFFT (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:
MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.
Model overview
The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.
This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.
Cost outcomes
CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished "target price."
CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.
If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.
Quality-adjusted target price
To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.
The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:
Hospital (accountable party), collaborators, and Advanced Payment Models
The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.
CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.
The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.
CDI program opportunities
There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:
The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.
The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.
Summary
Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.
As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.
Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.
Editor’s note
Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].
Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models
by Shannon Newell, RHIA, CCS, an AHIMA-approved ICD-10-CM/PCS trainer
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called ‘SHFFT’ (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:
MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.
Model overview
The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.
This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.
Cost outcomes
CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished ‘target price.’
CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.
If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.
Quality-adjusted target price
To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.
The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:
Hospital (accountable party), collaborators, and Advanced Payment Models
The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.
CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.
The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.
CDI program opportunities
There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:
The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.
The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.
Summary
Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.
As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.
Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.
Editor’s note
Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].
The Centers for Medicare & Medicaid Services (CMS) announced on Jan. 9 the launch of their Innovation Center’s Bundled Payments for Care Improvement Advanced (BPCI Advanced) payment model. It’s voluntary and can earn providers payment if all costs for a patient’s episode of care are “under a spending target that factors in quality.” This differs […]
AAPC Knowledge Center
Editor’s note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.
CMS’ proposed changes to implement Section 603 of the Bipartisan Budget Act of 2015 would reshape payments for off-campus, provider-based departments (PBD) if finalized and represent the most significant changes in the calendar year (CY) 2017 OPPS proposed rule.
The policy—mandated by Congress for CMS to find a way to implement what is often known as site-neutral payments—certainly had to be a priority for CMS staff while working on the proposed rule, and it may have delayed other initiatives in the works for 2017. Despite this, providers still need to take a close look at other aspects of this year’s proposed rule to accurately forecast the financial impact they may face in CY 2017 and beyond.
Forecasting financials
In the early days of the OPPS, determining the financial impact was a decidedly simpler affair. Providers could simply compare the current year’s payment for a CPT/HCPCS code to the proposed future rate. Essentially, line-item level comparisons were sufficient for your top volume of services or the services that represented the top 20% of your billed charges.
That is no longer the case with CMS’ increased packaging over the years, including the application of conditional packaging through status indicator Q, which requires payment impact to be examined more dynamically. This includes looking at certain services across the claim, as well as looking at the combination of services billed together to determine whether separate payment will be generated.
As policies continued to evolve, such as the introduction of even more comprehensive APCs (C-APC), expanded lab packaging, and an expansion of conditional packaging to the claim level, providers interested in forecasting financial impact will have to engage in far more sophisticated analyses to get their arms around the impact to their bottom line. All of this results in providers needing to engage in a process that now requires more people, more departments, and more information to make informed projections and decisions.
These trends continue in the 2017 OPPS proposed rule, with proposals that will require inter-departmental staff coordination and a nuanced look.
APC restructuring
In last year’s OPPS final rule, CMS moved forward with extensive APC reconfigurations for nine clinical families, following up reconfigurations for two families in the 2015 OPPS final rule. For 2017, CMS didn’t propose as many reconfigurations, but providers should note that even though CMS may not explicitly discuss APC reconfigurations, reconfigurations often occur as a result of the agency’s annual APC recalibration process. This moves CPT/HCPCS codes into and out of existing APCs, which can be uncovered by comparing the current and proposed Addenda B.
An example of explicit restricting that CMS discusses in the rule has to do with imaging service APCs, which CMS addressed in last year’s rule, and is again proposing changes after reviewing stakeholder recommendations. CMS proposes consolidating from 17 APCs to eight in 2017. The newly consolidated APCs would be:
5521, Level 1 Diagnostic Radiology without Contrast
5522, Level 2 Diagnostic Radiology without Contrast
5523, Level 3 Diagnostic Radiology without Contrast
5524, Level 4 Diagnostic Radiology without Contrast
5525, Level 5 Diagnostic Radiology without Contrast
5571, Level 1 Diagnostic Radiology with Contrast
5572, Level 2 Diagnostic Radiology with Contrast
5573, Level 3 Diagnostic Radiology with Contrast
CMS has listed the specific procedures assigned to these APCs, which are all assigned status indicator S (significant procedure not subject to multiple procedure discounting) in Addendum B of the proposed rule. This restructuring will have a financial impact, which could be positive or negative depending on your mix and volume of services.
An example of APC reconfiguration that is not explicitly discussed in the rule has to do with drug administration APCs. Currently, there are five levels of drug administration APCs, but the 2017 proposed rule OPPS Addendum B shows CMS has proposed to eliminate the fifth level, resulting in CPT/HCPCS codes in level 5 being moved to levels 3 and 4. This will have a financial impact which may be positive or negative depending on the individual service and what APC it’s being assigned to, as well as the new calculation of the APC’s relative weight. For example, the initial service hydration CPT code 96360 shows a huge increase in payment while other drug administration services show a decrease. Again, providers will want to examine this impact, as well as weigh in to CMS about whether the agency’s proposed reconfiguration makes clinical sense.
Comprehending C-APCs
Just because it’s now much more complicated to forecast financials based on CMS’ proposals doesn’t mean providers should stop doing it. In fact, as services get rolled up into more complex, comprehensive, and costly bundles, it’s even more important to account for each part and to assess financial impact.
The first step is to identify your most frequently billed services, either by volume or percent of charges. Then, identify the CPT codes from each and look for them in Addendum B of the proposed rule. If the CPT code has a J1 status indicator next to it, you’ll know it’s a C-APC.
At that point, you might want to pull five or 10 claims with that CPT code and look at each item and service reported on the claim with the procedure. If the code, which previously wasn’t associated with a C-APC, is now a J1 service, then you know CMS is proposing it to be paid as a C-APC service. Most other services won’t be paid for separately, even when reported on a different date of service, if they were all reported on the same claim. You can use that information, and the payment rate of the new proposed J1 service, to determine what kind of financial impact CMS’ proposed changes are likely to have on your organization.
Section 603
HIM and finance departments may also need to be involved as hospitals attempt to forecast the impact of the Section 603 provisions that would set payment rates for new PBDs at Medicare Physician Fee Schedule (MPFS) rates instead of the OPPS.
For example, grandfathered hospitals (or “excepted” hospitals, as CMS now calls them) would be paid at MPFS rates instead of OPPS for any expansion of services after November 2, 2015. CMS has identified clinical families at the APC level to define service expansions. Analyzing the impact of CMS’ proposals now is key in understanding the financial impact your organization will face if CMS finalizes its proposals. Additionally, understanding the impact now may help inform providers’ comments to CMS.
Additionally, keep in mind that your facility will not necessarily be losing money just because payments will be according to the MPFS and not the OPPS. That may have been nearly always true five years ago, but as CMS continues to increase packaging, MPFS rates may actually be better for your facility since you’ll be getting paid separately for more items and services. This certainly won’t be true across the board—it might not even be applicable to the majority of facilities. But it’s still worth looking into for those who are worried about facing a massive revenue swing if CMS’ proposal is finalized.
Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS) is on a national whistle-stop tour to listen to physicians and other healthcare professionals. She began her tour at Hartford Hospital in Connecticut Monday, Oct. 16. FierceHealthcare said she spoke with doctors, the Connecticut Medical Society, and other local health leaders about developing more […]
AAPC Knowledge Center
The Center for Medicare & Medicaid Service’s (CMS) Fraud Prevention System generated 22 percent of investigations initiated by program integrity contractors in 2016. That means if you were audited by zone program integrity contractors (ZPIC), it might’ve been the $ 192 million data analytics program that raised the flag. ZPIC contractors told the Government Accounting Office […]
AAPC Knowledge Center
CMS’ 2017 IPPS final rule released
CMS released the fiscal year (FY) 2017 IPPS final rule August 2, and ICD-10-CM/PCS code changes and the addition of the Medicare Outpatient Observation Notice (MOON) both had starring roles. CMS also made changes to several quality initiatives and reversed the agency’s 0.2% payment reduction instituted along with the 2-midnight rule first implemented in the FY 2014 rule.
"Most coders have been hearing about the magnitudes of new codes being added to the ICD-10-CM and ICD-10-PCS code sets, and the final rule does not disappoint," says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, director of HIM and coding for HCPro, a division of BLR, in Middleton, Massachusetts.
ICD-10-CM and ICD-10-PCS updates
The final rule includes tables with nearly 2,600 lines of new ICD-10-CM codes and 14,000 lines of ICD-10-PCS codes on the associated Excel spreadsheets, some of which were not mentioned in the proposed rule, says McCall.
"Even with the thousands of additions to the ICD-10-CM code set, I think many will find that the additions look scarier than they actually are," says McCall. "For example, adding laterality (right, left, bilateral, unspecified) to conditions like diabetes mellitus retinopathy codes (categories E08?E11 and E13) equated to over 250 ‘new’ codes, but in reality, they are just added specificity that equate them to the detail in other eye disorder codes."
The eye disorders (Chapter 7, categories H00?H59) overall have a significant number of additions by way of further specificity like new stages or presence of symptoms?creating over 300 codes in that category, says McCall.
CMS has also introduced nearly 4,000 new codes for ICD-10-PCS in the final rule. But, McCall says, similar to the ICD-10-CM additions, some of the new ICD-10-PCS codes aren’t new procedures, but simply increases in specificity for one or more characters, which may result in hundreds of new codes.
"An example is the added distinction by subdividing the body part option of the thoracic aorta into the ascending/arch and descending portions," says McCall. "Therefore, any PCS table that included an option for the thoracic aorta now includes different body part values for ascending/arch thoracic aorta and descending thoracic aorta. These can create hundreds of codes once you provide all approach options, all device options, and all qualifier options for the associated ICD-10-PCS tables."
One of the more significant coding changes CMS has made, says McCall, is recognizing hundreds of procedures that were illogically considered surgical in ICD-10-PCS for FY 2016 but will be reclassified as nonsurgical in FY 2017. The intent of the transition from ICD-9-CM Volume 3 to ICD-10-PCS was for procedures to remain in the same (or similar) MS-DRGs that they occupied prior to ICD-10 implementation. However, not all codes were successfully reclassified. The 2017 IPPS final rule addresses some of these instances, including percutaneous drainage procedures such as paracentesis, as well as procedures like esophageal banding and arterial catheterization. Tables 6P.4a?6P.4k include all the procedures that will be reassigned as nonsurgical for FY 2017, says McCall.
"The reason for the assignment errors were mapping errors from ICD-9-CM Volume 3 to ICD-10-PCS. For example, the mapping for paracentesis (whether it was diagnostic or therapeutic) should have been to ICD-9-CM Volume 3 procedure code 54.91, but for some reason a diagnostic paracentesis was mapped to 54.29 (other diagnostic procedures on abdominal region)," says McCall.
CMS responded in the final rule to this mapping issue by saying:
We agree with the commenters that diagnostic drainage of the peritoneal cavity is more accurately replicated with ICD-9-CM procedure code 54.91 (percutaneous abdominal drainage) for reporting diagnostic paracentesis procedures and it is designated as a non-O.R. procedure. Therefore, we agree that the designation of ICD-10-PCS procedure code 0W9G3ZX (drainage of peritoneal cavity, percutaneous approach, diagnostic) should also be changed from O.R. to non-O.R.
The MOON form
In addition to creating new diagnosis and procedure codes, CMS also created the MOON as part of the Notice of Observation Treatment and Implication for Care Eligibility Act.
The MOON is a CMS-developed standardized notice hospitals are required to give to Medicare patients. These patients must be receiving observation services as an outpatient for more than 24 hours, and the MOON must be given no later than 36 hours after observation services are initiated. Hospitals must give a verbal explanation of the MOON to patients and obtain a signature to acknowledge receipt and understanding of the notice.
Payment adjustments
CMS also indicated that payment rates will increase by 0.95% in FY 2017 compared to FY 2016 for hospitals participating in the Inpatient Quality Reporting (IQR) Program and EHR meaningful use, according to the rule.
"This also reflects a 1.5 percentage point reduction for documentation and coding required by the American Taxpayer Relief Act of 2012 and an increase of approximately 0.8 percentage points to remove the adjustment to offset the estimated costs of the two-midnight policy and address its effects in FYs 2014, 2015, and 2016," said CMS.
In addition, CMS created two adjustments to reverse the effects of the 0.2% cut it instituted along with the 2-midnight rule, which has been the source of an ongoing legal challenge by the American Hospital Association and other parties. More on this story can be found here: www.hcpro.com/HIM-320994-859/Court-gives-providers-a-chance-to-comment-on-2midnight-rule-payment-reduction.html.
CMS made a permanent adjustment of approximately 0.2% to remove the cut for FYs 2017 and onward, and a temporary adjustment of 0.8% to address the retroactive impacts of this cut for FYs 2014, 2015, and 2016.
Quality program updates
CMS finalized five changes to the Hospital-Acquired Condition Reduction Program in this rule, as well as updates to the IQR Program, changes to the Hospital Readmissions Reduction Program, and updates to the Hospital Value-Based Purchasing Program.
Listening to commenter feedback, CMS reduced requirements for reporting electronic clinical quality measures (eCQM) as part of the IQR Program. Originally, CMS proposed requiring hospitals to submit data on all 15 eCQMs, but finalized a policy requiring hospitals to report four quarters of data on an annual basis for eight of the available eCQMs.
The entirety of the final rule is available in PDF format on the Federal Register, and it is expected to be officially published Monday, August 22. CMS says the rule applies to approximately 3,330 acute care hospitals and approximately 430 long-term care hospitals, and it will affect discharges occurring on or after October 1, 2016.
The final rule can be downloaded here: www.federalregister.gov/public-inspection.
The related CMS fact sheet can be viewed here: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-08-02.html.