/ en Sat, 14 Jun 2025 05:25:22 -0500 Thu, 12 Jun 25 15:16:09 -0500 /cybersecurity-government-intelligence-reports/2022-12-13-tlp-white-nsa-apt5-citrix-adc-threat-hunting-guidance-december-2022 <h2>Executive summary</h2><p>APT5 has demonstrated capabilities against Citrix® Application Delivery Controller™ (ADC™) deployments (“Citrix ADCs”). Targeting Citrix ADCs can facilitate illegitimate access to targeted organizations by bypassing normal authentication controls. As such, NSA, in collaboration with partners, has developed this threat hunting guidance to provide steps organizations can take to look for possible artifacts of this type of activity. Please note that this guidance does not represent all techniques, tactics, or procedures (TTPs) the actors may use when targeting these environments. This activity has been attributed to APT5, also known as UNC2630 and MANGANESE.</p><h2>Introduction</h2><p>NSA recommends organizations hosting Citrix ADC environments take the following steps as part of their investigation. Treat these detection mechanisms as independent ways of identifying potentially malicious activity on impacted systems. Artifacts may vary based on the environment and the stage of that activity. As such, NSA recommends investigating any positive result even if other detections return no findings.</p> Tue, 13 Dec 2022 11:06:06 -0600 Public /2017-12-15-aha-today <div class="container"> <div class="row"> <div class="col-md-8"><img alt="AHA Today News logo" class="align-center" src="/sites/default/files/2023-02/aha-today-logo-900.jpg" /> <p>Thank you for your interest in AHA Today, the ���������� Association’s six-day-a-week email newsletter. Each weekday you’ll get the day’s top news stories, with the context and analysis that hospital and health systems leaders need to lead their organization. And on Saturdays, AHA Today recaps the news of the week that you may have missed.</p> <p>Other regular features include:</p> <ul> <li>Podcasts</li> <li>Blogs</li> <li>Upcoming events and educational opportunities</li> <li>Links to the newest reports and insights</li> <li>Toolkits and other resources</li> <li>Stories from the field spotlighting hospitals’ important work to advance health in the communities they serve</li> </ul> <p>We love your feedback! <a href="https://www.surveymonkey.com/r/BX9J5NR" target="_blank">Take our survey to help us continue to evolve the AHA Today email newsletter.</a></p> <div>   MktoForms2.loadForm("//sponsors.aha.org", "710-ZLL-651", 2219); MktoForms2.whenReady(function(form){ if(form.getId() == 2219 ) { form.onSuccess(function(values, followUpUrl) { form.getFormElem().hide(); document.getElementById("successAndErrorMessages").innerHTML="<p>Thank you, you are now subscribed to AHA Today!<\/p>"; return false; }); }; }); <div id="successAndErrorMessages"> </div> </div> </div> <div class="col-md-4"> <p> </p> </div> </div> </div> h1 { font-size: 3em !important; } .title { font-size: 2em !important; } Fri, 15 Dec 2017 00:00:00 -0600 Public /issue-landing-page/2016-11-16-ensuring-access-vulnerable-communities-taskforce-report-and-resources <div class="container row"><div class="row"><div class="col-md-8"><div class="outlineContent clearfix"><p><img src="/images/taskforce-ban2.jpg" data-entity-uuid data-entity-type alt width="793" height="286"></p><hr><p>Millions of Americans living in vulnerable rural and urban communities depend upon their hospital as an important, and often only, source of care. However, these communities and their hospitals face many challenges. As the hospital field engages in its most significant transformation to date, many are fighting to survive – potentially leaving their communities at risk for losing access to health care services. Recognizing these challenges and the need for new integrated and comprehensive health care delivery and payment strategies, the AHA Board of Trustees created the Task Force on Ensuring Access in Vulnerable Communities. Comprised of 29 hospital and health system leaders and state hospital association CEOs, the task force held meetings, heard from policymakers and conducted field hearings to speak with hospital and community leaders during a 15-month period.<br><br>The Task Force work is ongoing. This webpage is just one of the many ways AHA will keep you connected to the latest developments and resources as we address the critical issue of ensuring access to health care services.</p><hr><h2><span class="color_aha_blue"><strong>Task Force Report</strong></span></h2><p>The task force report outlines nine emerging strategies that can help preserve access to health care services in vulnerable communities. These strategies will not apply to or work for every community and each community has the option to choose one or more that are compatible with its needs.</p><ul><li><a href="/system/files/content/16/ensuring-access-taskforce-exec-summary.pdf" target="_blank">Executive Summary</a><a href="/system/files/content/16/ensuring-access-taskforce-report.pdf"></a></li><li><a href="/system/files/content/16/ensuring-access-taskforce-report.pdf">Full Report</a></li><li><a href="https://www.youtube.com/watch?v=v2TgJDL9O6o">Release Video</a></li><li><a href="/system/files/content/16/taskforce-charts-rural.pdf">Rural Chart Pack</a></li><li><a href="/system/files/content/16/taskforce-charts-urban.pdf">Urban Chart Pack</a></li></ul><hr><h2><strong class="color_aha_blue">Inpatient/Outpatient Transformation Strategy</strong></h2><ul><li><a href="/system/files/2018-02/inpatient-outpatient-transformation-strategy.pdf">Emerging Strategies to Ensure Access to Health Care Services – Inpatient/Outpatient Transformation</a></li></ul><hr><h2><strong class="color_aha_blue">Social Determinants of Health Strategy</strong></h2><ul><li><a href="/system/files/2018-02/social-determinants-health.pdf">Emerging Strategies to Ensure Access to Health Care Services - Social Determinants</a></li><li><a href="http://www.hpoe.org/Reports-HPOE/2017/AHA-community-health-initiatives.pdf">Community Health Initiatives at the ���������� Association</a></li><li><a href="http://www.hpoe.org/Reports-HPOE/2017/determinants-health-food-insecurity-role-of-hospitals.pdf">AHA Social Determinants of Health Series - Food Insecurity and the Role of Hospital</a></li><li><a href="http://www.hpoe.org/resources/ahahret-guides/3063">AHA Social Determinants of Health Series - Housing and the Role of Hospitals</a></li></ul><hr><h2><strong class="color_aha_blue">Virtual Care Strategies</strong></h2><ul><li><a href="/system/files/content/17/task-force-virtual-care-strategies.pdf" target="_blank">Emerging Strategies to Ensure Access to Health Care Services – Virtual Care Strategies</a></li><li><a href="/system/files/content/17/telehealth-case-examples.pdf">Telehealth — Delivering the Right Care, at the Right Place, at the Right Time: Case Examples of AHA Members in Action</a></li></ul><hr><h2><strong class="color_aha_blue">Emergency Medical Center Strategy</strong></h2><ul><li><a href="/system/files/2018-06/task-force-emergency-medical-center.pdf" target="_blank">Emerging Strategies to Ensure Access to Health Care Services – Emergency Medical Center</a></li><li><a href="/system/files/2018-05/emergency-medical-center-strategy-5-2018-jk.pdf">Comparison: Federal Policy Solutions to Ensure Access to Emergency Services</a></li><li><a href="/2018-05-07-overview-rural-emergency-medical-center-act">The Rural Emergency Medical Center Act of 2018</a></li><li><a href="/letter/2018-05-08-aha-rep-ron-kind-support-rural-emergency-medical-center-act-2018-hr-5678">AHA Action Alert on REMC Act (members-only)</a></li><li><a href="/letter/2018-05-08-aha-rep-ron-kind-support-rural-emergency-medical-center-act-2018-hr-5678">AHA Letter of Support of the REMC Act (Kind)</a></li><li><a href="/letter/2018-05-08-aha-rep-lynn-jenkins-support-rural-emergency-medical-center-act-2018-hr-5678">AHA Letter of Support of the REMC Act (Jenkins)</a></li><li><a href="/press-releases/2018-05-07-aha-applauds-introduction-rural-emergency-medical-center-act-2018">Press Release Applauds Introduction of REMC Act</a></li><li><a href="/letter/2017-05-18-aha-expresses-support-rural-emergency-acute-care-hospital-reach-act-s-1130">AHA Letter of Support Rural Emergency Acute Care Hospital (REACH) Act, S. 1130</a></li></ul><hr><h2 class="color_aha_blue">Indian Health Services Strategy</h2><ul><li><a href="/system/files/2018-01/stategies-to-ensure-access.pdf">Emerging Strategies to Ensure Access to Health Care Services - IHS</a></li><li><a href="/letter/2017-05-26-aha-reps-walden-pallone-re-bipartisan-indian-health-service-task-force">AHA Letter of Support for IHS Task Force (Walden/Pallone)</a></li><li><a href="/letter/2017-05-26-aha-sens-mullin-ruiz-re-bipartisan-indian-health-service-task-force">AHA Letter of Support for IHS Task Force (Mullin-Ruiz)</a></li></ul><hr><h2><strong class="color_aha_blue">Urgent Care Center Strategy</strong></h2><ul><li><a href="/content/17/emerging-strategies-urgent-care-centers.pdf" target="_blank">Emerging Strategies to Ensure Access to Health Care Services – Urgent Care Centers</a></li><li><a href="/content/17/urgent-care-center-discussion-guide.pdf" target="_blank">Is the Urgent Care Center the Right Strategy for your Community</a></li></ul><hr><h2><strong class="color_aha_blue">Global Budgets</strong></h2><ul><li><a href="/system/files/media/file/2019/03/task-force-global-budget-2017.pdf">Emerging Strategies to Ensure Access – Global Budgets</a></li></ul><hr><h2><strong class="color_aha_blue">Community Conversations</strong></h2><ul><li><a href="/content/17/community-conversations-toolkit.pdf">Ensuring Access in Vulnerable Communities: Community Conversations Toolkit</a></li><li><a href="/content/17/taskforcevulncomm-discussionguide.pdf">Discussion Guide for Boards and Hospital Leadership</a></li><li><a href="http://www.hpoe.org/resources/ahahret-guides/3061">A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health</a></li><li><a href="http://www.hpoe.org/Reports-HPOE/2016/creating-effective-hospital-community-partnerships.pdf">Creating Effective Hospital Community Partnerships to Build a Culture of Health</a></li><li><a href="http://www.healthycommunities.org/Resources/toolkit.shtml#.WYjFtITyt0y">Community Health Assessment Toolkit</a></li><li><a href="/ahahret-guides/2016-06-09-engaging-patients-and-communities-community-health-needs-assessment">Engaging Patients and Communities in the Community Health Needs Assessment Process</a></li><li><a href="http://hospitalsocialmedia.tumblr.com/">A Hospital Leadership Guide to Digital and Social Media</a></li><li><a href="/advancing-health-in-america">Advancing Health in America</a></li><li><a href="/ahahret-guides/2013-01-01-engaging-health-care-users-framework-healthy-individuals-and-communities">AHA Framework for Engaging Health Care Users</a></li><li><a href="/ahahret-guides/2015-01-28-leadership-toolkit-redefining-h-engaging-trustees-and-communities">Leadership Toolkit for Redefining the H: Engaging Trustees and Communities</a></li><li><a href="/system/files/2018-02/leadership-role-nonprofit-health-systems.pdf">The Leadership Role of Nonprofit Health Systems in Improving Community Health</a></li><li><a href="/system/files/2018-02/critical-conversations-to-changing-health-environment.pdf">Critical Conversations on the Changing Health Environment: Physician Engagement</a></li></ul><hr><h2><strong class="color_aha_blue">Frontier Health System</strong></h2><ul><li><a href="/system/files/content/17/task-force-frontier-2017.pdf">Emerging Strategies to Ensure Access — Frontier Health System</a></li></ul><hr><h2><strong class="color_aha_blue">Rural Hospital-Health Clinic Integration</strong></h2><ul><li><a href="/factsheet/2018-08-02-emerging-strategies-ensure-access-health-care-services">Emerging Strategies to Ensure Access — Rural Hospital-Health Clinic Integration</a></li></ul><hr><h2><strong class="color_aha_blue">Other Resources</strong></h2><ul><li><a href="http://www.hpoe.org/Reports-HPOE/2017/improving-care-for-high-need-high-cost-patients.pdf" target="_blank">Improving Care for High-Need, High-Cost Patients</a></li><li><a href="/data-and-insights/presentation-center/ensuring-access" target="_blank">Ensuring Access in Vulnerable Communities PowerPoint Presentation</a></li></ul></div></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><a href="/case-studies/2018-02-02-hospitals-and-health-systems-ensuring-access-their-communities">Hospitals and Health Systems Ensuring Access in Their Communities: Downloadable PDF</a></h3></div><div class="panel-body"><p><a href="/case-studies/2018-02-02-hospitals-and-health-systems-ensuring-access-their-communities"><img src="/sites/default/files/inline-images/ensuring-access-case-study-comp-rural-sm_0.jpg" data-entity-uuid="32d51105-e12e-468b-8f23-e4ae7c7aa262" data-entity-type="file" alt="Hospitals and Health Systems Ensuring Access in Their Communities cover" width="319" height="413">This is a compendium of case examples of AHA members from across the country employing the nine emerging strategies recommended by the association’s Task Force on Ensuring Access in Vulnerable Communities.</a></p></div></div></div></div></div> Wed, 16 Nov 2016 00:00:00 -0600 Public /role-hospitals-new-program-texas-health-harris-methodist-alliance-supports-laboring-mothers-throughout-delivery <div class="container"><div class="row"><div class="col-md-9"><div class="col-md-5"><p><img src="/sites/default/files/2025-06/ths-teambirth-alliance-shannonm-700x532.png" data-entity-uuid data-entity-type="file" alt="Texas Health Harris Methodist Hospital Alliance team member Shannon Manchesi" width="700" height="532"></p><p><em>Shannon Manchesi. </em></p><p><em>Photo Credit: Texas Health Harris Methodist Hospital Alliance</em></p></div><p>When Crystal arrived at Texas Health Harris Methodist Hospital Alliance to deliver her third child, she was met with a new approach to childbirth that immediately put her at ease. As the first patient to experience the newly launched TeamBirth program, Crystal noticed a significant shift in how her care team communicated. The shared decision-making model centered around a planning board and regular “huddles” that included her, her support person and the entire care team. These collaborative discussions helped Crystal feel seen and heard, especially after past experiences with postpartum hemorrhage and postpartum depression left her anxious about giving birth again. “I felt like we were all on the same page. They did a good job at explaining what was happening throughout the entire process,” Crystal said. “My transition to the mother-baby unit once Gunner arrived was also smooth.”</p><p>“Talking with detail and communicating every step helped decrease her anxiety,” said Shannon Manchesi, the labor and delivery nurse who cared for Crystal. “We want every woman giving birth to feel empowered to participate in decisions made during labor and delivery,” added Tina Gist, M.S.N., R.N., director of nursing, women and children and critical care. With TeamBirth, Crystal felt in control and supported throughout the process, transforming what could have been a stressful experience into one of comfort and trust.</p><p><a class="btn btn-primary" href="https://www.texashealth.org/newsroom/News-Releases/2025/TeamBirth-Helps-Mom-Feel-in-Control"><strong>LEARN MORE</strong></a></p></div><div class="col-md-3"><div><h4>Resources on the Role of Hospitals</h4><ul><li><a href="/topics/innovation">Innovation, Research and Quality Improvement</a></li><li><a href="/roleofhospitals">All Case Studies</a></li></ul></div></div></div></div> Thu, 12 Jun 2025 15:16:09 -0500 Public /role-hospitals-jefferson-health-program-aims-fast-track-philly-high-school-students-demand-entry-level-health-care-jobs <div class="container"><div class="row"><div class="col-md-9"><div class="row"><div class="col-md-7"><img src="/sites/default/files/2025-06/ths-jefferson-teen-workforce-700x532.jpg" data-entity-uuid data-entity-type="file" alt="Jefferson Health program aims to fast-track Philly high school students into in-demand, entry-level health care jobs. Female health worker instructs young female trainee on using IV bags" width="700" height="532" class="align-left"></div><p>After graduating from high school last June, Antoinette Smith-Bethea began working as a patient care technician at Jefferson Einstein Philadelphia Hospital, where she learned to check vitals, draw blood, and perform EKGs. Her ready-for-market skills were earned courtesy of the Jefferson Workforce Development Program, a collaboration between Jefferson Health, the School District of Philadelphia, and Esperanza College that aims to address the high turnover in entry-level health care positions by providing students with 1,000 hours of classroom instruction and hands-on training at Jefferson Einstein Philadelphia Hospital.</p><p>The program also includes a specialized skill boot camp to help students interested in health care careers with résumé building, job applications, and understanding Jefferson's orientation and onboarding practices. Smith-Bethea is one of 18 students who completed the program. She is scheduled to earn an associate’s degree in health sciences in May and then plans to apply for a position as an ultrasound technician.</p><p>Health care is one of the fastest-growing industries in the U.S., driven by rising life expectancy and advances in medical technology. By next year, the industry expects a nationwide shortage of 3.2 million health care workers, including medical assistants, patient care technicians, and surgery technicians. The Jefferson Workforce Development Program serves as an on-ramp into health care, helping students secure good-paying jobs and fill workforce needs.</p><p><a class="btn btn-primary" href="https://whyy.org/articles/entry-level-health-care-jobs-philadelphia-high-schools-jefferson/">LEARN MORE</a></p><p> </p></div></div><div class="col-md-3"><div><h4>Resources on the Role of Hospitals</h4><ul><li><a href="/workforce-home">Workforce</a></li><li><a href="/roleofhospitals">All Case Studies</a></li></ul></div></div></div></div> Thu, 12 Jun 2025 14:44:49 -0500 Public /testimony/2025-06-11-aha-statement-house-energy-commerce-subcommittee-health-hearing-june-11-2025 <p class="text-align-center"><strong>Statement</strong></p><p class="text-align-center"><strong>of the</strong></p><p class="text-align-center"><strong>���������� Association</strong></p><p class="text-align-center"><strong>for the</strong></p><p class="text-align-center"><strong>Committee on Energy and Commerce </strong></p><p class="text-align-center"><strong>Health Subcommittee</strong></p><p class="text-align-center"><strong>of the</strong></p><p class="text-align-center"><strong>U.S. House of Representatives</strong></p><p class="text-align-center"><strong>“Made in America: Strengthening Domestic Manufacturing and the Health Care Supply Chain”</strong></p><p class="text-align-center"><strong>June 11, 2025</strong></p><p>On behalf of our nearly 5,000 member hospitals and health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — the ���������� Association (AHA) appreciates the opportunity to submit this statement for the record to the Committee on Energy and Commerce Health Subcommittee hearing “Made in America: Strengthening Domestic Manufacturing and the Health Care Supply Chain.”</p><p>The AHA believes it is necessary to strengthen the domestic supply chain for essential pharmaceutical and other medical products and recognizes the value of reducing reliance on international sources. We are also aware that achieving this goal will require significant time due to the logistical complexity and resources involved in reorienting medical and pharmaceutical supply chains.</p><p>Each day in America’s hospitals and health systems, patients receive safe and effective care from provider teams using a wide array of pharmaceuticals and medical devices. Patients’ lives depend on the ready availability of drugs and devices to respond to emergent conditions like heart attacks and infections, and other critical illnesses like cancer and organ failure. The medical supply chains for pharmaceutical products and other medical devices are highly complex, requiring hospitals to draw on domestic and international sources. These supply chains are prone to significant disruption from a wide range of factors, including transportation interruptions, natural disasters, raw materials shortages and production breakdowns.</p><p>Despite ongoing efforts to bolster the domestic supply chain, international sources still supply a significant proportion of essential medical goods. For example, nearly 70% of medical devices marketed in the U.S. are manufactured exclusively overseas.<sup>1</sup> In 2024 alone, the U.S. imported over $75 billion in medical devices and supplies, according to AHA analysis of Census Bureau data. These imports include many low-margin, high-use essentials for hospital settings that are necessary for patient care. Some of these devices are single-use, designed to protect patients from infection, such as single-use blood pressure cuffs, stethoscope covers and sterile drapes. Others are small devices used ubiquitously in hospitals, such as anesthesia instruments, cautery pencils, needles, syringes and pulse oximeters. The low-margin nature of these products makes them difficult to produce within the U.S. At the same time, disruption in the availability of these devices would curtail hospitals’ ability to perform life-saving surgeries and keep patients safe from contagion, as well as hinder providers’ ability to effectively diagnose, monitor and treat patients.</p><p>Many pharmaceuticals are also sourced from overseas. For example, U.S. providers import many cancer and cardiovascular medications, immunosuppressives, antibiotics and combination antibiotics. For many patients, even a temporary disruption in their access to these needed medications could put them at significant risk of harm, including death. Carefully planned chemotherapy treatments and antibiotic schedules are essential to giving patients the best chance of overcoming their diseases. Similarly, the provision of necessary cardiovascular medications must be continuous to preserve their cardiovascular health.</p><p>As of the first quarter of 2025, there are 270 drugs on the active shortage list.<sup> </sup>A recent Government Accountability Office analysis found that the duration of drug shortages has increased, with nearly 60% of drug shortages lasting two or more years in 2024, compared to only one-third of shortages lasting that long in 2019.<sup>2</sup> In addition to finished pharmaceutical products, the U.S. sources many raw ingredients internationally for pharmaceuticals. These raw ingredients are commonly known as active pharmaceutical ingredients (APIs) and are the most important components of any pharmaceutical manufacturer’s supply chain. The U.S. gets nearly 30% of its APIs from China, and according to a 2023 Department of Health and Human Services estimate, over 90% of generic sterile injectable drugs — including many chemotherapy treatments and antibiotics — depend on APIs from either India or China. <sup>3</sup> While these statistics are an indicator of the importance of reshoring to protect America’s interests and strengthen the pharmaceutical and medical device supply chains, reshoring cannot, on its own, provide the supply chain stability needed to ensure unrestricted access to necessary drugs and devices for patient care. Included in the 270 active drug shortages are the lingering shortages of intravenous (IV) fluids stemming from the impacts of Hurricane Helene on a large North Carolina production facility in 2024.<sup>4</sup> Despite that facility being located on American soil, it was not impervious to supply chain disruptions. While AHA is supportive of efforts to onshore and reshore pharmaceutical and medical device supply chains, domestic disruptions highlight the need for a diverse supply chain that includes international sourcing.</p><p>To that end, a critical step in protecting America’s pharmaceutical and medical supply chains is understanding vulnerabilities from the beginning of production to the moment a drug is administered to a patient or a device is used to deliver care. Supply chain vulnerabilities often only become apparent when the chain has been broken, as in the case of the IV fluid shortage that resulted from Hurricane Helene. Proactively mapping and assessing the pharmaceutical supply chain, as well as supply chains for other medical devices and equipment, is an important step to improving resiliency in U.S. supply chains and protecting patients’ access to care.</p><p>The AHA recently expressed support for S. 1784, the Mapping America’s Pharmaceutical Supply (MAPS) Act. The bill would codify a recent executive order from the administration to secure essential medicine supply chains.<sup>5</sup> Additionally, it would require the Department of Health and Human Services to perform a comprehensive risk assessment of the entire U.S. pharmaceutical supply chain. The MAPS Act is an effective step toward strengthening the U.S. pharmaceutical and medical device supply chains. The AHA encourages the House of Representatives to take up similar legislation and look for more opportunities to encourage both onshoring and diversity in the supply chain to ensure health care resilience and protect U.S. national security.</p><p>Strengthening supply chains for essential pharmaceutical and other medical products is necessary, and the AHA recognizes the value of reducing reliance on international sources. Achieving this goal will require significant time and resources, given the complexity of medical and pharmaceutical supply chains, and the importance of supply chain diversity, in addition to the reshoring goal, should not be underestimated. AHA appreciates the committee’s attention to this topic and looks forward to further collaboration in the future.</p><div><hr><div id="ftn1"><p><small class="sm"><sup>1 </sup> </small><a href="https://www.medicaldevice-network.com/analyst-comment/trump-tariffs-us-medical-device-market/" target="_blank" title="(opens in a new window)"><small class="sm">https://www.medicaldevice-network.com/analyst-comment/trump-tariffs-us-medical-device-market/</small></a></p><p><small class="sm"><sup>2</sup> Drug Shortages: HHS Should Implement a Mechanism to Coordinate Its Activities GAO-25-107110. April 09, 2025. Publicly Released: April 09, 2025.</small><br><small class="sm"><sup>  3</sup>  </small><a class="ck-anchor" href="https://aspe.hhs.gov/sites/default/files/documents/3a9df8acf50e7fda2e443f025d51d038/HHS-White-Paper-Preventing-Shortages-Supply-Chain-Vulnerabilities.pdf" id="https://aspe.hhs.gov/sites/default/files/documents/3a9df8acf50e7fda2e443f025d51d038/HHS-White-Paper-Preventing-Shortages-Supply-Chain-Vulnerabilities.pdf"><small class="sm">https://aspe.hhs.gov/sites/default/files/documents/3a9df8acf50e7fda2e443f025d51d038/HHS-White-Paper-Preventing-Shortages-Supply-Chain-Vulnerabilities.pdf</small></a><small class="sm"> </small></p></div></div><p><small class="sm"><sup>4 </sup></small><a href="https://www.ashp.org/drug-shortages/shortage-resources/drug-shortages-statistics" target="_blank" title="(opens in a new window)"><small class="sm">https://www.ashp.org/drug-shortages/shortage-resources/drug-shortages-statistics</small></a></p><p><small class="sm"><sup>5</sup> </small><a href="https://www.rickscott.senate.gov/2025/5/sen-rick-scott-colleagues-introduce-the-maps-act-to-boost-u-s-medicine-supply-chain-curb-dependence-on-communist-china"><small class="sm">https://www.rickscott.senate.gov/2025/5/sen-rick-scott-colleagues-introduce-the-maps-act-to-boost-u-s-medicine-supply-chain-curb-dependence-on-communist-china</small></a><small class="sm"> </small></p> Wed, 11 Jun 2025 15:09:49 -0500 Public /news/perspective/2025-06-11-uniting-protect-access-care <p>The fate of the Trump administration’s legislative centerpiece — the One Big Beautiful Bill Act — continues to be the focal point in Washington, D.C.</p><p>After the bill’s narrow passage in the House, the Senate is working to put its own stamp on the reconciliation package, which encompasses policy changes on taxes, border security, energy and deficit reduction, including significant changes and cuts to Medicaid and other health care programs. Republicans are aiming to have the legislation through the Senate by the July 4 congressional recess; however, any changes made by the Senate would have to go back to the House for approval.</p><p>We continue to express concern about the harmful Medicaid and Health Insurance Marketplace provisions included in the House-passed bill, which would cut more than $800 billion from health care programs and result in almost 11 million people losing health care coverage. These cuts will strain already overburdened hospitals and emergency departments as they become the family doctor for millions of newly uninsured Americans, which makes care less accessible for everyone. They also would also set off a damaging ripple effect of job and economic losses as hospitals and communities struggle to manage under the weight of these cuts. Moreover, these payment reductions will simply become an additional “hidden tax” on other purchasers of health care services.</p><p>In particular, we also continue to be focused like a laser beam on ensuring the preservation of legitimate provider tax and supplemental payment programs, which serve as patches to help finance a chronically underfunded Medicaid program. The notion that these programs represent waste and fraud are far from the truth, as they operate within federal guidelines and are approved by state governments and by both Democratic and Republican administrations, including the Trump administration. Yet even with these financing mechanisms, Medicaid payments to providers are less than the cost of caring.</p><p>The Senate Finance Committee, which has jurisdiction over taxes and Medicaid, as soon as this week could release its legislative text, and there have been some discussions about additional restrictions on Medicaid state directed payments and provider taxes. This would further exacerbate the chronic underpayment for Medicaid services and threaten access to care for all patients in communities across the country.</p><p><strong>We continue to pull all levers to limit the scope and magnitude of health care reductions contained in this package.</strong> We have been meeting with senators and their staff to explain the devastating effects some of the policy changes under consideration would have on the people and communities they represent.</p><p>Meanwhile, the AHA is running targeted advertising using multiple platforms, including digital, social and traditional media, urging Congress to protect Medicaid and access to care. At the same time, the <a href="https://strengthenhealthcare.org/" title="Coalition to Strengthen America's Healthcare">Coalition to Strengthen America’s Healthcare</a>, of which the AHA is a founding member, is running ads on TV, podcasts, radio, newsletters and other digital platforms targeted at key senators and influencers. The Coalition also is engaging its grassroots supporters, and since February, the Coalition has generated more than 400,000 letters to Congress about the importance of Medicaid.</p><p>On Tuesday, June 17, we will host an Advocacy Day in Washington, D.C., during which our team will provide the latest updates on the reconciliation bill before hospital and health system leaders meet with their lawmakers. on Capitol Hill. If you cannot be in <a href="https://forms.office.com/pages/responsepage.aspx?id=QJMRube-Xk6EsjzBj3s2pnUzMzymJWtHjxrQd2BoFRpUNDNVUkdGWjYyRlJJTUNUVU8wWjVBNTRNWC4u&route=shorturl">Washington</a>, AHA members can register<a href="https://aha-advocacy.ispresenting.live/register/" title="Register to attend virtually for AHA Advocacy Day"> </a>to participate in the event virtually.</p><p>In addition, we continue to produce <a href="/advocacy/advocacy-issues/medicaid" title="new resources">new resources</a>, including how the bill’s Medicaid reductions could lead to job and <a href="/fact-sheets/2025-06-05-medicaid-spending-reductions-would-lead-losses-jobs-economic-activity-and-tax-revenue-states" title="Medicaid Spending Fact Sheet">economic losses in states</a>, as well as why Medicaid is so important to <a href="/fact-sheets/2025-06-05-medicaid-coverage-supports-rural-patients-hospitals-and-communities" title="Medicaid Supports rural hospitals and communities">rural hospitals and communities</a>. We also are running a <a href="/advocacy/advocacy-issues/medicaid" title="Medicaid video series">video series</a> in which hospital and health system leaders share the importance of Medicaid and how drastic cuts would impact access to care for their patients and communities.</p><p><strong>We’re at a critical juncture.</strong><em><strong> </strong></em><strong>It’s so important for hospital leaders, patients and community members to </strong><a href="/2020-10-07-get-involved" title="Contact your Senators"><strong>weigh in now with your senators</strong></a><strong> and tell them “Don’t Cut Hospital Care.” Your stories have the most impact with your lawmakers, and now is the time to tell them.</strong></p> Wed, 11 Jun 2025 14:38:10 -0500 Public /role-hospitals-uva-health-aims-reduce-carbon-footprint-paper-pill-bottles <div class="container"><div class="row"><div class="col-md-9"><div class="col-md-5"><p><img src="/sites/default/files/2025-06/ths-uva-paper-pill-bottles-700x532.jpg" data-entity-uuid data-entity-type="file" alt="UVA Health. An orange plastic pill bottle is shown on the left, next to one of UVA's new paper pill bottles " width="700" height="532"></p></div><p>At UVA Health, the iconic orange plastic pill bottle is getting a makeover. Some prescriptions are now being filled in a new, recyclable paper bottle. Made with 100% recyclable materials and a compostable paper core, the bottles, called Tully Tubes, debuted at some UVA Health pharmacies in April. They will eventually be available in all UVA Health pharmacy locations. The bottles are still child- and moisture-resistant.</p><p>“Traditional plastic vials can be difficult to recycle, but sustainable alternatives that maintain safety, quality and usability have been limited,” said (https://newsroom.uvahealth.com/2025/04/22/uva-health-pharmacy-paper-pill-bottles/) Carrie Kovacik, PharmD, manager of UVA Health’s ambulatory pharmacy supply chain. “These paper-based bottles offer a step forward in reducing our introduction of single-use plastics into our community.”</p><p>The paper bottles cost about the same to produce as traditional plastic bottles while generating about 30% less carbon. The reduction of UVA Health’s carbon footprint by switching entirely to paper bottles would be the equivalent of not driving more than 24,000 miles in a gas-powered vehicle.</p></div><div class="col-md-3"><div><h4>Resources on the Role of Hospitals</h4><ul><li><a href="/topics/innovation">Innovation, Research and Quality Improvement</a></li><li><a href="/roleofhospitals">All Case Studies</a></li></ul></div></div></div></div> Wed, 11 Jun 2025 10:50:32 -0500 Public /advancing-health-podcast/2025-06-11-ecosystem-approach-health-across-michigan-communities <p>To celebrate Community Health Improvement (CHI) Week, June 9 – June 13, two experts from Corewell Health share how an impactful health care ecosystem model is supporting local Michigan communities, and why creating region-specific programs, from school-based clinics to school nursing initiatives, has been effective for improving community health.</p><p>Visit <a href="/center/community-health-improvement-week">/center/community-health-improvement-week</a> to learn more about the work hospitals and health systems are doing for their communities.</p><hr><div></div><div class="raw-html-embed"><details class="transcript"> <summary> <h2 title="Click here to open/close the transcript."> <span>View Transcript</span><br> </h2> </summary> <p> 00:00:01:04 - 00:00:31:25<br> Tom Haederle<br> Welcome to Advancing Health. An increasing number of hospitals today are part of a larger health system. How can the big systems support the mission of their local member hospitals, while avoiding a one size fits all approach that may not work for everyone? As we recognize Community Health Improvement Week, we learn more about Michigan-based Corewell Health's approach, from tactical support to collaborative community partnerships that helps each hospital or health system be the best it can be. </p> <p> 00:00:31:27 - 00:00:54:23<br> Andrew Jager<br> My name is Andrew Jager at the AHA. Today, it's my pleasure to be joined by two colleagues from Corewell Health in Michigan. With me we have Dr. Corey Smith and Vanessa Briggs. Today, as part of Community Health Improvement Week, we're going to talk a little bit about the role of a health system in supporting hospitals to maintain a really robust process in identifying and understanding the health needs of the local communities that they serve. </p> <p> 00:00:54:26 - 00:01:09:14<br> Andrew Jager<br> Now, I'd like to turn to our guest to hear a little bit about how you see the role of health systems like Corewell Health in supporting local hospital offers to identify, understand and to address community health needs. Starting with Vanessa, how do you see the role of Corewell in this? </p> <p> 00:01:09:17 - 00:01:45:24<br> Vanessa Briggs<br> That's a really great question. And some of the lessons I think, that we've learned here at Corewell Health. It really does take a collaborative process. And that really requires diverse voices and perspectives and lived experiences, because that engagement process is really critical, because we think about -when we do CHNA - as an ecosystem. And an ecosystem model that can be replicated across all three regions, given the spanned and reach that Corewell Health has within Michigan. </p> <p> 00:01:45:27 - 00:02:29:05<br> Vanessa Briggs<br> And so our CHNA ecosystem is made up of public health partners, health and human service organizations, community based organizations, as well as community advocates. And we also include our Corewell Health local community board representatives and health professionals that have local but yet regional specific insight into the needs that are happening and needed within community. And so when we work alongside all of those individuals, when we call our ecosystem, it really allows us to deliver programs and work alongside our community to engage throughout the entire process for the CHNA. </p> <p> 00:02:29:07 - 00:02:40:04<br> Andrew Jager<br> I love that, Vanessa, really taking that ecosystem approach and then intentionally bringing in those local community voices to create that strong effort. Corey, what would you add to Vanessa's response? </p> <p> 00:02:40:06 - 00:03:03:02<br> Corey Smith, Ph.D.<br> Well, the one thing I would add is, for a health system like Corewell Health, it can be sometimes easy to think, given our size, that we are kind of the main actor in a space. Right? And I think it's important, especially at the regional level, at the local level, to remember the kind of the legacy and positionality that some of these local hospitals have in their communities and that they are a part of the fabric. </p> <p> 00:03:03:02 - 00:03:30:00<br> Corey Smith, Ph.D.<br> Right. And so I think in some of our regions, and one of the things that we're trying to lift up as best practice is to be conduct doing the needs assessment process as part of a collective, right, a collective group in collaboration with public health departments, with local organizations, with school districts and other stakeholders that have some interest and where it's relevant for them to be aware of and participating in the process of defining community health needs, </p> <p> 00:03:30:00 - 00:03:30:18<br> Corey Smith, Ph.D.<br> right? </p> <p> 00:03:30:20 - 00:03:55:13<br> Andrew Jager<br> Yeah, I love that sort of intentionality of recognizing the true complexity across the communities, the legacy, different perspectives, and the intentionality of bringing all those together in a process is great. So moving on to that process, I guess I'd ask Vanessa, you know, from the system level, what would you say are some of the most important resources or tools that that you can use to support that local priority identification? </p> <p> 00:03:55:15 - 00:04:22:08<br> Vanessa Briggs<br> Yeah. At Corewell we firmly believe that technical support to help prioritize and help our local hospitals and stakeholders. It really has to align all focus areas effectively. And so having that technical support that Corey's team actually provides for my team in healthier communities is critical to the success. And that's a huge resource that's beneficial to us. </p> <p> 00:04:22:10 - 00:04:28:18<br> Vanessa Briggs<br> And I'm sure Corey has some other examples that that he would like to share in terms of some resources as well. </p> <p> 00:04:28:21 - 00:04:44:24<br> Andrew Jager<br> Yeah, I'd love to hear Corey's thoughts, especially around, you know, what do you think about when you try to balance standardization across the hospitals in your health system and data collection, reporting, etc., with the flexibility that local teams really need to to get at those needs and address them in a local way? </p> <p> 00:04:44:26 - 00:05:16:09<br> Corey Smith, Ph.D.<br> Yeah, it's one of the main tensions that we wrestle with, right? And it can be enticing to want to go with standardizing across systems. Right. It's simpler. You know you can feel like you're focusing, but when you bring it to local stakeholders, it can feel misaligned with what they actually need and what they experience. So, you know, I think stepping back from the actual process of identifying the needs rather than bringing forth a standard set of here are the needs that we're going to identify at each hospital across our system. </p> <p> 00:05:16:11 - 00:05:52:24<br> Corey Smith, Ph.D.<br> We try to frame it as here is our broad theory of change for how we think we can address health needs across the Corewell Health service area, right? We think we need to have a balanced approach to investing in, initiatives that are going to create change at lots of different levels. And so rather than saying this is exactly, you know, the condition or the need that you need to work towards trying to offer a way to work rather than a how to work, I think is a critical part of what we try to bring into both the CHNA, the community health assessment needs process, but also the development of the strategies and response to that </p> <p> 00:05:52:24 - 00:06:17:18<br> Corey Smith, Ph.D.<br> process. So I think that's part of the way we balance that tension. And then we've thought a lot about, you know, what is a system's sort of backbone look like for local teams doing this work. And what kind of technical support can we bring to the table, whether it's, you know, in the in the form of how to create better surveys, whether it's in the form of bringing forth access to publicly available data sets that look more at community need. </p> <p> 00:06:17:21 - 00:06:41:15<br> Corey Smith, Ph.D.<br> Mining census data. Mining other forms of information that, you know, the communities themselves, they may have the capacity, but not the time necessarily to do that work. And even more recently, what tools are available from a technology standpoint site now that even boost the efficiency of accessing that kind of information even more, right? There are tools now that, you know, make that an even simpler process. </p> <p> 00:06:41:15 - 00:06:49:23<br> Corey Smith, Ph.D.<br> And then how do we make that data more publicly available to people to use as part of the CHNA process or in their own work? Right? </p> <p> 00:06:49:25 - 00:07:09:10<br> Andrew Jager<br> Those are such good examples of kind of how you think about balancing that tension, as you mentioned, between kind of having a standard set of measures and having things resonate with the local communities that you serve. You talked about, I think, Vanessa, there are three regions across Michigan that you serve. So I wonder, you know, from a practical level, what does this work look like? </p> <p> 00:07:09:10 - 00:07:14:24<br> Andrew Jager<br> Could you share how it plays out, maybe, in one of the initiatives from 1 or 2 of those regions? </p> <p> 00:07:14:27 - 00:07:47:06<br> Vanessa Briggs<br> So the way that we like to approach our work is we sort of like to say we use a system wide approach and we're developing what we're calling program portfolios that allows us to encapsulate programs that healthier communities can deliver at a regional level. This approach gives us a system wide strategy, but it gives us local context within the regions across east, west and south by addressing the needs that we have identified within our 21 hospitals. </p> <p> 00:07:47:08 - 00:08:28:13<br> Vanessa Briggs<br> And so examples of those programs, it ranges from doing school based clinics on the east side of the state, where we're actually providing primary care in the school for our students, as well as for residents in community. And the west side of the state, we have a school nursing program that allows us to have a different model, but yet still in the schools, providing training for the school administrative staff, providing basic care for our students in the schools, and helping them manage their chronic diseases whether it's asthma or diabetes. </p> <p> 00:08:28:15 - 00:08:54:09<br> Vanessa Briggs<br> So that's why we're able to sort of customize our approaches, but yet still have, if you will, a collection of programs in a portfolio that addresses the needs of children, adolescents in a school environment. And so that's a good way and a good example to show how you can have a system wide strategy, but yet still keep it very, very local based off of the needs that are in community, </p> <p> 00:08:54:17 - 00:09:33:28<br> Vanessa Briggs<br> the partnerships that we have in community. Because we know, as I mentioned, it takes an ecosystem to do this work. And so Corewell has deep relationships with other nonprofits within organizations to help us execute programs, whether it's prevention programs, chronic disease management programs, and even coalition building and doing what we like to call collective impact work. And so it's a variety of programs and interventions that are derived from our implementation plans and, as you know, come from the priorities that are identified in our community health needs assessments. </p> <p> 00:09:34:00 - 00:10:00:26<br> Andrew Jager<br> Such a powerful example, I think, of the ways that you're thinking about understanding what are the local assets of your communities and then partnering to address those needs in a way that that is really having an impact across the state. So thank you for that work. Corey, one of the questions I frequently get, and I imagine maybe you hear something like this too, is, you know, how do we show the impact of the work that we're having, you know, both through metrics as well as through sharing the stories of the work across our community. </p> <p> 00:10:00:26 - 00:10:13:00<br> Andrew Jager<br> So how do you share your work in a way that that gets people excited about the work you're doing, brings in partners, and also that can help to develop a system wide culture of learning, adaptation and continuous improvement? </p> <p> 00:10:13:02 - 00:10:36:26<br> Corey Smith, Ph.D.<br> Definitely a question that I get. You know, my background is in evaluation. And so this is something I've been thinking a lot about. Corewell Health for the time I've been here - and, and I think the question that's been sitting in my head for five years has fundamentally been, how do we evaluate at scale, you know, have three regions, with, you know, over 100 individual initiatives. </p> <p> 00:10:36:28 - 00:11:02:08<br> Corey Smith, Ph.D.<br> How do you think about evaluating at scale? Right. You want to have evaluation where it makes sense, but you also have limited resources. And so what we've been doing is working to establish a systematic way of making choices with our regional leadership about where to invest, evaluation resources based on local priorities. Right. So really trying to define first where do we need to do this evaluative work. </p> <p> 00:11:02:08 - 00:11:24:21<br> Corey Smith, Ph.D.<br> Where do we feel it's most important for us to either generate learning or evidence of impact. And then through that designing, evaluation and monitoring processes that are really going to help us hone in on the indicators that are going to be useful for tracking our progress over time, but also the critical outcomes that our stakeholders have helped us develop, </p> <p> 00:11:24:23 - 00:12:03:13<br> Corey Smith, Ph.D.<br> that our regional leadership has decided are most important. And then it's just a technical task, right? Then it's designing methodologies, whether they're quantitative and qualitative, whether they're optimally mixed. You know, the application of both is most often the best way to answer the evaluative questions that you may be trying to answer. The last thing I'll say about that is, you know, we really have been working to try and establish a set of regional sort of priority indicators that can serve as a guidepost where they're not going to be right the first time, and they're going to have to get better over time in terms of their relevance to local needs, but really trying to </p> <p> 00:12:03:13 - 00:12:15:21<br> Corey Smith, Ph.D.<br> establish what are some of our, you know, our north stars, our guideposts that we can organize around as we try to make decisions about what to do, and where to invest some of our resources. </p> <p> 00:12:15:23 - 00:12:29:22<br> Andrew Jager<br> Really well said. Any last words? I mean, a lot of the listeners are health system leaders. So what do you think they need to know about supporting a process that's locally led and owned with the system level resources? </p> <p> 00:12:29:24 - 00:12:58:04<br> Vanessa Briggs<br> The way that I sort of think about it is it really is important to have a system wide strategy, as I mentioned, whether or not it's in the interventions and creating portfolios to allow you to house like programs, or whether it's having Corey's team do evaluation, provide technical assistance across the entire system in doing our community health needs assessment. </p> <p> 00:12:58:06 - 00:13:39:14<br> Vanessa Briggs<br> But what's most important and critical is that that system wide strategy still needs to have and allow for adaptability and customization based off of local context. While we can move to centralize and provide benefits from economies of scale within a system wide approach, we can't lose sight that the relevance and the effectiveness of addressing unique needs at a local level or regional level is still critically important, because that's when you're able to address the needs that have been identified within community. </p> <p> 00:13:39:17 - 00:14:01:26<br> Vanessa Briggs<br> And I think that that's what's most important. We can have system wide strategies but that local context is what really matters, because then we know we're moving the needle to address health disparities, access to care, partnering with organizations, addressing transportation, food access. </p> <p> 00:14:01:28 - 00:14:24:17<br> Andrew Jager<br> Thank you so much for encapsulating the important work that hospitals do across the country every day to support the communities and to help people be as healthy as they can be. Well, thank you to each person listening for the work that you do to support health and resilience in your communities. Community Health Improvement Week is really about recognizing the important work that you do every day on behalf of America's hospitals and health systems, and more importantly, the communities that we all serve. </p> <p> 00:14:24:19 - 00:14:38:06<br> Andrew Jager<br> Special thanks to Vanessa and Corey for sharing your thoughts and expertise, for the great work that you're doing at Corewell for Michigan communities. Be well. And until next time, this is Andrew Jager from the wishing you all a very happy Community Health Improvement Week. </p> <p> 00:14:38:09 - 00:14:46:20<br> Tom Haederle<br> Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts. </p> </details></div> Wed, 11 Jun 2025 07:42:18 -0500 Public /lettercomment/2025-06-10-aha-comments-cms-long-term-care-hospital-fy-2026-proposed-payment-rule <p>June 10, 2025 </p><p>The Honorable Mehmet Oz, M.D.<br>Administrator<br>Centers for Medicare & Medicaid Services<br>7500 Security Boulevard<br>Baltimore, MD 21244-1850</p><p><em>Submitted Electronically</em></p><p><em><strong>Re: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2026 Rates; Requirements for Quality Programs; and Other Policy Changes; 90 Fed. Reg. 18,002 (April 30, 2025).</strong></em></p><p>Dear Administrator Oz:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 230 long-term care hospitals (LTCHs), our clinician partners — more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS’) fiscal year (FY) 2026 LTCH prospective payment system (PPS) proposed rule. We are submitting separate comments on the rule’s inpatient PPS and Transforming Episode Accountability Model proposals.</p><p>LTCHs care for some of the most complex and severely ill Medicare beneficiaries. As CMS points out in this rule, more than 90 percent of Medicare patients are dependent on a ventilator when arriving at an LTCH, have spent three or more days in an intensive care unit (ICU), or both. These patients have high rates of complex wounds, chronic illness, and other factors that make the LTCH patient population a uniquely resource-intensive group. For this reason, LTCHs maintain a deeply specialized expertise that enables them to care for these patients and maximize their chances of recovery. Indeed, many acute-care hospitals rely on LTCHs as partners to care for patients with these specific high-acuity needs by transferring them to LTCHs.</p><p>Unfortunately, and as explained further in this letter, Medicare payment dynamics and related factors have caused a contraction of the LTCH field. This not only limits the ability of certain high-need patients from receiving care at an LTCH, but also strains the entire continuum of care as acute-care hospitals and other providers must find ways to care for these patients. This rule has several proposals that will exacerbate the ongoing difficulties within the LTCH field, particularly the large proposed increase in the high-cost outlier threshold. The AHA offers numerous recommendations to mitigate these effects, and we urge CMS to adopt them in the final rule.</p><p>While we have concerns about the payment updates for this proposed rule, the AHA appreciates CMS’ efforts to alleviate the reporting burden on providers. Specifically, the AHA supports CMS’ proposal to remove four standardized patient assessment data elements (SPADEs) from the LTCH QRP and greatly appreciates CMS’ recognition of the need to balance administrative burden and value in quality measurement programs. By streamlining reporting requirements, CMS can free providers to focus on the quality and safety issues that matter the most to their patients. In addition, the AHA appreciates CMS’ efforts around deregulation and is responding to CMS’ Request for Information (RFI) on approaches and opportunities to streamline regulations and reduce administrative burdens on providers.</p><p>Our detailed comments follow.</p> Tue, 10 Jun 2025 15:45:47 -0500 Public