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Rural Health Briefing  September 16 2004

National News

1. Comment Period Now Open for Proposed Medicare Prescription Drug Rules

2. CMS Releases Funding Application for Uncompensated Care
3. HHS Announces Medicare Premium, Deductibles for 2005

4. Medicare Replacement Drug Demonstration Program

5. HHS Issues National Pandemic Influenza Preparedness Plan

6. Hospitals Report Quality of Care Data

7. High Rates of Eye Disease in U.S. Latinos

 

Across Arizona

1. West Nile Virus Prevention in Rural Arizona

2. National Health Service Corps Assignment Priorities for Arizona

3. 15th Annual Southwest Regional Trauma Conference

4. Using AzHHA DATABANK to Compare Information
5. Robideaux named Indian Physician of the Year 

Grants and Opportunities

1. FY 2003 Applications Due for Rural Health Care Universal Service Support

2. Nominations Sought for Community Health Leadership Program Award

3. NRHA/MultiPlan Rural Health Initiative Community Outreach Grant Program

4. Promote Rural Healthcare Education with Grant-in-Aid Partnership

5. Rural Development/CooperationWorks! Fund Supports Health Care

 

Events


Mark Your Calendars!

  • March 21-23, 2005, Rural Health Policy Forum, Washington, D.C.
  • June 8-10, 2005, Third Annual Western Region Flex Conference, Phoenix

 

 

National News

1. Comment Period Now Open for Proposed Medicare Prescription Drug Rules

  Proposed regulations implementing the 2006 prescription drug benefit of the Medicare Modernization Act call for administration of the program through private prescription drug plans or, when drug benefits are integrated with health care coverage, through Medicare Advantage prescription drug plans. The Centers for Medicare & Medicaid Services (CMS) also called for lower reimbursements for physicians administering certain medications under current law during the federal government’s 2005 fiscal year, which begins October 1.

   “Generally, coverage for the prescription drug benefit will be provided under private prescription drug plans (PDPs), which will offer only prescription drug coverage, or through Medicare Advantage prescription drug plans (MA-PDs), which will offer prescription drug coverage that is integrated with the health care coverage they provide to Medicare beneficiaries under Part C of Medicare,” CMS writes in an executive summary of the Part D proposal. “PDPs must offer a basic prescription drug benefit. MA-PDs must offer either a basic benefit or broader coverage for no additional cost. If this required level of coverage is offered, the PDP or MA-PD plan may also offer supplemental benefits through enhanced alternative coverage for an additional premium. All organizations offering drug plans will have flexibility in the design of the prescription drug benefit. Consistent with the [Medicare Modernization Act], this proposed rule provides for subsidy payments to sponsors of qualified retiree prescription drug plans.”

  Oncologists, rheumatologists, and urologists stand to receive substantially lower payments in FY2005 as a result of CMS’s switch to an average sales price basis for determining reimbursement of 32 parenteral medications. According to the Wall Street Journal, the decreased reimbursements will affect medications administered in hospitals and physician offices for several conditions, including anemia, prostate cancer, and rheumatoid arthritis.

  The comment period extends to October 4, 2004. Further details, including a link to send comments electronically can be found at: http://www.cms.hhs.gov/media/press/release.asp?Counter=1129.

2. CMS Releases Funding Application for Uncompensated Care
  The Centers for Medicare & Medicaid Services (CMS) on September 1 published an application for healthcare providers that wish to take part in the Section 1011 program, which offers reimbursement for care provided to undocumented immigrants. Beginning in FY 2005, the voluntary program -- established by the Medicare Modernization Act -- would require providers to ask patients their immigrant status to qualify for the funds. By placing the application on display, CMS met the statutory deadline to publish guidance on how Sec. 1011 will be implemented, but the agency did not release any guidance on payment methodology or patient documentation requirements. CMS officials said those instructions will be released shortly. The Coalition for Fair Payments to Healthcare Providers Treating Undocumented Immigrants, which includes AzHHA, last month sent detailed comments on CMS' proposed Section 1011 implementation plans. The application was published in the Federal Register at www.cms.hhs.gov/regulations/pra/. 

3. HHS Announces Medicare Premium, Deductibles for 2005

  The Department of Health and Human Services (HHS) has announced the Medicare premium, deductible and coinsurance amounts to be paid by Medicare beneficiaries in 2005. The new premiums, approximately the same as the actuarial forecast published in March for the Medicare Trustees Report, reflect general growth in health care costs, higher payments to physicians and Medicare Advantage coordinated care health plans under the Medicare Modernization Act (MMA), and building trust fund reserves.

  The principal contributing factor to the increased cost of Medicare Part B benefits, ccounting for about four-fifths of the higher benefit costs, is higher payments in Medicare's traditional plan. Most importantly, the recent Medicare law prevented physician payments from falling significantly. In 2005, payment rates for physicians will increase by 1.5 percent, preventing a 4.5 percent reduction that could have threatened access to high-quality physician services.

  Another contributing factor to higher benefit costs is improvement in the Medicare Advantage program under the MMA. As a result, many beneficiaries enrolled in Medicare Advantage health plans are expected to receive additional benefits including prescription drugs, more preventive care, and even dental and vision care, as well as lower co-payments that enable them to reduce their out of pocket costs.Two other MMA changes may help lower beneficiaries' out-of-pocket costs in 2005. First, the new Medicare law provides additional savings for Medicare beneficiaries by paying more appropriately for Medicare covered drugs and the administration of those covered drugs. Second, the new preventive benefits in Medicare will help beneficiaries cover the cost of screening tests for heart disease and diabetes, and will provide a "Welcome to Medicare" exam (including coverage for associated services) for beneficiaries entering the program.

  Information is available at 1-800-MEDICARE (1-800-633-4227) and, for hearing and speech impaired, at TTY/TDD: 1-877-486-2048.

More details at: http://www.raconline.org/news/news_details.php?news_id=1779

4. Medicare Replacement Drug Demonstration Program

  The Medicare Replacement Drug Demonstration is a time-limited Medicare demonstration that will cover certain drugs before Medicare's prescription drug program begins in 2006. In recent years, many new medications have been developed that replace some of older drugs, allowing patients with serious and life-threatening illnesses to avoid going to the doctor just to get their medication. These new "replacement" drugs include medications to treat some cancers, multiple sclerosis, rheumatoid arthritis, and pulmonary hypertension as well as other rare and serious diseases.

  Medicare is implementing a demonstration to provide a special bridge benefit to make them available to some beneficiaries before the new Medicare drug benefit becomes available in 2006. This demonstration will provide assistance with the cost of medications to some beneficiaries as early as Sept. 1, 2004. Participation in the demonstration is completely voluntary.

  This demonstration is not the Medicare Prescription Drug Program that will begin in 2006, and it is not the same as the Medicare-approved drug discount card program that Medicare introduced in June 2004. Participants will still be able to use the Medicare-approved drug discount card program. The deadline to enroll in the replacement drug program is September 30, 2004. Applications received after that date will be considered on a space available basis. Further details can be found at http://www.cms.hhs.gov/researchers/demos/drugcoveragedemo.asp

 

5. HHS Issues National Pandemic Influenza Preparedness Plan

  HHS has prepared a draft Pandemic Influenza Response and Preparedness Plan, which outlines a coordinated national strategy to prepare for and respond to an influenza pandemic. The draft plan can be found online at http://www.hhs.gov/nvpo/pandemicplan and is available for public comment until October 25, 2004.

  Intended as a roadmap for a national response, the plan provides guidance to national, state, and local policy makers and health departments for public health preparation and response in the event of pandemic influenza outbreak.

  While rare, the appearance of such a pandemic virus will likely be unaffected by currently available flu vaccines that are modified each year to match the strains of the virus that are known to be in circulation among humans around the world. Unlike the gradual changes that occur in the influenza viruses that appear each year during "flu season," a pandemic influenza virus is one that represents a major, sudden shift in the virus' structure that increases its ability to cause illness in a large proportion of the population.

  HHS supports pandemic influenza activities in five key areas: surveillance, vaccine development and production, antiviral stockpiling, research, and public health preparedness.

  This draft plan includes a core section and twelve annexes. The core plan describes coordination and decision making at the national level; provides an overview of key issues; and outlines action steps that should be taken at the national, state, and local levels before and during a pandemic. Annexes provide additional information to health departments and private sector organizations for use in developing local preparedness plans as well as additional technical information to support the core document.

6. Hospitals Report Quality of Care Data

  Nearly all of the nation's eligible hospitals have begun reporting data on the quality of care they deliver, a vital first step in improving patient care. The Medicare Modernization Act of 2003 (MMA) provided a financial incentive for hospitals to report quality of care data by linking it to the payments they will receive for treating Medicare beneficiaries.  Almost 100 percent of covered hospitals reported data by the August 15 deadline.

  Under the MMA, hospitals that submit quality information to CMS will be eligible to receive the full Medicare payment for health care services in 2005.  Although reporting is voluntary, those inpatient acute care hospitals that do not report will get a 0.4 percentage point reduction in their annual Medicare fee schedule update.

Beginning early in 2005, the hospital quality data will be available to consumers at www.medicare.gov, the CMS website for consumers, or by calling 1-800-MEDICARE (800-633-4227).   Currently, CMS publishes this information on www.cms.hhs.gov.

  Already CMS publishes quality information on www.medicare.gov for Medicare and Medicaid-certified nursing homes and Medicare-certified home health agencies. 

The data on quality of care that participating hospitals report will give consumers information about performance in three medical conditions - heart attack, heart failure and pneumonia. These conditions can result in hospital stays and are common among people with Medicare. 

  The quality data are reported as ten quality measures (standards of care) for these three conditions and have gone through years of extensive testing for validity and reliability by CMS and QIOs, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and researchers.  The National Quality Forum (NQF), a voluntary standard-setting, consensus-building organization representing providers, consumers, purchasers, and researchers, has endorsed these measures as valid, reliable indicators of health care quality.

  Next year, CMS anticipates gathering and displaying additional measures of clinical quality as well as measures related to patient satisfaction with the care they received.  There are no payment incentives currently associated with these additional measures.

Most of the nation's hospitals are subject to the annual payment update provision under MMA.  The provision does not impact some specialty, rural, and certain other hospitals.

Note: The full list of hospitals can be found at: http://www.qnetexchange.org under the tab labeled HDC and is titled Hospitals Eligible for Full APU.

7. High Rates of Eye Disease in U.S. Latinos

  Latinos living in the United States have high rates of eye disease and visual impairment, according to a research study, and a significant number may be unaware of their eye disease.  This study, called the Los Angeles Latino Eye Study (LALES), is the largest, most comprehensive epidemiological analysis of visual impairment in Latinos conducted in the U.S.  Researchers found that Latinos had high rates of diabetic retinopathy, an eye complication of diabetes; and open-angle glaucoma, a disease that damages the optic nerve. 

  Study investigators gave a detailed health interview and clinical examination to more than 6,300 Latinos, primarily Mexican-Americans, aged 40 and older from the Los Angeles area, assessing their risk factors for eye disease and measuring health-related and vision-related quality of life.  Each participant received a blood test for diabetes and a comprehensive eye exam that included photographs of the back of the eye.

  The researchers noted that many study participants did not know they had an eye disease.  One in five individuals with diabetes was newly diagnosed during the LALES clinic exam, and 25 percent of these individuals were found to have diabetic retinopathy.  Overall, almost half of all Latinos with diabetes had diabetic retinopathy.  Among those with any signs of age-related macular degeneration (AMD), a condition that can lead to a loss of central vision, only 57 percent reported ever visiting an eye care practitioner, and only 21 percent did so annually.  Seventy-five percent of Latinos with glaucoma and ocular hypertension (high pressure in the eye) were undiagnosed before participating in LALES. Overall, Latinos were much more likely to have received general medical care than to have received eye care.

  Study results are available in the June, July and August 2004 issues of the journal Ophthalmology.

                          

Across Arizona

1. West Nile Virus Prevention in Rural Arizona

  Of all the states, Arizona has endured the second highest per capita rate of mosquito-borne West Nile Virus infections in 2004 and public health officials are working together on many fronts to defeat it. In an August 27 videoconference, representatives from state agencies and rural areas highlighted the effectiveness of prevention and education as they shared strategies and facts about their ongoing efforts.

  Bob England, state epidemiologist from the Arizona Department of Health Services (ADHS), emphasized that all parts of the state are at risk. However, the key steps of prevention and education have proven highly successful at containing the further spread of the virus. Kay Dyson, mayor of Springerville, told of working closely with the Apache County Health Department and other public works agencies starting in 2002 to plan and vigorously implement a comprehensive, ongoing approach to this problem. They have even enlisted the aid of a 5-ft. tall mosquito costume, nicknamed ’Skeeter Sheriff, to bring extra attention to their campaign.

  Dr. Darren Vicenti of the Hopi Health Care Center detailed the cooperation they had received from local newspapers and radio and TV stations in their education efforts. The usefulness of Community Health Representatives in reaching into isolated pockets of their communities as well as interpreting the health information into native languages was described by Jill Shugart, also of the Hopi Health Care Center.

Since tourists are also at risk, distributing leaflets to motels, sporting stores and recreation areas should not be overlooked. Simple approaches to prevention are also important. Joseph Tabor from the University of Arizona recommended putting pieces of copper wire or tubing into flowerpot saucers because that prevents the growth of mosquito larvae.

  While the current mosquito season trails off by October across rural Arizona, the plans for next year will be gearing up to begin as early as next January in areas such as Yuma.

Prevention and education continue to be effective and health agencies are using all available tools to contain this virus.

  The 90-minute videoconference was made possible by the Rural Health Office with co-sponsorship from the EXCEL Group, the Arizona Telemedicine Program, the Phoenix Area Indian Health Service and the Northern Arizona Behavioral Health Authority. It can be viewed at: http://video.biocom.arizona.edu/video/videolibrary/CPH/RHO/default.htm

Visit ADHS’s website: West Nile Virus Prevention in Arizona or contact their 24-hour hotline, 800-314-9243 for further updates.

2. National Health Service Corps Assignment Priorities for Arizona

  HRSA has released a proposed list of healthcare facilities that will receive priority for the assignment of National Health Service Corps (NHSC) personnel from July 1, 2004 through June 30, 2005, based on their Health Professional Shortage Area (HPSA) score. The NHSC is comprised of clinicians who provide primary healthcare to adults and children in underserved communities throughout the United States. The HPSA list specifies which entities are eligible to receive assignment of Corps members who are participating in the NHSC Scholarship Program, the NHSC Loan Repayment Program, and others. The current list includes:

  • Chinle Comprehensive Health Care Facility
  • Copper Queen Medical Associates, (affiliated with Copper Queen Community Hospital, Douglas)
  • Fort Defiance PHS Indian Hospital
  • Hopi Health Care Center
  • La Paz Regional Hospital, Parker
  • Phoenix Area Indian Health Service
  • Phoenix Indian Medical Center
  • Navapache Regional Medical Center, Show Low
  • Sage Memorial Hospital, Ganado (listed as Navajo Health Foundation)
  • Tuba City Regional Health Care Corp. (listed as Tuba City Indian Medical Center
  • University Physicians Hospital, Tucson (listed as Kino Community Hospital)
  • USPHS Indian Hospital - Fort Yuma
  • USPHS Indian Hospital - Parker
  • USPHS Indian Hospital - San Carlos
  • USPHS Indian Hospital - Sells
  • USPHS Indian Hospital - Whiteriver
  • USPHS Phoenix Indian Medical Center
  • Winslow Memorial Hospital

  More than 34 federal programs depend on the shortage designation to determine eligibility or as a funding preference. For more information, visit http://bhpr.hrsa.gov/shortage/, e-mail sdb@hrsa.gov or call 1-888-275-4772.

3. 15th Annual Southwest Regional Trauma Conference

  Trauma remains the third leading cause of death in the United States and the leading cause of disability in young Americans. Advancements in trauma systems, treatment protocols, technology and training have made an impact on this challenging problem, but injury still remains the greatest silent epidemic of modern society. The 15th Annual Southwest Regional Trauma Conference, October 7-8, 2004 will provide the most current information on trauma and its management to all health care professionals working in this area.

  This year's conference in Tucson will offer sessions on resuscitation, airway management, brain trauma, x-ray interpretation, ultrasound basics as well as pregnancy and pediatric trauma topics plus much, much more. Participants will include prehospital providers, nurses, respiratory therapists, administrators, doctors and surgeons. Three concurrent sessions are offered throughout each day.
  This conference has been organized under the leadership of the Southern Arizona Trauma Network (SATNET) and in conjunction with the Division of General Surgery and Trauma at the University of Arizona Health Sciences Center and University Medical Center. Details at: Trauma Conference.

 

4. Using AzHHA DATABANK to Compare Information
  The average acute care length of stay at U.S. hospitals ranged from 4.7 days at urban hospitals to 3.1 days at critical access hospitals, according to May data logged by 646 participating DATABANK hospitals nationwide. DATABANK is a new Arizona Hospital and Healthcare Association (AzHHA) service that allows members to compare financial, personnel and utilization information with other Arizona hospitals and national peer groups on a monthly basis. Arizona’s DATABANK program soon will be operational with these and other statistics available at the state and individual hospital level. Several Arizona hospitals have already begun entering their data into the system.

  To assist in this process, AzHHA has made a DATABANK training presentation available at www.azhha.org/public/stats/databank.cfm#Training. The presentation provides an overview of the program and walks viewers through data entry, creating custom peer groups and running reports. For more information about DATABANK, please contact AzHHA’s Roxanne Fisher at rfisher@azhha.org or 602-445-4336, or Jim Haynes at 602-445-4300, ext. 308, or jhaynes@azhha.org.

5. Robideaux named Indian Physician of the Year

  Yvette Roubideaux, MD, MPH, (Rosebud Sioux) assistant professor at the Mel and Enid Zuckerman Arizona College of Public Health, received the "Indian Physician of the Year" Award from the Association of American Indian Physicians (AAIP) at their 33rd Annual Conference in July.

  The award recognizes her contributions to the AAIP organization and her work in Indian health on diabetes related efforts. She is the Chair of the National Diabetes Education Program (NDEP) American Indian Workgroup and helped lead its efforts to develop the “Control your Diabetes for Life” campaign, and the “Move It” campaign directed toward increasing physical activity among Native youth.  

Robideaux recently helped launch the NDEP American Indian Workgroup’s new diabetes prevention campaign based on the recent research results from the Diabetes Prevention Program. She previously served in the Indian Health Service as a Medical Officer and Clinical Director on the medical staff at the San Carlos Indian Hospital in San Carlos, as well as the Hu Hu Kam Memorial Hospital on the Gila River reservation in Sacaton.

  Dr. Roubideaux is the Director of the Indians Into Medicine (INMED) Program at the University of Arizona, in partnership with the Inter Tribal Council of Arizona, Inc.

 

Grants and Opportunities

 

Note: Technical assistance is readily available for the development of grant proposals and other funding applications from the experienced staff of the Rural Health Office and the State Office of Rural Health Program. Please contact Jennifer Peashock by email at mailto:peashock@email.arizona.edu.

1. FY 2003 Applications Due for Rural Health Care Universal Service Support

  September 20, 2004 is the final deadline for filing FCC Form 466 for rural health care providers seeking discounts for Funding Year 2003 under the rural health care universal service support mechanism. Form 466 informs the Rural Health Care Division (RHCD) of the Universal Service Administrative Company that the health care provider has entered into an agreement with a telecommunications carrier for a service eligible for universal service support. Those entities that have applied for support for Funding Year 2003 (July 1, 2003 - June 30, 2004) must have their completed FCC Form 466 packet postmarked by September 20, 2004.

  The completed FCC Form 466 must include the following:

1) FCC Form 466 (Services Ordered and Certification Form), completed by the health care provider;

2) contract document or tariff designation, provided by either the health care provider or
telecommunications carrier; and

3) if the health care provider is seeking support based on an urban/rural rate comparison, documentation must be included to show the rate for the selected service(s) in the nearest city of 50,000 or more within the state.

  The forms and accompanying instructions may be obtained at the RHCD website. Parties with questions or in need of assistance with the filing of their applications should contact RHCD’s Customer Service Support Center at 1-800-229-5476.

             

2. Nominations Sought for Community Health Leadership Program Award

  Deadline: September 22, 2004

  The Robert Wood Johnson Community Health Leadership Program (CHLP) honors 10 people each year for creating or enhancing health programs serving underserved or isolated communities. Nominations for these awards are open and can be made by consumers, community health leaders, health professionals and government officials who have been personally inspired by the nominees.  Each award is $120,000: $105,000 for program support and $15,000 as a personal stipend.

  Previous awards have been made to people who find creative ways, despite complex odds, to bring health services to their communities. Candidates…

  • must be working full time at the grassroots level.
  • may not have received significant national recognition.
  • must be in "mid-career," with at least five and no more than 15 years of community health experience.

  For more information, visit the CHLP Web site at www.communityhealthleaders.org or call the program office at (617) 426-9772.

3. NRHA/MultiPlan Rural Health Initiative Community Outreach Grant Program

  Application Deadline: October 15, 2004

  The National Rural Health Association (NRHA) and MultiPlan are inviting applications for a 2005 Rural Health Initiative Community Outreach Grant. The grant program allows rural hospitals to offer new services, expand existing services, or reach new populations. Eight grants will be awarded.

  To receive a grant, your hospital must be a member of the National Rural Health Association and must participate in MultiPlan's healthcare network.

Download the MultiPlan Grant Application Packet Here

For more information, contact MultiPlan's Network Services Department at
(800) 677-1098 or rural@multiplan.com

 

4. Promote Rural Healthcare Education with Grant-in-Aid Partnership

  Application Deadline: December 31, 2004

  Qualifying NRHA members may apply for small grants provided by GE Healthcare to promote rural healthcare education. These grants include two satellite TV channels that deliver healthcare education for staff and patients. This service also includes TV schedules, tools to promote participation and access to an online Healthcare Learning System (HLS) for administering staff continuing education. A qualifying hospital provides an annual cash match amount of $3000 annually over the 2-year grant period to cover the cost of programming, installation and maintenance of the satellite equipment required to receive programming.

  Eligibility is limited to organizational members in good standing with the National Rural Health Association and their State Rural Health Association that are located in a county published in the Office of Rural Health Policy's "List of Rural Counties and Designated Eligible Zip Codes in Metropolitan Counties."

  GE Healthcare will also give a license to successful applicants to receive the educational content, processes staff continuing education credits, and provides utilization tools and access to the Heathcare Learning System (HLS) at no additional cost. The current annual value of both channels is $20,000, including programming and satellite installation. The value of GE's contribution is $34,000 over the 2-year term.

For more information contact: GE Healthcare, Shannon Troughton, 262-548-2654 or National Rural Health Association Alan Morgan, 703-519-7910.

For complete details, download http://www.nrhrural.org/pdf/GEgrant.pdf

5. Rural Development/CooperationWorks! Fund Supports Health Care

  The Rural Development Fund was created within the Cooperative Development Foundation to support projects that answer the needs of rural people. The fund supports projects in rural health care, education, and child care/education. The Cooperative Development Foundation does not have one specific grant application or set of guidelines, since each Fund they administer has its own Board of Trustees.

  Fund descriptions are open to review to determine if a project fits within the specified funding priorities. If so, a letter or Executive Summary may be submitted describing the project to: Cooperative Development Foundation 1401 New York Avenue, NW, Suite 1100 Washington, DC 20005-2160 Or via e-mail: equinn@cdf.coop

  Full details can be found at http://www.cdf.coop/funds_rural.html - worksfund.

Contact: Cooperative Development Foundation 1401 New York Avenue, NW, Suite 1100 Washington, DC 20005-2160 Or via e-mail: equinn@cdf.coop

 

Contact Your Representatives

  a.  Arizona Congressional Delegation:  Links to Arizona members of the U.S. House of Representatives are available at: U.S. Representatives. Links to Arizona members of the U.S. Senate are available at:  U.S. Senate

  b. Arizona State Legislators: Available through the Arizona Legislative Information System (ALIS): Call 1-800-352-8404 or follow links at Arizona Legislature.

 

Important Links

 

 

Editor's Note:  This online newsletter is a project of the Arizona Rural Hospital Flexibility Program, housed in the Rural Health Office at the Mel and Enid Zuckerman Arizona College of Public Health, and supported through a grant from HRSA (Office of Rural Health Policy). The Rural Hospital Flexibility Program was created by Congress to improve the financial viability and stability of health care in rural areas, including creation of a new designation for rural hospitals as Critical Access Hospitals (CAHs).  Designated CAHs are eligible for cost-based reimbursement for services provided to Medicare patients.  In some states, including Arizona, additional reimbursement is also available for CAH services provided to Medicaid patients. 

Your comments, editorial suggestions, and discerning questions are welcome. Please send them as well as address changes to Jim Laukes, Editor, Rural Health Briefing.
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Tucson, Arizona 85724-5210
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