California Chronic Care Coalition releases report highlighting serious nature of wrongful health plan denials and calls for increased awareness of state’s appeal process

(SACRAMENTO) – The California Chronic Care Coalition (CCCC) today sounded the alarm on the health insurance industry’s practice of inappropriately denying patients the medicines, treatments and testing prescribed by their doctors. In their research study, “Standing Up For Your Rights Creates Results,” the California-based nonprofit found that the California Department of Managed Health Care (DMHC) reversed or overturned more than 60 percent of health plan decisions as part of the Independent Medical Review (IMR) process in 2017.

“The high percentage of cases that the DMHC reversed or overturned should raise red flags with consumers and policymakers alike,” said Liz Helms, president and CEO of CCCC. “It’s unacceptable that more than 60 percent of patients were inappropriately denied care because the health plan industry is trying to minimize costs.”

After a patient receives a denial for a service, medicine or treatment from their health plan, they can appeal the decision with their plan directly. Should the health plan deny the service a second time, patients have the right to request an IMR through the DMHC. An IMR is an independent review of a denied, delayed or modified health care service that the health plan has deemed to be not medically necessary, experimental/investigational or non-emergent/urgent.

“If these denials were only overturned because of the IMR process, think of the hundreds of thousands of Californians denied necessary care who never appealed the decision because they didn’t even know it was an option,” said Joan Werblun, RN, chair of CCCC. “It’s imperative that people living with chronic diseases and conditions, and all patients for that matter, know that they have the right to an appeal and they are not alone in their struggle to get the care they need.”

In 2017, the DMHC assessed $8,907,000ⁱ in fines and penalties against health plans, with Anthem Blue Cross being one of the major violators. In November 2017, DMHC took enforcement action against Anthem Blue Cross for its systemic violations of the grievance system, fining it $5 million for failing to identify, process and resolve consumer grievances in a timely manner. The $5 million fine was the result of 245 specific grievance system violations that occurred from 2013 through 2016. In each of these cases, Anthem deprived patients of their right to medical care.

While compiling the data necessary for “Standing Up For Your Rights Creates Results,” CCCC was alarmed at the number of individual denials requesting authorization or reimbursement of medications, procedures and testing. To evaluate the types and patterns of denials, CCCC took a closer look at 1,011 of more than 4,000 IMR cases, focusing on chronic conditions and serious illnesses such as cancer, mental health, musculoskeletal, cardiovascular and hepatitis. Those within these categories were denied requests which were vital for the effective treatment and management of their conditions. Although more than 50 percent of health plan decisions from this specific subset were reversed or overturned, it’s important to note the specific diseases and services that had higher counts of denials as it highlights the health plan industry’s routine practice of inappropriately denying care to patients in need.

In one such case, a young patient with juvenile spondyloarthritis was denied coverage of intravenous Remicade infusions as their health plan didn’t find it medically necessary. Before requesting Remicade, the patient had tried three other medications that failed to treat her inflammatory arthritis. To prevent long-term damage from leaving it untreated, the patient’s physician recommended Remicade infusions as the treatment is safe in the pediatric population and demonstrated significant improvement in arthritis, inflammatory markers, pain and physical function for juvenile spondyloarthritis. The independent reviewer determined the requested services were medically necessary and overturned the health plan’s denial.

Patients who need assistance navigating the complex health care system should visit My Patient Rights, a one-stop–shop created by CCCC to help patients receive the care they need and deserve. My Patient Rights provides information on how to file a complaint with a patient’s health plan, as well as the appropriate state agency. In addition, the website offers patients an avenue to learn about their rights and specific barriers put in place by health plans that may jeopardize their care.

To access CCCC’s “Standing Up for Your Rights Creates Results” report and the related infographic, visit www.CaliforniaChronicCare.org.

About the California Chronic Care Coalition
The California Chronic Care Coalition (CCCC) is a unique alliance of more than 30 leading health organizations and provider groups that promote the collaborative work of policy makers, industry leaders, providers and consumers to improve the health of Californians with chronic conditions. We envision a system of care that is accessible, affordable and of a high quality that emphasizes prevention, coordinated care, and the patient’s wellness and longevity. http://www.californiachroniccare.org

ⁱ California Department of Managed Health Care. (2017). Annual Report (Page 16). Retrieved from: https://www.dmhc.ca.gov/Portals/0/Docs/DO/2017-Annual-Report-web.pdf

New Senior Account Manager and Account Executive at the firm

(SACRAMENTO) — Perry Communications Group (PCG), a leading public affairs firm in California, today announced the promotions of Kaitlin Perry to Senior Account Manager and Jessica Hice to Account Executive.

“At PCG, we encourage our staff to constantly learn and grow,” said Kassy Perry, president and CEO of Perry Communications Group. “We work with our team to ensure that they can meet their immediate and long-term professional goals.”

Jessica Hice started with PCG in August 2018 and brings a background in journalism and interest in public policy. Using her foundation in political reporting, Jessica helps raise the profile of clients’ issues. She will continue to expand her role in media relations, event management and social media. Hice earned Bachelor’s Degrees in Journalism and Art from California State University, Sacramento.

Since joining PCG in 2016, Perry has moved up the ranks to assist the PCG team to achieve client goals. As a Senior Account Manager, she works with senior staff on day-to-day client management including public affairs activities, media relations, stakeholder engagement, vendor partnerships and digital strategies. Kaitlin graduated from Texas Christian University with a Bachelor of Science in Political Science and minor in Business.

If you are interested in joining our award-winning team, click here for available positions.

About Perry Communications Group
Perry Communications Group is an independent, full-service strategic communications firm specializing in public relations and public affairs. We work at the center of issues that matter and give new perspective to the issues and events making headlines today, as well as those that will in the future. We shape ideas, opinions, decisions and social change. The bottom line for us is always the same – we’re invested in the cause and our clients’ work. For more information, visit PCG at www.perrycom.com or call (916) 658-0144.

(SACRAMENTO, CA) — Perry Communications Group (PCG), one of California’s leaders in issues management and public affairs, announced today it hired Stephanie McGann Jantzen as a vice president to expand the firm’s capacity and bring new issue areas of expertise and business acumen.  PCG offers decades of excellence in providing its clients the best in service, strategy and results.

“As we have focused heavily in a few distinct issue areas in California and throughout the United States, I decided it was time to expand our portfolio of expertise,” said Kassy Perry, president & CEO of Perry Communications Group.  “As we move into the fields of technology, land use, government and economic development, Stephanie brings experience to our firm that dramatically increases our offerings for our clients.”

McGann Jantzen joins the agency after spending three decades as a political consultant, crisis communications specialist and public affairs strategist. Her areas of expertise include land use, renewable energy, local, state and federal government and economic development. As Vice President, she will manage client accounts, provide strategic advice and direction as well as oversee the growth of new issue areas and client development.

“I am thrilled to join Kassy and her powerhouse team at PCG,” McGann Jantzen said. “We have incredible clients approaching the firm, and I look forward to continuing that growth with an already successful organization. Kassy’s commitment to over-delivering results to all of her clients is consistent with my values, both professionally and personally. I’m honored to join this firm of outstanding women.”

McGann Jantzen was born into a political family in Sacramento, leading to her decades of policy and politics experience.  Her father was Chief of Staff to San Francisco’s former Mayor George Moscone, a candidate for Congress and created three lobbying firms in Sacramento with a focus on health care policy.

Stephanie has managed statewide California races, Congressional, Senate and Assembly campaigns, as well as local campaigns and ballot measures.   She led Northern California advance for Governor Pete Wilson in his first campaign for Governor of California and was Northern California staff for Jack Kemp’s campaign for President.

For thirteen years, McGann Jantzen served as Chief of Staff and Political Director for County Supervisor and then Assemblyman Roger Niello, a private sector business owner in the Sacramento region.  She also served as California consultant to the World Trade Center in Sacramento, meeting with delegations from several countries around the globe to discuss the California political landscape, including campaign strategies and policy discussions.

Previously, McGann Jantzen staffed political conventions and served as advance lead for former presidents and statewide officers, coordinating with Secret Service and California Highway Patrol.

She served as interim CEO of a Northern California technology company featured on CNBC’s show “Billion Dollar Buyer.”  She also worked with two technology start-up companies, one in green energy and the other in consumer-facing restaurant tech.

If you are interested in joining our award-winning team, click here for available positions.

About Perry Communications Group

Perry Communications Group is an independent, full-service strategic communications firm specializing in public relations and public affairs. We work at the center of issues that matter and give new perspective to the issues and events making headlines today, as well as those that will in the future. We shape ideas, opinions, decisions and social change. The bottom line for us is always the same – we’re invested in the cause and our clients’ work. For more information, visit PCG at www.perrycom.com or call (916) 658-0144.

Newsom includes development of a statewide Master Plan for Aging among his top initiatives

(SACRAMENTO) – We Stand With Seniors, the nonprofit, nonpartisan effort focused on educating state leaders about the need for a statewide, comprehensive Master Plan for Aging, commends Governor Gavin Newsom for being the first governor in recent history to address California’s aging population and the associated socioeconomic challenges.

“Let’s talk about something we too often overlook. The Golden State is getting grayer. We need to get ready for a major demographic challenge headed our way. For the first time in history, older Californians will outnumber young children. Over the next decade, our statewide senior population will increase by 4 million. In 25 years, it will double. And more than half will require some form of long-term care… It is time for a new Master Plan on Aging. We’ve deferred it for far too long. It must address person-centered care, the patchwork of public services, social isolation, bed-locked seniors in need of transportation, the nursing shortage and demand for In-Home Supportive Services that far outpaces its capacity.”
– Governor Gavin Newsom, 2019 State of the State Address

“Governor Newsom today showed he will truly stand with seniors by making good on a campaign promise to develop and implement a comprehensive and long-term plan that addresses the important healthcare, social and caregiving needs of the state’s growing population of older adults,” said Shelley Lyford, president and CEO West Health. “We look forward to immediately working with the governor and his administration on the development of this Master Plan for Aging and making successful aging a reality for all California seniors.”

In 2018, nonprofits West Health and The SCAN Foundation launched the nonpartisan, public awareness and education campaign, We Stand With Seniors, to educate policymakers about the need for a statewide, comprehensive Master Plan for Aging to address the challenges associated with the state’s rapidly aging population.

“For too long, the needs of California’s older adults, families and caregivers have been compromised by California’s scattershot approach of fragmented services,” said Bruce Chernof, president and CEO of The SCAN Foundation. “We view Governor Newsom’s commitment in today’s State of the State address as a catalyst for the state to undergo significant policy planning and changes so that older Californians can truly live with dignity and independence.”

The governor’s announcement, coupled with legislation introduced last week by Senator Hannah-Beth Jackson (D-Santa Barbara), is critical to addressing the care and support service needs of older Californians.

“I was pleased to see Governor Newsom recognize the issues facing California’s older adults in his State of the State today,” said Senator Hannah-Beth Jackson (D-Santa Barbara). “I look forward to working with him on a Master Plan for Aging through my Senate Bill 228 to address these challenges in a thoughtful and collaborative way. California must not leave our aging loved ones behind.”

About We Stand With Seniors
West Health and The SCAN Foundation’s We Stand With Seniors… Will You? nonpartisan, public awareness and education campaign focuses on the specific challenges seniors and their families face in accessing high-quality, affordable healthcare, dental care and supportive services and the cost to the state if these challenges are not addressed. Keep up with #StandWithSeniors by visiting www.WeStandWithSeniors.org and following on Facebook @WeStandWithSeniors and Twitter @WeStandWSeniors.

February 5 Capitol Film Premiere and Expert Panel Discussion Presented to California Leadership and Lawmakers; Hosted by Aging Advocacy Groups, Nonprofits and Legislative Caucuses

(SACRAMENTO) – We Stand With Seniors and the Assembly Aging and Long-Term Care Committee, in partnership with West Health, The SCAN Foundation, Archstone Foundation, Sutter Health, UDW Home Care Union and AARP California, will host Lives Well Lived: A Capitol Screening and Policy Discussion on Aging in California on February 5, 2019 at the Crest Theater in Sacramento. Co-hosted by Alzheimer’s Association, California Asian Pacific Islander Legislative Caucus, California Commission on Aging, California Legislative Women’s Caucus, LeadingAge California and Openhouse, the film screening and accompanying panel discussion will highlight the value of California’s older adults and the need for a state Master Plan for Aging.

“ʽLives Well Lived’ is a tribute to seniors who are defying the many negative stereotypes associated with growing older by living vibrant, productive lives and serving as inspirational role models for all of us to emulate,” said Shelley Lyford, president and CEO of West Health. “Californians deserve the kind of transformational policy changes from our leadership in Sacramento and a comprehensive plan that will enable every adult to successfully age with dignity, quality of life and independence.”

Lives Well Lived: Celebrating the Secrets, Wit & Wisdom of Age – a critically-acclaimed documentary film by Sky Bergman that celebrates the incredible lives of adults, ages 75 to 100, who are living their lives to the fullest – will be presented via a screening for Governor Gavin Newsom and his appointees, constitutional officers, legislators, aging advocates and the media.

“This film is a powerful statement for empowering our state’s older adults, families and caregivers – as well as marginalized communities,” said Bruce Chernof, MD, FACP, president and CEO of The SCAN Foundation. “Through a statewide, comprehensive Master Plan for Aging, California has an extraordinary opportunity to lead the nation in providing its aging population cost-effective, high-quality health and supportive services.”

Moderated by State Treasurer Fiona Ma, the panel discussion will focus on how a Master Plan for Aging in California will help address and solve the myriad challenges currently faced by the state’s diverse and rapidly aging population. Panelists include Assemblymember Adrin Nazarian, Chair of the Assembly Aging and Long-Term Care Committee; Shelley Lyford, West Health; Bruce Chernof, MD, FACP, The SCAN Foundation and Zach Gassoumis, PhD, University of Southern California’s (USC) Leonard Davis School of Gerontology.

Other speakers include Sky Bergman, Director of Lives Well Lived, Assemblymember Ash Kalra and Nina Weiler-Harwell, AARP California. For more information on partners and co-hosts, as well as tickets to Lives Well Lived: A Capitol Screening and Policy Discussion on Aging in California, visit www.WeStandWithSeniors.org/Lives-Well-Lived.

About We Stand With Seniors
West Health and The SCAN Foundation’s We Stand With Seniors… Will You? nonpartisan, public awareness and education campaign focuses on the specific challenges seniors and their families face in accessing high-quality, affordable healthcare, dental care and supportive services and the cost to the state if these challenges are not addressed. Keep up with #StandWithSeniors by visiting www.WeStandWithSeniors.org and following on Facebook @WeStandWithSeniors and Twitter @WeStandWSeniors.

About Lives Well Lived: Celebrating the Secrets, Wit & Wisdom of Age
The documentary film by Sky Bergman includes heartfelt interviews with forty older adults, encompassing over 3,000 years of life experience, who share their secrets and insights to living a meaningful life. Their intimate memories and inspiring personal histories entertain and inspire, while reminding us that older adults are, and should be, a valued part of our society. Watch the trailer at www.Lives-Well-Lived.com.

By Nancy McPherson and April Verrett
CALmatters
January 29, 2019

In his inauguration speech, Gov. Gavin Newsom pledged that “every senior should be able to retire with security.” That’s a significant commitment to address challenges facing older adults, families and caregivers who struggle in a dysfunctional system.

California has an insufficient system of long-term services and supports for older people and people with disabilities, as detailed in a 2015 report by the California Senate’s Select Committee on Aging and Long-Term Care.

The report painted an alarming picture of the shortcomings of the current system, but offered real solutions: California can build a better system to serve all who have long-term care needs.

Since the Senate issued its report, the problem is only becoming more critical. By 2030, the California Department of Finance projects 24 percent of the population will be at least 65. And, in the next 20 years, the number of adults with disabilities could grow by 20 percent.

This added pressure on the system is creating a crisis for the middle class and generational poverty as each generation spends more of its savings caring for family members.

According to an AARP study, the annual cost of nursing homes is more than double the $50,000 median income of older households in California. Although Medi-Cal is a major public payer for the system of long-term services and supports, the high cost of nursing homes and long-term services is causing an increase in the number of unpaid family caregivers. The study also showed that in 2013, 4.5 million family caregivers provided care valued at roughly $58 billion.

Fortunately, there are innovative ways to address the long-term care crisis to achieve the intended results without putting additional pressure on the state’s general fund.

While some people can afford private long-term care insurance, the market for those policies is disappearing. As premiums rise, insurance companies are dropping coverage for long-term care.

And, as most people find out when it is too late, Medicare does not adequately cover long-term care services, which are far too expensive for most to pay out of pocket.

What is desperately needed is a solution that fits the diverse long-term care needs of the Golden State. We need an affordable and accessible system of long-term care for all Californians, regardless of their income or ZIP code.

To come up with that solution 20 organizations representing long-term care stakeholders have come together to form the California Aging and Disability Alliance. This alliance is working on an innovative and cost-effective approach to the long-term services and supports challenges we face.

We believe the public would embrace funding a limited but meaningful range of services for those with long-term services and supports needs. This would have many positive effects, including providing some relief to the state in its Medi-Cal long-term services and supports costs.

In the next few months, California Aging and Disability Alliance will develop our proposal based on that principle and seek the active involvement of the Legislature. At the same time, we look forward to working closely with Gov. Newsom to support his ideas and plans on this issue.

As Gov. Newsom said: “I have never been a fan of pretense or procrastination. After all, our state is defined by its independent, outspoken spirit.”

We agree. California can do this, but only if we work together.

Nancy McPherson is state director for AARP California, nmcpherson@aarp.org. April Verrett, aprilv@seiu2015.org, is President of SEIU Local 2015, both are CADA members. They wrote this commentary for CALmatters.

Addario Lung Cancer Medical Institute study applies next-generation sequencing of blood plasma to identify tumor mutations that cause treatment resistance in patients with rare lung cancer

SAN CARLOS, CA — The Addario Lung Cancer Medical Institute (ALCMI), a patient-founded not-for-profit global research consortium, and researchers from the Dana-Farber Cancer Institute are launching a novel nationwide study to understand why treatment resistance develops in a specific group of lung cancer patients.

The Study of Plasma Next Generation Sequencing for Remote Assessment, Characterization, Evaluation of Patients with ALK Drug Resistance [SPACEWALK] uses the latest gene-sequencing technology on blood plasma of patients with a rare form of lung cancer. This type of lung cancer is defined by a mutation in a gene called anaplastic lymphoma kinase (ALK), which is present in about 5 percent of patients with non-small cell lung cancer (NSCLC). Although ALK-positive lung cancer makes up only a small percentage of all lung cancers, with more than 234,000 new cases of lung cancer expected in 2018, it is likely that up to 10,000 of those will be ALK-positive.

Most, but not all, patients with ALK-positive lung cancers benefit from targeted treatment with oral therapies directed at ALK. There are now five FDA-approved ALK inhibitors. Treatment can work for months or years before resistance develops and lung cancer begins growing again. Resistance can be caused by new mutations in the ALK gene, and some of these resistance mutations can be effectively targeted by switching to another ALK inhibitor. The SPACEWALK study seeks to better understand the molecular causes of drug resistance to help doctors determine if switching to a different ALK inhibitor could prove beneficial.

“I’m sure you can imagine how hard it is on patients and families to hear that a treatment has stopped working,” said Gina Hollenbeck, a stage IV cancer survivor. Hollenbeck is the president of ALK Positive, an international support group of patients with ALK-positive lung cancer and their caregivers who take an active role in raising awareness of research opportunities. “We’re very excited to see a nationwide study that can expand our understanding of treatment resistance and how to overcome it.”

Advances in gene-sequencing now allow doctors to understand a tumor’s genetic composition from a sample of a patient’s blood, sometimes called a “liquid biopsy.” In the past, genomic analysis required patients to undergo an invasive biopsy to collect tumor tissue for testing. With a liquid biopsy, doctors can analyze tumor DNA shed into the bloodstream, which means patients only need to go through a simple blood test. By using liquid biopsies, with blood samples shipped for analysis, the study enables patients across the country to participate. A study open to patients throughout the U.S. is especially important in conducting a meaningful study of uncommon conditions.

“As we gain more treatment options for ALK-positive lung cancer, we now need better diagnostic tools to help us choose the best treatment for each patient,” said Geoffrey R. Oxnard, M.D., the study’s principal investigator and a medical oncologist at Dana-Farber Cancer Institute who specializes in research and treatment of non-small cell lung cancer. “We are so excited to offer a research study across the U.S. that both allows these patients to participate in research toward understanding drug resistance, while also giving them a test result that could help guide them to a new treatment option.”

“These are exciting times in lung cancer research,” said Bonnie J. Addario, 14-year lung cancer survivor and ALCMI founder. “Learning more about the genetic composition of cancer tumors can unlock doors to new and better treatments. We’re pleased to play a part in advancing this promising path toward turning lung cancer into a well-managed condition.”

To learn more about this study visit https://www.alcmi.net/SPACEWALK.

About the Addario Lung Cancer Medical Institute
The Addario Lung Cancer Medical Institute (ALCMI, voiced as “Alchemy”), founded in 2008 as a 501c(3) non-profit organization by lung cancer survivor Bonnie J Addario, is a patient-centric, international research consortium driving research otherwise not possible. Working in tandem with its “partner” foundation, the Bonnie J. Addario Lung Cancer Foundation (ALCF), ALCMI powers collaborative initiatives in genetic (molecular) testing, therapeutic discoveries, targeted treatments and early detection. ALCMI overcomes barriers to collaboration via a world-class team of investigators from 26 member institutions in the USA, UK, and Europe. ALCMI combines scientific expertise found at leading academic institutions with patient access through its network of community cancer centers to accelerate research.

Sacramento, Calif. – My Patient Rights and the California Chronic Care Coalition are reminding Californians to make sure that they and their family members are aware of a new law that takes another step in addressing the opioid crisis. This law states that prescribers of pain-relieving opioids must also offer a prescription for the opioid-overdose reversal drug, naloxone, to high-risk patients. AB 2760 was passed overwhelmingly by the California Legislature and signed into law in September 2018 by Gov. Edmund G. Brown, Jr.

Accidental opioid overdoses account for about 80 percent of all opioid emergencies and 83 percent of prescription opioid-related deaths are unintended or accidental. While anyone taking opioids is at potential risk for an overdose, there are certain high-level, at-risk groups that are susceptible, so being prepared with the overdose reversal drug, naloxone, in close proximity is essential.

This problem has become so acute that the U.S. Surgeon General issued its first advisory in 13 years recommending emergency treatments like naloxone – which is so important to saving lives – be available for consumer use.

“For patients with chronic illness, pain relieving opioids are a lifeline but the risk of an overdose increases the more you take to combat the pain,” said Liz Helms, president and CEO of the California Chronic Care Coalition. “Requiring naloxone to be offered at the same time as prescribing an opioid pain medication will go a long way in preventing accidental overdoses and needless deaths. And since many caregivers are family members, it is important to make them aware that this potentially life-saving emergency treatment will be more readily available when opioids are prescribed.”

There are many reasons for accidental opioid overdose emergencies and these emergencies can occur even when opioids are used as directed. Those at high risk for accidental opioid overdose include:

• Those who take moderate to high doses of prescription opioids, usually over 90 morphine milligram equivalents a day
• Those who consume certain other sedating medications or alcohol, particularly benzodiazepines
• Those who have a history of substance abuse or previous overdose
• Those who have children, other family, friends and loved ones who have access to unlocked or unsecured prescription opioids

In 2016, more than 214 million prescriptions were written and filled for opioids. With this many patients taking opioids for medical conditions and medical procedures, it’s important to have the discussion and prepare for potential overdoses.

“Naloxone is a tool that can immediately save lives. And I hope this new law will provide an opportunity for discussion of the potential for accidental opioid overdose and how to prevent it,” said Assemblymember Jim Wood (D-Santa Rosa), author of AB 2760.

Anyone who uses opioids for pain control is at risk for an opioid overdose emergency. Now that naloxone co-prescription for high risk individuals is the law in California, make sure you and your families are prepared for the unexpected by talking about opioids, the potential for overdose even when used correctly, having naloxone with you, and recognizing the signs of overdose:

• Slow or shallow breathing
• Slowed heartbeat and weak pulse
• A loss of consciousness
• Pale, blue or cold skin

Knowing the risks, recognizing the signs and having naloxone on-hand will go a long way in potentially saving a life from accidental opioid overdose.

About My Patient Rights and the California Chronic Care Coalition
My Patient Rights was launched by the California Chronic Care Coalition to help people who have been denied treatment or medicines, experienced delays or are dissatisfied with the decisions made by their health plan.

The California Chronic Care Coalition (CCCC) is a unique alliance of more than thirty leading consumer health organizations and provider groups that engage policy makers, industry leaders, providers and consumers to improve the health of Californians with chronic conditions. We envision a system of care that is accessible, affordable and of a high quality that emphasizes prevention, coordinated care and the patient’s wellness and longevity.