CMS’ Evolving Payment Policies: Andy Wegman, Banner Health
In this episode of the “Achieving Health” podcast, hosts Chad Mulvany and Shawn Stack are joined by Andy Wegman, senior director of reimbursement services at Banner Health, to discuss the recent spike in CMS rulemaking and what it means for reimbursement leaders and their organizations.
Andy shares his thoughts on:
- Consequential policy changes in CMS’ prospective payment system (PPS) rules
- CMS’ approach to implementing Medicaid cuts from the One Big Beautiful Bill Act
- Reimbursement and community engagement strategies to help healthcare leaders respond to regulatory pressure
Transcript
CHAD MULVANY
On today's episode of “Achieving Health,” we'll be joined by special guest Andy Wegman, Senior Director of Reimbursement Services at Banner Health. He'll share his perspective on the latest CMS rulemaking and how his organization is preparing for upcoming payment and policy changes. Stay tuned.
ANNOUNCER
This is “Achieving Health,” a podcast from Forvis Mazars, where we delve into the topics that matter most to healthcare organizations across the continuum of care. Our goal is to help you navigate the dynamic healthcare landscape and achieve health at your organization.
CHAD MULVANY
Welcome to Achieving Health. I'm Chad Mulvany.
SHAWN STACK
And I'm Shawn Stack. Thank you for joining us.
CHAD MULVANY
I'd like to welcome our guest for today's episode, Andy Wegman. Andy is senior director of reimbursement services at Banner Health, one of the nation's largest nonprofit health systems.
Andy, there's been a lot of movement on the regulatory front over the last couple of months between CMS normal sort of rulemaking cycle for facility and outpatient rules, and adding to that, the rules implementing the One Big Beautiful Bill act, the work requirements, the Medicaid cuts. And we're very excited to hear how you and Banner are approaching strategic reimbursement in this landscape. Thank you so much for being here.
ANDY WEGMAN
Well thanks, Shawn, thanks, Chad. Happy with the opportunity to speak on these. Yes, there's a lot of different changes taking place right now as we speak. And trying to navigate these can definitely be overwhelming at times.
CHAD MULVANY
Andy, maybe before we get into the meat, would you please share a little bit about your career path, how you came to the industry in your current role, so our audience can have some perspective on your background?
ANDY WEGMAN
Definitely, yeah. So, in 2007, I actually began working as an auditor one at Noridian Healthcare Solutions. So, fun fact; I actually had to apply twice. The first time my application was actually rejected because the hiring supervisor was looking for someone with an accounting degree. So, I have a business management degree, I do now have a graduate accounting certificate, but not an accounting degree.
So, second time I applied for the position, it was with a different hiring manager and she was willing to take a chance on me. So, I guess I'll just say, Pam Marie, if you're listening, thank you for taking that chance on me 19 years ago.
While working at Noridian, I worked my way up; auditor two, senior auditor. In 2016, I was promoted to the provider audit and reimbursement Manager over jurisdiction E. I was in that role for four years until I came over to Banner Health in 2020 as a reimbursement consultant. In 2022, I was promoted to my current role of Senior Director of Reimbursement Services.
CHAD MULVANY
Andy, sounds like a great background, particularly that early career, having to apply two times, because I would imagine that when you interviewed with banner, it basically demonstrated that you could negotiate with a MAC.
ANDY WEGMAN
Yes.
SHAWN STACK
For those of our listeners who don't know, do you want to say a little bit about Banner and talk about the system?
ANDY WEGMAN
Yeah, I'd love to. So, Banner Health is one of the nation's largest fully integrated nonprofit health systems. We pioneer a sustainable care model that prioritizes prevention, manages chronic disease, and reduces health spending. We operate 33 hospitals in more than 400 sites across six states, delivering seamless care from primary to quaternary medicine, including health insurance, physician networks, world-renowned specialty services, and behavioral health.
We are accountable to the communities we serve. We reinvest every dollar back into advancing care research in our facilities, providing more than $1 billion each year in community benefit. Through our partnership with the University of Arizona, we drive clinical discoveries across more than 800 trials and train more than 1300 residents and fellows annually. We are headquartered in Phoenix, Arizona, and we serve Arizona, California, Colorado, Nebraska, Nevada, and Wyoming.
CHAD MULVANY
Yeah, that's a huge footprint and certainly a very complex organization. So, with that background in mind, when you think about this rulemaking cycle, what are the two or three most interesting either proposed—so, thinking like physician fee schedule, OPPS—or finalized—so, the facility rules—from this round of Medicare rulemaking?
ANDY WEGMAN
So, I think I'll probably mainly focus on really OPPS, you know, as we know, just the other day CMS released the IPPS final rule. So, still diving into that one. Happy to see some things got passed on and unhappy to see some things didn't.
But when we look at OPPS, I think for every 340B hospital, number one is going to be that the payments for separately payable drugs being reduced from average sale price plus 6% to average sale price minus 3-3.4%. Even though this is a quote unquote “budget neutral” issue, this is still going to have a significant impact.
CHAD MULVANY
Yeah, I fully agree with you. And I think when you sort of look at the separately payable Part B drug cut, the policy rationale for it to me is somewhat questionable because as you mentioned, you know, CMS tries to say that they're lowering drug prices for recipients of those drugs, but at the same time, they're raising cost sharing for everybody else by making it budget neutral.
And I think the other thing that to me is just sort of interesting is, you know, when you look, and we were talking about this before we started recording, when you look at the survey sample that CMS is basing this on, right? The first time around, the Supreme Court knocked down this policy because they didn't actually use hospital data.
They fielded the survey earlier this spring. But yet, you know, approximately 40% of hospitals responded. Half of the non-340B, less than 30% of the 340B. And when you look underneath that, it looks like it's, you know, you don't see, they noted that there weren't major teaching hospitals, that most of the 340B respondents tend to be lower revenue and rural. So, I do think that there may be some questions about the validity of that cut.
ANDY WEGMAN
I agree. Was the sample statistically valid? And as well as, you know, the concerns regarding the uniformity of the data collected?
CHAD MULVANY
Absolutely.
SHAWN STACK
Yeah. So, Andy, are there any changes coming out of these rules, either proposed or inpatient, that you've been shocked that your colleagues, not necessarily at Banner, I know you network a ton and talk to folks outside of Banner in your profession, that folks might be missing or underappreciating and things that are keeping you up at night that you think people might not be realizing the full impact?
ANDY WEGMAN
Lately, there's been a lot that's been keeping me up all night, I will just say that. You know, I'll say one thing and I won't necessarily say, I don't know if the field is underappreciating it or not, but I'll say one thing that gave me some, I'll say breathing room, is related to the Medicaid managed care state-directed payments, with CMS proposing to allow the state to delay the prohibition of separate payment terms for these state-directed payments until the new payment limit is met.
We are a heavily governmental provider, so the majority of our patients are Medicare and Medicaid patients. And with the abundance of Medicaid patients, we utilize these state-directed payments to help bridge that gap between how much it costs to provide care and what we receive back. So, just as an example, you know, the national average is that Medicaid payments cover 57 to 59% of the costs to take care of a patient.
So, for every dollar that we spend, we receive less than $0.60 back. The state-directed payments are to help bridge that gap. So, in Arizona, Banner serves 39% of all Medicaid inpatients in the state. If we focus on two specific main counties, Maricopa and Pima, we serve 40 to 43% of those Medicaid inpatients in those counties.
So, to be able to postpone the separate payment terms helps us to be able to track this better, to make sure that our payments that we are receiving are truly based on our Medicaid utilization. It's not based on how fast you're billing to the Medicaid payer, what issues you're having with claims, denials, things like that.
SHAWN STACK
Now, Andy, I know that you have at least two, right, critical access hospitals in Arizona. I know you have Payson Medical Center and Page Hospital. And then I think you have when I was looking, I think 2 or 3 in in Colorado that are also rural hospitals, right? You have East Morgan County, Sterling Regional Medical Center and McKee, I think Medical Center. I know those are, typically, those are Medicare/Medicaid payer mix.
But I've been concerned and I wondered if you think the same, that your academic medical centers as well, you're seeing a lot of transfers of Medicaid patients, right? So, that payer mix, too, is really hard to navigate with these types of cuts, right? Even at your, what most people would call or consider, your urban hospitals that should be okay. But you're seeing a lot of those Medicaid patients?
ANDY WEGMAN
Correct. Yes, I mean, it's all of our facilities, you know, and I will say this to, you know, as we discuss and we go into, let's just say, like the work requirements and things like that, that's where we start, you know, getting into the part where our Medicaid eligibility for our patients is going to start to decrease.
SHAWN STACK
Right.
ANDY WEGMAN
And so, what this is going to do is just put pressure on self-pay and put more pressure on the hospitals.
SHAWN STACK
Yeah. So, what are you doing? What strategically are you pulling into alignment here to maybe help address and fill in some of these gaps? I mean, outreach? Payer? Is there any payer/provider collaboration? Because let's face it, these Medicaid managed care plans are also going to be losing these members, eligible members, if they don't comply with either, you know, the work requirements or revalidations, right, every six months? I mean, are you doing anything here strategically to prepare for this?
ANDY WEGMAN
Yeah. So, I mean, I will say our patient access teams have continually done an amazing job just navigating these things when they're in our buildings. And we can try to help them if they don't have coverage so they know what's necessary for applying. But, you know, as I mentioned too, you know, Banner’s not only a healthcare provider, we also have the insurance side of things, right?
So, you know, Banner’s taking an active role in patient and our member engagement and outreach, you know? We're tasked with educating members about the new requirements, identifying those at risk of noncompliance and conducting outreach prior to even potential disenrollment. So, our responsibilities have now expanded to making sure that we're supporting our members’ navigation and compliance, making sure, you know, we're connecting with the requirements of the employment support services.
You know, do we need to connect members with job training programs, workforce agencies, educational opportunities, all of this? It's really a whole team approach of what's needed to navigate this moving forward.
SHAWN STACK
And you bring up a really important point here, Andy, because you wear, Banner wears two very separate hats, right? Because let's face it, I've talked to many organizations who own payers. It is a very separate entity and it's kept very separate. But you see the struggle on both sides. So, don't you agree that partnerships in this space with the payers on the Medicaid managed care side are just so important for payers and providers to collaborate in that effort?
ANDY WEGMAN
100%, yes. I mean, you know, even when we're looking at, you know, when we see patients that, you know, individuals that lose healthcare coverage, right? So, if they do fall through the cracks, these individuals are less likely to seek preventative care. So, we need to try to make sure that we can keep them on their coverage instead of, you know, them seeking the emergency department when something gets even more serious.
We need to make sure that we keep that preventative care going forward. It just helps everybody to be more healthy throughout the whole process as opposed to, you know, getting up to a diagnosis just with little time to really address the issue.
SHAWN STACK
Yeah, couldn’t agree more. I mean, continuity of care is truly a big risk. And I just got off the stage talking at a symposium and I said, you know, this is one of the things that quote unquote “legacy providers” really have done a phenomenal job over the last decade in perfecting and honing is continuum of care and cuts like this and, you know, disruption have really challenged us over the last five years in continuing that continuum of care for our members and our patients.
CHAD MULVANY
Andy, you mentioned earlier the importance of state-directed payments to Banner. How is Banner preparing for those cuts? I mean, you know what the runway looks like, so what is the organization doing to make sure that when they start to kick in and given how important they are, you're going to be able to navigate them?
ANDY WEGMAN
Yeah. So, that's a good and a very difficult question, right? You know, we have to look at this, you know, not only in the short term but long term as we're doing our long-range forecasting and seeing what will it be looking like, you know, five years, 10 years down the road when these reductions are fully implemented.
I mean, not really giving any specifics, but, you know, Banner, as well as any other healthcare provider, we're going to have to evaluate, you know, are there certain programs that are no longer sustainable? Are there service line reductions that are needed to be able to keep things moving, right? You know, hospitals operate on a razor-thin margin.
You know, I think that's something that a lot of people may forget. You know, they see the bill that they get, but especially, you know, talking with Banner Health nonprofit, everything is, you know, anything that we get is invested back into our communities. And with the reduction of these state-directed payments, it just makes it that much more difficult to invest in the items that we need to invest in.
CHAD MULVANY
Yeah, to make sure that they have access to the services they needed. And I think, you know, without naming specific services, what's unfortunate about this is the services that I worry about are the ones that are already, that we struggle with to access in many areas of the country, particularly those that are either rural or socioeconomically disadvantaged.
And there's a reason why those services aren't more readily available because of the payer mix and the underpayment. And then when you start to layer on everything else, you know, we were talking about 340B earlier, you know, when you think about what the intent of 340B was from Congress. And now CMS is basically implementing a budget-neutral shift in where those funds flow.
They're also doing the 3% recoupment from the prior settlement. It really does start to put a tremendous amount of pressure on the organization. And then you layer in the work requirements and the loss of coverage, both from the exchange and through the Medicaid work requirements for your expansion states in One Big Beautiful Bill. So, yeah, it's a lot to navigate.
ANDY WEGMAN
Yeah. It's a difficult cycle to think about, right? So, we think, our 340B hospitals are hospitals that have a disproportionate share of low-income patients. And so, that's how they're qualifying. And so, now we're going to be paying them less. And we're shifting, CMS is shifting those funds to other service lines that are not necessarily going to benefit the hospitals that have a disproportionate share of low-income patients.
SHAWN STACK
Now, keeping in mind, Andy, I know that you're modeling these, you're modeling the reimbursement changes that you think are going to be impacting, you know, as we as we come up on all these state-directed payment issues and cuts. But keeping in mind that this is not just state-directed payment cuts for hospitals, it's also for Medicaid programs.
So, I assume as you model these reimbursement shifts and cuts, I assume your government relations folks are also talking to state Medicaid agencies saying, do you realize what is going to happen, what type of impact this is going to have on these communities that we service, right? I mean, this is kind of dire across the board as far as coverage, right?
Because they're going to have to cut as they run out of money for some of these additional programs. But it could, like you said, it could really impact these challenged areas even more.
ANDY WEGMAN
Correct. And, I mean, a lot of times I always reference things back to Arizona, since that's where we have our biggest presence. And, you know it's, you know, it's an expansion state. The expansion population is funded by the hospitals. And so, we put up that local share to draw down federal dollars to ensure that these patients have coverage.
And so, when things like hold harmless limits get reduced, for state-directed payments the methodology going from average commercial rate to Medicare rates. I mean, these things all play a very important role in trying to determine, you know, what kind of coverage is going to be out there five years down the road for the patients that need that coverage.
CHAD MULVANY
You know, you make a great point about the provider taxes and the phasedown of the hold harmless limit. Obviously, the state knows this is coming. So, what conversations have they been having so far, if any, about trying to sort of sustain that expansion population, given that it was more or less self-funded by the hospitals?
ANDY WEGMAN
Yeah. So, we do work really closely with AHCCCS, or the State of Arizona, as their program. You know, as we have new models come out each year, you know, initial proposals and looking at estimates on how much is needed for coverage and making sure that the funding is appropriate, making sure that we're updating any of our calculations to just ensure that we're keeping that funding as stable as possible, but trying to, on the other hand as well, ensure that we are able to provide funding for other programs to work on that gap that I was kind of talking about earlier from the shortfall of seeing Medicaid patients.
And so, it's just, it's a balancing act. It really is. And we work closely with the state. We have some other consultants that we work with as well, the hospitals, we all work together to try to navigate these waters as they're coming at us.
SHAWN STACK
Yeah, Andy, you bring up a good point. I mean, there's just so many vulnerable services that are going to become more vulnerable through these cuts. I mean, things like, for listeners, things like inpatient psychiatry, crisis stabilization units, substance use disorder treatment programs, things like rural maternity units, neonatal support services, swing beds, rural outpatient clinics, community health programs.
These are really important services that these just, you know, these disproportionate communities now, through Medicaid expansion and through the programs that Medicaid offers, these great programs, these are at risk, right, Andy? And I'm assuming that your communities that Banner serves are big recipients now of these services, and those might be challenged in the future.
ANDY WEGMAN
They are, you know, and I will say that, you know, Banner, we just, we have a history. We are going to do what's best for our communities. And we're, you know, we buckle down. We make sure that we're going through everything and making sure that we're providing just the best care to our patients, the best community stewards. And yeah, it'll definitely, it gets difficult with these reductions. It's just going to be some difficult waters to manage through.
SHAWN STACK
And almost paralyzing for a rural hospital that is not part of a larger system, right, Andy? I mean, they don't have the resources necessarily.
ANDY WEGMAN
Yeah. I mean, it definitely helps with, you know, with our critical access hospitals, you know, having certain functions centralized so they're not bearing all these costs. You know, I think what's interesting is too, a lot of times people think, well, Medicare pays 101%. Well, you're not getting more than what you pay in. I will say that. So, there's definitely the need for efficiency and making sure, you know, if your rural facilities are struggling, you know, do we have our university or community hospitals that can, you know, just assist as a, just as a whole health system?
CHAD MULVANY
You know, Andy, the other thing, when you say, you know, critical access hospitals get paid by Medicare at 101%, I mean that that presumes that there hasn't been a significant shift to MA, which in a lot of cases, that's not how those contracts are structured. So, you kind of layer on that piece of pressure as well. I think, you know, one of the interesting things that I'll be watching over the next couple of years is kind of the tension between the policy community, both in D.C. and state capitals, who have, for whatever reason, decided that consolidation integration is driving cost.
But then at the same time, all the services that we've been talking about that Shawn specifically called out that are important for communities to have access to, all communities to have access to, like, what's the tension between allowing integration to occur in order to support access to those services or having a regulator block it just sort of blindly? Because now evidently consolidation is, you know, they're looking at the cost side of it, but they're also not looking fully at, you know, the avoided cost of providing that care in the community versus having someone either a) not get the care or b) have to go someplace else where it's going to be more expensive, likely.
SHAWN STACK
Or delay it until they're so sick that their care is going to be so expensive. right?
CHAD MULVANY
Correct.
ANDY WEGMAN
Exactly. And then they end up in the emergency department and well, now the cost of providing that care just quadrupled.
CHAD MULVANY
Yeah.
ANDY WEGMAN
As opposed to just being able to take the preventative measures, having that coverage on the front end.
CHAD MULVANY
Andy, what else is, not that we haven't already talked about enough, but what else is keeping you up at night on the regulatory front?
ANDY WEGMAN
On top of all these items that we've already been discussing, right? You know, I think—and personally, one of the things that, you know, as I'm reading all the various proposed rules and things like that is—all of CMS’ proposals to, and I'll just say it in air quotes, “codify their long-standing policy” for this, that and the other thing, right?
You know, a little bit about, you know, the IPPS proposed rule that came out, right? So, initially discussing the need to fragment all of your overhead for every department utilization of those services. And, you know, CMS was obviously focusing on nursing allied health since it's paid as a passthrough cost.
But I mean, is that appropriate just to pick that one and not the other ones, right? And, you know, luckily with the final rule, they did not make any changes to that, you know? So, they're—sorry, they didn't make any changes to the current rule. So, it's not to the point where you need to fragment everything out. But something that did get finalized in the final rule is regarding removing certain costs from the accumulated cost stat for allocating A&G costs.
You know, right now, you know, the focus of this was really CMS focusing on transplant costs—we do operate two transplant hospitals—and with the ruling, their big focus was on purchased services and really looking at like the purchased organs. But we have purchased services all throughout other departments as well.
So, it just leads us down a rabbit hole of saying, okay, well then we should probably be looking at these purchased services because they may not be receiving any benefit from A&G. And so, they shouldn't be receiving that allocation either. And then, when all this picking and choosing and I'll just say fragmenting and everything, it just really opens up the hospitals for more audit risk.
And then it just gets to be based on each auditor's interpretation of the regulations. And so that's really my concern, you know, as this shift really starts to move things from how things have been operating to more of a well, now each auditor is going to be taking a look at something. They may come up with a different response than the next auditor, and it's just going to make it a little bit more difficult to ensure you're handling these things consistently.
SHAWN STACK
So, switching gears, what's one piece of advice you give, Andy, to someone who recently moved into a formal leadership role in reimbursement, healthcare, anything that you'd want to share there for someone new coming in?
ANDY WEGMAN
Yeah. So, I mean, actually there's a there's a couple of them. I mean, first and foremost, I would say just make sure your values align with the company that you're working for. Just on the, right on the front end, you know? When you work for a company that shares your same values and they're a part of a team that cares about you both personally and professionally, there's nothing you won't do to ensure everyone’s successful. So, that's definitely number one. I've been very, very happy working with Banner. It's been a great company.
The second one, it's kind of funny, but just, I realized early on in my career that I don't know everything. So, you know, that is brought to my attention every single day. You know, there's always the new, new thing popping up. And I will say, be honest, admit that you may not know the answer to a question.
I feel like sometimes people are so afraid, and so they do the whole let's fake it ‘til you make it, right? No, just ask the question, you know? If you don't know, say that you don't know, you know? Not knowing something is the catalyst to researching a topic, discussing it with your peers, and just eventually learning something new that can help you throughout your career.
When leading a team, you need to listen to them and build both personal and professional relationships with them. Trust your team members as they look to you to grow and take on more challenges.
SHAWN STACK
A lot of it too, is knowing and building relationships with your colleagues, not only just at your organization, but outside of your organization, that you can lean on in those—maybe it's a PAMA question, you know, a lab question or something—building that network of trusted advisors that you know know more than you do in that one specific area. Don't you think that's important too, Andy?
ANDY WEGMAN
100%. And even with the things that you do know. So, another fun fact, right? So, when starting off as an auditor one, I'll say the first real auditable issue that you learn is Medicare bad debts. And so, I've known about Medicare bad debts and the reimbursement of them for over 19 years. But there's still always different nuances that come up regarding Medicare bad debts.
So, it's just not only the stuff that you may not have the best grasp of, but just even things that you do. And things change, it's important to be able to have peers—again, inside, outside of your organization—that you can discuss situations with. And you know, what-if scenarios and things like that.
And as we've seen now, especially over the past couple of years here, I mean, just all the different regulatory changes coming down, it's a lot to try to take on. And you can't just take it on as one person. You definitely need to utilize your team, your peers to navigate these to make sure you're handling things accurately.
SHAWN STACK
Yeah, couldn’t agree more. What's something you and your colleagues recently accomplished that you're proud of, Andy, or challenges did you have that you overcame and how did you do it?
ANDY WEGMAN
Yeah. So, I think, you know, one thing that I've been really proud of my team is just we've been successful obtaining additional IME and DGME FTE cap space for every round of section 126, as well as section 4122. And when you kind of talk about challenges, I guess I wouldn't necessarily say it’s a challenge, but just, I think knowing where your health system’s short-term and long-term risks are for physician staffing in your markets is key.
You know, working with senior leadership and your GME office to map out a plan to address those risks. You know, Banner’s been expanding their GME footprint substantially over the past few years, and we continue to do so to meet the needs of our community. At Banner here we have something, we call it “One Team,” you know, we're all one team. We all work together for a common purpose.
And, you know, obviously at the end of the day, that is for our patients. And looking at things from different perspectives, whether it's reimbursement services or if it's, you know, the GME office, you know, the intricacies of training residents, right, or senior leadership and what they're seeing in the markets and what we might be facing here in the next few years.
It's just really important for us to all work together to make sure that as one team, we are moving in the direction that we want to for our patients.
SHAWN STACK
Well, Andy, this was fantastic. I want to thank you again for joining today's episode and and sharing your insights. You're a wealth of knowledge. I always enjoy talking to you. And we'd also like to thank our listeners for tuning in. You can follow “Achieving Health” on Apple Podcasts, Spotify, Amazon Music, or wherever you listen to podcasts. You can also now find us in the Health Podcast Library.
If you want to learn more about the topics we discussed here, be sure to check out the show notes for related content. You can also subscribe to our Healthcare FORsights and follow us on LinkedIn to get regular insights and updates. And we welcome you to reach out to me, Chad and the team here at Forvis Mazars if you have any questions about how these topics may affect your organization. Chad and I will be back next week on Wednesday, August 19, for the next round of “Washington Watch” updates. Until then, here's wishing good health for you and the communities you serve.
ANNOUNCER
You can follow “Achieving Health” on your favorite podcast platform or visit forvismazars.us/AchievingHealthPodcast to learn more.
“Achieving Health” is produced by Forvis Mazars LLP, an independent member of Forvis Mazars Global, a leading global professional services network. Ranked among the largest public accounting firms in the United States, the firm's 7,000 dedicated team members provide an Unmatched Client Experience through the delivery of assurance, tax and consulting services for clients in all 50 states and internationally through the global network.
The information set forth in this podcast contains the analysis and conclusions of the panelists based upon his, her, or their research and analysis of industry information and legal authorities. Such analysis and conclusions should not be deemed opinions or conclusions by Forvis Mazars or the panelists as to any individual situation as situations are fact specific.
The listener should perform their own analysis and form their own conclusions regarding any specific situation. Further, the panelists’ conclusions may be revised without notice, with or without changes in industry information and legal authorities.