Association of Medicaid Expansion With Quality in Safety-Net Hospitals.

Importance: Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown. Objective: To compare changes in quality from 2012 to 2018 between SNHs in states that expanded Medicaid vs those in states that did not. Design, Setting, and Participants: Using a difference-in-differences analysis in a cohort study, performance on quality measures was compared between SNHs, defined as those in the highest quartile of uncompensated care in the pre-Medicaid expansion period, in expansion vs nonexpansion states, before and after the implementation of Medicaid expansion. A total of 811 SNHs were included in the analysis, with 316 in nonexpansion states and 495 in expansion states. The study was conducted from January to November 2020. Exposures: Time-varying indicators for Medicaid expansion status. Main Outcomes and Measures: The primary outcome was hospital quality measured by patient-reported experience (Hospital Consumer Assessment of Healthcare Providers and Systems Survey), health care-associated infections (central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical site infections following colon surgery) and patient outcomes (30-day mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia). Secondary outcomes included hospital financial measures (uncompensated care and operating margins), adoption of electronic health records, provision of safety-net services (enabling, linguistic/translation, and transportation services), or safety-net service lines (trauma, burn, obstetrics, neonatal intensive, and psychiatric care). Results: In this difference-in-differences analysis of a cohort of 811 SNHs, no differential changes in patient-reported experience, health care-associated infections, readmissions, or mortality were noted, regardless of Medicaid expansion status after the Affordable Care Act. There were modest differential increases between 2012 and 2016 in the adoption of electronic health records (mean [SD]: nonexpansion states, 99.4 [7.4] vs 99.9 [3.8]; expansion states, 94.6 [22.6] vs 100.0 [2.2]; 1.7 percentage points; P = .02) and between 2012 and 2018 in the number of inpatient psychiatric beds (mean [SD]: nonexpansion states, 24.7 [36.0] vs 23.6 [39.0]; expansion states: 29.3 [42.8] vs 31.4 [44.3]; 1.4 beds; P = .02) among SNHs in expansion states, although they were not statistically significant at a threshold adjusted for multiple comparisons. In subgroup analyses comparing SNHs with higher vs lower baseline operating margins, an isolated differential improvement was noted in heart failure readmissions among SNHs with lower baseline operating margins in expansion states (mean [SD], 22.8 [2.1]; -0.53 percentage points; P = .001). Conclusions and Relevance: This difference-in-differences cohort study found that despite reductions in uncompensated care and improvements in operating margins, there appears to be little evidence of quality improvement among SNHs in states that expanded Medicaid compared with those in states that did not.

The Health Resources and Services Administration's Ryan White HIV/AIDS Program in rural areas of the United States: Geographic distribution, provider characteristics, and clinical outcomes.

BACKGROUND: People living with HIV (PLWH) residing in rural areas experience substantial barriers to HIV care, which may contribute to poor HIV health outcomes, including retention in HIV care and viral suppression. The Health Resources and Services Administration's Ryan White HIV/AIDS Program (HRSA RWHAP) is an important source of HIV medical care and support services in rural areas. The purpose of this analysis was to (1) assess the reach of the RWHAP in rural areas of the United States, (2) compare the characteristics and funded services of RWHAP provider organizations in rural and non-rural areas, and (3) compare the characteristics and clinical outcomes of RWHAP clients accessing medical care and support services in rural and non-rural areas. METHODS AND FINDINGS: Data for this analysis were abstracted from the 2017 RWHAP Services Report (RSR), the primary source of annual, client-level RWHAP data. Organizations funded to deliver RWHAP any service ("RWHAP providers") were categorized as rural or non-rural according to the HRSA FORHP's definition of modified Rural-Urban Commuting Area (RUCA) codes. RWHAP clients were categorized based on their patterns of RWHAP service use as "visited only rural providers," "visited only non-rural providers," or "visited rural and non-rural providers." In 2017, among the 2,113 providers funded by the RWHAP, 6.2% (n = 132) were located in HRSA-designated rural areas. Rural providers were funded to deliver a greater number of service categories per site than non-rural providers (44.7% funded for ≥5 services vs. 34.1% funded for ≥5 services, respectively). Providers in rural areas served fewer clients than providers in non-rural areas; 47.3% of RWHAP providers in rural areas served 1-99 clients, while 29.6% of non-rural providers served 1-99 clients. Retention in care and viral suppression outcomes did not differ on the basis of whether a client accessed services from rural or non-rural providers. CONCLUSIONS: RWHAP providers are a crucial component of HIV care delivery in the rural United States despite evidence of significant barriers to engagement in care for rural PLWH, RWHAP clients who visited rural providers were just as likely to be retained in care and reach viral suppression as their counterparts who visited non-rural providers. The RWHAP, especially in partnership with Rural Health Clinics and federally funded Health Centers, has the infrastructure and expertise necessary to address the HIV epidemic in rural America.

Financial burden of cancer care under the Affordable Care Act: Analysis of MEPS-Experiences with Cancer Survivorship 2011 and 2016.

PURPOSE: To examine whether the implementation of Affordable Care Act (ACA) reduced the financial burden associated with cancer care among non-elderly cancer survivors. METHODS: Using data from the MEPS-Experiences with Cancer Survivorship Survey, we examined whether there was a difference in financial burden associated with cancer care between 2011 (pre-ACA) and 2016 (post-ACA). Two aspects of financial burden were considered: (1) self-reported financial burden, whether having financial difficulties associated with cancer care and (2) high-burden spending, whether total out-of-pocket (OOP) spending incurred in excess of 10% or 20% of family income. Generalized linear regression models were estimated to adjust the OOP expenditures (reported in 2016 US dollar). RESULTS: Our sample included adults aged 18-64 with a confirmed diagnosis of any cancer in 2011 (n = 655) and in 2016 (n = 490). There was no apparent difference in the prevalence of cancer survivors reporting any financial hardship or being with high-burden spending between 2011 and 2016. The mean OOP decreased by $268 (95% CI, - 384 to - 152) after the ACA. However, we found that the mean premium payments increased by $421 (95% CI, 149 to 692) in the same period. CONCLUSIONS: The ACA was associated with reduced OOP for health services but increased premium contributions, resulting in no significant impact on perceived financial burden among non-elderly cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: The financial hardship of cancer survivorship points to the need for the development of provisions that help cancer patients reduce both perceived and materialized burden of cancer care under ongoing health reform.

Posterior lumbar fusions at physician-owned hospitals - is it time to reconsider the restrictions of the Affordable Care Act?

BACKGROUND CONTEXT: Caused by perceptions regarding unnecessary healthcare resource utilization, high costs of care, and financial incentives towards "cherry-picking" cases in physician owned hospitals, the Affordable Care Act (ACA) of 2010 imposed restrictions on existing physician-owned hospitals from expanding. Despite an increasing number of individuals requiring access to spine surgical care, no study has evaluated the surgical safety and costs of elective posterior lumbar fusions (PLFs) being performed in physician-owned vs. non-physician-owned hospitals. PURPOSE: We assessed differences in 90-day costs and outcomes between patients undergoing elective 1- to 3-level PLFs at physician-owned hospitals vs. nonphysician-owned hospitals. STUDY DESIGN: Retrospective cohort study of 2007 to 2014 100% Medicare claims database. PATIENT SAMPLE: The 2007 to 2014 Medicare 100% Standard Analytical Files (SAF100) was queried using International Classification of Diseases 9th Edition (ICD-9) procedure code for patients undergoing elective 1- to 3-level PLFs (81.07, 81.08, and 81.62). The Medicare Hospital Compare database was used to identify provider codes for physician-owned hospitals. These provider codes were cross-referenced to identify records of patients receiving elective PLFs at these hospitals from the SAF100 database. OUTCOME MEASURES: Ninety day complications, readmissions, emergency department (ED) visits, charges, and costs. METHODS: Multivariate logistic and linear regression analyses were used to assess significant differences in 90-day complications, readmissions, charges and costs between the two groups. RESULTS: A total of 6,679 (2.9%) patients received an elective PLF at a physician-owned hospital (N=39; 2.2%) whereas 225,090 (97.1%) received surgery at nonphysician-owned hospital (N=1,774; 97.8%). After controlling for age, gender, region, hospital factors (socio-economic status area, urban vs. rural location and volume) and Elixhauser co-morbidity index, undergoing surgery at physician-owned hospital was associated with lower odds of thromboembolic complications (OR 0.66 [95% CI 0.53-0.82]; p<.001), urinary tract infections (OR 0.87 [95% CI 0.79-0.95]; p=.002) and renal complications (OR 0.52 [95% CI 0.43-0.63]; p<.001) within 90-days following the surgery. Patients undergoing PLFs at physician-owned hospitals vs. nonphysician-owned hospitals also had lower risk-adjusted inpatient charges (-$10,218), inpatient costs (-$2,302), 90-day charges (-$9,780) and 90-day costs (-$2,324). No significant differences were noted between physician-owned and nonphysician-owned hospitals with regards to 90-day wound complications (OR 1.08 [95% CI 0.94-1.22]; p=.279), pulmonary complications (OR 1.06 [95% CI 0.97-1.17]; p=.187), cardiac complications (OR 0.92 [95% CI 0.83-1.01]; p=.089), septic complications (OR 0.77 [95% CI 0.56-1.01]; p=.073), all-cause ED visits (OR 0.96 [95% CI 0.89-1.04]; p=.311), revision surgery (OR 1.09 [95% CI 0.72-1.59]; p=.653) and readmissions (OR 0.98 [95% CI 0.89-1.08]; p=.680). CONCLUSION: Our results suggest that patients undergoing elective 1- to 3-level PLFs at physician-owned hospitals do not experience a greater number of complications and/or readmissions while having lower risk-adjusted charges and costs over the 90-day episode of care. The findings call on the need for revaluation/reconsideration of the ACAs restriction on the expansion of these physician-owned hospitals.

Repercusiones de "ObamaCare" para la reforma sanitaria en Chile / "ObamaCare": effects for the health reform in Chile

Health care raises structural issues in a democratic society, such as the role assigned to the central government in the management of health risk and the redistributive consequences generated by the implementation of social insurance. These are often cause of strong political controversy. This paper examines the United States of America health reform, popularly known as "ObamaCare". Its three main elements, namely individual mandate, creation of new health insurance exchanges, and the expansion of Medicaid, generated a redistribution of health risks in the insurance market of that country after almost a century of frustrated legislative efforts to guarantee minimum universal coverage. The article proposes that a change of this magnitude in the United States will produce effects in a forthcoming parliamentary discussion on the health reform in Chile, which still maintains a highly deregulated private health system.

Comparing the Hospital-Acquired Condition Reduction Program and the Accreditation of Cancer Program: A Cross-sectional Study.

Under the Hospital-Acquired Condition Reduction Program (HACRP), introduced by the Affordable Care Act, the Centers for Medicare and Medicaid must reduce reimbursement by 1% for hospitals that rank among the lowest performing quartile in regard to hospital-acquired conditions (HACs). This study seeks to determine whether Accredited Cancer Program (ACP) hospitals (as defined by the American College of Surgeons) score differently on the HACRP metrics than nonaccredited cancer program hospitals. This study uses data from the 2014 American Hospital Association Annual Survey database, the 2014 Area Health Resource File, the 2014 Medicare Final Rule Standardizing File, and the FY2017 HACRP database (Medicare Hospital Compare Database). The association between ACPs, HACs, and market characteristics is assessed through multinomial logistic regression analysis. Odds ratios and 95% confidence intervals are reported. Accredited cancer hospitals have a greater risk of scoring in the Worse outcome category of HAC scores, vs Middle or Better outcomes, compared with nonaccredited cancer hospitals. Despite this, they do not have greater odds of incurring a payment reduction under the HACRP measurement system. While ACP hospitals can likely improve scores, questions concerning the consistency of the message between ACP hospital quality and HACRP quality need further evaluation to determine potential gaps or issues in the structure or measurement. ACP hospitals should seek to improve scores on domain 2 measures. Although ACP hospitals do likely see more complex patients, additional efforts to reduce surgical site infections and related HACs should be evaluated and incorporated into required quality improvement efforts. From a policy perspective, policy makers should carefully evaluate the measures utilized in the HACPR.

The Annual Gynecologic Examination Updated for the 21st Century.

The concept of an annual gynecologic screening visit to identify disease at an early stage has long been an established component of women's health care. Women and their health care providers have historically accepted the schedule of an annual gynecologic examination with cervical cancer screening and a pelvic examination. Recently, researchers questioned the value of the annual breast and pelvic examinations in asymptomatic women and re-established the intervals for Pap test screening with the addition of human papillomavirus co-testing to establish cervical cancer risk. The updated well woman examination is now an opportunity to engage women in health education, screening for chronic disease risks, and health care concerns such as depression and violence.

Knowledge of and Attitudes Toward Evidence-Based Guidelines for and Against Clinical Preventive Services: Results from a National Survey.

POLICY POINTS: Both the underuse and overuse of clinical preventive services relative to evidence-based guidelines are a public health concern. Informed consumers are an important foundation of many components of the Affordable Care Act, including coverage mandates for proven clinical preventive services recommended by the US Preventive Services Task Force. Across sociodemographic groups, however, knowledge of and positive attitudes toward evidence-based guidelines for preventive care are extremely low. Given the demonstrated low levels of consumers' knowledge of and trust in guidelines, coupled with their strong preference for involvement in preventive care decisions, better education and decision-making support for evidence-based preventive services are greatly needed. CONTEXT: Both the underuse and overuse of clinical preventive services are a serious public health problem. The goal of our study was to produce population-based national data that could assist in the design of communication strategies to increase knowledge of and positive attitudes toward evidence-based guidelines for clinical preventive services (including the US Preventive Services Task Force, USPSTF) and to reduce uncertainty among patients when guidelines change or are controversial. METHODS: In late 2013 we implemented an Internet-based survey of a nationally representative sample of 2,529 adults via KnowledgePanel, a probability-based survey panel of approximately 60,000 adults, statistically representative of the US noninstitutionalized population. African Americans, Hispanics, and those with less than a high school education were oversampled. We then conducted descriptive statistics and multivariable logistic regression analysis to identify the prevalence of and sociodemographic characteristics associated with key knowledge and attitudinal variables. FINDINGS: While 36.4% of adults reported knowing that the Affordable Care Act requires insurance companies to cover proven preventive services without cost sharing, only 7.7% had heard of the USPSTF. Approximately 1 in 3 (32.6%) reported trusting that a government task force would make fair guidelines for preventive services, and 38.2% believed that the government uses guidelines to ration health care. Most of the respondents endorsed the notion that research/scientific evidence and expert medical opinion are important for the creation of guidelines and that clinicians should follow guidelines based on evidence. But when presented with patient vignettes in which a physician made a guideline-based recommendation against a cancer-screening test, less than 10% believed that this recommendation alone, without further dialogue and/or the patient's own research, was sufficient to make such a decision. CONCLUSIONS: Given these demonstrated low levels of knowledge and mistrust regarding guidelines, coupled with a strong preference for shared decision making, better consumer education and decision supports for evidence-based guidelines for clinical preventive services are greatly needed.

Accountable Care Organizations: what they mean for the country and for neurointerventionalists.

The Affordable Care Act is celebrating its fifth anniversary and remains one of the most significant attempts to reform healthcare in US history. Prior to the federal legislation, Accountable Care Organizations had largely been part of an academic discussion about how to control rising healthcare costs, but have since become a fixture in our national healthcare landscape. A fundamental shift is underway in the relationship between healthcare delivery and payment models. Some elements of Accountable Care Organizations may remain unfamiliar to most healthcare providers, including neurointerventional specialists. In this paper we review the fundamental concepts behind and the current forms of Accountable Care Organizations, and discuss the challenges and opportunities they present for neurointerventionalists.

Comparing the Maryland Comprehensive Cancer Control Plan With Federal Cancer Prevention and Control Recommendations.

INTRODUCTION: Since the introduction of the Affordable Care Act (ACA) in 2012, 11 million more Americans now have access to preventive services via health care coverage. Several prevention-related recommendations issued by the US Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC), and Advisory Committee on Immunization Practices (ACIP) are covered under the ACA. State cancer plans often provide prevention strategies, but whether these strategies correspond to federal evidence-based recommendations is unclear. The objective of this article is to assess whether federal evidence-based recommendations, including those covered under the ACA, are included in the Maryland Comprehensive Cancer Control Plan (MCCCP). METHODS: A total of 19 federal recommendations pertaining to cancer prevention and control were identified. Inclusion of federal cancer-related recommendations by USPSTF, CDC, and ACIP in the MCCCP's goals, objectives, and strategies was examined. RESULTS: Nine of the federal recommendations were issued after the MCCCP's publication. MCCCP recommendations corresponded completely with 4 federal recommendations and corresponded only partially with 3. Reasons for partial correspondence included specification of less restrictive at-risk populations or different intervention implementers. Three federal recommendations were not mentioned in the MCCCP's goals, objectives, and strategies. CONCLUSION: Many cancer-related federal recommendations were released after the MCCCP's publication and therefore do not appear in the most current version. We recommend that the results of this analysis be considered in the update of the MCCCP. Our findings underscore the need for a periodic scan for changes to federal recommendations and for adjusting state policies and programs to correspond with federal recommendations, as appropriate for Marylanders.

Quality of Life and General Health After Elective Surgery for Cervical Spine Pathologies: Determining a Valid and Responsive Metric of Health State Utility.

BACKGROUND: As part of the Affordable Care Act, health utility metrics are being investigated to define a cost-effective, value-based health care model. EuroQOL-5D (EQ-5D) and Short Form-6D (SF-6D) are commonly used quality-of-life instruments. Domains in the EQ-5D questionnaire are thought to be less responsive in measuring quality of life after cervical surgery. OBJECTIVE: To evaluate the validity and responsiveness of SF-6D and EQ-5D in determining health and quality of life after elective cervical spine surgery. METHODS: A total of 420 patients undergoing elective cervical spine surgery over a period of 2 years were enrolled in a prospective longitudinal registry. Patient-reported outcomes Neck Disability Index (NDI), EQ-5D, and SF-12 were recorded. Based on previously published equations, SF-6D was calculated using NDI and SF-12 scores. Patients were asked whether "surgery met their expectations" (meaningful improvement). The validity and relative responsiveness of SF-6D (NDI), SF-6D (SF-12), and EQ-5D to discriminate between meaningful and nonmeaningful improvement were calculated. RESULTS: Sixty-six percent of patients (277) reported a level of improvement after surgery that met their expectations (meaningful improvement). SF-6D (NDI) (area under the curve [AUC] = 0.69) was a more valid discriminator of meaningful improvement compared with the SF-6D (SF-12) (AUC = 0.65) and EQ-5D (AUC = 0.62). SF-6D (NDI) was also a more responsive measure compared with SF-6D (SF-12) and EQ-5D (standardized response mean difference: 0.66, 0.48, and 0.44, respectively). CONCLUSION: SF-6D is a more valid and responsive measure of general health and quality of life compared with EQ-5D. SF-6D derived from disease-specific disability scores was more valid and responsive than that derived from the generic preference-based SF-12. Cost-effective studies should use SF-6D as a measure of QALY after cervical spine surgery.

Does time pressure create barriers for people to receive preventive health services?

OBJECTIVE: Regular use of recommended preventive health services can promote good health and prevent disease. However, individuals may forgo obtaining preventive care when they are busy with competing activities and commitments. This study examined whether time pressure related to work obligations creates barriers to obtaining needed preventive health services. METHODS: Data from the 2002-2010 Medical Expenditure Panel Survey (MEPS) were used to measure the work hours of 61,034 employees (including 27,910 females) and their use of five preventive health services (flu vaccinations, routine check-ups, dental check-ups, mammograms and Pap smear). Multivariable logistic regression analyses were performed to test the association between working hours and use of each of those five services. RESULTS: Individuals working long hours (>60 per week) were significantly less likely to obtain dental check-ups (OR=0.81, 95% CI: 0.72-0.91) and mammograms (OR=0.47, 95% CI: 0.31-0.73). Working 51-60 h weekly was associated with less likelihood of receiving Pap smear (OR=0.67, 95% CI: 0.46-0.96). No association was found for flu vaccination. CONCLUSIONS: Time pressure from work might create barriers for people to receive particular preventive health services, such as breast cancer screening, cervical cancer screening and dental check-ups. Health practitioners should be aware of this particular source of barriers to care.

Medicaid expansion in opt-out states would produce consumer savings and less financial burden than exchange coverage.

In the twenty-three states that have decided against expanding Medicaid under the Affordable Care Act, uninsured adults who would have been eligible for Medicaid and have incomes at or above the federal poverty guidelines are generally eligible for Marketplace (insurance exchange) premium tax credits and plans with generous benefits. This study compared estimated out-of-pocket spending for care and premiums, as well as the financial burdens they impose, for the families of these adults under two simulation scenarios: obtaining coverage through a silver plan with subsidized cost sharing and enrolling in expanded Medicaid. Compared with Marketplace coverage, Medicaid would more than halve average annual out-of-pocket spending ($938 versus $1,948), while dramatically reducing the percentage of adults in families with out-of-pocket expenses exceeding 10 percent or 20 percent of income (6.0 percent versus 17.1 percent and 0.9 percent versus 3.7 percent, respectively). Larger reductions would be seen for families with smokers, who under Medicaid would no longer be subject to Marketplace tobacco user surcharges. Medicaid expansion may offer a greater opportunity than access to Marketplace insurance to promote the financial well-being of previously uninsured low-income adults.

State Medicaid expansion decisions and disparities in women's cancer screening.

BACKGROUND: There are substantial disparities in breast and cervical cancer screening that stem from lack of health insurance. Although the Affordable Care Act (ACA) expands insurance coverage to many Americans, there are differences in availability of Medicaid coverage across states. PURPOSE: To understand the potential impact of Medicaid expansions on disparities in preventive care for low-income women by assessing pre-ACA breast and cervical cancer screening across states currently expanding and not expanding Medicaid to low-income adults. METHODS: Data from the 2012 Behavioral Risk Factor Surveillance System (analyzed in 2014) were used to consider differences in demographics among women for whom screening is recommended, including income and race/ethnicity, across expansion and nonexpansion states. Self-reported screening was compared by state expansion status overall, for the uninsured, and for low-income women. Logistic regressions were estimated to assess differences in self-reported screening across expansion and nonexpansion states controlling for demographics. RESULTS: Women in states that are not expanding Medicaid had significantly lower odds of receiving recommended mammograms (OR=0.87, 95% CI=0.79, 0.95) or Pap tests (OR=0.87, 95% CI=0.79, 0.95). The difference was larger among the uninsured (OR=0.72, 95% CI=0.56, 0.91 for mammography; OR=0.78, 95% CI=0.65, 0.94 for Pap tests). CONCLUSIONS: As women in nonexpansion states remain uninsured and others gain coverage, existing disparities in cancer screening by race and socioeconomic status are likely to widen. Health risks and associated costs to underserved populations must be taken into account in ongoing debates over expansion.

Affordable Care Act standards for race and ethnicity mask disparities in maternal smoking during pregnancy.

OBJECTIVE: This study compared maternal smoking during pregnancy between the new Patient Protection and Affordable Care Act (ACA) data collection standards and Federal Office of Management and Budget (OMB) standards. METHOD: Data were from the Massachusetts Standard Certificate of Live Births on 1,156,472 babies from 1996 to 2010. A parent reported whether the mother smoked during pregnancy (yes/no), her race (5 options) and, separately, her ethnicity (39 categories). Prenatal smoking rates were compared between the ACA and OMB standards. Detailed ethnicity from the birth certificate was then examined within all broad categories of the ACA standards: White, Black/African American, Other Hispanic, Other Asian/Pacific Islander, and Other categories. RESULTS: For Hispanic/Latina and Asian mothers, the ACA standards captured the variability in smoking across and within racial/ethnic groups more than the OMB standards. However, for White and Black/African American mothers, the broad ACA categories masked striking differences in prenatal smoking. While the overall prevalence among Whites was 10.2%, this ranged from 0.8% for Iranians to 21.0% for Cape Verdeans. Among Black/African Americans (7.6%), this ranged from 0.5% for Nigerians to 12.9% for African Americans. The ACA standards also combined ethnic groups with sizeable populations into Other Hispanics and Other Asian/Pacific Islanders. CONCLUSION: When population health surveys and other reporting tools are being revised, state and federal agencies should consider expanding all race/ethnicity categories to capture detailed ethnicity on everyone.