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Saturday, 26 March 2016

Princess Health and March 26th, 2016 Nearly Tweets Only. Princessiccia

Princess Health and March 26th, 2016 Nearly Tweets Only. Princessiccia

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March 26th, 2016 Nearly Tweets Only

Today was a solid one. I accomplished all of my goals for this day. I maintained the integrity of my calorie budget. I remained abstinent from refined sugar. I exceeded my water goal and I had a great workout this afternoon. I also made fantastic support exchanges and conversations very important.

I prepared a nice meal this evening in a kitchen other than mine! Italian Enchiladas (see Tweets below) was absolutely something different. Amber and Kristin loved them! We enjoyed the dinner and had a great visit.

It's a nearly Tweets Only edition tonight. Tomorrow, little Noah takes part in his first Easter egg hunt! A bunch of us will be taking him. That kid will have his own entourage tomorrow!

My Tweets Today:






























Thank you for reading and your continued support,
Strength,
Sean

Friday, 25 March 2016

Princess Health and March 25th, 2016 Titled Food Schedule. Princessiccia

Princess Health and March 25th, 2016 Titled Food Schedule. Princessiccia

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March 25th, 2016 Titled Food Schedule

The first half of this day was relaxed and full of rest. I stayed up way too late last night watching Better Call Saul. I still managed a full eight hours sleep--but here's the deal: When I sleep in like this--and it's almost 11am when I get out of bed, my food schedule is automatically tilted and challenged. On a day like today, when the second half is jam packed with work and an extra commitment--it makes it extra challenging. This is when planning becomes super-important.

I had two back to back location broadcasts today--a 3-5 and a 5:30 to 8pm, followed by being a judge at a big karaoke contest involving sixteen singers performing three songs each. The contest didn't wrap until nearly 1am. The top three finishers were amazing singers. It was a fun contest, even with it being way too long of a production. But anyway--oh yeah, the tilted food schedule...you see,

I had a very late brunch--and that pushed my lunch until at least the middle of my first broadcast. The client had plenty of free food--but I knew the choices there wouldn't be anything for me. I planned and prepared by picking up the ingredients for my favorite, sour cream chicken tacos, and set it up in the back of the station's broadcast vehicle. Lunch around 4:30--then around 8pm, I had an "on-the-go" dinner of almonds, two kinds of cheese and a banana. It worked very well. Add the coffee with half & half and plenty of water, capped with some good fruit as my #lastfoodofday, and I could count this day as exceptional in the food department.

I maintained the integrity of my plan in every way. I'm very proud of that. Today could have gone differently in many ways. But it didn't. That's a wonderful thing.

I decided early in the day that my activity level would be high enough to excuse not going to the gym. I did do my morning routine before coffee, thing.

I'm exhausted. Wow, good thing I was off this morning!

I'm letting the Tweets take it the rest of the way...

My Tweets Today:


































Thank you for reading and your continued support,
Strength,
Sean
Princess Health and Ky. Republicans like Indiana Medicaid plan, but head of Medicaid directors' group says Ind. isn't far enough along to be a model. Princessiccia

Princess Health and Ky. Republicans like Indiana Medicaid plan, but head of Medicaid directors' group says Ind. isn't far enough along to be a model. Princessiccia

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Gov. Matt Bevin and other Republicans have said they want to make Kentucky's version of Medicaid look like Indiana's, but a leading Medicaid official says that Indiana's program hasn't proven itself to save money or improve health, so it's unlikely other states will be allowed to use it as a model, Phil Galewitz reports for Kaiser Health News and The Washington Post.

Matt Salo, executive director of the National Association of Medicaid Directors, told Galewitz, �Other states have looked at it, but the Obama administration has made it pretty clear that Indiana is going to be a test case and much evaluation will need to be done before they approve any more like it.�

Now Bevin's office says it is looking at other states, too, as it negotiates with the U.S. Department of Health and Human Services, trying to come up with a revised program to save money, perhaps by August.

"The Indiana model is just one of many models that we are looking at for influence in crafting a plan that is specifically tailored for the needs of Kentucky," Bevin spokeswoman Jessica Ditto said in an e-mail. "We are working closely, and in good faith, with HHS as this process moves forward and have confidence that what we offer for their consideration will be a thoughtful, deliberate and unique plan that will improve health outcomes in a sustainable manner."

Under federal health reform, then-Gov. Steve Beshear expanded Medicaid to those in the state with incomes up to 138 percent of the federal poverty level, adding 400,000 people. The federal government pays for this expanded population through this year, but then the state will be responsible for 5 percent of the expansion, rising to the reform law's limit of 10 percent in 2020.

Bevin has said that Kentucky's revised program should require its members to have "skin in the game," and that the state cannot continue to pay for the health insurance of "able-bodied adults."

Healthy Indiana Plan

That sounds like Indiana, which has monthly fees and co-payments and refers its participants to a work program.

Even if it is just a dollar, everyone on Medicaid in Indiana pays something, whether it's through a monthly fee or through co-payments.

The Healthy Indiana Plan has two levels, HIP Plus and HIP Basic. Both plans offer incentives for using preventive services, but HIP Plus, which requires a monthly fee, also includes dental and vision services.

Those fees go into an account that is like a health savings account and is used for the first $2,500 of medical expenses each year. The state of Indiana pays the bulk of the $2,500 and if the participant's health-care expenses exceed this amount, the state will pay for the additional care at no cost to the individual.

HIP Plus is considered the best value and is available to everyone in the state with income below 138 percent of the federal poverty level. The consequences for not paying the required monthly fee vary by income level.

Those in HIP plus who make at or below the poverty level and fail to pay the fee are moved down to HIP Basic plan, which requires co-payments of up to $8 per service and $75 for each inpatient hospital stay. Both plans have a co-payment for using the emergency room for non-emergency reasons, $8 the first time and then $25 per visit thereafter.

HIP Basic members who make more than the poverty level are locked out of coverage for six months if they fail to make their monthly payment.

"No other program has been allowed to require health spending accounts, much less threaten to yank coverage for a person not paying in," Galewitz writes, paraphrasing Salo.

HIP members who are unemployed or work less than 20 hours a week are referred to available employment, work search and job training programs to help them gain employment or find better employment. This is a free and voluntary program and does not affect the receipt of benefits.

All members of HIP Plus must pay something. About half of Indiana Medicaid members have annual incomes below $600; they must pay a $1 monthly premium.

The monthly fee adjusts with income and family size. For example, a single person who makes $16,242, the maximum for expanded Medicaid, pays $27.07 per month to get HIP Plus, or $324.85 per year. A family of two could make as much as $21,983 and would pay $36.64 or $439.68 per year; and a family of four could make $33,465 and would pay $55.78, or $669.36 per year. Information comes from the eligibility calculator on the Healthy Indiana Plan website.

Is Indiana's plan working?

Indiana health officials told Galewitz that 94 percent of those who have signed up for HIP Plus continue to pay their fees.

Michelle Stoughton, senior director of government relations for Indianapolis-based Anthem Insurance Cos., called that a success. She said nearly 75 percent of Anthem's members on this HIP Plus have visited a dentist, and 65 percent sought vision care in the first three months of coverage. Anthem is one of three private insurers providing coverage under the Healthy Indiana Plan.

�What we heard for years .?.?. is that these people won�t pay and don�t have the ability to pay,� Stoughton told Galewitz. �But this has turned those arguments around and been able to show that people do want to be engaged.�

Indiana's hospitals and doctors support the Healthy Indiana Plan, mostly because the state increased their Medicaid rates, hospitals by an average of 20 percent and doctors' reimbursements by an average of 25 percent, Galewitz reports.

"As a result, Medicaid has gained more than 5,300 providers in the past year, and patients report few problems getting care," he writes. But he also noted that about 2,200 members have lost coverage since it began in May 2015 because they didn't pay their monthly fees.

Critics of Indiana's plan worry that the monthly payments and complicated structure will keep the poor from getting care. which goes against the core goal of Medicaid expansion, Galewitz writes. In addition, some conservative groups say the program may be more expensive than traditional Medicaid, because it provides dental and vision care and pays providers more. Others say that the red tape in the plan exceeds that of any state's Medicaid expansion.

The state had also hoped third parties would step up and help the poor pay for their monthly contributions, but this hasn't happened, Joan Alker, executive director of the Georgetown University Center for Children and Families, told Galewitz. She said, �It�s premature for Indiana to take a victory lap.�

Princess Health and Will There Ever Be Enough Straws to Break Corporate Health Care Managers' Impunity's Back? - Novartis Settles Yet Again, This Time for Bribing Doctors. Princessiccia

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Umpteenth verse, same as the first...

As just reported by Bloomberg,

Novartis AG said it agreed to pay $25 million to settle a U.S. Securities and Exchange Commission case that claimed the Swiss drugmaker paid bribes to health professionals in China to increase sales from 2009 to 2013.

In particular,

The SEC detailed a number of Foreign Corrupt Practices Act violations where Novartis employees provided items of value to health-care professionals in China, under the supervision of complicit managers. It also cited examples of how the company improperly recorded as legitimate expenses payments employees made for travel and entertainment, conferences, lecture fees, marketing events, educational seminars and medical studies.

For some vivid examples,

In one example cited in the SEC order on Novartis, a sales representative at the drugmaker�s Sandoz China subsidiary submitted a $1,154 receipt to buy holiday gifts for 25 health-care professionals, which was instead used to pay for their spa and sauna sessions. A regional sales manager approved the purchase, the SEC said.

The SEC order also cited how Sandoz China sponsored 20 health-care professionals to attend a 2009 medical conference in Chicago. During the trip, the company paid for the group�s recreational activities such as a Niagara Falls excursions, $150 in 'walking around' money for their spouses, and cover charges to a strip club. The group was accompanied by a Sandoz China senior manager and other staff, according to the SEC.

So, thus far, the allegations were that Novaris bribed Chinese physicians to use their products, and the bribes includes gifts, travel money, and admission to a strip club.  It is likely that these bribes induced the physicians to unnecessarily or excssively prescribe Sandoz drugs to patients, leading to excess expenses, overtreatment, and quite likely adverse effects that should have been prevented.

As per the Wall Street Journal, and as usually happens in such cases, Novartis was allowed to settle without "admitting or denying the findigs." In the Bloomberg article, a Novartis spokesperson gave the usual vague response,

'The issues raised by the SEC, which relate to our subsidiaries in China and go back as far as 2009, largely pre-date many of the compliance-related measures introduced by Novartis across its global organization in recent years,' Novartis spokesman Eric Althoff said in an e-mailed statement Thursday.

The implication was that the company no longer does these bad things, but did not include a promise not to do them. And, of course, just like in many, many other health care cases, and in many, many other cases involving big, powerful, or influential organizations, no one at a top management level went to jail, or even suffered any negative consequences, even for such sleazy allegations as those in this case.  Finally, partially because the amount of this settlement was so small related to the financial bulk of the company involved, this case was relatively anechoic, only reported in the small items in the business press.

Summary

As we are distracted by bloviating billionaires and other spectacles on the US 2016 campaign trail, we continue to accumulate evidence of the corruption of large health care organizations and the impunity of their leaders.  Yet this evidence remains anechoic, even given the apparent recidivism involved.  For example, it was only in last November that we discussed what were then the latest misadventures by Novartis and its leadership.  At that time, our post included these section headings covering 2014-15:

-  Japanese Health, Labor and Welfare Ministry Found that Novartis Concealed Serious Adverse Effects
- Novartis Executive Pleads Guilty to Bribing Polish Official
- Novartis Subsidiary Sandoz Settles Allegations that it Misrepresented Pricing Data to US Medicaid
- Express Scripts Settles Allegations that it Accepted Kickbacks from Novartis
- Novartis Settles US Allegations of Kickbacks to Enhance Sales of Multiple Drugs

Furthermore, in that post we also documented Novartis' previous record.   In March, 2014, we had noted:
- Italian authorities had fined Novartis and Roche for colluding to promote the use of an expensive opthamologic treatment
- the NY Times published interviews with physicians ostensibly showing how Novartis turned them into marketers for the drug Starlix
- Japanese investigators charged Novartis with manipulating clinical research
- Indian regulators canceled a Novartis import license, charging the company with fraud.

Also,  in 2013, Novartis was fined for anti-competitive practices in its marketing of Fentanyl by the European Commission (look here), and in 2011 its Sandoz subsidiary settled allegations of misreporting prices in the US for $150 million (look here)   Other Novartis misadventures from 2010 and earlier appear here.  So Novartis has quite an impressive, if not infamous record of ethical failures.

Yet no Novartis top manager suffered any negative consequences then (although one apparent mid-level company manager at the Polish subsidiary did plead guilty), and all these previous episodes apparently did not suggest a pattern of recidivism to US authorities this time sufficient to attempt to impose any negative consequences on higher level managers.  Meanwhile, Novartis executives continue to be paid handsomely.  The 2015 Novartis executive compensation report listed over 51 million Swiss francs paid

Also, this goes on while large health care companies continue to pay out dizzying amounts to physicians, health care professionals, hospitals and academic institutions, which partially may secure their loyalty.  Novartis, for example, which ProPublica lists as only the 28th biggest payer to physicians, paid out $31.7  million in 2013-14 just to US physicians.    The 2015 Novartis board of directors included Dr Nancy C Andrews, the Dean of the Duke Medical School and Vice-Chancellor for Academic Affairs at Duke University,  Dr Dimitri Azar, Dean of the College of Medicine at the University of Chicago, Illinois, and Dr Charles L Sawyers, a professor and department chair at Weill-Cornell Medical School.   I am unaware that anyone of them have publicly raised any concerns about Novartis' recent misadventures, although I am also unaware whether anyone has publicly asked them such questions. 

No wonder that ordinary US (and other countries' citizens) feel that they are trapped in a hopeless economic situation by rigged systems designed to benefit from the corrupt insiders.  No wonder that someone of them are seeking the protection of some of those powerful insiders.  But I digress...

In terms of health care, as we have said like a broken record (if anyone remembers what that means), or, if you prefer, where every verse is same as the first...

There seems to be increasing recognition that the continuing rise in US health care costs is unsustainable, and that these costs are not buying us good health care.  There are calls to avoid unnecessary, and sometimes harmful care.  Yet there is a persistent disconnect between how continuing dishonest behavior by health care organizations, impunity of their leaders, and lack of accountability by their board members fuel rising costs, shrinking access, and bad outcomes for patients.

To truly reform health care, we will have to at least recognize the causes of the current dysfunction.  Recognizing how health care dysfunction is created by unaccountable, dishonest leadership should lead to true reform that would promote well-informed, honest, accountable leadership that puts patients' and the public's health ahead of personal gain.

Our musical interlude ("second verse, same as the first,") Herman's Hermits, Henry VIII



Princess Health and Survey of Cincy-area students, including some in Kenton County, finds pot and vaping more popular than cigs; drug use down. Princessiccia

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Students in Greater Cincinnati, including Northern Kentucky, are more likely to use marijuana and electronic vapor products than cigarettes, according to a drug-use survey of students in the region.

Graph from PreventionFirst report
The survey found that students in the area were most likely to use alcohol (16.3 percent) within the past 30 days, followed by marijuana (11.7 percent), electronic vapor products (13.4 percent), tobacco (8.2 percent) and non-prescribed prescription drugs (4.6 percent).

This was the first year a question was included about electronic vapor products in the biennial surveys by PreventionFirst (formerly the Coalition for a Drug-Free Greater Cincinnati), a comprehensive effort to reduce adolescent alcohol and drug use.

The good news is that most students are not using alcohol, tobacco or other drugs, says the report.

The study surveyed nearly 40,000 students in grades seven through 12 from 88 public and private schools in several counties in Greater Cincinnati and Kentucky's Kenton County. They were asked whether they'd used any of 21 drugs.

The survey found that use of alcohol, tobacco and marijuana have declined significantly since 2000: alcohol down 46 percent, tobacco down 61 percent and marijuana declining 22 percent. Since 2012, non-prescribed prescription drug use has declined 29 percent.

It found that students' perception of the harm that alcohol can do has increased, while they were less concerned about marijuana.

With marijuana, as students get older "their perception of harm decreases, and use increases," said PreventionFirst CEO Mary Haag told Terry DeMio  of the Cincinnati Enquirer.

"Marijuana has become very prevalent and it's becoming more so," Hamilton County Commissioner Dennis Deters, who chairs the Hamilton County Heroin Coalition, told DeMio. "It's dangerous to our children and it enhances their risk when they become adults for serious addiction."

The report calls age 13 a "pivotal age" because this is when first drug use often occurs in students.

The report also finds that peer and parental disapproval rates are at an all-time high.

"We know how important friends and parents are in a young person's life," Haag said in the news release. "Students whose peers and family express disapproval are more likely to make the healthy choice to not use drugs and alcohol."

Thursday, 24 March 2016

Princess Health and March 24th, 2016 Throwback Thursday. Princessiccia

Princess Health and March 24th, 2016 Throwback Thursday. Princessiccia

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March 24th, 2016 Throwback Thursday

Yesterday's visit with Jon and his his dad, Bob, was a fantastic experience. They're great people. The two of them stopped by the studio early this morning on their way out of town. Jon brought along some homemade tomato juice. He makes this with his own homegrown tomatoes and a little salt--that's it. It's as pure and organic as can be. Naturally I tried it (see the tweet below)--and loved it! Jon left me a jar of it before they hit the road. He's a planner and very prepared! He has coolers stocked for the trip with some of his favorite things. It's impressive.

It's Throwback Thursday Before-Picture Time!
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#TBT Jon Ludtke and Me--Before--two 500 pound guys.

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Jon and his father dropped by the studio this morning on their way out of town

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Bob, Jon and me--Selfie!

Today was nearly eleven hours. It was packed all day long with the radio show, commercial production, a midday board of directors meeting for Arts and Humanities, more production and preparing things so I can be off in the morning. That's right, I get to sleep in! Which is exactly what prompted me to take a small nap a little after 6pm. I was exhausted and felt like if I didn't nap--I might crash before dinner and this blog post. Besides, I'm truly a night owl by heart and if I don't need to be up super early, then I tend to indulge my night owl side. I'll likely not stay up too awful late. But I just might watch an episode or two of AMC's Better Call Saul. The writing on that show, just like Breaking Bad, is some of the best in television history, in my opinion.

I do have location broadcasts tomorrow. One from 3 to 5pm at a car dealer and another from 5:30 to 8pm at a big karaoke finals contest. I'm also a judge at that contest--and that will put me out there until approximately 11pm tomorrow night. I'll be planning well in order to navigate my food tomorrow. Dinner will likely be one of my on-the-go combos of almonds, fruit and cheese. I will have an opportunity to prepare a nice breakfast and lunch at home.

My Tweets Today:








































Thank you for reading and your continued support,
Strength,
Sean
Princess Health and Boyd, Clark counties approve needle exchanges; Boyd's is a limited, one-for one; Covington's proposed limits draw objections. Princessiccia

Princess Health and Boyd, Clark counties approve needle exchanges; Boyd's is a limited, one-for one; Covington's proposed limits draw objections. Princessiccia

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By Melissa Patrick
Kentucky Health News

Clark and Boyd counties are the ninth and 10th Kentucky counties to approve a needle-exchange program, and Madison and Anderson counties are talking about it. Meanwhile, the city of Covington has approved an exchange with conditions that don't match its health department's plan, and one of the conditions might not even be legal.

Needle exchanges were approved under the state's anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and the hepatitis C virus (HCV), which are commonly spread by the sharing of needles among intravenous drug users.

Clark County Health Director Scott Lockard noted that the federal Centers for Disease Control and Prevention has "identified 54 counties in Kentucky as being vulnerable to rapid dissemination of HIV or HCV infection among persons who inject drugs. Of the top 25 most vulnerable counties in the nation 16 of them are in our state."

Clark County

On March 23, the Clark County Fiscal Court approved on a 4-2 vote a needle exchange that will start on or before June 1, but the program will need re-authorization in January, Greg Kocher reports for the Lexington Herald-Leader.

"Both the Fiscal Court and the [Winchester] City Commission inserted a sunset clause in the orders requiring the health department to present data on our program in January 2017 in order to get re-authorization for a longer time period," Lockard told Kentucky Health News in an e-mail.

He noted that the CDC identified nearby Wolfe County as the most vulnerable county in the nation to rapid dissemination of HIV and HCV among drug users, with adjoining Powell and Estill counties 15th and 25th, respectively.

"Residents from all three of these counties frequently come to Clark County for medical services from our provider community and the health department," he said. "More must be done in the area of prevention if we are to avoid a situation similar to what Scott County, Indiana, encountered."

That county, about 30 miles north of Louisville, has drawn national attention for its high rates of HIV and hepatitis C, mostly caused by intravenous drug users who share needles. According to published reports, "from November 2014 to mid-June 2015, the Indiana county of 24,200 reported 170 HIV cases. It reported 130 new cases of hepatitis C in 2014," noted Bill Robinson of The Richmond Register.

According to Lockard, Clark County's program will use a patient negotiation model, which does not require a one-to-one needle exchange, during the initial visit, but will try to get close to a one-for-one model on subsequent visits.

"We will educate participants that they need to return needles to get needles," he said.

Boyd County

The Boyd County Fiscal Court voted 4-1 March 15 to approve a one-to-one needle exchange for one year, Lana Bellamy reports for The Daily Independent. 

The Ashland City Commission had already given its approval for the exchange, which may begin as early as July. Bellamy reports that the program will be paid for by special taxing districts, and all of the fiscal court members voiced concerns about the sustainability of the funding.

Ashland-Boyd County Health Department Director Maria Hardy told the court that syringes typically cost about 97 cents each, but the health department will be able to buy needles from a distributor for 9 cents each, Bellamy writes.

The Boyd County program will assign tracking numbers to its participants to protect their identities and allow a maximum of 40 needles to be exchanged each week.

County Commissioner John Greer, the only member to vote against the resolution, said he was concerned the program would encourage drug abuse and Sheriff Bobby Jack Woods agreed, Bellamy reports. This is a common concern among opponents of needle exchange programs, though evidence-based studies have proven otherwise.

Covington

During the same week, the City of Covington approved a needle-exchange program, but with conditions that could kill the program, Terry DeMio reports for The Cincinnati Enquirer.

The conditions are that all participants be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. That could be illegal, DeMio reports.

A Northern Kentucky Health Board spokeswoman told DeMio that they believe that they cannot require anyone to undergo any medical procedures, but said they were checking with legal counsel. Other health and harm-reduction officials told DeMio that this requirement is not legal, and that such a condition would likely prevent a program from getting off the ground.

"The Covington commission's resolution includes other conditions that differ from the health board's model program, too, and would require passage from the Kenton County Fiscal Court and the Board of Health before it's approved," DeMio writes.

These conditions include a requirement that two other counties in the Northern Kentucky Health District also adopt a needle-exchange program (only Grant County has); restrict use of the program residents of the district's four counties; and moving the exchange to St. Elizabeth Healthcare hospital.

The city also wants a one-for-one exchange, Michael Monks reports for The River City News.

The health department says its plan is "need-based," not one-for-one, because studies show that is the best way to reduce the risk of community exposure and spread of HIV and HCV. This is the main goal of the program, although needle-exchange programs also provide HIV and HCV testing and access to drug treatment.

The health department's plan is to initially provide clients with the number of syringes they would use in a week, along with a safe container for their return with instruction to return the used needles for new ones. Participants who don't return dirty needles after three trips would not receive new syringes, DeMio reports.

The department has been trying to establish needle-exchange programs in the district since the law passed one year ago. The Kenton County Fiscal Court is expected to discuss a needle exchange plan March 29, DeMio reports.

Dr. Lynne Saddler, the health department's director, told the Enquirer "that the Covington resolution was a start and that more discussion is planned by the health department."

Other counties

Madison County Health Department officials are also worried about becoming another Scott County, Indiana, as they face an epidemic of heroin use in their county, Bill Robinson reports for The Richmond Register.

Thus they have begun the process of educating their public officials, Robinson writes. Public Health Director Nancy Crewe presented her detailed findings to support a needle exchange at a quarterly joint meeting of the county Fiscal Court, Richmond City Commission and Berea City Council, noting that they were just beginning the long process of educating the public.

A needle exchange program was also brought up at the March meeting of the Anderson County Fiscal Court meeting, and was met with some disparaging remarks, Ben Carson reports for The Anderson News.

"What jackass thought of that idea?" asked Magistrate David Montgomery. "We might as well give them the dope, too."

Despite these comments, Montgomery did volunteer to be on a committee to explore a needle exchange program along with members of the health board, Lawrenceburg City Council, law enforcement, EMS and county jailer.

Robinson also reports that the Bourbon County Fiscal Court has voted to reject an exchange.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant, and Jessamine.
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