| covid_19_vaccine_health_equity_resources | COVID-19 Vaccine Health Equity Resources | Latest_News | Shared_Content/News/Membership_Memo/2021/January_21/covid_19_vaccine_health_equity_resources | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/MembershipMemo/2021/January/Doctor-Patient-Exam-Room-645x425px.jpg" class="pull-right" alt="doctor and patient in exam room" />
</div>
<h5>January 21, 2020</h5>
<h2>
COVID-19 Vaccine Health Equity Resources
</h2>
<p>
Public confidence in and willingness to receive the COVID-19 vaccines will determine the outcome of this mass-scale public health intervention. As public vaccination begins in Washington, the WSMA will pay particular attention to amplifying resources targeted to minority communities disproportionally impacted by the disease, as part of our effort to support health care's COVID-19 response.
</p>
<p>
The following resources from the <a href="https://coronaviruspreventionnetwork.org/about-covpn/">COVID-19 Prevention Network (CoVPN)</a> were provided courtesy of Fred Hutchinson Cancer Research Center.&nbsp;</p>
<h3>
Community Forum with Dr. Kizzmekia Corbett: Everything You Should Know About COVID-19 Vaccines
</h3>
<p>
On Jan. 27, we invite you to join us and Dr. Kizzmekia Corbett, leading scientist for the development of the COVID-19 vaccine, for a community forum to discuss what you should know about COVID-19 vaccines. Learn more and register <a href="https://urbanhealth.jhu.edu/upcoming-events/covidvaccine/covid19vaccines.html">here</a>.
</p>
<h3>
COVID-19 Vaccine Recommendations and Research with Children and Pregnant Persons
</h3>
<p>
The American Academy of Pediatrics has updated the FAQs on its website to include information about vaccine recommendations and research with children and pregnant persons. You can check out those FAQs <a href="https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/covid-19-vaccine-frequently-asked-questions/">here</a>.
</p>
<h3>
COVID Vaccine Matters
</h3>
<p>
Dr. Larry Corey and Dr. Chris Beyrer of the COVID-19 Prevention Network have penned a series of blogs on the Johns Hopkins Coronavirus Resource Center, which can be found <a href="https://coronavirus.jhu.edu/vaccines/blog">here</a>.
</p>
<h3>
Community Engagement Materials Menu (updated Jan. 4, 2021)
</h3>
<p>
The CoVPN created many community engagement materials to help educate communities about COVID-19 and the research happening. You can access all of the CoVPN Community Engagement materials that have been created and share with your friends, colleagues, and communities via a secure Dropbox <a href="https://www.tinyurl.com/CoVPN-Assets">here</a> (Password: CoVPNTria!$) or see the attached menu document. This menu update includes an mRNA Info Sheet, and several infographics about mRNA vaccines (as JPEGs and ideal for social media sharing/posts).
</p>
<h3>
Iman and COVID-19
</h3>
<p>
This series was developed to address the concerns of Muslim communities regarding COVID-19 and COVID-19 research. The sessions are recorded and available on the CoVPN Facebook page <a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.facebook.com_PreventCOVID19_live_&amp;d=DwMFaQ&amp;c=eRAMFD45gAfqt84VtBcfhQ&amp;r=hoeLWrgkcGp-453_2gPJ5DNr-hknzs9C67Xd38SC5BU&amp;m=QBaH8NdaLJjRj4vj0X40c-CvI0ND99GY35NTC0DvHiU&amp;s=-0Qg9qQium9mlVEcFVDKbIsYMskBlyUuVCX6CKB535g&amp;e=">here</a>.
</p>
<h3>
PANDEMIA Series
</h3>
<p>
This series was developed in partnership with the Latino Commission on AIDS to address the concerns of Latinx communities regarding COVID-19 and the COVID-19 vaccine trials. The session recordings of past episodes are available on the CoVPN YouTube page <a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_channel_UCpOWHfd2CjhIhaITS4vfueA&amp;d=DwMFaQ&amp;c=eRAMFD45gAfqt84VtBcfhQ&amp;r=hoeLWrgkcGp-453_2gPJ5DNr-hknzs9C67Xd38SC5BU&amp;m=QBaH8NdaLJjRj4vj0X40c-CvI0ND99GY35NTC0DvHiU&amp;s=9_i7u9hTW1lKxN8l6Xv_toBBKu31OfAAMBbGbvFZRgk&amp;e=">here</a>.
</p>
<h3>
COVID in Black Series
</h3>
<p>
This series was developed to address the concerns of Black communities regarding COVID-19 and the COVID-19 vaccine trials. The session recordings of past episodes can be found on the CoVPN YouTube page <a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.youtube.com_channel_UCpOWHfd2CjhIhaITS4vfueA&amp;d=DwMFaQ&amp;c=eRAMFD45gAfqt84VtBcfhQ&amp;r=hoeLWrgkcGp-453_2gPJ5DNr-hknzs9C67Xd38SC5BU&amp;m=QBaH8NdaLJjRj4vj0X40c-CvI0ND99GY35NTC0DvHiU&amp;s=9_i7u9hTW1lKxN8l6Xv_toBBKu31OfAAMBbGbvFZRgk&amp;e=">here</a> and on the CoVPN Facebook page <a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.facebook.com_PreventCOVID19_live_&amp;d=DwMFaQ&amp;c=eRAMFD45gAfqt84VtBcfhQ&amp;r=hoeLWrgkcGp-453_2gPJ5DNr-hknzs9C67Xd38SC5BU&amp;m=QBaH8NdaLJjRj4vj0X40c-CvI0ND99GY35NTC0DvHiU&amp;s=-0Qg9qQium9mlVEcFVDKbIsYMskBlyUuVCX6CKB535g&amp;e=">here</a>.
</p>
<p>
<a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.facebook.com_113093058708720_videos_145964847321739&amp;d=DwMFaQ&amp;c=eRAMFD45gAfqt84VtBcfhQ&amp;r=hoeLWrgkcGp-453_2gPJ5DNr-hknzs9C67Xd38SC5BU&amp;m=QBaH8NdaLJjRj4vj0X40c-CvI0ND99GY35NTC0DvHiU&amp;s=iTU1HQbQ3CPJvKvayMX6ktsismwYa6fZAV3Qgg0_iDE&amp;e=">The COVID-19 Vaccine and the Black Community</a> was an informative discussion on COVID-19 vaccines and clinical trials organized by Alpha Phi Alpha, Inc. and features Dr. Kizzmekia Corbett and Dr. Barney Graham (NIH), Dr. Wayne Frederick (Howard University), and Dr. Wayne Riley (formerly with Meharry Medical College), along with other Black health experts and leaders.
</p>
<p>
<a href="https://urldefense.proofpoint.com/v2/url?u=https-3A__www.facebook.com_watch_-3Fv-3D443922446740843&amp;d=DwMFaQ&amp;c=eRAMFD45gAfqt84VtBcfhQ&amp;r=hoeLWrgkcGp-453_2gPJ5DNr-hknzs9C67Xd38SC5BU&amp;m=QBaH8NdaLJjRj4vj0X40c-CvI0ND99GY35NTC0DvHiU&amp;s=qdGhZSGa6ZREh_QASoWshFu8I0SJOyrmaDcW4cLp2X8&amp;e=">Making It Plain: What Black America Needs to Know about COVID-19 and Vaccines</a> was a powerful town hall discussion hosted by leading Black health, faith, and social organizations to address questions and concerns from Black communities.
</p>
</div> | 1/21/2021 12:00:00 AM | 1/1/0001 12:00:00 AM |
| state_redoubles_covid_19_vaccination_efforts_how_wsma_members_can_help | State Redoubles COVID-19 Vaccination Efforts. How WSMA Members Can Help | Latest_News | Shared_Content/News/Membership_Memo/2021/January_21/state_redoubles_covid_19_vaccination_efforts_how_wsma_members_can_help | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img src="/images/Newsletters/MembershipMemo/2021/January/COVID-vaccine-Illustration-blue645x425px.png" class="pull-right" alt="COVID vaccine illustration" />
</div>
<h5>January 21, 2020</h5>
<h2>
State Redoubles COVID-19 Vaccination Efforts. How WSMA Members Can Help
</h2>
<p>
State officials have announced a multipronged approach to accelerating Washington's COVID-19 vaccine rollout. The updated strategy includes increasing eligibility and capacity, organizing mass vaccination clinics, and bringing private partners on board. With the state mobilizing to meet the needs of millions of its residents, these efforts will ramp up quickly in the weeks ahead. Make sure your practice is prepared - and learn how you can assist with this extraordinary public health initiative.
</p>
<h3>
Phase 1B updated - and now underway
</h3>
<p>
The Washington State Department of Health has <a href="https://www.doh.wa.gov/Newsroom/Articles/ID/2573/Moving-to-the-next-phase-Vaccine-expansion-plan-meant-to-accelerate-the-pace-of-vaccinations-statewide">moved up its timeline for public vaccinations</a>, moving the state into the first tier of Phase 1B on Monday. The Department of Health also increased eligibility for the phase, lowering the minimum age in this first tier to all residents 65 or older, in line with the federal government's updated guidance issued last week. The state will continue to prioritize older adults in multigenerational households under the new guidance.
</p>
<p>
State officials say they are moving up the timeline and expanding eligibility to give vaccine providers greater flexibility, and that communities still vaccinating workers in health care settings should continue prioritizing getting them protected. The state has set a goal to vaccinate 45,000 people a day, and is working to build capacity now, under the assumption of increasing vaccine supplies in the weeks ahead.
</p>
<h3>Using WAIIS to order vaccine</h3>
<p>Beginning today, facilities and providers that have enrolled in the COVID-19 vaccination program can order vaccine on the <a href="https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/DataReportingandRetrieval/ImmunizationInformationSystem">Washington Immunization Information System</a>. For those who have not previously used the WAIIS, the Department of Health is sharing a <a href="https://www.doh.wa.gov/Portals/1/Documents/Pubs/348-351-CreateSubmitVaccineOrder.pdf">training guide on ordering and receiving vaccine</a>, as well as an <a href="https://www.youtube.com/watch?v=XNfgezFWQrk&amp;feature=youtu.be">instructional video</a>. There is also a <a href="https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/348-777-CDC-COVIDRedistributionAgreementandChecklist.pdf">checklist</a> for COVID-19 vaccine transfers and redistribution, as well as a <a href="https://www.youtube.com/watch?v=dGGj5Kgm7do&amp;feature=youtu.be">video</a>.</p>
<p>Facilities and providers can submit orders to be delivered the following week beginning on Fridays and closing on Mondays. The DOH is requesting that providers and facilities order the amount of vaccine they are able to administer in one week. They are also cautioning that vaccine supply remains problematic, and that facilities and providers should expect their orders to be cut. Should you have additional questions on ordering, receiving, or transferring the COVID-19 vaccine in the WAIIS, please contact <a href="mailto:covid.vaccine@doh.wa.gov">covid.vaccine@doh.wa.gov</a>.</p>
<h3>
New reporting requirements for vaccine providers
</h3>
<p>
Part of the state's push to pick up the pace of vaccinations is a new mandate for vaccine providers stipulating that 95% of vaccine allocations be administered within a week of receipt, effective immediately (doses acquired prior to this week must be administered by Jan. 24). Additionally, providers must submit vaccine data to the state within 24 hours of administration, and daily information on dosages (i.e. quantity on hand, number administered) must be submitted to the Department of Health.
</p>
<p>
For these new data submission requirements, the state is requiring vaccine providers to submit data using WA HEALTH. The data to be reported to WA HEALTH is limited in scope and is not patient-level data. Existing vaccine reporting requirements through WAIIS remain in place. The WSMA has shared our concerns with the state that this additional burden would be particularly onerous for small to midsized groups providing vaccines.
</p>
<h3>
Building capacity
</h3>
<p>
To help reach its goal of vaccinating 45,000 people a day, the state announced an expanded distribution system, to include mass vaccination locations across the state and a new statewide public-private partnership called the Washington State Vaccine Command and Coordination Center. This public-private partnership will support the Department of Health and the secretary of health in constructing an infrastructure and coordinating available resources to deliver vaccines across the state as effectively and efficiently as possible. The WSMA has been invited to participate in this effort.
</p>
<h3>
Volunteers needed
</h3>
<p>
To help this extraordinary public health effort scale, Washington not only needs more facilities to enroll as vaccine providers, but also needs volunteers - physicians, physician assistants, and health professionals of all stripes. If your practice is not able to take on the logistical challenges of becoming a vaccine provider, consider volunteering to serve in the mass vaccination sites or in other capacities as determined by the state in the days ahead. To volunteer, register with the Washington State Emergency Registry of Volunteers at <a href="https://www.waserv.org/">WAserv.org</a>.
</p>
<h3>
Department of Health vaccine updates webinar
</h3>
<p>
The Department of Health is hosting a vaccine updates webinar on Jan. 26, from noon-1 p.m. covering:
</p>
<ul>
<li>Current and upcoming COVID vaccines</li>
<li>Emergency Use Authorization process</li>
<li>Vaccine safety profile</li>
<li>Advisory Committee on Immunization Practices vaccine recommendations</li>
<li>Contraindications and precautions to vaccination</li>
<li>Management of anaphylaxis </li>
<li>COVID vaccine resources</li>
</ul>
<p>
This free webinar is targeted toward health care providers, local health jurisdictions, school and child care nurses, and other health professionals.
</p>
<p>
Register for the webinar <a href="https://cplusc.zoom.us/webinar/register/WN_OT9KqhvXQcqWeeF_PZbRPw">online</a>.
</p>
</div> | 1/21/2021 12:00:00 AM | 1/1/0001 12:00:00 AM |
| stormy_seas | Stormy Seas | Latest_News | Shared_Content/News/Latest_News/2021/stormy_seas | <div class="col-md-12">
<div class="col-md-5 pull-right" style="text-align: center;"><img alt="" src="/images/Newsletters/Reports/2021/Jan-Feb-2021-Reports-Cover-645x425px.jpg" class="pull-right" /></div>
<h5>January 19, 2021</h5>
<h2>Stormy Seas</h2>
<h5>
<em>Members only; sign-in required.</em>
</h5>
<p>By John Gallagher</p>
<p>
When the COVID-19 pandemic exploded in early March, Ki Shin, MD, was on
vacation in Hawaii with his wife, also a physician, taking a break from
their practice in the small town of Montesano. "We got there on Monday
and then the governor's restriction happened," Dr. Shin recalls. "All
of a sudden, we were out of town and my staff was freaking out. It was
an immediate crisis. Not a lot of information was available to us, and
we had a lot of scared people, staff and patients included."
</p>
<p>
Upon their return home, the Shins immediately set about trying to
stabilize their practice. Faced with a 40% drop in appointments, the
couple took a 50% pay cut so that they could keep their staff on
payroll.
</p>
<p>
"For us not to get paid for a couple of months was totally doable, but
that was not true for the staff," says Dr. Shin.
</p>
<p>
After a rough few months, some of the financial pressures eased. The
Shins obtained a loan under the Paycheck Protection Program (PPP), the
part of the federal Coronavirus Aid, Relief, and Economic Security Act
designed to help small businesses. They also received $30,000 from
Medicare, which covered the practice's overhead for a month.
</p>
<p>
Eventually, patients started returning, and Dr. Shin's practice is
stable again, but still not entirely recovered. "The [patient] volume
is coming up, but it's not back to normal," he says. "It's about 90% of
what it was previous to COVID."
</p>
<h3>Survey answers detail challenges</h3>
<p>
The recovery of Dr. Shin's practice, and other practices around
Washington, is a hopeful sign. However, the new normal falls short of
the old one. Moreover, the ever-changing course of the pandemic,
including the potential for another lockdown, makes the outlook for
practices in Washington uncertain at best.
</p>
<p>
"Physicians are doing okay right now, but they are still so
vulnerable," says Jennifer Hanscom, executive director and CEO of the
WSMA. "The ground they're standing on is shaky. There might be an
earthquake brewing underneath."
</p>
<p>
Shawn Andrews, primary care medical director at Summit Pacific Medical
Center in Elma, says that the effects of the pandemic seem to vary by
type of practice.
</p>
<p>
"In terms of finances, the larger practices will survive," she says.
"Our budgets are not pretty but we're viable, and that's not a given
for everyone this year. We're not in the same boat as folks in private
practice or even some other critical access hospitals."
</p>
<p>
A fall 2020 survey of WSMA members found that the pandemic has taken a
significant toll on practices, making their financial viability a real
concern. Of 69 members from a range of practices and specialties who
responded to the survey, more than half reported a temporary reduction
in compensation because of the pandemic. Nearly half the survey
respondents said that they had to lay off or furlough staff, including
physicians.
</p>
<p>
Almost a quarter of the respondents said that the financial impact of
the pandemic on their practice is between $500,000 and $1 million.
Those figures echo a national survey of 3,500 physicians conducted by
the AMA last summer, which found practice revenue dropped by roughly
one-third.
</p>
<p>
While the worst of the pandemic appears to be over, the ripple effects
continue. The vast majority of the physicians who responded to the WSMA
survey said that their patient volume was down compared to before the
pandemic, with more than a third saying it was down between 25% and
75%. Even more troubling was that fact that more than 40% reported
having a month or less of cash on hand to pay operating expenses. The
WSMA benchmark is 18 weeks.
</p>
<h3>
Extra costs, curtailed services drive need for more financial help
</h3>
<p>
As it did for Dr. Shin's practice, the federal PPP loan provided a
financial lifeline for many practices.
</p>
<p>
"Luckily we got one of the PPP loans," says Juliette Erickson, MD, a
physician in a private practice in Grays Harbor. "That helped us
tremendously and got us over the hump. We stopped having weekly
meetings on how to pay the next paycheck and started focusing on
medicine again."
</p>
<p>
However, as much as the loans helped, their benefit was limited. More
than 80% of the physicians in the WSMA survey said that additional
financial support would be helpful. In part, that's because new safety
protocols have also meant more expenses.
</p>
<p>
Chelsea Unruh, MD, a physician at Yelm Family Medicine, says that the
expenses related to COVID-19 requirements have added up. Like other
clinics, Yelm Family Medicine does initial screenings of patients in
its parking lot, but the costs don't stop there.
</p>
<p>
"We have had to rebuild our back parking lot for these car visits,"
says Dr. Unruh. "We have had to outfit our front desk with shields. We
are investing in rapid testing and signing contracts for long-term use
of specific machines."
</p>
<p>
Then there is the extra expense of additional personal protective
equipment. "The cost of PPE went up," notes Hanscom. Now practices are
having to bear the costs of full PPE, masks, and sanitizers that
previously were used much more sparingly.
</p>
<p>
Like Dr. Unruh, Dr. Erickson also sees clients with COVID-19 symptoms
in the clinic parking lot. "I'm dressed in full PPE," she says. "It's
not the best way to see an ill person, but it's the best we can do and
still protect our staff and patients."
</p>
<p>
The need to sanitize exam rooms thoroughly between patient visits can
also have a direct impact on patient volume. "We decreased the number
of patients we're seeing per hour," says Dr. Shin. "I was able to see
four patients an hour, but with the cleaning between visits, we chose
to limit it to three patients per hour."
</p>
<p>
Even with such precautions in place, some staff still have to
quarantine because they were exposed to the virus outside of work.
</p>
<p>
"The other income challenge has been the loss of time from our staff,
from exposures or from being ill themselves," says Dr. Unruh. "None of
those exposures happened at work, but we don't get to control the
private lives of our staff. To exclude someone for 14 days because they
made a poor choice has been rough on morale and staffing."
</p>
<p>
To protect staff and patients, some practices have curbed services,
including Dr. Shin's. "In Montesano, there are no blood draw labs, so
lots of patients were coming into our clinic even though [the labs]
were for someone else," Dr. Shin says. The practice eliminated that
service, forcing patients in the area to travel farther for it. Dr.
Erickson says that she is referring more patients to the ER because her
clinic lacks the proper PPE to treat suspected COVID-19 patients.
</p>
<p>
But Dr. Andrews says that patient volume at her hospital's ER, as well
as its urgent care clinics, is still down significantly. "Many people
wait until they are very ill to seek services, and often suffer much
worse outcomes," she says. Nonetheless, she says that larger practices
have been better positioned to withstand the pressures from the
pandemic for a variety of reasons, including business plans less
impacted by long term drops in volumes, better PPE availability, and
space to separate well patients from symptomatic ones.
</p>
<h3>Telehealth use soars</h3>
<p>
The pandemic accelerated several trends that were already underway.
Chief among these has been the growth of telehealth. Three-quarters of
the physicians in the WSMA survey said that they implemented telehealth
as a result of the pandemic.
</p>
<p>
"We had never done telehealth before," says Dr. Unruh. "Then suddenly
we had half a day per provider devoted to telehealth visits."
</p>
<p>
As helpful as telehealth has proven, it has its drawbacks. In rural
areas, internet connections can be spotty, if patients have broadband
service at all.
</p>
<p>
"It's hard to do telehealth where people don't have iPads or iPhones,"
says Dr. Erickson.
</p>
<p>
For Dr. Erickson, telehealth has also inadvertently caused a staffing
problem. One of the three doctors in her practice began doing
telehealth at the start of the coronavirus outbreak as a way of
bringing income into the practice and fell in love with it. She has
accepted a full-time job as a telehealth physician and will be leaving
the practice.
</p>
<p>
"This is her way of moving with her career, but she would never have
found that job if we were not financially struggling in the first
place," says Dr. Erickson.
</p>
<p>
Moreover, as useful as telehealth has proven, its long-term future as a
viable option is still in doubt. "CMS holds the key for that," says Dr.
Andrews. "CMS will decide what we can and can't get paid to do." If
telehealth is not reimbursed or not reimbursed at a reasonable rate,
practices will not be able to sustain it. Accordingly, the WSMA has
made telehealth reimbursement a priority for its advocacy efforts in
the 2021 state legislative session.
</p>
<h3>Independent practices face tough challenges</h3>
<p>
Among the other changes hastened were retirement decisions. "We have a
group of anesthesiologists who are in their late 50s to late 60s," says
Brian Nyquist, MD, a partner at Olympic Anesthesia in Bremerton. "We
had several people who were close to retirement that retired. We knew
it was coming, but it's not like you can hire people before you need
them."
</p>
<p>
The flip side of the retirements, says Dr. Nyquist, is that the
"business kerfuffle of COVID" has made recruiting easier. While
previous attempts to recruit were uphill battles, he says that there
are more physicians applying for open positions at his practice. He
believes that because of COVID-19, "a lot of corporate owners,
management services, and practices have clamped down on people and
contracts," leading physicians to look for new opportunities.
</p>
<p>
Whether that applies to rural practices is an open question.
"Recruiting is incredibly challenging, but more physicians are
realizing that independent practices are a joy to work in because you
are more autonomous," says Dr. Erickson.
</p>
<p>
However, the financial pressures of the past year may make it harder
for independent practices to survive. "There's been a nationwide trend
away from private groups," says Dr. Nyquist. "We are privileged to
continue to be a private group. For now we're positioned pretty well,
but there are lots of pressures—most of them financial, some
societal—that want to drive physicians to work for hospitals. I
fear that this is probably going to exacerbate that."
</p>
<p>
Even when a vaccine is available, the effects of the pandemic will
still be felt. "For the next year, I don't see how we don't do things
we're doing now, like not have a waiting room," says Dr. Shin. "I don't
think we're going to change the number of patients we serve per hour. I
think we're looking at this as a long- term issue."
</p>
<p>
While the financial situation for Washington physicians had stabilized
by year's end, the specter of another spike in coronavirus cases still
haunts practices. "If we went back to a dark winter where we couldn't
even see patients in the office, we would absolutely struggle again,"
says Dr. Erickson. "It keeps you up at night."
</p>
<p>
Still, she remains committed to keeping the clinic afloat. "We've been
here 35 years, and there are literally not many options in town," she
says. "The most important thing is how we continue to do our work."
</p>
<p>
<em>John Gallagher is a freelance journalist specializing in covering
health care.</em>
</p>
<p>
<em>This article was featured in the January/February 2021 issue of WSMA Reports, WSMA's print newsletter.</em>
</p>
</div> | 1/19/2021 12:00:00 AM | 1/1/0001 12:00:00 AM |