Acadia Buys CRC Health

Acadia Healthcare Company Inc. said it will acquire CRC Health Group Inc. for $1.18 billion, expanding its in-patient mental health and substance abuse treatment facilities. Acadia is headquartered in Franklin, TN and owns 76 facilities with about 5,800 beds in 24 states, Puerto Rico and the U.K. CRC Health Corporation was founded in 1995 and is headquartered in Cupertino, California. CRC Health Corporation operates as a subsidiary of CRC Health Group, Inc. They have about 120 facilities and sees about 40,000 patients daily. CRC was expected to generate $450 million in revenue in 2014, and adjusted earnings of $115 million

The acquisition is Acadia’s fifth in the past 12 months, adding 27 facilities and more than 1,500 beds. Earlier this year, Acadia purchased Partners in Care, a U.K.-based company for $662 million.

The behavioral health and substance abuse industry is considered by business analysts to be highly fragmented in the U.S. and the U.K. with significant room to add new beds in existing facilities. Growth and consolidation is on the horizon for all these big players.

CRC Health, based in Cupertino, California, is a substance-abuse treatment provider that has about 120 facilities and sees about 40,000 patients daily, according to the statement. CRC is expected to generate $450 million in revenue this year, and adjusted earnings of $115 million, Acadia said.

 

Origins Behavioral Health Acquires Two Caron Treatment Center Locations

Origins Behavioral Health (headquartered in South Padre Island, Texas soon to be located in West Palm Beach, Florida) will acquire two treatment sites from Caron Treatment Centers (headquartered in Pennsylvania). The Hanley Center in West Palm Beach, Florida, and Gate Lodge in Vero Beach, Florida., will add over 100 beds to Origin’s current capacity of around 80 beds.

Origins is clearly on course to be a big player on the East Coast and increase its service offerings through acquisitions and organic growth. Less than half of current patients are from inside Texas with the rest skewed to the West Coast. This recent round hopes to change that. The Hanley Center has a 30-year history and is a noteworthy acquisition. 

Expansion fever is in the air since there are at least 10 acres of available land on the Hanley property zoned for treatment that has yet to be developed. They are in the process of moving all corporate functions to West Palm Beach and Robert Park, Origins’ longtime executive director has relocated to Florida and has assumed the executive director role at Hanley Center..

Origins is looking to partner with other organizations that are like-minded and are leaders in the evolving business of addiction treatment.

 

Insider’s Guide: List of Therapeutic + Prep Boarding Schools

This is an ever-growing list of therapeutic and preparatory boarding schools from around the country. The list is updated regularly with new information on tuition, descriptions as well as new listings. *Fonthill Counseling accepts no financial compensation for posting or reviewing therapeutic boarding schools on the list (Just in case you were wondering). 

Youth Initiative High School
Viroqua, Wisconsin
Grades: 9-12
Gender: Co-Ed
Tuition: $6300/year, $675 Enrollment
Designation: Private, Non-Profit
Description: The Youth Initiative High School was founded in 1996 when a group of high school students from the Viroqua area decided to take responsibility for their education. Today, YIHS continues to emphasize the development of student responsibility, initiative, and citizenship in all aspects of school life. Students are full voting members of the school community, serving alongside parents and faculty on the Board of Trustees and on many other committees. YIHS students also take responsibility for raising a significant part of the school’s annual budget through a variety of independently organized fundraising activities. They are also responsible for cleaning and maintaining the school’s facilities. YIHS is an independent high school and does not receive substantial funds from federal, state, or local government. Tuition at YIHS is arranged on a flexible basis in order to enable students from families of all income levels to participate in the school, with several students each year working to pay their own tuition. YIHS has been recognized as a Developing Member of the Association of Waldorf Schools of North America (AWSNA) and our graduates have been accepted to colleges and universities throughout the United States and overseas.

Academy of Sisters
Bend, Oregon
Grades: 9-12
Gender: Girls
Tuition: $7200/month, $3000 Enrollment
Designation: Private Subsidiary (J Bar J Youth Services), Non-Profit
Description: The Academy at Sisters is a therapeutic and academic boarding school for at-risk girls ages 13-18 located in Bend, Oregon. They provide evidence-based intervention for mental health and substance abuse issues. Located at the base of the Cascade Mountains, the community of Bend was recently ranked the second safest small town in the U.S.A.

Chrysalis School
Eureka, Montana
Grades: 8 – 12
Gender: Girls
Tuition: $
Designation: Private, For Profit
Description: Chrysalis is a small therapeutic boarding school located in northwestern Montana, just 5 miles from the British Columbia border. The school sits on 65 acres, nestled between Carpenter Lake and the Koocanusa Reservoir. The campus is home to girls ages 13-18. The typical stay is between 18 and 24 months, but is individualized for each resident’s needs with the expectation of program graduation. Students live “family-style” in one of three homes, hold each other accountable for actions, and become responsible for themselves. The home environment encourages girls to build on personal strengths, while they examine and challenge old patterns which have prevented growth. Chrysalis is not a program of primary treatment for either addictions or eating disorders; substance abuse may have been an issue in the past, but residents must have established several months of sobriety and be committed to a program of recovery prior to acceptance. If eating disorders have been diagnosed, primary treatment and a similar program of recovery would be expected prior to acceptance.

West Melbourne Christian Academy
Melbourne, Florida
Grades: K – 12
Gender: Co-Ed
Tuition: $4550/year
Designation: Private, Non-Profit
Description: At West Melbourne, teachers represent parents and encourage students to submit to the truth and love of Christ. Teachers are role models and demonstrate the lordship of Christ in every area of life. Finally, teachers play the primary role in the school’s objective of students obtaining academic excellence as well as physical, social, and spiritual growth. 

Mojave Academy
Datil, New Mexico
Grades: 
Gender: 
Tuition: $
Designation: 
Description: CLOSED

New Haven School
Spanish Fork, Utah
Grades: 9-12
Gender: Co-Ed
Tuition: $475/day; $38,416
Description: New Haven’s campuses contain several residential homes and a school, allowing them to work with up to 90 families at a time. Teams are assigned to each house of 12-17 students. Students receive therapy weekly including: specialty groups, experiential, individual and family sessions. They are a fully accredited private school allowing the students to continue earning credits in a traditional school setting.They are also able to work with students struggling with Dyslexia, Language-based, ADHD, TBI, and Executive Functioning issues.

The Vanguard School
Lake Wales, Florida
Grades: 9-12
Gender: Co-Ed
Tuition: $44,000
Description: The Vanguard School is located in Lake Wales, FL. It is a private, special education school that serves 138 students in grades 5-12. The Vanguard School is nonsectarian in orientation. The school belongs to the National Association of Independent Schools.

In 2010, The Vanguard School had 7:1 student/teacher ratio. The Florida average is 15 students per full-time equivalent teacher.

High Mowing School
Wilton, New Hampshire
Grades: 9-12
Gender: Co-Ed
Tuition: $49,900
Description:

Oakland School
Keswick, Virginia
Grades: 9-12
Gender: Co-Ed
Tuition: $
Description:

Bachman Academy
McDonald, Tennessee
Grades: 9-12
Gender: Co-Ed
Tuition: $
Description:

Auldern Academy
Siler City, North Carolina
Grades: 9-12
Gender: Female
Tuition: $
Description: Auldern Academy is located in Siler City, NC. It is a private school that serves 48 students in grades 9-12. Auldern Academy is all-female and is nonsectarian in orientation. The school belongs to the National Independent Private Schools Association.

In 2010, Auldern Academy had 6:1 student/teacher ratio. The North Carolina average is 15 students per full-time equivalent teacher.

 

Denied: 60 Minutes Exposes Insurance Denials for Mental Health

On December 14, Scott Pelley had a segment on how the insurance industry routinely denies claims for mental health treatment. It’s heart wrenching but important to watch so you can learn how to advocate for yourself. Many providers like doctors, psychiatrists, and therapists are often so removed from the payment side of practice they fail to appreciate how devastating it is to have insurance reject payment for necessary treatment. 

Insider’s Guide: CPT Codes and Why They Matter

Most lingo of mental health and substance abuse is unintentionally seemingly undecipherable psycho-babble which actually turns out to be pretty important. There are diagnostic codes (eg. Bipolar Disorder II), NPI numbers, license numbers, and CPT codes. Today, we’ll be examining the role of the often quiet but super important CPT code. 

Acronym

Let’s start with the basics like what CPT stands for. It’s an acronym for the Current Procedural Terminology. 

What is it Code for?

CPT is the coding set maintained by the American Medical Association (AMA) through the CPT Editorial Panel. The CPT code defines all AMA-approved medical, surgical, mental health, substance abuse and diagnostic services. It’s designed to provide consistent and uniform information about medical and mental health services and procedures among physicians, coders, patients, accreditation organizations, insurance companies and payers for administrative, financial, and analytical purposes.

For example, let’s say you are working with a therapist at Fonthill Counseling for individual outpatient therapy each week and using your insurance to cover the cost. Fonthill creates an invoice (aka ‘Superbill’) after each session and sends it to the insurer. In that invoice, Fonthill puts in the CPT code ‘90837’ which is numeric language for ’50 Minute Outpatient Therapy Session.’ The invoice also includes several other pieces of info but we’ll cover that another time. Let’s say that one week, you want to bring your family in for a session since there seems to be some unresolved issues with your recent move to a new home in a new community. The family comes in and has a great, productive session. Following the session, Fonthill creates another invoice but this time uses the CPT code ‘90847’ which is for ’50 Minute Outpatient Family Therapy with Client.’ 

If Fonthill did not put in any CPT code, the insurer would not pay for the service and Fonthill would send you a bill for the session. Sometimes, there are services (CPT Codes) insurance does not pay for. 

Some insurance companies, for instance, do not cover for clients to have a phone session with their psychiatrist to discuss medication changes. The service has a CPT code (99443) but if the insurance company does not consider it a good return on investment, they will not cover it. 

How Do I know Which CPT Codes are Covered by Insurance?

Bottom line – most ‘typical’ procedures or services for mental health counseling like individual outpatient therapy are covered. If you need or are recommended by a professional for an ‘atypical’ service, first – find out what the service is called and, if possible, what the CPT code is. Next, contact your insurer with the info and ask how much they cover for that. If they say they do not cover it, ask how to receive an exception for your situation. You have a much better chance of getting an exception if the service was recommended in a psychological evaluation or discharge summary from inpatient at a hospital.  

Are CPT Codes Updated?

New editions or updates are released each October. The current version is the CPT 2014. It is available in both a standard edition and a professional edition. Not every CPT code changes every year. Mental health CPT codes do not change very often.  

5 Stupid Things My Teen is Doing

For this installment of Stupid Things, we start off nice and easy and then drop down into some weird crap. Kids are bored. I get it. We clearly need more devices since the iPhone 6 Plus, iPad, Mac, XBox, Playstation and all the other tech stuff just isn’t stimulating enough. We humbly present to you more stupid things teens are doing…

images (2)1. GoPro
GoPro is a small video device created for skateboarders, mountain bikers and surfers to self-film their adventures. GoPro went public this year. Why does this matter? Because their marketing budget exploded and with it, their target market which is now anyone who wants to film them self doing anything. Just let your imagination wander and you’ll soon realize why gopro-ing could be a problem for teens. They do some stupid prank at school, film it, post it on instagram and, voila! Instant evidence for the local DA to use against them.   

 

 

2. Vodka Eyeballingimages (1)
Pouring vodka in your eye sockets in order to get drunk faster and more efficiently is another dumb but real thing. It makes sense to the adolescent brain since the mouth is just soooo far away, best to use an eye. 

 

 

3. Beezin
Let’s continue our ‘eye’ theme. It’s called “Beezin,” (why do stupid teen things always leave off the last ‘g’?). Here’s the how-to – rub Burt’s Bees lip balm on the eyelids. It’s just that simple! No complicated steps like some of our other Stupid Things. The peppermint oil found in the balm creates a tingling sensation that some teens say enhances the feeling when they are already drunk or high. Others say its a way to keep them alert after a long night (…because that thing the brain and body do to restore itself each night is just soooo inconvenient, what’s that called? Oh, right! Sleep). If your kid is prone to stupid acts, look for pink-eye type irritation. Kids site the ‘natural’ ingredients as evidence of it’s safety but a Burt’s Bees rep argued “There are lots of natural things that probably shouldn’t go in eyes — dirt, twigs, leaves, food — and our lip balm.” 

images

 

4. Purple Drank
Just when you thought the good ‘ole days (1990’s) were behind us, creative teens desperate to feel something other than a stable middle class existence have resurrected use of cough syrup. Here’s the recipe – cough syrup, Mountain Dew (or Red Bull, etc) and Jolly Ranchers. Not sure what they’ll die from first, the dextromethorphan, guaifenesin, pseudoephedrine or Type II Diabetes. Keep an eye out for pilfered medicine cabinets (and pantries). 

 

 

5. Butt Chugging 
Yes, leave it only to bored American teens to come up with this one. It’s simple – take a tampon, soak it in alcohol, and insert into your butt. And yes, kids really do this.

That’s it folks. Join us next time for the sad but humorous exploration of how tomorrow’s leaders are spending their time today. 

Insider’s Guide: Getting Insurance to Pay for Residential Treatment

imagesThis is our second installment on how to get insurance to pay for residential treatment and therapeutic programs. Below is some great information to help you beat the insurance companies at their own game. Insurance companies count on your ignorance, laziness and distractibility to avoid paying for services they are legally obligated to cover. 

With the Affordable Healthcare Act and the Mental Health Parity Act in full swing it’s time to learn how to get the most out of the insurance you pay for. We’ve included some tricks, strategies and how-to’s to help you out. Though we’re focusing on Residential Treatment for our discussion here, this info is applicable to therapeutic programs like wilderness programs, therapeutic boarding schools and intensive outpatient programs.

Ok, let’s get started with some basics… 

What If I Need Additional Help?

First, read through everything below. These strategies are time consuming and require steady attention but they are not impossible. If you still don’t feel confident in holding your insurer accountable, contact us for a free consult and we’ll help you figure out how to move forward. 

What is the Insurance Company’s Criteria for Residential Treatment?

…Or more importantly, how does an insurer define residential treatment? Each insurer has their own definition but most have virtually identical criteria. For our purposes, residential treatment is defined as specialized mental, behavioral health or substance abuse treatment that occurs in a residential (overnight) treatment center where the provider is responsible for clinical service, safety, shelter, and food.

Licensure differs by state, but these facilities are typically designated either as residential, subacute, or intermediate care facilities and may occur in care systems that provide multiple levels of care. Residential treatment is 24 hours per day and often requires a minimum of one physician (or psychiatrist) visit per week in a facility based setting. 

What Specific Criteria Do They Look For?

Now, let’s drill down a bit more and look at some of the more common criteria requirements insurance companies are looking for when determining whether to pay for residential treatment to a struggling teen or young adult. 

  • Was there a sincere attempt to first use evidence-based outpatient therapy in the home community by a licensed professional before residential treatment was requested and outpatient therapy did not work? Basically, they want evidence that you tried outpatient therapy with weekly sessions (or more often) and because it was not effective, a more intensive level of care like residential treatment was justified.
  • Prior to admission, did you contact your health plan for list of in-network residential treatment options? More on this later – what to do if you can not find a good option.
  • Is there uncontrollable risk-taking to self or others or other dangerous behavior?
  • Has there been a documentable and rapid decrease in level of functioning in one or more life domains. Another way to describe it is a decline in functioning resulting in the ability to perform self-care. 
  • Is there a likelihood of no improvement in current environment (ie. home or college)
  • Is there a reasonable expectation that patient will improve in residential setting and be able to return to outpatient therapy for aftercare? 

How to Request this Higher Level of Care?

Now that you understand the criteria, let’s talk about how to actually request residential treatment. 

  • Write a letter strongly recommending admission to residential treatment 
  • Provide copies of assessments and testing performed by a licensed professional that indicate 1) a formal diagnosis and 2) specific recommendations that list residential treatment.
  • Explain how outpatient therapy has not been successful
  • Explain why current circumstances make it unlikely that patient will show improvement (ie. Improvement is not likely in home setting due to social stressors such as negative peers that sell drugs but remain in the environment)
  • Document unsafe, declining behaviors – show symptoms and behaviors that represent a decline from usual state and include either self-injurious or risk-taking behavior that cannot be managed outside of 24 hr care. Can your kid maintain abstinence outside of 24 hr care? 
  • Explain that the residential treatment program uses evidence-based clinical interventions.
  • Request the residential treatment program directly contact your insurer for pre-authorization. Pre-authorization is the insurance company’s way of giving formal permission to use a higher (and more expensive) level of care. Make sure to obtain the tracking number and verification of the call from the residential treatment program. If approved, obtain written authorization confirming admission approval.

After you send off your request, your insurer should should respond in 5 days. Don’t wait that long – call them every day to find out the status of your request. Yes, seriously – call every day. 

Accepted! Now Some Additional Insurance Mandates

The insurance company accepted your request (more below on what happens when they do not accept it) and a wave of relief comes over you planning for some quiet time once your kid is safely transitioned. But before you get too comfy, there are a few things you want to make sure the residential treatment program will do to ensure insurance covers as much as possible. It’s easier to ask these questions during the admissions process rather than at discharge. Here’s a list of what to look for or ask for:

  • A basic physical during admission (urine screening for drug facility)
  • Onsite nursing and 24hr access to med care
  • Multidisciplinary assessment (also called a Biopsychosocial Intake) performed within 72 hr of admission, including information obtained from patient’s previous providers (ie. therapist, primary care physician)
  • Individual therapy with a licensed therapist (ie. LPC, LCSW, LMFT) at least one time per week
  • Weekly meetings with doctor for medication management
  • Weekly family therapy
  • Discharge plan created one week after admission which acts as a set of exit criteria
  • Licensed in the state in which they are located. Some facilities are owned by huge companies in another state. Make sure they are credentialed and licensed.

Denied. Now on to The Appeal Process

Denials are just a way of life in the therapeutic treatment world but it’s certainly not the end. Here are some information on what to do when you experience a denial.

  • First Thing – Do not let the denial get you mad and do not attempt to use logic, common sense or science to understand why. Insurance is a business and their business model is take in money and pay for as little service as possible – period. 
  • If residential treatment is verbally denied, request written denial. They must deny in writing and often will send the residential treatment program as well as the insured person a copy. 
  • Do not just ignore the denial and send your kid off unless you are willing to pay out of pocket and work your tail off at discharge to get the insurer to pay for it.
  • How to appeal depends upon the reason for denial. The insurance company will likely list specific criteria either your kid or the residential treatment program did not meet.
  • If the insurer states that residential treatment is not a covered benefit but they offer  other mental/behavioral health benefits, they are required by law to pay. In Harlick v Blue Cross of California – On August 26, 2011 the court confirmed that California’s Mental Health Parity Act requires health plans to provide coverage of “all medically necessary treatment” for “severe mental illnesses” under “the same financial terms as those applied to physical illnesses,” and are obligated to pay for residential treatment for people with eating disorders even if the policy excludes residential treatment.

And It’s Still Denied – What Next?

If you submit an appeal with additional information and site the law but still are denied or hear nothing, you can request an independent review from your state’s regulatory body that oversees insurance compliance. It’s amazing how quickly insurance companies can ‘find missing paperwork’ or reverse a denial when regulators and attorney’s get involved. 

  • Send a certified-mail cover letter describing the dispute
  • Provide all relevant evaluations, assessments and testing you already sent to the insurer
  • Submit a doctor’s letter stating care is medically necessary
  • You can also hire an attorney that specializes in insurance issues like this. They are often worth their specialist price tag.

Plan B – If You Can Afford It

If residential is denied and you don’t want to push the insurer for whatever reason, you can pay out of pocket for room and board and try to get the clinical services covered. This approach is often what is equivalent to out-of-network coverage. The insurer is more likely to cover outpatient therapy, group therapy and medication management (virtually the same as if client was living at home and going to therapy).

You can also request that the residential treatment primary therapist get a single case agreement which forces the insurer to pay at in-network rate and you only owe the copay, as usual. 

What if Our Family Member is at Therapeutic Boarding School?

With the growth of therapeutic boarding schools, we’ve received a ton of questions about how insurance pays for the clinical aspects of these hybrid programs. Here are some tricks we’ve picked up over the years:

  • Think like the insurance company – they want to hear your son or daughter is being referred to as a patient and not a student.
  • Make sure to request a physical assessment is done at admissions. This promotes the perspective that he/she is a patient and not a student. Remember – we want the insurer to understand this is a therapeutic program, not as much an academic program.
  • We also want to ensure the program is keeping daily records such as treatment plan updates, nursing and medical notes and service notes – health plans will want copies. We want to be documenting progress as well as setbacks. 

When we conduct placement services, we always request the therapeutic program develop a treatment plan with some specific exit criteria. The first day of treatment is the first day of discharge planning. Some plans will want exit criteria so err on the side of having the program provide it early on. It’s also a good clinical practice to give the providers a clear target. 

In Which State Should Insurance Regulators Be Notified if Insurance Refuses to Cooperate?

The state in which treatment is being provided is where insurance regulators should be contacted if your insurance company refuses to play nicely. The state in which you live may be where your insurance is attached, but legal oversight for provision of service and insurance regulation is in the treatment state. 

Can Insurance Pay for Services Retroactively?

Theoretically, yes. Practically, it’s pretty difficult and will require regular attention and contact with the insurer. They will likely ‘lose’ applications, claim forms and anything else you send. If you get insurance to agree to pay for residential treatment or other therapeutic services after treatment has started, you can request for retroactive coverage. It’s best to write a letter (and send it certified mail and keep a copy for your records) stating why you didn’t understand or it was not stated clearly in a policy that treatment was covered. 

Will Insurance Cover Partial Hospitalization Programs (PHP)?

Partial Hospitalization Programs or PHPs is typically a level of care designed for individuals who need structured mental health, behavioral health or substance abuse programming but do not need 24-hour supervision (ie. inpatient or hosplitalization). Many hospitals and residential treatment programs offer partial hospitalization or day treatment services. Good PHPs are designed to provide support, education, medical monitoring and accountability during the hours of the day often identified as most troublesome for patients. Patients participate in therapeutic groups, structured activities and discharge planning similar to those offered in the inpatient and residential programs. Many patients who have been in an inpatient or residential program can “step down” to this level of care because it continues to provide a high amount of structure and support. 

Insurance generally covers PHP at a per diem rate (daily rate) but will not cover overnight which the hospital or treatment program may charge extra for. Make sure to clearly understand how the treatment center charges for PHP before signing up. Also make sure insurance covers it and what portion it covers. 

So we covered several of the topics and tricks that can help you navigate the insurance company maze when it comes to paying for residential treatment. If you need additional help, contact us today – help@fonthillbehavioralhealth.com 

5 Signs of Suicide Risk in College Students

FACT: 15% of graduate and 18% of undergrads have seriously considered attempting suicide

FACT: 15% of graduate and 18% of undergrads have seriously considered attempting suicide

There is nothing more exciting than dropping of your college freshman in late August as the cool nights of Autumn return. But not all students carry with them the same energy and positive outlook for the Fall. Some are carrying some heavy baggage from High School or even younger while others don’t start to develop any major issues until they first get to college (and their first taste of freedom from parents). What parents don’t know is that you likely know your college friends (or at least a side of them) better than their own parents do, and you may be able to tell that something is wrong way before anyone else. This quick list is as much for parents as it is for you students out there. 

The following signs might indicate a student is considering suicide:

  1. A good student who’s behavior suddenly changes – they start ignoring assignments and missing classes which are likely signs of depression or drug and alcohol abuse, which can affect their health and happiness and put them at risk of suicide. And yes, good students and good kids use drugs. Seriously. 
  2. Anyone who doesn’t have friends or who suddenly rejects their friends may be at risk. A friend who suddenly rejects you, claiming, “You just don’t get it,” may be having emotional problems.
  3. College students may be physically or emotionally abused by a member of their family or their girlfriend or boyfriend – or suffering from abuse that occurred long ago but triggered by the new college environment. Abusive relationships can make a college student feel like crap about themselves. Signs that a person may be in an abusive relationship include unexplained bruises or other injuries that he or she refuses to discuss. 
  4. This is a common one – Significant changes in a someone’s weight, eating or sleeping patterns, and/or social interaction style may indicate that something is wrong. Eating disorders are super common at college. Lot’s of perceived competition, anxiety and stress that translates into really unhealthy views of one’s self. 
  5. Coming Out? College students may suffer from depression or have thoughts of suicide if they have a difficult time adjusting to their sexual orientation or gender identity. Gay, lesbian, bisexual, and transgendered students have higher suicide attempt rates than their heterosexual peers.

We understand regret and their could certainly be a real consequence of getting help for someone who seems to be really hurting. They might get pissed at you for not minding your own business. But think of it this way – is the regret of possibly losing a friend better or worse than the potential of knowing you could have saved your friend’s life but did nothing? Tough choice but that’s part of the burden of mental illness.