4A (Expenses $ 114634705 including grants of $ 49294022) (Revenue $ 85407319)
QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL (THE HOSPITAL), LOCATED IN KAMUELA, HAWAII ON THE ISLAND OF HAWAII, IS A NOT-FOR-PROFIT, ACUTE CARE HOSPITAL THAT PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY CARE SERVICES FOR THE RESIDENTS AND VISITORS OF NORTH HAWAII. THE HOSPITAL WAS CHARTERED IN NOVEMBER 1987 AND COMMENCED OPERATIONS IN MAY 1996. THE HOSPITAL IS CURRENTLY LICENSED FOR 35 BEDS. ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA. THE NUMBER OF PATIENTS SERVED FROM 7/1/2021 - 6/30/2022 THROUGH OUTPATIENT VISITS WAS 98,794 AND THE NUMBER OF ADMISSIONS WAS 1,679. SEE SCHEDULE O FOR MORE INFORMATION.

SCHEDULE H, PART V, SECTION B, LINE 3E
THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY AND IDENTIFIED THROUGH THE CHNA.

SCHEDULE H, PART V, SECTION B, LINE 5
"Input from Community Representatives Community Meetings - Organizations throughout the state, called ""community connectors,"" helped to reach individuals from key communities for group talk story sessions. These organizations were invaluable partners, each trusted and recognized within their target communities, and willing both to provide input from their own work as well as create space and encourage their clients, partners, staff, and stakeholders to participate. Each meeting focused on both a geographic region and either an ethnic community or a vulnerable population. Key Informant Interviews - The Ward Team conducted 80 key informant interviews with individuals in key stakeholder positions able to provide input and insight on behalf of a target population. These tended to be organizational leaders serving stakeholder communities versus members of those actual populations that joined community meetings. Interviews were typically one on one between an interviewer and a key informant, lasting anywhere from 45 to 90 minutes. Small Groups - The Ward Team also held a series of private small group meetings with key leaders in three of these areas (food security, mental health, and housing). (Note that two of these necessitated additional one-on-one interviews, rather than small groups, given scheduling difficulties and the desire to speak with key individuals). These interviews followed the completion of most of the key informant interviews and community meetings and benefitted from that learning to date. The focus of discussion was around identifying COVID-19 adaptation strategies that worked and how that learning can be carried forward and built upon. Much of this discussion has augmented the Best Practice strategies highlighted in the report Community Advisory Committee - In 2021, the Community Advisory Committee (CAC) was composed of community leaders serving various target communities. CAC members were especially generous with their time, input, and expertise throughout the process. In addition to being key informants, they also participated in meetings during the last phase of the assessment and report and helped to make critical connections where there were gaps, ensure that things were ground-truthed with what they saw in their communities, and provided input as to how the priorities could be helpful both within the clinical and community-based contexts. SEE APPENDIX F OF THE CHNA FOR A LIST OF KEY INFORMANTS AND THEIR RESPECTIVE ORGANIZATIONS."

SCHEDULE H, PART V, SECTION B, LINE 6A
CHNA HOSPITAL FACILITIES NINETEEN HEALTHCARE ASSOCIATION OF HAWAII (HAH) MEMBER HOSPITALS CONTRIBUTED TO THE PRODUCTION OF THIS CHNA: ADVENTIST HEALTH CASTLE KAHUKU MEDICAL CENTER KAISER FOUNDATION HOSPITAL - HONOLULU KAPI'OLANI MEDICAL CENTER FOR WOMEN & CHILDREN KUAKINI MEDICAL CENTER KULA HOSPITAL LANA'I COMMUNITY HOSPITAL MAUI MEMORIAL MEDICAL CENTER MOLOKAI GENERAL HOSPITAL QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL PALI MOMI MEDICAL CENTER THE QUEEN'S MEDICAL CENTER THE QUEEN'S MEDICAL CENTER - WEST O'AHU REHABILITATION HOSPITAL OF THE PACIFIC SHRINERS HOSPITALS FOR CHILDREN - HONOLULU STRAUB MEDICAL CENTER SUTTER HEALTH KAHI MOHALA WAHIAWA GENERAL HOSPITAL WILCOX MEDICAL CENTER

SCHEDULE H, PART V, SECTION B, LINE 6B
CHNA OTHER THAN HOSPITAL FACILITIES THE HEALTHCARE ASSOCIATION OF HAWAII PARTNERED WITH SOLUTIONS PACIFIC AND WARD RESEARCH TO CONDUCT A CHNA FOR THE STATE OF HAWAII. IN ADDITION, THE REPORT INVOLVED NUMEROUS OTHER HEALTH CARE FACILITIES AND RESOURCES WITHIN THE COMMUNITY THAT WERE ABLE TO RESPOND TO THE HEALTHCARE NEEDS IN THE COMMUNITY. THESE RESOURCES ARE LISTED ON PAGE 94 OF THE CHNA.

SCHEDULE H, PART V, SECTION B, LINE 7A and 10A
WEBSITE WHERE THE CHNA AND IMPLEMENTATION PLAN CAN BE ACCESSED: https://www.queens.org/about/community-benefit-qhs/

SCHEDULE H, PART V, SECTION B, LINE 11
"NEEDS ASSESSED TOGETHER, THE HEALTHCARE ASSOCIATION OF HAWAII (HAH) MEMBER HOSPITALS PRIORITIZED THE AREAS OF NEED FOR THE STATE. THE TOP RANKED GOALS WERE: . Financial Security . Food Security . Mental and Behavioral Health . Housing . Trust and Equitable Access IN ADDITION, THE FOLLOWING SIGNIFICANT HEALTH NEEDS WERE IDENTIFIED: . Work together for equity and justice . Strengthen safe families . Prepare for emergencies . Restore environment and sense of place . Shift kupuna care away from ""sick care"" . Nurture community identity and cohesiveness . Invest in teenagers and healthy starts SENIOR MANAGEMENT OF THE QUEEN'S HEALTH SYSTEMS (QUEEN'S), THE NONPROFIT PARENT COMPANY OF A FAMILY OF HEALTH CARE-RELATED COMPANIES THAT INCLUDES THE QUEEN'S MEDICAL CENTER (QMC), QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL (NHCH) AND MOLOKAI GENERAL HOSPITAL (MGH), DISCUSSED THE COMMUNITY HEALTH NEEDS AND AGREED TO ADDRESS THE FOLLOWING PRIORITIES FOR THE SYSTEM: . Financial Security . Food Security . Mental and Behavioral Health . Housing . Trust and Equitable Access Through the Queen's Health System's Native Hawaiian Health program, QHS and affiliates worked to address many of the priorities included in the CHNA. Demonstrated Results in Improved Health Outcomes: The growth of seven culturally safe clinical programs within primary and specialty care settings across the health system resulted in the following improved outcomes (as of the end of FY 2022): . 219 unique patient encounters (FY 2022 target = 174) . A reduced inpatient readmissions to 42, exceeding the goal of greater or equal 71 and an improvement from 73 in FY21. . 1,004 NH no shows or cancellations in primary care/wound care settings exceeding the goal of greater or equal 2,391 and 1,004 less than FY21. . 103 new NH patients, far exceeding the goal of 80 and 12 more than FY 21. . 9.738 patient encounters, exceeding FY22 target of 9,471 and 540 more than FY 21. . 5% improvement of NH wound healing rate through appointment compliance exceeding target of greater or equal 3.24% and 1.76% more than FY21. Three phase-one projects treating high-risk diabetic patients while assessing the effectiveness of culture-responsive interventions showed proof-of-concept and achieved these positive outcomes: Queen Emma Clinics' Kilolani Project: . Increased Native Hawaiian encounters in FY22 by 1,400. . Included 128 high risk diabetes patients. Queen's Medical Center - West O'ahu's Na Pua Kaiona Project: . Decreased no show/cancellations by 43%. . Increased the number of Native Hawaiian visits by 14%. . Decreased emergency room visits by 0.44%. . Improved wound healing rate by 5.37%. Queen's North Hawaii Community Hospital's Kahu a Ola Project: . Provides interdisciplinary team care for 125 high risk Native Hawaiian patients . Hula is used as a culture-based intervention to lower risk factors such as hypertension, obesity, and hemoglobin A1c. . Decrease Hemoglobin A1c - average for 3 quarters was 7.2 . Decrease Body Mass Index - average for 3 quarters was 34.7 . Decrease Blood Pressure - average for 3 quarters was 139/81 Additionally, while COVID-19 vaccinations among Native Hawaiians lagged behind non Hawaiians, the Mobile Vaccine Clinic, supported by the Native Hawaiian Health team, created community access and culture-responsive networking. In FY22, it showed a promising trend to increase Native Hawaiian vaccinations as seen in the outcomes below: . Mobile vaccinations: 1,825 (25%) Native Hawaiians to 5475 (75%) non-Hawaiians. . West O'ahu Vaccine Clinic: 6,257 (18%) Native Hawaiians to 27,628 (82%) non-Hawaiians. . Blaisdell Vaccine Clinic: 4,220 (11%) Native Hawaiians to 33,758 (89%) non-Hawaiians. Future Goals: . The Native Hawaiian Health Program seeks to develop new models of care that focus on illness prevention, coordinated care and proactive health management. . Preparations are underway to enter several risk-based arrangements with different payers. . Queen's also strives to improve data analytics to better understand the population's healthcare needs and to optimize care and support. NEEDS NOT ADDRESSED ALTHOUGH NHCH WILL NOT DIRECTLY BE ADDRESSING ALL OF THE AREAS OF NEED LISTED ON THE CHNA REPORT, WE HAVE SUPPORTED AND PARTNERED WITH OTHERS TO ADDRESS SEVERAL OF THEM AND WILL CONTINUE TO SUPPORT OPPORTUNITIES TO ADDRESS COMMUNITY HEALTH NEEDS IN COLLABORATION WITH OTHERS."

SCHEDULE H, PART V, SECTION B, LINE 13B
INCOME LEVEL OTHER THAN FPG FOR CITIZENS OF FOREIGN COUNTRIES, THE INCOME QUALIFYING LEVEL IS BASED ON THE RESIDENT'S COUNTRY'S MINIMUM WAGE.

SCHEDULE H, PART V, SECTION B, LINE 13H
OTHER ELIGIBILITY CRITERIA MEDICARE OR MEDICAID/QUEST ELIGIBILITY

SCHEDULE H, PART V, LINES 16A, 16B & 16C
THE FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY ARE WIDELY AVAILABLE ON QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL'S WEBSITE AT: https://www.queens.org/locations/hospitals/north-hawaii/pay-your-bill/ THE FINANCIAL ASSISTANCE POLICY'S APPLICATION FORM AND TRANSLATIONS ARE WIDELY AVAILABLE ON QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL'S WEBSITE AT: https://www.queens.org/locations/hospitals/north-hawaii/pay-your-bill/fina ncial-assistance/

SCHEDULE H, PART V, SECTION B, LINE 16J
OTHER METHOD FOR PUBLICIZING POLICIES NOTICES THAT FINANCIAL ASSISTANCE IS AVAILABLE ARE POSTED IN ALL PATIENT REGISTRATION, BILLING OFFICE AND EMERGENCY DEPARTMENT AREAS. THESE NOTICES DO NOT CONTAIN THE FULL DETAILED TEXT OF THE POLICY. REGISTRATION PERSONNEL ARE KNOWLEDGEABLE TO ASSIST PATIENTS WITH QUESTIONS AND ARE ABLE TO GIVE THEM THE FINANCIAL ASSISTANCE APPLICATION.

SCHEDULE H, PART I, LINE 6
COMMUNITY BENEFIT REPORT - RELATED ORGANIZATION COMMUNITY BENEFITS ARE REPORTED ANNUALLY AS PART OF THE FORM 990. THIS IS NOT SEPARATELY AVAILABLE TO THE PUBLIC. A FORMAL REPORT ISSUED BY THE PARENT COMPANY, THE QUEEN'S HEALTH SYSTEMS, INCLUDES THE COMMUNITY BENEFITS OF THE QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL. THIS REPORT IS PUBLISHED PERIODICALLY AND IS SEPARATELY AVAILABLE TO THE PUBLIC.

SCHEDULE H, PART I, LINE 7
COSTING METHODOLOGY THE COSTING METHODOLOGY CONSIDERS ALL PATIENT SEGMENTS. AMOUNTS REPRESENT THE NET COSTS FOR THE VARIOUS PROGRAMS AND OPERATIONS, CONSIDERING ACTUAL AMOUNTS INCURRED AND CALCULATED BENEFITS BASED ON COST-TO-CHARGE RATIOS AND AVERAGE RATES (I.E. WAGE RATES).

SCHEDULE H, PART III, LINE 2
BAD DEBT METHODOLOGY NHCH PROVIDES AN ALLOWANCE AGAINST ACCOUNTS RECEIVABLE THAT COULD BECOME UNCOLLECTIBLE BY ESTABLISHING AN ALLOWANCE TO REDUCE THE CARRYING VALUE OF SUCH RECEIVABLES TO THEIR ESTIMATED NET REALIZABLE VALUE. NHCH ESTIMATES THE ALLOWANCE BASED ON THE AGING OF THE ACCOUNTS RECEIVABLE, HISTORICAL COLLECTION EXPERIENCE BY PAYOR AND OTHER RELEVANT FACTORS. NHCH PROVIDES MEDICAL SERVICES TO PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY (PATIENTS ARE NOT BILLED - CHARITY CARE) AND PATIENTS WHO REFUSE TO PAY (BAD DEBTS). THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER NHCH'S FINANCIAL ASSISTANCE POLICY IS CALCULATED BASED ON THE COST-TO-CHARGE RATIO. THE HOSPITAL ADOPTED THE FINANCIAL ACCOUNTING STANDARDS BOARD'S ACCOUNTING STANDARDS UPDATE 2014-09 TOPIC 606 (ASU 606) EFFECTIVE JULY 1, 2018. ASU 606 AND THE HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION (HFMA) DIFFERENTIATE BAD DEBT FROM IMPLICIT PRICE CONCESSIONS. THE HOSPITAL MAKES A DETERMINATION REGARDING A PRICE CONCESSION TO STANDARD PRICING ON A PORTFOLIO BASIS PRIOR TO ASSESSING THE CREDIT RISK OF INDIVIDUALS WITHIN THE PORTFOLIO. PATIENT SERVICE REVENUE IS RECORDED NET OF CONTRACTUAL ALLOWANCES AND DISCOUNTS, INCLUDING AN ESTIMATE FOR IMPLICIT PRICE CONCESSIONS. BAD DEBT IS RECORDED AS AN OPERATING EXPENSE AND RESULTS WHEN A PATIENT, DETERMINED TO HAVE THE FINANCIAL CAPACITY TO PAY FOR HEALTHCARE SERVICES, IS UNWILLING TO DO SO. THE AMOUNT SHOWN ON PART III, LINE 2 IS THE PRICE CONCESSION AMOUNT FOR THE TAX YEAR ENDED JUNE 30, 2022.

SCHEDULE H, PART III, LINE 3
BAD DEBT AS COMMUNITY BENEFIT THE PORTION OF THE BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY WAS CALCULATED BY APPLYING THE COST TO CHARGE RATIO TO THE TOTAL BAD DEBT EXPENSE. BAD DEBT PERTAINING TO PATIENT CARE SHOULD BE INCLUDED AS A COMMUNITY BENEFIT BECAUSE, CONSISTENT WITH NHCH'S MISSION, PATIENTS RECEIVE CARE REGARDLESS OF WHETHER NHCH COLLECTS PAYMENT FOR SERVICES PERFORMED.

SCHEDULE H, PART III, LINE 4
"BAD DEBT EXPENSE FOOTNOTE NHCH PROVIDES MEDICAL SERVICES TO PATIENTS WHO DO NOT HAVE THE ABILITY TO PAY (PATIENTS ARE NOT BILLED - CHARITY CARE) AND PATIENTS WHO REFUSE TO PAY (BAD DEBTS). THE AUDITED FINANCIAL STATEMENTS DO NOT DESCRIBE BAD DEBT EXPENSE. THE AUDITED FINANCIAL STATEMENTS DO DESCRIBE THE RECEIVABLES FOR PATIENT SERVICES. ""ACCOUNTS RECEIVABLE PRIMARILY COMPRISE AMOUNTS DUE FOR HEALTHCARE SERVICES FROM PATIENTS AND THIRD-PARTY PAYORS AND ARE RECORDED NET OF AMOUNTS FOR CONTRACTUAL ADJUSTMENTS, IMPLICIT PRICE CONCESSIONS AND BAD DEBTS."""

SCHEDULE H, PART III, LINE 8
TREATMENT OF MEDICARE SHORTFALL COMMUNITY BENEFIT THE HOSPITAL MUST TREAT PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE GOVERNMENT SETS NON-NEGOTIABLE MEDICARE RATES AND THE REIMBURSEMENT HAS NOT KEPT PACE WITH THE RISING COSTS OF PROVIDING THESE SERVICES. DUE TO THE REQUIREMENT TO PROVIDE CARE AND THE INABILITY OF THE MEDICARE REIMBURSEMENT TO KEEP PACE WITH THE COST OF PROVIDING SERVICES, WE FEEL THAT THE LOSS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES IS PART OF NHCH'S MISSION AND IS A BENEFIT TO THE COMMUNITY. MEDICARE COSTING METHODOLOGY THE MEDICARE AMOUNTS ABOVE ARE CALCULATED WITH DATA FROM THE JUNE 30, 2022 COST REPORT USING THE STEP DOWN METHOD.

SCHEDULE H, PART III, LINE 9B
APPLICATION OF THE COLLECTION PRACTICES TO THOSE QUALIFYING FOR FINANCIAL ASSISTANCE CHARITY CARE WILL BE GRANTED TO ALL UNDERINSURED AND UNINSURED PATIENTS. THE SCREENING PROCESS WILL OPTIMALLY OCCUR AT THE TIME OF SERVICE, BUT MAY OCCUR ANYTIME DURING THE COLLECTION PROCESS INCLUDING POST ASSIGNMENT TO AN OUTSIDE COLLECTION AGENCY. ACCOUNTS FOR PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE ARE IDENTIFIED FOR A YEAR AND ASSESSED ANNUALLY AND/OR DURING SUBSEQUENT VISITS TO THE HOSPITAL. PROMPT PAYMENT DISCOUNTS ARE AVAILABLE FOR PATIENTS WHO PAY FOR SERVICE AT THE TIME OF TREATMENT. THE CARE PAYMENT PROGRAM IS AVAILABLE FOR ELIGIBLE PATIENTS AND PROVIDES LOW MONTHLY PAYMENTS WITH 0% INTEREST.

SCHEDULE H, PART VI, LINE 2
NEEDS ASSESSMENT ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA AND THE BOARD IS COMPRISED OF COMMUNITY MEMBERS. THIS ALLOWS THE HOSPITAL TO ASSESS THE NEEDS OF THE COMMUNITY THAT IT SERVES. IN ADDITION, MANY COMMUNITY HEALTH SERVICES ARE OFFERED IN THE FORMS OF ACTIVITIES OR PROGRAMS THAT HELP TO ASSESS AND IMPROVE COMMUNITY HEALTH. AS REPORTED IN SCHEDULE H, PART V, SECTION B, FOR THE 2021 TAX YEAR, QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL COMPLETED A CHNA WITH THE ASSISTANCE OF THE HEALTHCARE ASSOCIATION OF HAWAII.

SCHEDULE H, PART VI, LINE 3
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE NOTICES ARE POSTED IN ALL PATIENT REGISTRATION, BILLING OFFICE AND EMERGENCY DEPARTMENT AREAS REGARDING THE AVAILABILITY OF FINANCIAL ASSISTANCE TO LOW-INCOME AND UNINSURED PATIENTS. THIS INFORMATION IS ALSO POSTED ON THE HOSPITAL WEBSITE AND ON PATIENT BILLING STATEMENTS. APPROPRIATE STAFF MEMBERS THAT COMMUNICATE WITH THE PUBLIC REGARDING THEIR BILLS ARE TRAINED AND KNOWLEDGEABLE ABOUT THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY.

SCHEDULE H, PART VI, LINE 5
PROMOTION OF COMMUNITY HEALTH THE MAJORITY OF THE ORGANIZATION'S BOARD IS COMPRISED OF COMMUNITY MEMBERS FROM THE NORTHERN HAWAII AREA AND HAS AN OPEN MEDICAL STAFF. THE HOSPITAL CONDUCTED DIFFERENT EVENTS INCLUDING HEALTH FAIRS AND EDUCATION DAYS IN THE LOCAL COMMUNITY, HOTELS AND SCHOOLS OF THE AREA AS WELL AS TAKING A LEAD ROLE IN BREAST CANCER AWARENESS MONTH.

SCHEDULE H, PART VI, LINE 6
AFFILIATED HEALTH CARE SYSTEM NHCH IS A MEMBER OF THE QUEEN'S HEALTH SYSTEMS (QHS) AFFILIATED GROUP. THE GROUP INCLUDES QUEEN'S MEDICAL CENTER (QMC), QUEEN EMMA LAND COMPANY (QEL), QUEEN'S INSURANCE EXCHANGE (QIE), QUEEN'S DEVELOPMENT CORPORATION (QDC), MOLOKAI GENERAL HOSPITAL (MGH) AND QUEEN'S UNIVERSITY MEDICAL GROUP (QUMG). QHS PROVIDED LEGAL, ACCOUNTING AND ADMINISTRATIVE SUPPORT SERVICES TO NHCH AND QIE PROVIDED MEDICAL MALPRACTICE INSURANCE TO NHCH. IN RETURN, NHCH ASSISTED QMC IN FULFILLING ITS MISSION TO PROVIDE IN PERPETUITY QUALITY HEALTH CARE SERVICES TO IMPROVE THE WELL-BEING OF NATIVE HAWAIIANS AND ALL THE PEOPLE OF HAWAII.

SCHEDULE H, PART VI, LINE 7
STATE FILING OF COMMUNITY BENEFIT REPORT N/A

SCHEDULE H, PART VI, LINE 4
COMMUNITY INFORMATION QUEEN'S NORTH HAWAII COMMUNITY HOSPITAL IS LOCATED IN KAMUELA, HAWAII, ALSO KNOWN AS WAIMEA, HAWAII, IN THE KOHALA DISTRICT OF THE NORTHEASTERN REGION OF THE ISLAND OF HAWAII. IT IS A NOT-FOR-PROFIT, ACUTE CARE HOSPITAL THAT PROVIDES INPATIENT, OUTPATIENT AND EMERGENCY CARE SERVICES FOR ABOUT 30,000 RESIDENTS AND VISITORS OF NORTH HAWAII. THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF APPROXIMATELY ONE-FOURTH, OR 1,000 SQUARE MILES, OF THE BIG ISLAND'S 4,028 TOTAL SQUARE MILES. THERE ARE CURRENTLY NO OTHER GENERAL ACUTE CARE HOSPITALS IN THE PRIMARY SERVICE AREA. THE HOSPITAL WAS CHARTERED IN NOVEMBER 1987 AND COMMENCED OPERATIONS IN MAY 1996. THE HOSPITAL IS CURRENTLY LICENSED FOR 35 BEDS. ADMITTING PHYSICIANS ARE PRACTITIONERS IN THE LOCAL AREA.