Results / Cross-border patient mobility (4th milestone)

The study prepared in the frames of this subproject can be downloaded by clocking on the picture below (in Hungarian).

Results of the subproject were summarized in the following points. Click on the text for details.

Within the framework of the third legal accessibility project, we have made a progress on issues that are important for the enforcement of patients’ rights, based on which, this year we focused on the institutional and legal environment. The subproject aimed to draft concrete, textual legal proposals for bilateral solutions and elaborate a guideline supporting their implementation in the field of ambulance services and healthcare with the involvement of the competent actors, in order to manage the increasing cross-boreder patient flow, and to improve the quality of care in the border areas lacking functions. To this end we:

  • analsysed the institutional and legal environment,
  • assessed the possibilities of cross-border service provision in 4 hospitals located along the border,
  • made a proposal for the text of intergovernmental agreement in order to facilitate cross-border patient care,
  • prepared model contracts for the hospitals concerned with cross-border service provision with the involvement of the relevant partners,
  • organized the professional annual seminar of the EMS task force,
  • organised an EMS study tour to Lower-Austria,
  • made a proposal for the text of intergovernmental agreement on the cross-border movement of ambulances elaborated a guideline (in Hungarian) for supporting the implementation of cross-border patient care.

Interviews

According to the 2018 analysis of national situation, four publicly funded Hungarian healthcare institutions, located along the border section and identified as being highly involved in cross-border cooperation, were tested within the frames of an interview method. The criteria for selecting the service providers were the following ones:

  1. the selected healthcare institutions should be located far from each other, preferably along four different border section of Hungary (examination of the Austrian and the Ukrainian border was omitted because of the existence of significant differences either in technical or price level of given services);
  2. the hospitals should represent different levels of progressivity, from the basic urban hospitals with four departments to the university clinic.

The following institutions were involved in the interviews: the Vaszary Kolos Hospital (in Hungarian-Slovak relation), the Mohácsi City Hospital (in Hungarian-Croatian relation), the Albert Szent-Györgyi Health Center of the University of Szeged, the UNI-MED Szeged Healtcare Ltd. that assures the full-range paid healthcare services (in Hungarian-Romanian and in Hungarian-Serbian relation), as well as the Zala County Szent Rafael Hospital (in Hungarian-Slovenian relation). During the interviews with the institutions, their experience with cross-border health services and the issues of resources that support their participation in cooperation were explored.

The interviews were based on a pre-developed standard set of questions based on the experience of the third milestone national survey. Two interviews were conducted at the Albert Szent-Györgyi Health Center of the University of Szeged, regarding that an economic company specially established for that purpose, UNI-MED Szeged Healtcare Ltd. assures a full-range paid outpatient and inpatient healthcare services.

The conclusion of the interviews were summarized and examined within the framework of a multi-approach benchmark, hereby giving an overall picture on the development potentials of cross-border patient mobility.

Second international EMS seminar (30 September 2019)

The second interactive seminar on cross-border ambulance services was held on 30September in Budapest, in which local experts and experts from the neighbouring EU Members States discussed the frameworks of long-term cooperation based on the Austrian-Czech good practice.

We invited to the seminar the regionally (i.e. borderlands’) competent leaders of the ambulance services and the representatives of the competent ministries and state institutions of domestic and neighbouring countries.  

Participants of the seminar:

  • Ács Zoltán – Operačné stredisko záchrannej zdravotnej služby (Emergency Medical Service Operations Center) (SK)
  • Dr Balogh Tamás – CESCI (HU)
  • Dr Csató Gábor – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Dr Engelbrecht Imre – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Dr Juca Dacian – SMURD (Emergency Situations Department) (RO)
  • Dr Gencsi László – Ambulanta Bihor (Bihor County Ambulance Service) (RO)
  • Dr Golopencza Pál – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Dr Gyenes Kata – Állami Egészségügyi Ellátóközpont (National Healthcare Services Center) (HU)
  • Dr Jova Anett – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Oec. Mirjana Hanžeković Zavoda za hitnu medicinu koprivničko-križevačke županije (Institute for Emergency Medicine of Koprivnica-Križevci County (HR)
  • Juraj HrehorcakOperačné stredisko záchrannej zdravotnej služby (Emergency Medical Service Operations Center) (SK)
  • Hüse-Nyerges Enikő – CESCI (HU)
  • Vladimira Križaj-GrabantZavod Za hitnu medicinu međimurske županije (Institute for Emergency Medicine of Medjimurje County) (HR)
  • Christian LeglerNotruf NÖ (Notruf Lower-Austria) (AT)
  • Dr Lórántfy Mária – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Lucia MesárošováOperačné stredisko záchrannej zdravotnej služby (SK)
  • Ocskay Gyula – CESCI (HU)
  • Dr. Susanne OttendorferNotruf NÖ (Notruf Lower-Austria) (AT)
  • Július PavčoOperačné stredisko záchrannej zdravotnej služby (Emergency Medical Service Operations Center) (SK)
  • Dr Licniu VenterAmbulanta Bihor (Bihor County Ambulance Service) (RO)
  • Siegfried Weinert MScNotruf NÖ (Notruf Lower-Austria) (AT)
  • Dr Zágori Szilvia – Emberi Erőforrások Minisztériuma (Ministry of Human Capacities of Hungary) (HU)

Study tour to Lower Austria (9-10 December 2019)

In order to gather experiences about the well-functioning Austrian-Czech practice and to demonstrate the advantages of service sharing to professional representatives, a two-day long study tour to Lower Austria was organised. Participants travelled by minibus to St. Pölten where they visited the coordination centre of Notruf 144 Niederösterreich, the University Hospital of St. Pölten, as well as the ambulance station and disaster management centre of the Red Cross and interviewed the local professionals. In addition, they met with the experts of NÖGUS, responsible for coordinating local and cross-border cooperation.

Participants:

  • Dr Bathó János – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • MUDr Jan Ciernik – Zdravotnická záchranná služba Jihomoravského kraje (Emergency medical service of the South Moravian Region) (CZ)
  • Dr Gencsi László – Ambulanta Bihor (Bihor County Ambulance Service) (RO)
  • Dr Golopencza Pál – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Alexander Heller – Landessicherheitszentrale Burgenland (Security Center of Burgenland) (AT)
  • Juraj HrehorcakOperačné stredisko záchrannej zdravotnej služby (Emergency Medical Service Operations Center) (SK)
  • Hüse-Nyerges Enikő – CESCI (HU)
  • Dr Jova Anett – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Dr Juca Dacian – SMURD (Emergency Situations Department) (RO)
  • Christian LeglerNotruf NÖ (Notruf Lower-Austria) (AT)
  • Dr Lórántfy Mária – Országos Mentőszolgálat (National Ambulance Service of Hungary) (HU)
  • Christine PhilippBurgenland Province (AT)
  • Siegfried Weinert, MSc – Notruf NÖ (Notruf Lower-Austria) (AT)
  • Dr Zágori Szilvia – Emberi Erőforrások Minisztériuma (Ministry of Human Capacities of Hungary) (HU)

Analysis and recommendation

A senior expert invited by CESCI thoroughly analysed the institutional and legal background of cross-border patient care then, reviewed and introduced the mechanisms of publicly financed patient care, which are theoretically appropriate for financing cross-border healthcare cooperation, as well as the reality of their application in light of the recent Gov. Decision No. 1798/2019. (XII. 23.).

Considering the related international, bilateral and national legistlative environment of healthcare and regional development, a proposal was made for an interstate agreement enhancing cross-border patient care; as well as for cross-border movements of ambulance, capitalizing also the experiences of seminar and the study tour.

Finally, a guide was made for the organisation of cross-border patient mobility based on the practical handbook of the Institute of International Sociology of Gorizia.

Main findings of the interviews and aptitude assessment

  • In spite of the fact that only one of the four hospitals (Esztergom) of the five explored border regions has formalized cooperation (at least partially) next to the cost of public funding, but all hospitals regularly provide care for persons insured abroad. Thus, there is a claim for cross-border healthcare, but Hungary does not exploit, consciously, the potential possibilities in it, because it has not established the favourable regulatory framework of this cooperation.
  • Regional/interregional cooperation for spatial development and professional (e.g. Zalaegerszeg-Muraszombat) cooperation has an incentive effect on cross-border healthcare provision in certain frontier areas. However, there is a lack of nationally determined development intention, namely forward-looking, systematic thinking and a regulatory environment capable of ensuring long-term cooperation.
  • From the institutional side, cross-border healthcare provision is typically motivated by the desire to increase institutional revenues and the intent to increase the capacity utilization. Simply, it is motivated by profit maximization. Although, cross-border healthcare cooperation is primarily motivated by the principles of humanity and solidarity.
  • It is an unusual approach (e.g. in the case of the institution in Szeged) in which contractual relationships, established with foreign business insurers outside of the social security, are not considered as cross-border healthcare cooperation for Hungarian healthcare.
  • There is a particular mixture within the institutional thinking regarding the institutional conditions for participating in cross-border cooperation. Szeged and Zalaegerszeg clearly approach the possibility of participating in such cooperation through logic of free institutional capacities; although, they consider it necessary that institutional care remains below the performance-volume threshold. However, this approach ignores the mandatory rules of the European patient care regime which is compulsory in Hungary, too.
  • The language barriers typically do not constitute a barrier to cross-border healthcare cooperation in the reflected institutions, the required language skills are adequately available everywhere.
  • A real claim has developed for cross-border ambulance services on the Hungarian-Slovakian border.

Main findings of the seminar

The seminar was opened by Dr. Gábor Csató, Director General of the National Ambulance Service of Hungary who highlighted the importance of cross-border cooperation. Then Gyula Ocskay, Secretary General of CESCI presented the Legal Accessibility initiative giving the framework of this project. After him, Enikő Hüse-Nyerges, project manager, and dr Tamás Balogh, expert of CESCI, introduced the past and recent activities and results of the sub-project on ambulance services. They spoke about the overall study and proposals on the Hungarian legal and administrative framework of cross-border EMS elaborated in 2017 and about the legislative proposal for cross-border movement of ambulances which is elaborated by now.

Following the introduction of the participants, Susanne Ottendorfer and Siegfried Weinert, representatives of the “Notruf NÖ”, presented the cooperation model between Lower Austria and the Czech Republic. They spoke about the history, the legal and administrative frames, and the practical details of the cooperation. The states, which have a cooperation agreement for mass disasters since 2000, signed a state treaty in 2016 in order to improve the availability of emergency healthcare in the border regions. The basic principle is that the patient should be transferred as fast as possible to the closest and adequate healthcare institution independently from their nationality, the EMS unit and the location of the hospital. Based on the state treaty, cooperation agreements were elaborated and signed which clarify the details of the cooperation including the language use, the communication and cooperation protocols or the transfer of drugs across the border.

Regarding the practical side of the cooperation, the speakers introduced the core element: a web application providing information exchange and communication between the coordinating centres. On the one hand, the application is able to localise each active EMS units around the place of deployment and makes it possible to ask for intervention from the other side of the border through only a couple of clicks. On the other hand, real-time communication is provided through the internal chat function. The application itself is quite simple, it was developed with a minimal budget and it is transferable within a reasonable time to other border regions.

At the end, the speakers pointed out the fact that the launch of the cross-border cooperation has resulted in an improved quality of life and cost efficiency in the border regions. They also drew the attention to the fact that it is enough to mutually approve each other’s national regulation: there is no need for legal derogation (simalrly as in case of the ECBM). At the end of the section, the participants had the opportunity to ask questions from the speakers, like questions about solving of practical problems, financing and institutional agreements.

After lunch break, the representatives of participating countries were able to share their opinions on the different aspects of potential cooperation during the interactive section in the afternoon:

  • There was an agreement among the participants concerning the actors to be involved in the cooperation, which are the competent ministries, dispatcher services and emergency services. Siegfried Weinert added that based on their experiences, sometimes less is more, which means that the less institution were involved in the agreement process, the faster a possible solution would be found.
  • Considering communication issues, only the question of data protection seems to be problematic. Each country has different solutions for the admission, management and storage of patient data. The possibilities of sharing these pieces of data across the border should be examined individually in light of the national and the EU GDPR regulations.
  • In case of financing, participants agreed that an extra budget would not possibly be needed to the implementation of cross-border tasks, because the compensation of cross-border case numbers and related costs are most likely to occur.

Besides, in case of Slovakia, it was emerged that they regularly make analysis about the optimisation of the number and location of ambulance stations, the next one of which could also be made by considering the capacities on the Hungarian side.

In the end of the seminar, in order to enhance cooperation Gyula Ocskay offered the help of CESCI in organising bilateral professional meetings and a study tour to Lower Austria with the aim that the participants may understand the Austrian-Czech good practice.

Main findings of the study tour

The first agenda item of the study tour was the visit of the coordination centre of the Notruf 144 Niederösterreich. The Chief Executive Officer of the organization, Christof Constantin Chwojka, greeted the delegation and gave his support for the cooperation in the future. After that, Siegfried Weinert and Christian Legler staff members for planning, preparing and managing the cross-border cooperation initiatives took the floor. They introduced the details of the structure and operation of the Notruf 144, including the coordination mechanisms concerning the EMS and further healthcare services, as well as, the background infrastructure together with the applied technical solutions. The participants had the opportunity to get an insight into the routine of the dispatchers; in addition, the participants could see the practice of cross-border cooperation through simulation of the on-line application for dispatchers in operation.

The application automates and formalises cross-border assistance with the help of a data sheet. The system offers three possibilities to determine the subject of assistance from the Czech point of view:

  • rescue operation in the Czecz Republic, request for the support from the Austrian EMS;
  • rescue operation in Austria, the Czech EMS takes over the operation;
  • rescue operation in Austria, which is handed over to the Austrian emergency operation centre.

After that, the dispatcher should choose the professional classification of the case from a list (respiratory arrest, allergy, etc.), however the groups of diseases/types of services are different on the two sides of the border. The parties decided to keep their own (national) classifications, and adding their groups to the jointly developed, more comprehensive categories instead of harmonisation. Introduction about this is provided to all the dispatchers. Apart from the dropdown menu, the dispatcher can add a more detailed description of the case. Beside that, the location of the case must be added on the data sheet.

After filling in all the required fields of the data sheet, a list of nearby Austrian and Czech rescue units appear with their types (ALS, BLS), and their distance from the case, both in kilometres and in times. The dispatcher chooses the most competent rescue unit(s) – according to his/her opinion – and sends the request for cooperation.

The application sends the request to the receiver in the filler’s language, which is translated with the help of Google Translate. The receiver can accept or deny the request with a click (one by one in a case of requesting more rescue units). If the request is accepted, the chat function opens which provides real-time communication between the dispatchers of both sides. The application automatically translates the text to the receiver’s language with the help of Google Translate.

On the Austrian side, these are the dispatchers and the supervisor who are allowed to ask for cross-border assistance if an adequate number of national rescue unit is not available on the Austrian side.

In the case of cross-border assistance, the rescue unit is always in contact with its own coordination centre via radio (the Austrian network reaches to Brno) or mobile phone. The dispatchers of the two sides continuously communicate with each other on chat. The rescue unit determines if the patient should be taken to hospital according to its inner protocol, while the two dispatchers choose the nearest suitable hospital together.

In case of cross-border action, each rescue unit works according to its national regulation (medical license, usage of distinguishing signs, etc.) and professional protocol, which is mutually respected by the parties. In practice, it means that a Czech doctor does not need a chamber membership and permission or the driver and the vehicle also do not need any extra permission to use the distinctive signs on the other side of the border.

The participants raised several technical questions, as a result of which the previously indistinct aspects were clarified.

The second day started in the University Clinic of St. Pölten, where Mag. Dr. Bernhard Kadlec commercial director shortly introduced the hospital, then he showed the emergency and supporting departments to the participants. The university hospital offers high quality care, especially in the field of cardiology and neurology. They accept 500 000 out-patient per year in 18 departments. In addition, they operate their own, digitally-based logistic centre which provides several hospitals in the region with equipment and medication on a daily basis.

In the remaining part of the morning, Elke Ledl, Head of the Lower-Austrian Healthacross Initiative aiming to enhance cross-border cooperation in the field of healthcare introduced their first INTERREG-V project implemented with the participation of Gmünd and České Velenice, which grounded the current widespread cooperation of the Lower-Austrian and the Czech provinces as a result of a 13-year long cooperation. Finally, she spoke about the initiatives launched together with Slovakia and Hungary. She highlighted that beside the political will to cooperate, the information of citizens are also crucial in order to eliminate the mental border which exists in their daily routine.

As last agenda items, the group visited the Red Cross EMS station in St. Pölten, then the disaster and logistic centre in Münchendorf, where Michael Sartori held a short briefing on their activity of the group, the relating infrastructure and tools. In Austria, 90% of the emergency medical services are provided by the Red Cross.

As an overall conclusion, it was conceived, that the Austrian healthcare institutional system is substantially more decentralised than the Hungarian one, in which the institutions have a significant freedom of decision within the well-based provincial framework. This might limit the applicability of the model in Hungary.

Based on the presented hospital and ambulance station, the applied healthcare devices and equipment, treatments and protocols are highly similar to the Hungarian ones. However, there are substantial differences in technologies applied in the case of supporting functions, and in the employee- and patient-friendliness, as well as cost- and time-effective organisation of services. In this regard, the Austrian system can certainly be considered as a good example.

The Austrian-Czech cooperation is exemplary, concerning both of its aims, as well the simplicity and transparency of its operation. Of course, there are questions to be clarified on bilateral level, but it can be said that it would worth adapting this model in Hungary and the neighbouring states.

Main findings of the analysis and proposals

Considering the available legal and institutional frames, the most favourable and most advantageous tool for cross-border healthcare cooperation in Hungary is the health card to be introduced based on bilateral cooperation agreements, according to the rules of the EU patient care regime which is limited to the geograpfic territory and service providers of the cooperation. Its functionality conforms to the functionality of the form E112 in every other respect.

The interest articulation and aims of the current Hungarian governmental health policy do not generally consider the advantages that may be come from cross-border healthcare cooperation, as a result of which the exploitation of these advantages are  realistically not expected.

Bodies responsible for the planning of healthcare system have not collected regular, automatically structured data on cross-border healthcare services since 14 years. Thus, it would be crucial to display the cross-border aspects in the data collection to ground the structure change imposed by Gov. Decision 1798/2019. (XII. 23.). The National Health Insurance of Hungary (NEAK) is already capable of producing some part of the necessary data. However, these set of data are currently not produced on a regular basis, but based on individual, ad hoc requests, which require significant amounts of extra work. It causes workload that can be reduced if these types of data processing become the default functions of NEAK’s database.

Cross-border healthcare cooperation lies in the competency of minimum two large sectors: regional development and healthcare (foreign affairs and transportation are also attached to this). Thus, any successful cooperation and action can only be established with the close cooperation of at least these two sectors. In light of this, interstate agreements should be made according to the following legislations:

  • XXI/1996 on regional development and area management,
  • LXXV/2014 on European Territorial Cooperation,
  • CLIV/1997 on healthcare,
  • and No. LXXXIII/1997 on compulsory health insurance services.

Valid Hungarian healthcare acts are familiar with the term of cross-border healthcare service but these attach a meaning to it which is irrelevant in respect of regional (real cross-border) cooperation. Even with this, we don’t find it necessary to modify the concept of cross-border healthcare services according to paragraph 5/B. of legislation No. LXXXIII/1997. Instead, the introduction of the concept of “service offered in the framework of cross-border healthcare cooperation” with an adequate content would be an appropriate solution.

Goals of cooperation of the involved parties, within the frames of healthcare, as well as rescue/ambulance segment of cross-border cooperation can be effectively achieved if the framework of their harmonised action is as little spontaneous as possible. In this field, significant achievements can be reached by long-term commitments. Within the field of cross-border cooperation, typical instruments for this are the framework agreements and the administrative/implementing agreements – with framework filling character – concluded on the basis thereof, as well as (in the case of legal relationships which are not covered by social security schemes) service contracts between healthcare institutions and their patients. Within the frame of the project, the following suggestions were prepared in this regard:

  • a framework convention sample for bilateral agreements on cross-border healthcare cooperation;
  • a framework convention sample on intergovernmental regulation of cross-border rescue that was elaborated by utilising the Austrian-Czech treaty, the experiences of the related study tour and the comprehensive study prepared within the framework of this initiative in 2017;
  • an agreement sample on the implementation of cross-border healthcare cooperation framework convention;
  • a model form of a contract to provide services in order to regulate the relationship between healthcare providers and their non-insured (cost of the care is self-funded) clients.

In order to create cooperation between cross-border healthcare services and healthcare providers practical questions should be clarified:

  • which partners (who?),
  • in which areas, in regard of which actions/services (what?),
  • in which geographical area (where?),

want to create/develop cooperation, furthermore:

  • from what community resources [EU] they want to launch cooperation,
  • and from what resources [own or national] they want to provide the operation (from what resource?).

This requires the consideration of the following circumstances in any cases:

  1. Organisers and participants of future cooperation should know each other’s relations accurately. The large number of partners, the same or similar interests without the proper harmonisation, would rather counteract than strengthen each other. Considering this, in favour of successful cooperation, the mapping of all cross-border structures and local actors is fundamental during the preparation of cooperation. Participants should also answer the question that how their aims suit the system of objectives of the cooperation intended to be established between healthcare service providers and how to integrate them into the new cooperation – if possible.
  2. In light of paragraph 27 (9) of legislation LXXXIII/1997 on compulsory health insurance services the National Healthcare Services Center (ÁEEK) and The National Health Insurance of Hungary (NEAK) should be involved in the preparation of agreements that establish cooperation between cross-border healthcare service providers even whether targeting publicly or privately funded patient care.
  3. The interoperability of borders is the basic condition of efficiency and sustainability of cross-border cooperation. In light of this, it is important to recognise that the development of cooperation between cross-border healthcare service providers requires close consultation not only among future cooperating partners, but also among those, who are responsible for other sectoral development (e.g. transportation).
  4. In favour of smooth cooperation, contacting with governmental partners and planners of the neighbouring states in cross-border healthcare cooperation is nearly as important as the other factors mentioned above.
Title of the indicator

Required

Fulfillment

International professional seminar

1

1
EU member states participating at the seminar

6

5*
Aptitude assessment

4

4
Draft proposal for interstate agreement

1

1
Legislative proposal for cross-border movement of ambulances

1

1
PILOT-agreement of regional patient care

4

1**
Guide for organising cross-border patient mobility

1

1

* The Slovenian participants were unable to attend the seminar due to time conflict.

** On the basis of the results of the aptitude test, one contract template sample, possible to use widely, was developed instead of 4 institution-specific contracts.

In this case, the scope of healthcare cooperation can be divided into two major areas.

In case of ambulance services, it would be necessary to continue the discussions, launched within the frame of the project, at bi- and/or multilateral level. As a result of the previous events, the next professional meeting, which is expected to take place in February of 2020, is being organized by the Healthcare State Secretary of the Ministry of Human Capacities, the Ministry of Foreign Affairs and Trade, and by the National Ambulance Service (NAS) with the competent authorities of two neighbouring countries, Austria and Slovakia. The meeting will focus on a potential state treaty based on the Austrian-Czech best practice, which is under revision by the legal staff of the National Ambulance Service. To the invitation of the Ministry of Human Capacities and the NAS, CESCI takes part in the further work as facilitatator of the discussions.

However, it would also worth countinuing to maintain and to strengthen the relationships with the other neighbouring EU member states. This could be implemented by bilateral meetings and/or multilateral consultations, similar to previous ones (e.g. seminar).

Regarding patient mobility across the Hungarian borders, cooperation is currently less advanced, because of the complexity of the topic and the structural problems of the sector in Hungary.

However, within the framework of the project, preparation of the cooperation on a professional level was carried out, which might be continued by reviewing the cross-border aspects of the policy area, as well as launching consultations with the neighbouring countries by the competent actors, mainly on national level. With the appropriate intentions, a suitable framework could be provided by the upcoming transformation process to be implemented according to the Government Decree 1798/2019. (XII. 23.).

Last, but not least, it is important to maintain and to strengthen both topics in the cross-border cooperation discourse also at the level of the European Union. Among others, the DG REGIO initiatives or platforms, such as the EUREGHA forum, bringing together local and regional stakeholders of the cross-border healthcare cooperation, offer possibilities for it.