Chiropractor Dr. Scott Zack explores the continuing move toward multidisciplinary medicine within U.S. health care.
With a nationwide shift toward multidisciplinary medicine underway and following a number of recent changes within health care in the United States, opportunities, primary care provider Dr. Scott Zack suggests, are abound for the country’s tens of thousands of qualified chiropractors.
According to the respected primary care physician, who’s based in the Detroit metropolitan area of Michigan, more and more chiropractors are embracing multidisciplinary medicine. “Now is the perfect time,” he explains, “for chiropractors to be working with other medical disciplines to promote chiropractic medicine’s patient-centered, holistic approach to health care.”
The health care landscape in the U.S. is changing, and demand for more affordable, more efficient, more effective, and higher quality patient care is increasing rapidly, according to Dr. Scott Zack. “Chiropractors have long been at the forefront of innovation within health care,” says the expert.
Chiropractors are, he believes, ideally positioned to address rocketing health care costs, and to help to tackle America’s ever-growing opioid crisis. “Prescribing practices must be improved,” suggests Michigan-based Dr. Zack, “with a view to helping to prevent addiction to opioid medications.”
In 2017, over 17,000 people in the U.S. died from prescription opioid overdoses, according to the Centers for Disease Control and Prevention. “Taking into account all opioid-related deaths during the same year, the number rises to more than 45,000,” reveals chiropractor Scott Zack.
Research indicates, he points out, that the overwhelming majority of illicit opioid users first misused prescription variants of the same drugs, provided by their doctor. “Early integration of appropriate and effective multidisciplinary medicine, such as chiropractic care, could, therefore,” says Dr. Zack, “have potentially saved many tens of thousands of lives in recent years alone.”
Elsewhere, Dr. Zack believes that more widespread adoption of chiropractic care can also help to ease the burden of skyrocketing costs tied to routine health care in the United States. “Our health care system is the most expensive in the world and this continues to place an enormous burden on society,” suggests the chiropractor, a specialist in musculoskeletal disorders and based in the Oakland County charter township of West Bloomfield, Michigan.
Musculoskeletal conditions are, he says, often poorly managed within mainstream medicine. “Only around 10 percent of people with suspected musculoskeletal disorders seek out more cost-effective chiropractic care,” explains Dr. Zack, “leaving the remaining 90 percent to rely on often vastly expensive traditional care for their pain management.”
Dr. Scott Zack says that a nationwide move toward multidisciplinary medicine is already underway and that chiropractic care is, and should remain, central to this revolution within health care in the United States.
“It’s with this firmly in mind that I believe,” he adds, wrapping up, “that chiropractic medicine is central to helping to make health care in America not only more effective, but considerably more affordable, too.”
Dr. Scott Zack, from Michigan, provides straightforward answers to a variety of commonly asked questions surrounding chiropractic care.
From insurance cover to how many treatments are needed, Michigan-based primary care physician and chiropractor Dr. Scott Zack addresses a number of the most commonly proposed questions centered around the field of chiropractic medicine.
“I’m most commonly asked about the list of ailments which chiropractors can effectively treat,” reveals Dr. Zack, a seasoned primary care physician and chiropractor from the Detroit metropolitan area of Michigan.
Asked what conditions chiropractors typically treat, Dr. Zack explains how a chiropractor may address anything from back pain to joint injuries. “Chiropractors care for patients with a variety of health conditions,” reveals the physician. Those in the field, however, are, he says, best known for dealing with back and neck pain. Muscular, ligament, and joint injuries or disorders may also be addressed, according to the expert.
Dr. Scott Zack is, he says, also often asked how many chiropractic sessions are typically required. “This always depends on the patient,” explains the chiropractor, “and, in particular, his or her individual condition or conditions.”
“Rest assured, however,” adds Dr. Zack, “as chiropractors, we’ll always do everything in our power to help patients to feel better as quickly as possible, and with as few treatments as necessary.”
Another common question asked of chiropractors is what type of training or education they have, according to Dr. Zack, who’s based in the Oakland County charter township of West Bloomfield, Michigan. “Doctors of chiropractic, as we’re known, are educated as primary health care providers,” he explains, “with an emphasis on the diagnosis and treatment of conditions related to the body’s muscles, ligaments, joints, and nerves.”
Educational requirements for chiropractors are, Dr. Scott Zack reveals, among the most stringent of any profession within the medical field. Four years of undergraduate college education followed by four or five further years of highly demanding academic study is the norm, according to the expert.
“Chiropractors are routinely educated in human anatomy, neurology, physiology, orthopedics, diagnostic imaging, laboratory procedures, nutrition, and more,” he adds.
Dr. Zack’s final commonly asked question surrounds insurance. “Often I’m asked, ‘Will my insurance cover chiropractic care?'” he reveals.
The answer, Dr. Zack says, is yes. Chiropractic care is included, he underscores, in almost all health insurance plans, including Medicare, Blue Cross Blue Shield plans, and certain Medicaid offerings.
“If you’re interested in receiving chiropractic care, check out your insurance company’s website,” adds Dr. Scott Zack, wrapping up, “and look for a searchable database of practitioners within their network who are covered by your policy.”
Physician Dr. Scott Zack, from Oakland County, Michigan, provides a professional insight into what to expect during a visit to a qualified chiropractor.
According to the National Center for Biotechnology Information, chiropractic treatment is now one of the most popular forms of integrative health care in the United States. With more than 33 million American adults visiting a chiropractor within the last year, Dr. Scott Zack provides a closer look at what to expect for those yet to experience chiropractic care.
With treatment largely focused on the relationship between the spine and how the rest of the body functions, chiropractic care centers primarily around spinal manipulation intended to address conditions affecting the body’s joints, muscles, and nerves. “Many chiropractors also routinely employ a wide variety of treatments outside of spinal manipulation, from therapeutic ultrasound and thermal therapies to corrective exercise and low-level laser therapy,” explains Dr. Scott Zack, a renowned chiropractor from Michigan.
Thermal therapies, he says, can range from the application of heat or ice to diathermy and paraffin baths. Further to the above, additional treatments may include stretching or strengthening techniques, electrotherapies, soft tissue friction, neural mobilization, general exercise, taping, bracing, and relaxation and rehabilitation procedures, according to Dr. Zack. “Some chiropractors may also suggest counseling for issued tied to, for example, diet, weight loss, and smoking cessation, as well as other lifestyle factors,” adds the expert.
During a patient’s first appointment, Dr. Zack explains that, following a discussion surrounding symptoms and health history, an individualized treatment plan will be outlined. Diagnostic studies, he says, such as X-ray, may also be called for.
As more and more evidence supporting the benefits and efficacy of chiropractic treatment continues to be published, demand for chiropractic care increases each year in the United States.
“With research time and time again showing demonstrable, objective, and clinically significant improvements in mobility and the elimination or reduction of pain, chiropractic medicine is proven to be as effective as, or more effective than, non-steroidal anti-inflammatory medications,” reveals Dr. Zack. It is, he says, the ideal non-drug solution to conditions ranging from neck and back pain to inner-ear issues and carpal tunnel syndrome.
Indeed, the American College of Physicians recently released updated guidelines for the treatment of acute, subacute, and chronic pain, chiefly centered around the back and neck, recommending that patients first explore non-pharmacologic therapies such as chiropractic care before turning to medication or opting for surgery.
“If you’re interested in receiving chiropractic care, check out your insurance company’s website,” suggests Dr. Scott Zack, wrapping up, “and look for a searchable database of practitioners within their network who are covered by your policy.”
Michigan-based chiropractor Dr. Scott Zack offers a detailed look at new bill seeking to provide full Medicare coverage for services provided by America’s 70,000 chiropractors.
Seeking an amendment to the title of the Social Security Act to provide Medicare coverage for physician services furnished by doctors of chiropractic within the scope of their licenses, the Chiropractic Medicare Coverage Modernization Act of 2019 continues to represent a significant move forward for chiropractic care in the United States. Having previously outlined the new bill set to revolutionize Medicare coverage, Detroit metropolitan area chiropractor Dr. Scott Zack further explores the so-called modernization act.
“The newly introduced congressional bill, it’s hoped, will revolutionize Medicare coverage of chiropractic services across the United States,” suggests Dr. Zack, an established chiropractor and primary care provider based in the Oakland County charter township of West Bloomfield, situated within the Detroit metropolitan area of Michigan.
“The latest development,” he continues, “has seen the act referred to the Committee on Ways and Means, in addition to the Committee on Energy and Commerce, for a yet-to-be-determined period.”
This is because, he says, consideration of such provisions, in each case, falls within the jurisdiction of the individual committee concerned. “The bill seeks to amend title XVIII of the Social Security Act to provide Medicare coverage for all physicians’ services furnished by doctors of chiropractic within the scope of their license, and for other purposes,” adds Dr. Zack.
In 1972, coverage was established under the Medicare program for beneficiaries to receive chiropractic care. “Unfortunately,” says Dr. Scott Zack, “the now-antiquated statute restricts beneficiaries to just one service, meaning that Medicare chiropractic coverage has failed to keep up with private-sector coverage and other federal health delivery systems.”
Now, however, due to positive evidence-based outcomes and the proven cost-effectiveness of chiropractic care, Medicare coverage should, says the Michigan-based chiropractor, be brought more in line with that provided via the Department of Veterans Affairs, Department of Defense, and the Federal Employee Health Benefits Program, as well as through private health insurance coverage.
“The purpose of the modernization act is to expand recognition and coverage of chiropractic care under the Medicare program,” further explains Dr. Scott Zack, “in connection with the performance of any authorized function or action.”
Currently, only the provision of ‘manual manipulation of the spine to correct a subluxation’ is covered by Medicare, according to Dr. Scott Zack. “No other physician-level Medicare providers have ever been restricted in this way,” he adds, wrapping up, “so it’s vital that the Chiropractic Medicare Coverage Modernization Act of 2019 be passed in order to address the antiquated statute currently in place on behalf of qualified chiropractors across the United States.”
Chiropractor Dr. Scott Zack delves into new report surrounding access to chiropractic care and the cost of spine conditions among older adults in the United States.
As the American Journal of Managed Care finds that chiropractic care may reduce medical spending on diagnostic services among older adults with a spine condition, chiropractor Dr. Scott Zack examines the all-new report, released by the peer-reviewed medical journal earlier this month.
“The American Journal of Managed Care’s objective,” explains Dr. Zack, “was, chiefly, to examine the extent to which the accessibility of chiropractic care affects spending on medical spine care among Medicare beneficiaries.”
An established chiropractor and primary care provider, Dr. Scott Zack is based in the Oakland County charter township of West Bloomfield, situated within the Detroit metropolitan area of Michigan.
“Almost 80 percent of people will suffer a bout of severe spinal or other back pain at some point in their life,” explains Dr. Zack, “which is why it’s so important that we continue to champion the benefits of chiropractic care in treating such conditions.”
In what’s known as a retrospective cohort study, the American Journal of Managed Care used beneficiary relocation as the basis for its report, according to Dr. Zack. “AJMC used a combination of patient data and associated Medicare claims to perform a quasi-experimental study designed to examine the effect of accessibility to chiropractic care on healthcare spending,” reveals the expert.
The American Journal of Managed Care used the data to estimate the effect of higher or lower chiropractic accessibility upon spine-related medical spending. “With around 45,000 chiropractors in the United States, local accessibility varies considerably,” Dr. Scott Zack explains.
“The AJMC concluded, however,” he continues, “that, among older adults, in particular, access to chiropractic care was indeed shown to reduce medical spending on services tied to problematic spinal conditions.”
First published in 1995, the American Journal of Managed Care is a monthly peer-reviewed medical journal produced by Managed Care & Healthcare Communications. “AJMC provides a forum for peer-reviewed literature surrounding healthcare research and its outcomes,” explains Michigan-based chiropractor Dr. Scott Zack.
Marketed as an independent publication dedicated to disseminating clinical information to managed care physicians and other healthcare professionals, it aims to stimulate scientific communication in the field of managed care, according to the journal’s publisher. “AJMC helpfully addresses a broad range of issues relevant to clinical decision making and examines the impact of management, clinical, and policy interventions and programs,” adds Dr. Scott Zack, wrapping up, “much to the benefit of the wider healthcare profession.”
Chiropractor Scott Zack takes a closer look at a recent American Medical Association open access study into chiropractic care and its effect on low back pain.
Demonstrated to combat pain and disability, and to improve function, a recent JAMA Network Open study has also revealed chiropractic care to reduce patients’ need for pain medication, while also reporting a significantly higher level of satisfaction than those who receive so-called usual care. An established chiropractor from West Bloomfield, located within the Detroit metropolitan area of Michigan, Dr. Scott Zack takes a closer look at the study, published in the American Medical Association’s monthly open-access medical journal.
The study in question was first published in JAMA Network Open. JAMA Network Open is a monthly open-access medical journal published by the American Medical Association. The American Medical Association, first founded in 1847 and later incorporated in 1897, is the largest association of physicians in the United States.
“A study completed last year by the American Medical Association’s JAMA Network Open remains among the most recent and important studies into chiropractic care and its effect, in particular, on low back pain,” explains Dr. Scott Zack.
JAMA Network Open’s researchers gathered 750 active-duty military personnel for the study, each of whom had complained of recent back pain. “Half were assigned to receive medication and physical therapy,” Michigan-based Scott Zack explains, “or what the medical profession would call ‘usual care.'”
So-called usual care, he says, also typically includes what’s known as self-care. “‘Self-care’ is any instructed activity carried out by a patient in order to take care, in this instance, of their physical health,” Dr. Zack reveals.
The other half of those assigned to the study were provided with up to 12 chiropractic treatments. “After only six weeks of treatment, those who were assigned to receive chiropractic care reported less pain, less disability, and improved function,” reveals Scott Zack, “according to the JAMA Network Open study.”
Those who had received chiropractic care further expressed a much-reduced need for pain medication. “They also reported a significantly higher level of satisfaction with their care,” adds Dr. Scott Zack. With low back pain costing up to $200 billion each year in the U.S. in-for example-care costs and missed work, it’s also a leading cause of disability around the world, according to the chiropractor.
“Especially in light of the current opioid crisis,” says Scott Zack, “we desperately need effective, safe, and non-drug alternatives to treat pain across the board, and, in particular, low back pain.”
The American Medical Association and JAMA Network Open study, he says, suggests that chiropractic care is the obvious choice.
Harvard Medical School’s Harvard Health Publishing also recently weighed in on the JAMA Network Open study. The study, they say, lends support for chiropractic care to treat low back pain. Harvard Health Publishing also highlighted that while chiropractic treatments aren’t free, it’s fortunate that insurance coverage for chiropractic care is now becoming increasingly more common in the United States.
“I look forward to further studies,” Dr. Scott Zack adds, wrapping up, “including studies featuring those with long-term or long-lasting back pain, older patients, and a mix of pain types, such as pain caused by a pinched nerve, muscle spasms, and so on.”
Detroit metropolitan area Chiropractor Dr. Scott Zack provides a closer look at the newly introduced congressional bill set to revolutionize coverage of chiropractic services.
Introduced as the Chiropractic Medicare Coverage Modernization Act of 2019, a new congressional bill is set to revolutionize Medicare coverage of chiropractic services in the United States. That’s according to Michigan-based chiropractor Dr. Scott Zack as he provides a closer look at the all-new bill.
“The Chiropractic Medicare Coverage Modernization Act of 2019 will put Medicare’s coverage of chiropractic services in line with that of many other healthcare providers and private health plans,” explains Dr. Zack.
The bill, introduced recently by the U.S. House of Representatives, will see Medicare updated to increase coverage of chiropractic services offered by qualified professionals, such as Dr. Scott Zack. The bipartisan Chiropractic Medicare Coverage Modernization Act of 2019, known legislatively as H.R. 3654, was introduced on Tuesday, July 9.
As a result, Medicare beneficiaries will now be more easily able to access the chiropractic profession’s non-drug approach to the management of back, neck, and other musculoskeletal pain, according to Dr. Zack. “Evaluation services, management services, diagnostic imaging, and more will also be covered,” he explains.
The bill, primary care physician and chiropractor Dr. Scott Zack believes, will play an important part in national efforts to combat the prescription opioid abuse and overuse epidemic which is currently gripping the United States. “The broader the spread of non-drug approaches to pain management which we can take in America today, the better,” adds the expert.
The bill was widely encouraged by the American Chiropractic Association which has since highlighted how the new legislation will now allow Medicare beneficiaries access to the same chiropractic services already afforded to members of the U.S. military, veterans, and federal employees. The American Chiropractic Association is the largest professional chiropractic organization in the United States. The association regularly lobbies for pro-chiropractic legislation and policies, and supports meaningful research routinely used to inform America’s more than 70,000 licensed chiropractors.
The association’s president, Robert C. Jones, applauded news of the bill and praised the U.S. House of Representatives for recognizing what he called the necessity of modernizing Medicare’s coverage to meet the chiropractic needs of beneficiaries. “Medicare currently serves more than 55 million people,” adds Dr. Zack of the program.
Since the 1970s, Medicare beneficiaries have been forced to pay out of pocket for all chiropractic services with the sole exception of manual manipulation of the spine. “Chiropractors, however,” explains Dr. Scott Zack, “offer many further, highly effective, safe, and non-drug-based therapies tailored toward pain management of conditions of the back, neck, wider musculoskeletal system, and extremities.”
Furthermore, he goes on to reveal, no other physician-level Medicare providers have ever been restricted in this way. “It’s wonderful, then,” adds Dr. Scott Zack,wrapping up, “to see the Chiropractic Medicare Coverage Modernization Act of 2019 finally addressing this on behalf of chiropractors across America.”
Chiropractor and primary care physician Dr. Scott Zack looks toward this year’s National Chiropractic Month.
Supporting Medicare equality, educating the public, and prompting those in need of help to make an appointment with a chiropractor, National Chiropractic Month is set to kick off on Tuesday, October 1. A chiropractor and primary care physician from West Bloomfield, located within the Detroit metropolitan area of Michigan, Dr. Scott Zack reveals more about the annual awareness initiative.
“Almost 80 percent of Americans will suffer a bout of severe back or neck pain at some point in their life,” explains Dr. Zack, “which is why it’s so important that we champion the incredible benefits of chiropractic care in treating pain in these areas of the body in particular.”
The world’s first chiropractic adjustment was performed in 1895 by D.D. Palmer, who, at the time, was a leading proponent of alternative medicine. Two years later, he established the Palmer School of Care in Davenport, Iowa, today is known as Palmer College of Chiropractic.
A decade and a half on, in 1913, chiropractic care received official recognition in the United States. “Over the next 25 years, 39 states officially recognized chiropractic care as a legitimate option within the healthcare field,” adds Dr. Scott Zack.
National Chiropractic Month is held each year to educate the public surrounding the many benefits of chiropractic care.
With opioid painkillers still routinely prescribed as a quick fix for severe back and neck pain, it’s important, says Dr. Scott Zack, that the public is aware of how excessive use of such drugs, for example, can be detrimental to their health. “National Chiropractic Month emphasizes,” he suggests, “an alternative method of treatment, in chiropractic care, which we now know to yield much better, safer, and healthier results.”
The initiative is also intended to support Medicare equality, according to Dr. Scott Zack. “The American Chiropractic Association advocates federal legislation,” he explains, “which would afford patients with the option to receive Medicare reimbursements for chiropractic care.”
National Chiropractic Month is further held to prompt those who may benefit from receiving chiropractic care to make an appointment with a practitioner, such as primary care physician Dr. Scott Zack. “In addition to treating severe neck and back pain, chiropractic care can also help to prevent against future injuries and treat other chronic musculoskeletal conditions,” he reveals, “so, why not use this year’s upcoming National Chiropractic Month as the perfect opportunity to make an appointment with a qualified local chiropractor?”
According to the initiative’s organizers, National Chiropractic Month is also important as it benefits the U.S. economy. “Back and neck pain episodes in America result in as much as a $100 billion drain on the economy every year currently, mostly due to costs associated with reduced productivity and lost wages,” Dr. Scott Zackexplains.
“National Chiropractic Month is intended, therefore,” he adds, wrapping up, “to help people get right back on their feet, as quickly as is healthy, both for their own benefit and for the benefit of our nation’s economy.”
National Chiropractic Month 2019 kicks off on Tuesday, October 1.
With millions of Americans now reliant on opioids prescribed by doctors, Dr. Scott Zack reveals how alternative therapies may be key to fighting the nation’s growing opioid crisis.
In 2017, more than 47,000 Americans died following opioid overdoses, including both prescription and non-prescription, illicit drugs, according to the National Center for Health Statistics. During the same year, it was also estimated that approximately 1.7 million people in the United States struggled with addiction to prescription-only opioid pain relievers, as reported by the Center for Behavioral Health Statistics and Quality.
“1.7 million people, suffering from substance use disorders tied to prescription opioid painkillers, reflects a number which is more than 2.5 times greater than the estimated 650,000 who struggled with the illicit drug heroin during the same period,” reveals Dr. Scott Zack, an established Michigan-based primary care provider, and chiropractor. This, he says, only serves to further highlight the current and growing problem surrounding prescription opioid abuse and misuse in the United States.
The so-called economic burden of opioid abuse, according to the Centers for Disease Control and Prevention, is believed to be in the region of $78.5 billion per year. “This includes the costs of lost productivity, addiction treatment, healthcare, and criminal justice involvement,” explains Dr. Zack.
What’s now essential, then, according to the chiropractor and primary care provider, is that instead of immediately looking to opioid medications as a solution for pain management, doctors instead must also look toward forms of alternative therapies, such as chiropractic care. “Ultimately,” Dr. Zack suggests, “opioids simply mask pain, while therapy, such as chiropractic care, heals it instead.”
Opioids, he says, are a quick fix, and no evidence exists to suggest that opioid medications are capable of helping to improve function in patients who rely on them. “This is where chiropractic medicine differs,” adds the expert.
Dr. Scott Zack continues, “Instead of a pill which is effective for a few hours, chiropractic care allows a patient to feel good in the long term, without reliance on dangerous medications, and proven to afford improved function in patients with often longstanding, highly painful health complaints.”
Studies have shown that, of various alternative therapies, chiropractic medicine in particular can, by simultaneously increasing range of motion and bolstering pain thresholds neurologically, help patients to achieve a level of ongoing, natural relief from pain, entirely without the need for prescription medication or other drugs.
“Alternative therapies, I believe,” adds Dr. Zack, wrapping up, “should represent the first port of call in many instances when dealing with new pain complaints, and pose a viable alternative for patients already reliant on opioids and similar medications.”
Chiropractor Dr. Scott Zack considers the latest market research analysis and explains more surrounding the rapid growth currently occurring in the industry.
Last year, prominent market research and consulting firm from San Francisco, California, estimated that, by 2025, the chiropractic care market in the United States could be worth close to $18 billion annually. An established Michigan-based primary care provider and chiropractor, Dr. Scott Zack reflects on the findings.
“Supported by figures from the American Chiropractic Association, recently published estimates suggest that the U.S. chiropractic care market will reach an annual value of more than $17.9 billion by 2025,” reveals Dr. Zack.
A report conducted in 2018 by market research and consulting firm Grand View Research, Inc. puts the actual value at $17.93 billion, reflecting a compound annual growth rate equivalent to 4.32%, and up by more than $5.5 billion from $12.26 billion in 2017.
Based in San Francisco, California, business consulting firm Grand View Research offers action-ready market research reports and custom market analysis, according to the organization’s website.
“The growth we’re already seeing is largely thanks to increasing adoption among patients of non-invasive solutions for the management of chronic pain,” Dr. Zack suggests, “as well as ever-increasing awareness surrounding the growing problem of prescription drug addiction and abuse.”
These, he says, are two of the primary factors responsible for recently forecast rapid growth, and growth which is already happening, in the chiropractic care market, both in the United States and overseas.
“We’re already seeing significant growth, much in line with what’s predicted between now and 2025,” points out Dr. Zack, an experienced and well-respected chiropractor currently based in Bloomfield Hills, Michigan.
What’s more, according to the expert, the introduction of new laws surrounding chiropractic care is further supporting growth in the industry, encouraging more people to the field both as patients and as qualified practitioners.
According to Grand View Research’s report, meanwhile, during 2017-2018, an impressive 95 percent of individuals who sought past-year chiropractic care cited their treatment as an effective form of therapy for their back, neck, and other musculoskeletal pain.
“The results,” adds Dr. Zack, wrapping up, “speak for themselves.”
Dr. Scott Zack is an experienced chiropractor and primary care provider based in the Oakland County charter township of West Bloomfield, located within the Detroit metropolitan area of Michigan. Concerned with the diagnosis and treatment of mechanical disorders of the musculoskeletal system, chiropractors such as Dr. Zack and his colleagues focus on alternative therapy centered chiefly around the spine. Chiropractic manipulation is today widely utilized in the treatment of lower back and sciatic nerve pain, headaches, extremity conditions, whiplash, and other neck pain, among numerous other increasingly common health complaints.