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UK HealthCare Hospital SystemUNIVERSITY OF KENTUCKY 2021 FINANCIAL STATEMENTS
UK HealthCare Hospital SystemAn Organizational Unit of the University of KentuckyFinancial StatementsYears Ended June 30, 2021 and 2020CONTENTSPAGEIndependent Auditor's Report1Management's Discussion and Analysis3Financial StatementsStatements of Net Position14Statements of Revenues, Expenses and Changes in Net Position15Statements of Cash Flows16Notes to Financial Statements17
Independent Auditor’s ReportBoard of TrusteesUK HealthCare Hospital SystemUniversity of KentuckyLexington, KentuckyWe have audited the accompanying financial statements of the UK HealthCare Hospital System(System), an organizational unit of the University of Kentucky (University), as of and for the yearsended June 30, 2021 and 2020, and the related notes to the financial statements, which collectivelycomprise the System’s basic financial statements as listed in the table of contents.Management’s Responsibility for the Financial StatementsManagement is responsible for the preparation and fair presentation of these financial statements inaccordance with accounting principles generally accepted in the United States of America; thisincludes the design, implementation and maintenance of internal control relevant to the preparationand fair presentation of financial statements that are free from material misstatement, whether due tofraud or error.Auditor’s ResponsibilityOur responsibility is to express an opinion on these financial statements based on our audits. Weconducted our audits in accordance with auditing standards generally accepted in the United States ofAmerica. Those standards require that we plan and perform the audit to obtain reasonable assuranceabout whether the financial statements are free from material misstatement.An audit involves performing procedures to obtain audit evidence about the amounts and disclosuresin the financial statements. The procedures selected depend on the auditor’s judgment, including theassessment of the risks of material misstatement of the financial statements, whether due to fraud orerror. In making those risk assessments, the auditor considers internal control relevant to the entity’spreparation and fair presentation of the financial statements in order to design audit procedures thatare appropriate in the circumstances, but not for the purpose of expressing an opinion on theeffectiveness of the entity’s internal control. Accordingly, we express no such opinion. An audit alsoincludes evaluating the appropriateness of accounting policies used and the reasonableness ofsignificant accounting estimates made by management, as well as evaluating the overall presentationof the financial statements.We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basisfor our audit opinion.1
Board of TrusteesUK HealthCare Hospital SystemUniversity of KentuckyPage 2OpinionIn our opinion, the financial statements referred to above present fairly, in all material respects, thefinancial position of the System as of June 30, 2021 and 2020, and the changes in its financialposition and its cash flows for the years then ended in accordance with accounting principlesgenerally accepted in the United States of America.Emphasis of MatterAs discussed in Note 1, the financial statements of the System are intended to present the financialposition, changes in financial position and cash flows of only that portion of the business-typeactivities that is attributable to the transactions of the System. They do not purport, and do not,present fairly the financial position of the University as of June 30, 2021 and 2020, the changes in itsfinancial position or its cash flows for the years then ended, in conformity with accounting principlesgenerally accepted in the United States of America. Our opinion is not modified with respect to thismatter.Other MattersRequired Supplementary InformationAccounting principles generally accepted in the United States of America require that themanagement’s discussion and analysis as listed in the table of contents be presented to supplement thebasic financial statements. Such information, although not a part of the basic financial statements, isrequired by the Governmental Accounting Standards Board, who considers it to be an essential part offinancial reporting for placing the basic financial statements in an appropriate operational, economicor historical context.We have applied certain limited procedures to the required supplementary information in accordancewith auditing standards generally accepted in the United States of America, which consisted ofinquiries of management about the methods of preparing the information and comparing theinformation for consistency with management’s responses to our inquiries, the basic financialstatements and other knowledge we obtained during our audit of the basic financial statements. Wedo not express an opinion or provide any assurance on the information because the limited proceduresdo not provide us with sufficient evidence to express an opinion or provide any assurance.Louisville, KentuckyOctober 8, 20212
UK HEALTHCARE HOSPITAL SYSTEMAN ORGANIZATIONAL UNIT OF THE UNIVERSITY OF KENTUCKYMANAGEMENT’S DISCUSSION AND ANALYSISYEARS ENDED JUNE 30, 2021 AND 2020The following Management’s Discussion and Analysis (MD&A) provides an overview of the financial positionand activities of the UK HealthCare Hospital System for the years ended June 30, 2021 and 2020. UKHealthCare Hospital System includes Albert B. Chandler University Hospital, including Kentucky Children’sHospital (collectively Chandler); UK HealthCare Good Samaritan Hospital (Good Samaritan); KentuckyHealthcare Enterprise, Inc. (KHE), a wholly owned for-profit subsidiary; Surgery Blue LLC, a wholly owned forprofit subsidiary, its for-profit subsidiary, Surgery Center of Lexington, LLC (51% ownership); and Beyond BlueCorporation, a wholly owned non-profit subsidiary (collectively, the System or UK Healthcare). Managementhas prepared this discussion, and we encourage you to read it in conjunction with the financial statementsand the notes appearing in this report.About UK HealthCare SystemUK HealthCare, the University’s advanced academic medical center and clinical care network, is uniquelyequipped to provide advanced subspecialty care to the people of Kentucky. The academic medical center andhealth system provides patient care on par – in terms of both volume and complexity – with the nation’s top 25percent of academic medical centers. In July 2021, UK HealthCare was listed number one in Kentucky in thelatest U.S. News and World Reports Best Hospitals ranking for the sixth year in a row. To be recognized as aBest Hospital, UK HealthCare had to rank high nationally on a stringent data-driven ratings system thatgauges performance. The analysis includes multiple clinical specialties, procedures and conditions. Scoresare based on a variety of patient outcome and care-related factors such as mortality and patient safety, aswell as reputation.The System operates two hospital units under one Joint Commission Accreditation and two licenses inaddition to ambulatory services. The major service units include Albert B. Chandler Hospital, Good SamaritanHospital and the Kentucky Clinic. The System has a combined total of 965 licensed beds with an averagedaily census of 787 patients. On a monthly basis, the system provides over 1,419 inpatient surgeries, 1,430outpatient surgeries, 37,909 radiology procedures, 7,872 emergency department visits, and 210,613 hospitalbased outpatient clinic visits.Under a management contract entered into with the Kentucky Cabinet for Health and Family Services, theSystem also operates and manages Eastern State Hospital, a 300,000 square-foot facility located on theUniversity’s Coldstream Research Campus. The psychiatric facility, opened in September 2013, provides amodern setting for both acute and long-term inpatient psychiatric treatment for adults living within FayetteCounty and the 50 surrounding counties.UK HealthCare’s Markey Cancer Center remains the state’s only cancer center designated by the NationalCancer Institute (NCI), which reflects the University’s position as a frontrunner in cancer treatment andresearch. UK HealthCare is one of an elite group of medical centers in the United States that have a NCIdesignation, a federally funded Center on Aging, and a highly prized Clinical and Translational Science Awardgrant.UK HealthCare’s dramatic growth within the last decade is in large part the result of a commitment to supportthe state’s overall system of care by working hand-in-hand with local community providers to bring specialtycare closer to the patient. These relationships take on different dimensions in each locality (managementagreements, affiliate networks, outreach, etc.) and support keeping less acute care in the local communityand smoothing the process for more complex, serious cases to be treated in UK HealthCare’s Lexingtonfacilities. The goal is better care at all points of the continuum.3
Financial HighlightsThe System’s overall financial position remains strong with assets of 3.03 billion, deferred outflows ofresources of 4.4 million, liabilities of 831.1 million, and deferred inflows of resources of 79 thousand. Netposition, which represents the System’s residual interest in assets after liabilities are deducted, was 2.20billion or 72.7% of total assets. For the fiscal year ended June 30, 2021, the System reported net incomebefore other revenues, expenses, gains and losses of 689.0 million, generating a margin of 27.5%.Financial results for fiscal year 2021 exceeded prior year's revenues with net outpatient revenues, includingthe provision for doubtful accounts, increasing approximately 173.0 million or 19.8% over the prior fiscal yearand net inpatient revenues, including the provision for doubtful accounts, which increased 74.3 million or6.6% over the previous fiscal year. The primary driver was that the System was able to recognize 482.3million of Medicaid Directed Payments revenue during the current fiscal year. Total assets increased 499.1 million or 19.7%. This increase is due to increases in cash and cashequivalents of 145.3 million, accounts receivable, net, of 62.5 million, inventories and other assetsof 12.0 million, estimated third-party payer settlements of 98.7 million, long-term investments of 98.7 million, capital assets, net, of 81.3 million, and other noncurrent assets of 1.2 million. Thisincrease was offset by a decrease in notes receivable of 745 thousand.Deferred outflows of resources decreased 1.1 million, which represents the unamortized differencebetween the reacquisition price and the net carrying amount of the refunded debt.Total liabilities increased 4.8 million or 0.6% as a result of increases in accounts payable andaccrued expenses of 45.9 million and other long-term liabilities of 8.1 million. These increases wereoffset by decreases in unearned revenue of 25.9 million, long-term debt of 22.5 million, and capitallease obligations of 813 thousand.Deferred inflows of resources increased 13 thousand, which represents the beneficial interest froman irrevocable external trust that the system will receive in future years.Total net position increased 493.1 million or 28.9% primarily due to the current year net income.Operating revenues increased 357.6 million or 16.6% primarily due to an increase in net patientrevenue of 339.2 million.Operating expenses increased 219.7 million or 12.9%. The largest increases came from supplies of 84.6 million, personnel costs of 60.2 million, and purchased services of 49.4 million.The net nonoperating revenues increase of 116.1 million primarily resulted from increases of 93.7million in investment income, 30.3 million in Provider Relief Fund, and 415 thousand in capital gifts.These increases were offset by an increase of 8.0 million in other nonoperating expenses and adecrease of 800 thousand in gifts and non-exchange grants.4
Operating StatisticsThe following table presents utilization statistics for the System for fiscal years ended 2021, 2020 and 2019:Discharges:MedicareMedicaidCommercial/Blue CrossPatient/CharityTotal dischargesAverage daily censusAverage length of stayOutpatient visits:Hospital clinicsEmergency visitsTotal 585,697104,116689,813600,712111,819712,5312021. Total discharges decreased by 1,859 or 4.7% compared to the prior fiscal year. The decrease occurreddue to decreases in Medicaid discharges of 350, Medicare discharges of 828, Commercial/Blue Cross of 326,and Patient/Charity of 355. Overall, the Diagnosis-Related Group case mix index increased to 2.2395 from2.0850 and the average length of stay increased by 0.65 days to 7.66 days. The case mix for Chandler was at2.3961 while Good Samaritan was at 1.4361. Total outpatient visits increased by 194,457 or 28.2% over theprior year.Using the Financial StatementsThe System presents its financial reports in a “business type activity” format, in accordance withGovernmental Accounting Standards Board Statement (GASB) No. 34, Basic Financial Statements – andManagement’s Discussion and Analysis – for State and Local Governments and GASB Statement No. 35,Basic Financial Statements – and Management’s Discussion and Analysis – for Public Colleges andUniversities – an amendment of GASB Statement No. 34. In addition to this MD&A section, the financial reportincludes Statements of Net Position, Statements of Revenues, Expenses and Changes in Net Position,Statements of Cash Flows and Notes to the Financial Statements. GASB requires that statements bepresented on a System-wide basis.Reporting EntityThe System is an organizational unit of the University of Kentucky (the University), which is a component unitof the Commonwealth of Kentucky (the Commonwealth) and is included in the basic financial statements ofthe Commonwealth. The financial statements of the System include Kentucky Healthcare Enterprise, Inc.(KHE), a wholly owned for-profit subsidiary; Surgery Blue, LLC, a wholly owned for-profit subsidiary, its forprofit subsidiary, Surgery Center of Lexington, LLC (51% ownership); and Beyond Blue Corporation, a whollyowned non-profit subsidiary. The System provides inpatient, outpatient, and emergency care services forresidents of the Commonwealth.Statement of Net PositionThe Statement of Net Position is the System’s balance sheet. It reflects the total assets, deferred outflows ofresources, liabilities, deferred inflows of resources, and net position (equity) of the System as of June 30,2021, with comparative information as of June 30, 2020. Liabilities due within one year, and assets available5
to pay those liabilities, are classified as current. Other assets and liabilities are classified as non-current. Netposition, the difference between total assets plus deferred outflows of resources and total liabilities plusdeferred inflows of resources, is an important indicator of the System’s current financial condition, while thechange in net position is an indicator of whether the overall financial position has improved or worsenedduring the year. Generally, assets, deferred outflows of resources, liabilities, and deferred inflows of resourcesare reported using current values. A major exception is capital assets, which are stated at historical cost, lessaccumulated depreciation.A summarized comparison of the System’s assets, deferred outflows of resources, liabilities, deferred inflowsof resources, and net position at June 30, 2021, 2020 and 2019 follows:Condensed Statements of Net Position (in thousands)ASSETS AND DEFERRED OUTFLOWS OF RESOURCESCurrent assetsCapital asset, netOther noncurrent assetsDeferred outflows of resourcesTotal assets and deferred outflows of resourcesLIABILITIES AND DEFERRED INFLOWS OF RESOURCESCurrent liabilitiesNoncurrent liabilitiesDeferred inflows of resourcesTotal liabilities and deferred inflows of resourcesNET POSITIONNet investment in capital assetsNonexpendable otherRestricted expendableUnrestrictedTotal net position202120202019 1,389,1601,140,183498,9974,4033,032,743 4777,700587,4071,66711,7351,600,722 2,201,531535,0541,61611,7481,159,980 1,708,398509,7821,59014,667905,335 1,431,374 685,1181,014,284502,8666,8062,209,074Assets. As of June 30, 2021, the System’s total assets amounted to approximately 3.03 billion. Capitalassets, net of depreciation, of 1.14 billion or 37.7% of total assets represented the System’s largest asset.Cash and cash equivalents of 1.03 billion or 33.9% of total assets is the second largest asset, and long-terminvestments of 410.5 million or 13.6% of total assets were the System’s third largest asset. Accountsreceivable, net, primarily patient-related, of 264.2 million or 8.7% represents another significant asset of theSystem.Total assets increased by 499.1 million during the year ended June 30, 2021. The increase was the result ofseveral factors: cash and cash equivalents increased 145.3 million, accounts receivable, net, increased 62.5 million, inventories and other assets increased 12.0 million, estimated third-party payer settlementsincreased 98.7 million, long-term investments increased 98.7 million, capital assets, net, increased 81.3million, and other assets increased 1.2 million. These increases were offset by a decrease in notesreceivable of 745 thousand.6
Deferred Outflows of Resources. Deferred outflows of resources totaled 4.4 million, a decrease of 1.1million, which represents the unamortized difference between the reacquisition price and the net carryingamount of the refunded debt. The System refunded General Receipts 2005 Notes Series A and GeneralReceipts 2007 Notes Series A and B during fiscal year 2015.Liabilities. As of June 30, 2021, the System’s liabilities totaled 831.1 million. Long-term debt (current andnon-current), which consists of general receipts notes and note payable to the University, comprised thelargest liability of 505.2 million or 60.8% of total liabilities. Accounts payable and accrued liabilities totaled 190.5 million or 22.9% of liabilities, while unearned revenue represented approximately 76.4 million or 9.2%of liabilities. Capital lease obligations totaled 24.4 million or 2.9% of liabilities. Long-term liabilities, otheraccounted for 34.5 million or 4.2% of liabilities and consisted primarily of unamortized bond premium.Total liabilities increased 4.8 million or 0.6% as a result of increases in accounts payable and accruedexpenses of 45.9 million and other long-term liabilities of 8.1 million. These increases were offset bydecreases in unearned revenue of 25.9 million, long-term debt of 22.5 million, and capital lease obligationsof 813 thousand.Deferred Inflows of Resources. The System is the residual principal and income beneficiary of anirrevocable trust that is held and controlled by external trustees. For the years ended June 30, 2021 and2020, the System received income from this trust of approximately 400 and 500, respectively. The marketvalue of the irrevocable external trust assets as of June 30, 2021 and 2020 was approximately 79 thousandand 66 thousand, respectively.Net Position. Net position as of June 30, 2021 totaled approximately 2.20 billion, or 72.7% of total assets.Net investment in capital assets totaled 587.4 million or 26.7% of total net position. Restricted net positiontotaled approximately 13.4 million or 0.6% of total net position. Unrestricted net position accounted for 1.60billion or 72.7% of total net position. Total net position increased 493.1 million or 28.9%.Restricted net position is subject to externally imposed restrictions governing its use. Although unrestrictednet position is not subject to externally imposed stipulations, substantially all of the unrestricted net positionhas been internally designated for capital projects and working capital requirements.2020 Versus 2019. When comparing the fiscal year ended June 30, 2020 to the year ended June 30, 2019: Total assets increased by 327.0 million during the year ended June 30, 2020. The increase was theresult of several factors: cash and cash equivalents increased 301.1 million, inventories and otherassets increased 7.0 million, capital assets, net, increased 44.6 million, and estimated third-partypayer settlements increased 7.8 million. These increases were offset by decreases in accountsreceivable, net, of 30.4 million and long-term investments of 3.1 million.Deferred outflows of resources decreased 1.3 million, which represents the unamortized differencebetween the reacquisition price and the net carrying amount of the refunded debt. The Systemrefunded General Receipts 2005 Notes Series A and General Receipts 2007 Notes Series A and Bduring the fiscal year 2015.Total liabilities increased 48.7 million primarily due to an increase in accounts payable and accruedexpenses of 19.2 million, unearned revenue of 38.4 million, capital lease obligations of 2.0 million,and other long-term liabilities of 169 thousand. This was offset by a decrease of long-term debt of 11.0 million.Deferred inflows of resources as of June 30, 2020 and 2019 were approximately 66 thousand and 64 thousand, respectively, which presents the future gains by the System that is applicable to afuture reporting period.Total net position increased 277.0 million, primarily due to net income from continuing operations.7
Statement of Revenues, Expenses and Changes in Net PositionThe Statement of Revenues, Expenses and Changes in Net Position is the System’s income statement. Itdetails how net position has fluctuated during the year ended June 30, 2021, with comparative information forthe year ended June 30, 2020. This statement is prepared on the accrual basis of accounting, wherebyrevenues and assets are recognized when the service is provided and expenses and liabilities are recognizedwhen others provide the service, regardless of when cash is exchanged. All items that increase or decreasenet position must appear on the Statement of Revenues, Expenses and Changes in Net Position asrevenues, expenses, gains or losses.Financial activities are reported as either operating or nonoperating. GASB Statement No. 35 requires giftsand investment income to be classified as nonoperating revenues. The utilization of long-lived capital assetsis reflected in the financial statements as depreciation, which amortizes the cost of an asset over its expecteduseful life.Condensed Statements of Revenues, Expenses and Changes in Net Position(in thousands)OPERATING REVENUESNet patient service revenuesSales and servicesManagement contract revenueTotal operating revenuesOPERATING EXPENSESSalaries and benefitsSupplies and purchased servicesOther expensesDepreciationManagement contract expensesTotal operating expensesNET INCOME FROM CONTINUING OPERATIONSNONOPERATING REVENUES (EXPENSES)Provider relief fundAdditions to permanent endowmentsGrants and giftsInvestment incomeInterest expenseTransfers to the University of KentuckyOther, netTotal nonoperating expensesINCREASE IN NET POSITIONNET POSITION, beginning of yearNET POSITION, end of year8202120202019 2,347,631115,49443,4472,506,572 2,008,38398,67941,9302,148,992 708,3981,431,3741,309,308 2,201,531 1,708,398 1,431,374
Operating RevenuesTotal operating revenues were approximately 2.51 billion for the year ended June 30, 2021, an increase of 357.6 million or 16.6% over fiscal year 2020. The most significant source of operating revenue for theSystem was net patient service revenues of 2.35 billion, an increase of 339.2 million or 16.9% in fiscal year2021 over 2020.Inpatient net revenue, including bad debt, increased 74.3 million or 6.6% over prior year. The primary driverof the increase was prior years' adjustments of 93.6 million, including prior year Disproportionate ShareHospital (DSH) revenue. Directed Payments also increased 29.3 million due to increased Medicaid eligiblepatients. These increases were offset by lower patient discharges of 1,859 resulting in 48.6 million decreasein inpatient net revenue.Directed Payments are the difference between the System's average commercial rate and the rates MedicaidManaged Care Organizations pay for healthcare services. The payments are applicable to both inpatient andoutpatient hospital services. A per day and per visit gap has been calculated and is applied to MedicaidManaged Care volume.Surgery Blue had a net patient revenue increase over last year of 1.5 million due to increased volume andpatient mix.Outpatient net revenue, including bad debt, increased by 173.0 million or 19.8% over prior year. The primarydriver was outpatient activity, which increased by 204,114 hospital clinic visits offset by a decrease of 9,657emergency room visits. The increased outpatient activity resulted in a 111.7 million increase in outpatient netrevenue. Directed Payments also increased by 61.3 million due to increased of Medicaid eligible patients.The System was able to recognize 482.3 million of Directed Payments revenue during the current fiscal year.Bad debt provision decreased by 9.5 million or 10.7% over the prior year as the System has seen feweraccounts referred to bad debt starting in April 2020 due to COVID-19 changes. Medicaid had presumptivecoverage from April 2020 through March 2021. The Medicaid posted charges increased approximately 13.7%during that timeframe.TOTAL OPERATING EXPENSESManagement contract expenses2.1%Depreciation4.0%Other expenses12.4%Salaries and wages33.0%Purchased services9.2%Fringe benefits8.1%Supplies31.2%9
Operating ExpensesTotal operating expenses, including 76.2 million of depreciation, were 1.93 billion, an increase of 219.7million or 12.9% over the prior year.Salaries and wages increased 60.6 million over the prior fiscal year. The increase in salaries and wages wasdriven by a full-time equivalent (FTE) increase of 1,302, a 12.6% increase over prior year. The majority of thisincrease, 764 FTEs, was related to patient services. FTEs of 174 were related to information technology.FTEs of 122 were pharmacy related. The other FTEs were related to COVID-19 84 FTEs, graduate medicaleducation of 37 FTEs, and finance of 16 FTEs. These increases were offset by an administration and supportdecrease of 38 FTEs. Fringe benefits decreased 421 thousand or 0.3% primarily due to the decrease ofemployer retirement contribution from 10% to 5% in fiscal year 2021.Supplies expenses increased 84.6 million or 16.3% primarily due to increases in drugs, antibiotics, variablehospital supplies, and an increase in the outpatient population. Purchased services increased 49.4 million or38.8% primarily due to the increase in contract labor expenses. Other expenses increased 16.9 million or7.6% primarily due to increases in leases, computer licenses, maintenance, and subscriptions.Nonoperating Revenues (Expenses)Total net nonoperating revenues were 110.7 million in fiscal year 2021 compared to 5.5 million in totalnonoperating expenses during the prior fiscal year, an increase of 116.1 million. This increase was mainlydue to an increase in investment income of 93.7 million because of capital market upturn, an increase inProvider Relief Fund of 30.3 million, and an increase of 415 thousand in capital gifts. These increases wereoffset by an increase of 8.0 million in other nonoperating expenses, and a decrease of 800 thousand in giftsand non-exchange grants.Transfers to the University of Kentucky were 195.9 million in 2021 compared to 157.9 million in 2020primarily because of an increase in noncapital transfers of 16.0 million. The increase is due to increasedtransfers to support the Center for Clinical and Translational Services, Pediatrics, and the College ofMedicine. In addition, there was an increase in transfers to the University of Kentucky for capital purposes of 22.0 million, primarily due to a 25.0 million transfer for the College of Medicine health education buildingconstruction.2020 Versus 2019. Total operating revenues were 2.15 billion for the fiscal year ended June 30, 2020, anincrease of 390.4 million over the fiscal year ended June 30, 2019. The increase in operating revenues wasprimarily due to increased net patient service revenues.Operating expenses totaled 1.71 billion, an increase of 201.2 million over fiscal year 2019. The increasewas due primarily to higher costs for personnel and supplies.Net nonoperating expenses totaled to 5.5 million in fiscal year 2020 compared to nonoperating revenues of 13.0 million in the prior year, a decrease of 18.5 million. This decrease was mainly due to a reduction ininvestment income of 16.5 million because of capital market downturn and a decrease of 6.7 million inother nonoperating revenues. These decreases were offset by a reduction of interest expense of 5.3 millionand an increase of 330 thousand in gifts and non-exchange grants.Statement of Cash FlowsThe Statement of Cash Flows details how cash has increased or decreased during the year ended June 30,2021, with comparative financial information for the year ended June 30, 2020. It classifies the sources anduses of cash into the following categories: Operating activitiesNonc
million in investment income, 30.3 million in Provider Relief Fund, and 415 thousand in capital gifts. These increases were offset by an increase of 8.0 million in other nonoperating expenses and a decrease of 800 thousand
