497 家互联网医院名单全角度分析，实体医院主导占八成、疫情后增速放缓

2020 年，互联网医疗在疫情防控中作用积极，再次成为行业关注焦点。动脉网此前已经推出了《互联网医院政策报告》分析行业政策趋势。不过，政策在执行过程中，各地推动进度与力度不尽相同。

那么，目前互联网医院建设实际有哪些特点？我们以 2018 年 9 月国家卫健委出台《互联网医院管理办法（试行）》为时间起点，从多个公开渠道搜集到目前 497 家互联网医院的资料（数据截至 4 月 30 日）。

通过这些互联网医院的成立时间、地域分布、申办主体、医保接通情况等维度分析，我们试图更准确地观察行业动向。为了确保分析结果的合理性，我们严格把握了资料来源的权威性，搜集标准主要如下：

互联网医院名单：优先使用卫生健康部门公示的名单、其次是医院官网官微信息和主流媒体公开报道；互联网医院公司若无法证实已获得互联网医院资质的，不计入名单；

互联网医院成立时间：优先使用各级卫生健康部门披露的审批时间，其次是主流媒体、医院官网官微披露的获批时间或上线时间；

申办主体基本信息：以各级卫生健康部门、医院官网官微、企业官网官微公开内容为准；

医保接通情况：以各级卫生健康部门或医保局、主流媒体公开报道、医院官网官微为准。

全国互联网医院总览，实体主导占八成
互联网医院根据申办主体的不同，分为实体医院主导型和企业主导型。497 家互联网医院中，有 415 家是实体医院主导，占 83.5%。

互联网医院主导方，动脉网制图

医生是互联网医院最核心的资源，实体医院天然具备这项优势，企业却需要长时间沉淀，或在短期内付出巨大成本才能积累起一定数量的医生。

在互联网医院发展早期，探索这一形态的实体医院并不多。随着互联网医院运行模式的完善，政策加以肯定、推动并进行规范，实体医院越来越多开始建设互联网医院，直至目前占比远远超过企业主导型互联网医院。

同时，互联网医院刚刚经历了新一轮的建设高峰。

2018 年 9 月国家卫健委《互联网医院管理办法（试行）》出台之后，互联网医院正式进入审批、监管等规范化发展的阶段，新政出台当年审批的互联网医院并不多。因此，我们以 2019 年为起点，在下图中梳理出了每个月互联网医院的成立情况（以获得执业许可的时间或上线时间为准，二者都不明确的未展示在图中）。

2019 年以来互联网医院成立情况，动脉网制图

可以看出，成立数量整体呈上升趋势，2019 年 4 月迎来第一个高峰，在 8 月国家医保局《关于完善「互联网 +」医疗服务价格和医保支付政策的指导意见》出台后，12 月又迎来第二个高峰。

到 2020 年，2 月建立的互联网医院最多，达到 65 家。这或许也是互联网医院诞生以来，单月建设数量最多的阶段。

2 月正值新冠肺炎疫情的高峰期，疫情防控的迫切需要推动了互联网医院建设。疫情期间，原有互联网医院纷纷开通线上发热门诊、慢病复诊、肺炎咨询，此外还不断有互联网医院紧急获批和上线。

据媒体报道，武汉大学人民医院的互联网医院「武大云医」申办仅耗时一天，也成为了湖北省首个获得线上诊疗资质的互联网医院。武汉大学人民医院院长王高华介绍，2 月 3 日向省卫健委提出申请，第二天就批复同意了。

这样的速度并不只发生在疫情最严重的武汉。在天津，2 月 5 日，天津医科大学总医院互联网医院向天津市卫健委申请增加呼吸内科。当天下午 16:14 工作人员正式受理后，迅速进行审核、审批，于 16:25 将此事项办结，耗时仅 11 分钟。

随着疫情平稳，2020 年 3 月开始，互联网医院增长速度放缓，4 月回落到疫情之前的水平。

疫情期间，互联网医院满足了大量慢病患者的用药需求，提供在线复诊、开方、药品配送服务，部分还可医保报销。然而，互联网医院不能只靠疫情防控来推动，尽管行业在此期间进行了很好的用户教育、习惯培养，但疫情之后，在线问诊对患者的吸引力是否能维持，充满不确定性。

所以，互联网医院的服务模式亟待升级，需重构医疗健康服务流程，而非简单复制线下流程。

497 家互联网医院的类型，动脉网制图

从目前互联网医院类型来看，综合医院和中医院占主流，专科医院类型多样。综合医院科室齐全，能满足患者多种就诊需求。中医院虽然在线上无法把脉，同样可以开出在线处方。

4 月 10 日，上海中医药大学附属龙华医院在互联网医院开出中医处方。一名强直性脊柱炎患者此前一直在龙华医院风湿免疫科治疗，通过长期稳定的治疗，病情已明显缓解。该患者通过互联网医院视频就诊后，医生为他开出了中草药处方，物流公司可将中医药饮片配送到患者家中。

妇幼保健院、儿童医院和妇产医院也是占比较高的医院类型。孕产妇、儿童原本就是就诊需求较高、就医又不方便的人群。重庆医科大学附属儿童医院疫情期间在 2 月 3 日上线互联网医院，2 月份累计问诊量 1.2 万余人次，累计在线处方量 397 张，其中 54% 为异地患儿，药品配送至四川、贵州、云南及市内多地，极大方便了患者就医。

其他的专科医院中，以慢病或口腔、眼科这类消费需求较强的专科为主，这些医院能够满足患者医疗、健康管理、消费等的多层次需求。

互联网医院地域分布，山东数量最多
由于全国各地医疗资源、医疗水平、医疗信息化水平不尽相同，各地建设互联网医院的情况也有较大差别。

互联网医院整体分布，动脉网制图

从上图可看出，现阶段互联网医院主要分布在东部、南部沿海省份，这些区域优质医疗资源集中、医疗信息化程度也较高，有良好的基础。其中，山东、江苏、安徽、浙江、福建、广东等省份还被国家卫健委确定为「互联网 + 医疗健康」示范省。

互联网医院最多的几个区域，原本就是进行行业探索较早的地区。目前，山东的互联网医院已达到 133 家。

2019 年以来，海南、上海、天津、黑龙江等地加快了互联网医院建设的脚步。其中，海南的互联网医院以企业主导型为主，目前的 24 家互联网医院中，有 22 家属于此类。

陕西也在加紧推动互联网医疗服务，受疫情防控需求推动，已有多家医院获批互联网诊疗资质，但互联网医院较少。而北京仅已批准几家实体医院的互联网诊疗服务，暂未批准互联网医院。

现阶段，互联网医院还呈现出逐渐往地级市、县或县级市拓展的特点。根据行政区划，我们梳理出了各类城市拥有的互联网医院数量：

从行政区划看互联网医院的分布，动脉网制图

从上图可看出，总共有 200 多家互联网医院位于直辖市和省会城市，200 多家在地级市，县级城市有 76 家。

截至目前，全国大多数省份都已制定了互联网医疗的发展目标，河北、湖北、四川等考虑了区域分布因素，除了省会城市的大型三甲医院之外，要求各地市、州同步建设互联网医院或开展互联网医疗服务。

互联网医院分布也体现了政策推动之下，覆盖面逐步下沉的趋势。尤其是在浙江、广东、山东、江苏几个省份，地级市、县级城市已经较为广泛地覆盖了互联网医院。

互联网医院申办主体分析
若从实体医院和企业这两个互联网医院的申办主体来分析，会发现哪些规律呢？

实体医院主导，公立三甲最多、民营占比小

我们先来看实体医院，其根据出资方、医院等级又分为不同类型，这也会使互联网医院呈现出不同特征。

目前申办互联网医院的 415 家实体医院中，公立 375 家、民营 40 家，在实体医院主导的互联网医院中，分别占 90%、10%。与此形成反差的是，根据《2018 年中国卫生健康统计年鉴》，全国公立医院有 1.2 万个，民营医院 2.1 万个，民营医院数量远超公立医院。

也就是说，大约有 3.1% 的公立医院建设了互联网医院，但只有 0.2% 的民营医院建设了互联网医院。

公立医院和民营医院建设互联网医院的情况，动脉网制图

对公立医院来说，尤其是大三甲医院，建互联网医院主要是将常见病、慢病患者进行分流，打造线上线下一体化流程，提升患者就医和医院管理的整体效率。同时，公立医院能够加快投入互联网医院建设，与其主管部门的行政管理推动也有一定关系。

而对门诊量更低的民营医院来说，将常见病、慢病患者转移到线上并不是刚需，他们更多考虑如何提升医疗和服务质量，以此吸引患者。若要建互联网医院，也希望达到这样效果。即民营医院必须考虑建设运营成本与效益之间的关系，尤其是营利性民营医院。

申办互联网医院的民营医院类型，动脉网制图

上图是建立互联网医院的民营医院类型，综合医院仍然是多数。专科医院覆盖了眼科、妇产、口腔等消费属性强的领域。在各类专科医院中，互联网有助于塑造医院品牌和拉近医患距离，从而促进医院经营。

但整体上看，民营的各类专科医院建设互联网医院较少，未来是否能持续通过互联网扩大获客渠道还不确定。不过，疫情期间，线下医疗服务量整体下滑，民营医疗机构更是如此，通过拓展线上服务，至少能够将疫情带来的影响降到最低。

从实体医院等级来看，全国的三级医院中，近 13% 已建设了互联网医院。这其中，已有 253 家三甲医院拓展互联网医院，占全国 1442 家三甲医院的 17.5%。

这些三甲医院中，四川大学华西医院、中南大学湘雅系医院以及复旦大学附属中山医院、复旦大学附属华山医院等知名医院均已上线互联网医院。

不同等级医院建设互联网医院的情况，动脉网制图

前文已经提到，从行政区划的维度看，互联网医院正在从直辖市、省会城市向地级市、县级城市铺开。从上图同样可以看出，二级医院建设互联网医院的比例仅有 0.61%。

二级医院除了分布在各个市辖区之外，还广泛分布在地级市和县级城市。所以，互联网医院的下沉，从医院等级这个层面看，也是同样的趋势。

但是，医院等级也体现了其服务定位、服务能力，所以，并非每家医院都有必要或有实力单独建一家互联网医院。

实体医院建设互联网医院，可独立申请互联网医院作为第二名称，也可以与第三方机构合作申请互联网医院作为第二名称，后者在实体医院主导的互联网医院医院中，占了约 10% 的比例。

合作共建的互联网医院，医院名和企业名都要体现到互联网医院的名称中。通过这种方式，企业既要提供平台建设支持，还要提供资源、持续参与后续运营。

互联网医疗企业、医疗信息化企业广泛参与合作共建互联网医院，微医、纳里健康等均与多家实体医院共建了互联网医院，这种形式可以探索实体医院的医生、医疗资源与企业的平台覆盖、建设运营能力深度结合，双方形成优势互补。

企业建互联网医院，意在搭建自身业务闭环
互联网医院界定了常见病、慢病的复诊，似乎是局限了问诊范围，但仍有各种类型的企业投身其中。

早期主导互联网医院的企业，以互联网医疗、医疗信息化、医药电商企业为主。随着时间的推移，各个细分领域参与企业越来越多样化，包括上游的医药、医疗器械以及下游的保险企业等。

主导互联网医院的企业类型，动脉网制图

以上是我们本次统计的企业主导型互联网医院中，各类企业的数量。互联网医疗、医疗信息化、医药电商等仍是主力，其他企业类型多样。

医疗需求并非高频需求，加上在线问诊又严格界定了范围，所以，各种新类型的企业投入成本建设互联网医院，并非在线上问诊本身这个环节，而是通过合规资质来打通其业务闭环。

例如，在药品集采政策等对药品流通格局的影响下，药企可以开拓新的销售渠道和服务方式；医疗器械以互联网医院为切入点，与线下医疗机构合作，围绕产品展开相关诊疗，可迅速推广产品。而保险企业通过互联网医院将业务环节前移，可以更好地对客户进行健康管理，减少疾病发生，从而降低成本，或者积累医疗数据更合理地设计产品。

医保支付起步，推进迅速
我国覆盖全民的基本医保制度已经建立，根据国家医保局最新数据，截至 2019 年底，基本医保覆盖面稳定在 95% 以上。患者到线下就医，以医保支付和个人支付为主，而在线上，医保支付才刚刚起步。

互联网医院医保接通情况，动脉网制图

我们本次统计的互联网医院中，仅 49 家接通了医保支付，26 家表示暂未开通，但此事项正在进行或已提上日程。

大部分互联网医院没有公开资料显示开通或未开通，我们将其列入「不明确」类。不过，这类重要的民生服务在一般情况下，主管部门或医院都会通过适当渠道公布，所以，「不明确」这类大概率是暂未接通医保。

已接通医保支付的互联网医院中，结算方式主要有直接在线结算、医保平台结算以及其他支付方式。

直接在线结算即患者通过互联网医院复诊后，系统自动算出个人支付部分，患者按此支付即可。平安好医生湖北互联网医院、微医互联网总医院武汉专区、福建省级机关医院等均属于此类。

医保平台支付需要互联网医院入驻，例如江苏南通市第六人民医院进驻了南通医保 APP，可实现在线复诊、医保支付、药品配送等服务。

山东省互联网医保大健康服务平台也是类似模式，该平台从开设互联网医院、纳入医保定点，到患者身份验证、复诊确认，再到医保在线结算，构建了互联网医院医保在线支付结算的完整闭环，是互联网医院服务模式的新探索。

此外，在互联网医院与医保信息系统、药店等对接还不够成熟的情况下，也有部分地区采用个人支付部分生成二维码、患者扫码支付，或者患者先在网上自费支付，之后再到医院报销。

疫情防控对互联网医院的医保支付打通有强力推动作用，湖北、上海、江苏、浙江、天津等地多家互联网医院医保支付火速上线。疫情之后，医保支付的完善成为大趋势。

几个需要突破的问题
我们在搜集和分析上述互联网医院名单的过程中，发现还有一些问题需要突破。

首先，各地对复诊的时限要求不一。例如，上海在《上海市互联网医院管理办法》中要求，患者需要提供 2 个月内的实体医院就诊病历，天津市第一中心医院、福建省人民医院均要求提供 3 个月内的就诊资料，重庆医科大学附属儿童医院要求 5 个月内的就诊记录。

大多实体医院还要求初诊记录需为本医院的就诊记录，这样一来，复诊的医疗资源与互联网只是有限范围内、有限区域内的结合。

初诊地、复诊时限的标准问题，急需从政策层面加以完善。

其次，实体医院越来越多地开通了互联网医院，但线上运营并非他们的强项，如何在建好后发挥实际价值、不当成自上而下的任务，才是更大的考验；而如何合理分配这些医疗资源，也需要一盘棋考虑。

前文已经提到，许多知名大三甲医院已建成互联网医院，虽然在政策推动下，互联网医院已逐渐在往二级医院延伸，但患者对三甲医院的信任会长期存在，既然通过三甲医院可以在线咨询复诊，何不就选择三甲医院呢？也就是说，三甲医院对患者的虹吸效应可能会更强。这似乎与分级诊疗的大趋势是相悖的。

所以，如何提高实体医院互联网医院的运营能力？如何通过服务模式的变革，整合各级医疗资源？这不仅是实体医院、主管部门面临的问题，也是值得行业深思的，因为问题存在正意味着市场需求的所在。

再次，大量实体医院上线了互联网医院，会导致平台型互联网医院的医生大量流失吗？我们认为，从总体上看，医生的时间和精力有限，此消彼长的关系有可能会出现。但是，「此」和「彼」一定是对立的吗？是否可以达成良好的合作和行业生态？这些也是值得探索的方向。

另一方面，不少人认为互联网医疗行业再次迎来风口，但我们无意跟风，也并非鼓动大家都去开互联网医院，而是希望通过更加完整的数据和严谨的分析，让行业有更冷静和理性的思考。In 2020, Internet health care plays an active role in epidemic prevention and control, once again becoming the focus of the industry. Arterial network has launched “Internet hospital policy report” to analyze the industry policy trend. However, in the implementation process of the policy, the progress and strength of promotion vary from place to place.
So, what are the characteristics of Internet hospital construction? We have collected data of 497 Internet hospitals from various public channels (data as of April 30) starting from the issuance of “Internet hospital management measures (Trial)” by the national health and Health Commission in September 2018.
Through the analysis of the establishment time, regional distribution, bidding subjects and medical insurance connection of these Internet hospitals, we try to observe the industry trend more accurately. In order to ensure the rationality of the analysis results, we have strictly grasped the authority of the data sources, and the collection criteria are as follows:
List of Internet hospitals: priority should be given to the list publicized by the health department, followed by the official micro information of the hospital website and the public report of the mainstream media; if the Internet hospital company cannot confirm that it has obtained the qualification of the Internet hospital, it will not be included in the list;
Establishment time of Internet hospital: priority should be given to the approval time disclosed by health departments at all levels, followed by the approval time or online time disclosed by mainstream media and official micro disclosure on the official website of the hospital;
Basic information of the bidding subject: subject to the public contents of the health departments at all levels, official websites of hospitals and official websites of enterprises;
Medical insurance connection: it is subject to public reports of health departments or medical insurance bureaus at all levels, mainstream media, and official and micro hospital websites.
Overview of national Internet hospitals, 80% of which are dominated by entities
Internet hospitals can be divided into two types according to different applicants: entity hospitals and enterprises. Of the 497 Internet hospitals, 415 are entity hospitals, accounting for 83.5%.
Internet hospital leader, arterial network mapping
Doctors are the core resource of Internet hospitals. Physical hospitals naturally have this advantage. However, enterprises need to settle for a long time or pay a huge cost in a short time to accumulate a certain number of doctors.
In the early stage of the development of Internet hospitals, there were not many physical hospitals exploring this form. With the improvement of the operation mode of Internet hospitals and the affirmation, promotion and standardization of policies, more and more physical hospitals have begun to build Internet hospitals, until now, the proportion is far more than that of enterprise led Internet hospitals.
At the same time, the Internet hospital has just experienced a new round of construction peak.
In September 2018, after the promulgation of the administrative measures for Internet hospitals (Trial) by the national health and Health Commission, Internet hospitals officially entered the stage of standardized development such as approval and supervision, and there were not many Internet hospitals approved in the year of the new deal. Therefore, starting from 2019, we sort out the establishment of the Internet hospital in each month in the figure below (subject to the time of obtaining the license or the online time, both of which are not clearly shown in the figure).
Establishment of Internet hospital since 2019, arterial network mapping
It can be seen that the number of establishments is on the rise as a whole, and the first peak is in April 2019. After the guidance on improving “Internet +” medical service prices and medical insurance payment policies issued by the State Health Insurance Bureau in August, the second peak is in December.
By 2020, the largest number of Internet hospitals will be established in February, reaching 65. This may also be the stage with the largest number of construction in a single month since the birth of the Internet hospital.
In February, the novel coronavirus pneumonia epidemic peak was in the peak. The urgent need for epidemic prevention and control promoted the construction of Internet hospitals. During the outbreak, the original Internet hospitals have opened online fever clinic, chronic disease follow-up, pneumonia consultation, in addition to the Internet hospitals continue to be approved and online.
According to media reports, Wuhan University People’s Hospital’s Internet hospital, wudayun medical, took only one day to apply for the bid and became the first Internet hospital in Hubei Province to obtain online diagnosis and treatment qualification. Wang Gaohua, President of the people’s Hospital of Wuhan University, said that he applied to the provincial health and Health Commission on February 3 and approved the application the next day.
This speed is not only in Wuhan, where the epidemic is most serious. In Tianjin, on February 5, the Internet Hospital of the General Hospital of Tianjin Medical University applied to the Tianjin Health and Health Commission for the addition of respiratory medicine. At 16:14 p.m. of the same day, after the official acceptance, the staff quickly reviewed and approved the matter, and completed it at 16:25, taking only 11 minutes.
With the stable epidemic situation, the growth rate of Internet hospitals has slowed down since March 2020, and fell back to the level before the epidemic in April.
During the epidemic period, Internet hospitals met the drug demand of a large number of patients with chronic diseases, and provided online follow-up, prescription, drug delivery services, some of which could also be reimbursed by medical insurance. However, Internet hospitals can not only rely on epidemic prevention and control to promote. Although the industry has conducted good user education and habit training during this period, whether the appeal of online consultation to patients can be maintained after the epidemic is full of uncertainty.
Therefore, the service mode of Internet hospital needs to be upgraded, and the medical and health service process needs to be reconstructed instead of simply copying the offline process.
Types of 497 Internet hospitals, arterial network mapping
In terms of the current types of Internet hospitals, general hospitals and traditional Chinese medicine hospitals are the mainstream, and the types of specialized hospitals are diverse. The comprehensive hospital has a complete set of departments, which can meet the needs of patients. Although traditional Chinese medicine hospital can not feel the pulse online, it can also prescribe online prescriptions.
On April 10, Longhua Hospital Affiliated to Shanghai University of traditional Chinese medicine opened in Internet hospital
Only 49 of the Internet hospitals in our statistics have connected to the medical insurance payment, 26 of which have not yet opened, but this matter is in progress or has been put on the agenda.
Most of the Internet hospitals do not have public information indicating that they are open or not. We have classified them as “unclear”. However, in general, such important livelihood services will be announced by competent departments or hospitals through appropriate channels. Therefore, the “unclear” rate is that the medical insurance is not connected.
In the Internet hospitals that have connected to medical insurance payment, the settlement methods mainly include direct online settlement, medical insurance platform settlement and other payment methods.
Direct online settlement means that the system automatically calculates the personal payment part after the patient’s re visit through the Internet hospital, and the patient can pay according to this part. Ping’an good doctor Hubei Internet hospital, micro medical Internet general hospital Wuhan special area, Fujian Provincial Hospital and so on are all in this category.
Medical insurance platform payment requires Internet hospitals to enter. For example, the Sixth People’s Hospital of Nantong City in Jiangsu Province has entered Nantong Medical Insurance app, which can realize online follow-up, medical insurance payment, drug distribution and other services.
Shandong internet medical insurance big health service platform is also a similar model. The platform has constructed a complete closed-loop of online payment and settlement of medical insurance of Internet hospitals, from the opening of Internet hospitals, inclusion of medical insurance fixed points, to patient identification verification, follow-up confirmation, to online settlement of medical insurance, which is a new exploration of Internet hospital service model.
In addition, when the connection between the Internet hospital and the medical insurance information system and drugstore is not mature enough, there are also some areas where the personal payment part is used to generate the QR code and the patient scanning the code for payment, or the patient pays at his own expense on the Internet first, and then goes to the hospital for reimbursement.
The epidemic prevention and control has a strong role in promoting the medical insurance payment of Internet hospitals, and many Internet hospitals in Hubei, Shanghai, Jiangsu, Zhejiang, Tianjin and other places have launched medical insurance payment quickly. After the epidemic, the improvement of medical insurance payment has become a general trend.
Several problems to be solved
In the process of collecting and analyzing the above list of Internet hospitals, we found that there are still some problems that need to be solved.
First of all, there are different requirements on the time limit for further consultation. For example, in the Shanghai Internet hospital management measures, patients need to provide medical records of physical hospitals within 2 months, Tianjin first central hospital and Fujian people’s hospital all need to provide medical information within 3 months, and Chongqing Medical University Affiliated Children’s hospital requires medical records within 5 months.
Most of the physical hospitals also require the first visit record to be the visit record of the hospital, so that the medical resources of the follow-up visit and the Internet are only a combination within a limited scope and a limited area.
It is urgent to improve the standard of the time limit of the first visit and the second visit from the policy level.
Secondly, more and more physical hospitals have opened Internet hospitals, but online operation is not their strong point. How to give full play to the actual value after construction and not be regarded as a top-down task is a greater test; how to reasonably allocate these medical resources also needs a game of consideration.
As mentioned above, many famous top three hospitals have built Internet hospitals. Although Internet hospitals have gradually extended to the second level hospitals under the promotion of policies, patients’ trust in top three hospitals will exist for a long time. Since the top three hospitals can consult online for further consultation, why not choose top three hospitals? That is to say, the siphon effect of the top three hospitals on patients may be stronger. This seems to contradict the general trend of hierarchical diagnosis and treatment.
So, how to improve the operation ability of Internet hospitals? How to integrate medical resources at all levels through the change of service mode? This is not only the problem faced by physical hospitals and competent departments, but also worthy of consideration by the industry, because the existence of the problem means the market demand.
Thirdly, a large number of physical hospitals have launched Internet hospitals, which will lead to the loss of doctors in platform Internet hospitals? We believe that in general, the doctor’s time and energy are limited, and the relationship between this and that may arise. But must this and that be opposite? Can good cooperation and industry ecology be achieved? These are also directions worth exploring.
Finally, we need to explain that we have invested a lot of energy to collect the information in this paper. On the one hand, due to the limitation of statistical channels, there may be errors, but we have improved the accuracy through as many authoritative sources as possible (the sources have been explained at the beginning of this paper).