Health Care Reform Memo: October 29, 2012
Deloitte Center for Health Solutions publication
The health care reform memos are issued on a weekly basis, highlighting news from the previous week's activities in the administration and implications for the C-suite and various stakeholder groups.
My take: employers as catalysts for health care transformation
From Paul Keckley, Executive Director, Deloitte Center for Health Solutions
I speak to groups about health care three to four times weekly, but in my 35 years, last Wednesday’s was a first. The topic was simple enough: “what middle market employers should know about health reform and what they can do to prepare.” The audience: 1,100 business executives gathered at the Ohio State University-GE Capital 2012 National Middle Market Summit in Columbus, Ohio. The agenda: some serious heavy weights—Warren Buffett, Jeff Immelt, and rock star-entrepreneur Sammy Hagar—a/k/a The Red Rocker—who I followed on the program.
I was probably the only one in the room that could not sing along with his 1984 hit “I Can’t Drive 55” and my suit and tie definitely contrasted with his tee shirt and sandals. When I took the stage, I had a sinking feeling that health care was last on the audience members’ minds: after all, they had just given the 65-year-old music legend a standing “O” as much for his success as an entrepreneur (Cabo Wabo Tequila, Sammy’s Beach Bar Rum) as his music. Sometimes I feel like a brown shoe at a white tie affair: it was certainly the case last week.
Here’s what I told the group:
- Health care is a big deal. It impacts everyone. It is the fastest growing line item expense in the budgets of the federal and state government, and one of the fastest for companies that provide insurance coverage and in the average U.S. household. And it touches everyone.
- Health costs can be reduced, but only if the health care system—including individuals, policymakers, and employers—drive changes to the fundamentals of the industry. Incentives based on volume must be replaced by incentives for doing the right things that are evidence-based the first time. And the health system must embrace accountability; adherence to evidence-based necessary care; mechanisms to alter unhealthy behaviors; transparency for prices and quality; and technologies that enable improved coordination, reduced error, and improved efficiency. To embrace these changes, employers must understand the health system, not just how their benefits are designed. There’s a difference.
- The Affordable Care Act (ACA) is one of many legislative efforts to fix the system. But transformation of the health system requires more than federal legislative action: in most communities and states, employers are catalysts for meaningful improvements.
Business leaders get it. They see a need to get the U.S. fiscal house in order. They recognize the solution requires a combination of actions including tax reforms and reduced government spending. And they understand health reform must be on the table at the same time. Health costs impact corporate profits and global competitiveness for large multi-nationals—that’s well documented. But even among smaller and mid-sized companies, it’s about access to a productive workforce without being hampered by health costs that defer growth and innovation. These findings from the National Center for the Middle Market (NCMM) 3rd quarter survey underscore the salience of health care to the viability of mid-sized companies:
Source: NCMM Middle Market Indicator (MMI) 3Q 2012
Note: middle market companies have between $10 million and $1 billion in revenues.
As I reflect, it may have been the most challenging speech I’ve ever given, perhaps because I followed Sammy, and perhaps because the topic is so delicate: employers have a huge opportunity to impact reform of the health system, but they need to understand health care—not just benefits design—and most don’t.
They know their costs are significant and growing: for single coverage, employers pay 83 percent of the $5,615 total premium and for family coverage, they invest 73 percent of the $15,745 total premium to get and keep a healthy, productive workforce (Source: Kaiser Family Foundation, 2012 Employer Health Benefits Survey). They understand their employees value health coverage as a benefit. Their issue is affordability: in the last decade, 10 percent of employers dropped coverage due to costs, and in the decade ahead, we estimate 9 percent more will drop simply due to costs (Source: 2012 Deloitte Survey of U.S. Employers). They know it matters to their employees: only 20 percent of employees with employer-sponsored coverage feel protected from health costs that might wipe out their household financial security. But most don’t understand the health system—how it actually operates, how clinical decisions are made, how necessary and unnecessary costs are incurred, or how each of the system’s multiple sectors relate to each other or not.
I am going to download Sammy’s songs this week and learn the words to “I Can’t Drive 55” so I can sing along next time. I need to get out of my musical comfort zone.
And employers need to get out of their comfort zone and play an active role in fixing the health system. They need to invest time in understanding the health system, not just its costs, and become catalysts in its transformation.
Paul Keckley, Ph.D., Executive Director, Deloitte Center for Health Solutions
Study: premium rate review
Per Section 10003 of the ACA, health insurers must justify increases in premium rates above 10 percent to either state or federal reviewers. Kaiser Family Foundation researchers analyzed 846 rate filings from 41 states that were reviewed by state regulators (798) or the U.S. Department of Health and Human Services (HHS) (448): “As of August 1, 2012, 44 states and DC have rate review programs that have been deemed by HHS to be effective in at least one insurance market, meaning that they meet such criteria as having the authority under state law to determine the reasonableness of rate increases, having a transparent process for making the information publicly available, and allowing public comment on proposed rate changes.”
Findings from 32 states and DC, which had publically available rate review data:
- One in five resulted in a lower premium increase than the insurer initially requested
- Individual group premium: 8.9 percent average rate increase requested, 6.3 percent average rate increase approved
- Small group premium: 5.2 percent average rate increase requested, 4.7 percent average rate increase implemented
Findings in states where federal reviews were conducted:
- The average premium rate request was 16 percent. Note: the average rate request is higher for federal reviews because HHS can only review rate increases at or above 10 percent; states with rate review programs in place monitor all increases
- 77 percent of filings were determined unreasonable by HHS
- 19 percent were found to be “not unreasonable” by HHS
Background: prior to the passing of the ACA, many states had rate review programs in place; Section 10003 set a floor of requirements. States with effective programs in place began reviewing proposed increases in September 2011. HHS conducts reviews in states without effective programs in place, but does not have the authority to deny rate increases. HHS and states are required to make information publicly available for requests at or above 10 percent.
(Source: Kaiser Family Foundation, “Quantifying the Effects of Health Insurance Rate Review,” October 2012)
CMS: 2.3 million Medicare beneficiaries saved an average of $657 on prescription drugs
Thursday, the Centers for Medicare & Medicaid Services (CMS) reported that in the first nine months of 2012, 2.3 million beneficiaries in the Medicare prescription drug “donut hole” saved an average of $657, and 20.7 million beneficiaries received at least one preventive service with no deductible or co-payment as a result of Sections 3301, 4103, 4104, and 4105 of ACA. To date, CMS reports that 5.6 million beneficiaries have saved $4.8 billion on prescription drugs since the enactment of these provisions.
Physicians hesitant to participate in Medicare with looming SGR fix
According to a Medical Group Management Association (MGMA) survey of physicians, 82 percent of practices would be likely to participate in accountable care organizations, patient-centered medical homes, or bundled payment and shared savings pilots if Congress passed legislation to override mandated sustainable growth rate (SGR) reductions for the next five years. Key findings:
- If the scheduled 27 percent reduction in Medicare reimbursement takes place on January 1, 2013: 45 percent of practices say they are very likely to reduce the number of appointments for new Medicare patients, 27 percent say they probably would reduce the number of appointments available for their current Medicare patients, 31 percent are very likely to stop accepting new Medicare patients altogether.
- More than half would likely reduce size of their staff; 75 percent say they would reduce employee salaries or benefits.
- In the past five years, 60 percent percent of practices reported reducing staff salaries, benefits, or delaying buying new clinical equipment or facilities.
(Source: MGMA, “Performance and Practices of Successful Medical Groups: 2012 Report Based on 2011 Data,” October 2012)
Note: stay tuned for an upcoming Issue Brief from the Deloitte Center for Health Solutions—“Understanding the Sustainable Growth Rate: Analyzing the `Doc Fix.’”
Study: safety net hospitals hurt by cuts in DSH payments, lower Medicaid enrollment
Thursday, the National Association of Public Hospitals and Health Systems (NAPH) released its analysis of the Congressional Budget Office’s forecast of insurance coverage for fiscal year (FY) 2014 to FY2019, concluding hospitals will spend $53.3 billion more on uncompensated care by 2019 than estimated prior to the enactment of ACA. Two major factors were cited for the increase: reductions in Medicaid disproportionate share hospital (DSH) payments to safety net hospitals starting in FY2014, and lower participation in Medicaid as a result of the June 28 Supreme Court ruling that disallowed mandatory eligibility at 133 percent of the federal poverty level (FPL).
Background: beginning in FY2014, per Section 2551 of the ACA, CMS will reduce DSH Medicaid allotments by a total of $18.1 million. States with a lower percentage of their population uninsured will receive a 50 percent reduction, and states with a larger percentage of uninsured will receive a 25 percent reduction. Per Section 3133 of ACA, CMS will reduce DSH Medicare payments by a total of $22 billion over ten years. Initially CMS will reduce Medicare DSH payments by 75 percent in FY2014, and subsequently increase payments based on the percent of the population uninsured and the amount of uncompensated care.
Class action lawsuit settled, Medicare enrollees with long-term medical problems entitled to coverage
Last Monday, the U.S. Department of Justice announced the proposed settlement of a class action lawsuit brought on behalf of Medicare plaintiffs that, if approved by the U.S. District Court judge, will change a long-standing policy toward payments for certain home, skilled, and long-term care services for Medicare enrollees whose health status was not deemed to be “improved” as a result of the services. The proposed settlement agreement requires that CMS re-write the Medicare manual for nursing and therapy services to make clear that provision of these services no longer requires evidence that their provision is directly linked to health status improvement. Note: the settlement will be most meaningful to patients and family members with Alzheimer’s/Parkinson’s, stroke, spinal cord and traumatic brain injuries, and others. The settlement stemmed from a case where an 81-year-old woman was denied home health services through Medicare because her multiple sclerosis was not improving.
Study: Medicaid block grants could cut $1.7 trillion in Medicaid
Block grants to states for Medicaid could cut $1.7 trillion from the Medicaid program over the next ten years ($932 billion from repealing the ACA and $810 billion from transitioning to a block grant), per an analysis by the Urban Institute and the Kaiser Commission on Medicaid and the Uninsured. Key findings:
- Hospitals payments could be reduced $363.8 billion and nursing home payments $220.2 billion from 2013-2022 under a block grant scenario
- Medicaid enrollment could be reduced by 17 million if the ACA is repealed
- 77 percent increase in state spending with no efficiency gains; 46 percent if Medicaid spending per enrollee was held to the rate of growth in GDP per capita under a block grant scenario
(Source: Kaiser Commission on Medicaid and the Uninsured and the Urban Institute, “National and State-by-State Impact of the 2012 House Republican Budget Plan for Medicaid,” October 2012)
Compounding update: compounding pharmacy license revoked, CDC finds facility contaminated
The fallout continued last week for the Massachusetts compounding pharmacy linked to the multi-state fungal meningitis outbreak responsible for 294 known cases of fungal meningitis and 24 deaths. Tuesday, the Massachusetts Board of Pharmacy permanently revoked the New England Compounding Center’s (NECC) license after several health and safety violations were discovered. An inspection conducted by the Massachusetts Department of Public Health and U.S. Food and Drug Administration (FDA) found that black fungus particles were visible in sealed vials of the recalled steroid, NECC distributed products on 13 separate occasions before receiving sterility test results, large batches of compounded sterile product were distributed directly to facilities for general use without requiring a prescription for an individual patient, and sterilization procedures were not followed properly.
Related: members of the U.S. House Energy and Commerce Committee sent a letter to NECC’s owner and former owner seeking documents related to the recent outbreak as well as the history of investigations and operations of the NECC and associated entities dating back to 2002. NECC’s owner declined to comply with the Committee’s earlier request for a briefing on the outbreak. The letter highlighted that prior to the meningitis investigation, joint federal and state inspections of the NECC facility occurred in 2002, 2003, and 2004 in response to an adverse event reported to the FDA. Public Citizen’s Health Research Group issued a letter to HHS Secretary Kathleen Sebelius requesting that the HHS Office of Inspector General (OIG) investigate whether the FDA exerted full use of its legal authority to regulate NECC after prior inspections discovered violations.
House GOP claims HHS improperly using tax dollars in promoting ACA
Last week, GOP Chairmen of the House Subcommittee on Oversight Dave Camp (R-MI) and Charles Boustany (R-LA) sent HHS Secretary Kathleen Sebelius a letter inquiring about the status of materials requested in May 2012 regarding the use of taxpayer dollars on the promotion of the ACA. The Subcommittee claims HHS is improperly using taxpayer dollars to promote “Obamacare.” The information is requested by October 31, 2012.
Senate HELP Committee seeks feedback on track and trace system policy change
The Senate Committee on Health, Education, Labor, and Pensions (HELP) released a draft proposal on drug distribution security, referred to as a “track and trace” system, last week requesting comments from stakeholders on the policy options proposed in the report. Comments are due November 7, 2012, the day after the election, and policymakers hope to draft and pass legislation by the end of the year. Congress attempted to address drug distribution safety earlier this year, but efforts were stalled due to disagreements on the requirements and implementation of a track and trace system.
Background: “track and trace” language was included in the re-authorization of the Prescription Drug User Fee Act (PDUFA) of 2012 this summer, but was removed due to industry opposition. Manufacturers oppose the use of individual identifiers that require tracking of single packages of drugs but favor tracking at the lot level.
A federal track and trace system would allow the FDA to track a drug from its origination, through the manufacturing process, to the point of sale. If a counterfeit, diverted, stolen, or otherwise damaged product is reported, the FDA would be able to ensure timely intervention to prevent the damaged product from being distributed widely. Currently, some states have laws in place to enhance drug security, but a federal system would standardize processes across state lines. In 2015, California will require unique identifiers to be placed on all drugs.
State employee health costs
State government workers have richer health benefits than the private sector, but the gap has narrowed from $1,523 in 2007 to $891 in 2012 while the numbers of state workers not paying a co-payment or premium has shrunk from 39 percent in 2007 to 30 percent in 2012 with an average of $425/month out-of-pocket (vs. 17 percent in the private sector). (Source: Bureau of Labor Statistics [BLS] National Compensation Survey)
Massachusetts health department officials issued warnings to compounding center
Massachusetts Department of Health officials notified the NECC of safety and quality improvements dating back to 1999. Per the Department’s records, each citation was resolved. To date, nearly 300 cases of fungal meningitis and 24 deaths have been linked to the tainted injectable from NECC.
- Tuesday, an Indiana law preventing Planned Parenthood from obtaining reimbursement from the state Medicaid program because it provides abortion services was overturned by the Seventh Circuit U.S. Court of Appeals. The ruling differs from a Fifth Circuit U.S. Court of Appeals decision to uphold legislation that refuses state funding to Planned Parenthood and other abortion providers in Texas.
- A settlement between legal advocates and the state of Pennsylvania's public welfare office acknowledges up to 100,000 individuals may have been wrongly terminated from the state’s Medicaid program due to eligibility. The state agreed to increase use of electronic databases to more accurately verify Medicaid eligibility. If re-enrolled, beneficiaries may submit receipts for reimbursement for any cost incurred for Medicaid covered expenses during the period they were without coverage.
- Enrollees in California's Major Risk Medical Insurance Program will see reduced premium rates in 2013 matching the Pre-Existing Condition Insurance Plan (PCIP), the federal program established per Section 1101 of the ACA for individuals with pre-existing health conditions unable to access affordable coverage. This measure will serve as a stopgap until 2014 when high-risk subscribers may purchase coverage through the state Health Benefit Exchange.
- Mississippi estimates more than 300,000 residents could be added to its Medicaid program by 2025 with projected cumulative state costs (2014-2025) of $1.07 billion. The cost to state government will be just under $100 million in 2017 when the federal match is reduced to 95 percent.
- In a letter to Governor Mary Fallin (R-OK), Senator Tom Coburn (R-OK) recommended Oklahoma not expand Medicaid to 133 percent of the FPL and instead work on improving public programs already in place.
Report: decline in the number of employers offering retiree health benefits
The number of private businesses offering retiree health benefits decreased significantly between 1997 and 2010, and employers that still offer retiree health benefits have generally adapted benefit packages resulting in increased retiree premiums, decreased eligibility, or reduced coverage features. Notable findings:
- Private firms offering retiree health benefits decreased from 29 percent to 17 percent resulting in a net 4 percent decrease in the percentage of retirees over age 65 with health benefits.
- Most employers (78 percent) are very or somewhat likely to increase retiree contributions to premiums in the future.
- Employees expecting health benefits upon retirement have decreased, from 45 percent to 32 percent of workers.
- While 35 percent of current employees age 45 to 64 expected to receive health benefits upon retirement, 25 percent of early retirees and 16 percent of Medicare-eligible retirees actually received them in 2010.
(Source: Employee Benefit Research Institute, “Employment-Based Retiree Health Benefits: Trends in Access and Coverage, 1997‒2010,” October 2012)
Updated recommendations for cervical cancer screening and hormone therapy
Last Monday, the American College of Obstetricians and Gynecologists (ACOG) issued new guidelines recommending that most women should be screened for cervical cancer (Pap test) once every three to five years, instead of annually. The new guidelines also recommend that women over the age of 30 receive the Pap test and the human papillomavirus (HPV) test simultaneously every five years.
Related: the U.S. Preventive Services Task Force (USPSTF) recommended against the use of combined estrogen and progestin hormone therapy treatments for the prevention of chronic conditions in postmenopausal women, and the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. Both treatments received a grade “D” rating from the Task Force based on the evidence of both the benefits and harms of the service.
Background: per Section 2713 of ACA any group health plan or insurer in the group or individual market must provide preventive health services rated grade “A” or “B” by USPSTF with no cost sharing or co-payment beginning August 1, 2012.
Report: medical devices spending up almost 1 percent
In 2010, medical device spending was 6 percent ($156 billion) of the $2.6 trillion the nation spent on health care, representing an increase of 0.7 percent from 1989 to 2010. During this time, the Health Care Consumer Price Index (MC-CPI) increased 4.7 percent, and the Medical Care Services Consumer Price Index (MCS-CPI) increased 5 percent
(Source: Gerald Donahoe, Guy King, “Estimates of Medical Device Spending in the United States,” October 2012)
Study: declines in U.S. biomedical and health R&D funding threaten global competition
A Research!America analysis of biomedical and health research and development (R&D) spending in the U.S. revealed that R&D declined 3 percent ($4 billion) in FY2011, the first spending decline since 2002. The report noted that much of this decline comes from the expiration of $10.4 billion in funding designated to the National Institutes of Health (NIH) by the American Recovery and Reinvestment Act. Per the report, sequestration might threaten the nation’s biomedical and health research capacity and ability to compete globally by reducing federal biomedical and health research funding by 8-10 percent. Notable findings:
- Federal funding for research declined 14 percent in FY11, totaling $39.5 billion in 2011
- Overall industry investment in R&D increased 1.4 percent from 2010, $77.6 billion in 2011
- Pharmaceutical industry investment in R&D increased 3 percent from 2010, $38.5 billion in 2011
- Biotechnology investment in R&D declined 3 percent ($800 billion) from 2010, $29.2 billion in 2011
- Medical device industry investment in R&D increased 7.4 percent from 2010, $9.8 billion in 201
(Source: Research!America, “2011 U.S. Investment in Health Research,” October 2012)
“Congress needs to grant the FDA whatever additional powers it deems necessary to inspect the pharmacies, monitor their sales and judge the safety or effectiveness of their products. The problems need to be addressed on a nationwide basis, not just through states, which often have limited resources and expertise.”
— The New York Times, Editorial Page, “Deeper Concerns about Drug Compounding,” October 26, 2012
“I was always confident that the Affordable Care Act, a.k.a. Obamacare, was constitutional. It was interesting to see them, or Justice Roberts in particular, take the approach that this was constitutional under the taxing power. The truth is that if you look at the precedents dating back to the 1930s, this was clearly constitutional under the Commerce Clause. I think Justice Roberts made a decision that allowed him to preserve the law but allowed him to keep in reserve the desire, maybe, to scale back Congress’ power under the Commerce Clause in future cases.”
— President Barack Obama, Rolling Stone, October 2012
- Economic outlook: the GDP is expected to grow 2.3 percent next year, up from 1.65 percent in first half of 2012; unemployment is expected to end 2013 at 7.6 percent vs. 7.8 percent in 2012; job growth is expected to average 175,000/month. (Source: USA Today survey of 48 economists, October 15-18, 2012)
- Obesity and school food: kids consume 30-50 percent of their calories at school; one in three is overweight or obese. (Source: U.S. Department of Agriculture [USDA])
- High caffeine sports drinks: emergency room (ER) visits attributable to sports drinks increased ten times from 1,128 in 2005 to 13,114 in 2009. (Source: Substance Abuse and Mental Health Services Administration [SAMHSA], November 22, 2011)
- Debate viewership: October 3 (domestic policy)—67.2 million, October 11 (domestic and foreign policy)—51.4 million, October 22 (foreign policy)—65.6 million. (Source: Nielsen)
- College tuition: average cost for tuition, room, and board after financial aid is $12,110 vs. sticker price of $17,860 for public four-year schools and $23,840 for private four-year school sticker price of $39,520; represents a sticker price increase of 3 percent and actual price increase of 4.8 percent over prior year. (Source: The College Board)
- Multigenerational homes: 4.3 million U.S. households—5.6 percent of total—have three or more generations—up from 3.7 percent in 2000. (Source: U.S. Census Bureau 2009-2011 American Community Survey)
- Campaign 2012 polling: 31.6 percent of the samples used in polling in this cycle are on mobile devices. (Source: Real Clear Politics average of the eight polls it follows)
- Medicare appeals: Part A hospitals: 14.1 million Medicare claims were denied, 295,000 were appealed, 40 percent of the appeals were successful; Part B physicians: 93 million claims denied, 2.4 million appealed, 53 percent reversed. (Source: CMS)
- Lower income household consumption: households with incomes in the bottom fifth account for 8.7 percent of total consumption—unchanged since 2000; 47.7 percent have personal computers vs. 19.8 percent in 2000, households with six or more rooms increased from 21.9 percent to 30 percent, 75.5 percent have cell phones. (Source: American Enterprise Institute, BLS Consumer Expenditure Survey)
- Medicaid enrollment: Medicaid spending increased 2 percent in FY2012 with a 3.2 percent increase in enrollment compared to a 9.7 percent increase in spending and a 4.4 percent increase in enrollment in FY2011. (Source: Kaiser Commission on Medicaid and the Uninsured, October 2012)
- Medical school applicants: 45,266 applicants for 2012 school year, a 3.1 percent increase from 2011. Total enrollment is projected to increase by 30 percent within the next three to four years. In 2013, four new medical schools are scheduled to open. (Source: Association of American Medical Colleges [AAMC], “Medical School Enrollment Continues to Climb with New Diversity Gains,” October 2012)
- Medical cost burden: the recession did not increase the percentage of individual discretionary spending for health care over 10 percent because individuals decreased out-of-pocket spending overall to adjust to their lower compensation; 19 percent of people under age 65 spend more than 10 percent of their discretionary income on health care. (Source: Health Affairs, “Despite the Recession’s Effects on Incomes and Jobs, the Share of People With High Medical Costs Was Mostly Unchanged,” October 2012)
- Adverse birthing events: on average 52,000 women experience severe maternal morbidity per year; 114 percent increase in 2009 from 1998 for postpartum hospitalizations. (Source: Obstetrics & Gynecology, “Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the United States,” November 2012)
- Health insurance coverage: in 2011, 92.5 percent of children had access to health insurance. Significant drop in health insurance coverage for kids occurred in 20 states, down from 34 states between 2009 and 2010. (Source: Georgetown University Health Policy Institute Center for Children and Families, “Uninsured Children 2009-2011: Charting the Nation’s Progress,” October 2012)
- Access to orthopedic surgeons for Medicaid enrollees: in the past six years the number of orthopedic surgeons accepting children enrolled in Medicaid with a broken arm dropped 40 percent; access to orthopedic surgeons for children with private insurance decreased 10 percent since 1996. (Source: American Academy of Pediatrics, “Fewer Orthopedic Surgeons Accepting Pediatric Medicaid Patients,” October 2012)
- Consumer reaction to health information exchange: 86 percent want personal health information (PHI) to be protected, 86 percent want to be continually informed about who has seen their health information, and 78 percent want to control what information is shared. (Source: Annals of Family Medicine, “Health Care Consumers’ Preferences Around Health Information Exchange,” October 2012)
- Global comparisons: the U.S. spends 2.5 times more than the average health expenditure per person of the 34 Organisation for Economic Co-operation and Development (OECD) countries. Notable comparisons: physicians/1,000: U.S. 2.4 vs. OECD 3.1; hospital beds/1,000: U.S. 2.6 vs. OECD 3.4; life expectancy at birth: U.S. 78.7 vs. OECD 79.8. (Source: OECD Health Data 2012)
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