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Empowering Patients As Partners In Health Care


July 24th, 2014

Recently, the National Patient Safety Foundation’s Lucian Leape Institute brought together 40 patient safety experts — health professionals, patients, advocates, and others — to develop recommendations for how best to engage patients and families in improving patient safety. They represented patient advocacy organizations, health systems, professional societies, researchers, and international safety organizations.

During the course of two lengthy roundtable discussions, participants were asked to reflect on an experience in which they or someone close to them had experienced harm at the hands of the health care system and how they responded. Among the stories we heard:

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The Alternative Payment Methodology In Oregon Community Health Centers: Empowering New Ways Of Providing Care


July 21st, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Oregon model.

The Alternative Payment Methodology (APM) demonstration project enables participating Oregon community health centers to receive a monthly payment based on the size and composition of their patient population. This payment replaces the model of earning revenue based on the number of individual patients seen, shifting the paradigm from the number of doctor visits to the provision of high-quality, team-based, patient-centered care.

So what are the real changes physicians are seeing on the ground in clinics where APM is being implemented?

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Recent Health Policy Brief: E-Cigarettes And Federal Regulation


July 11th, 2014

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) describes federal policy makers’ recent efforts to propose rules for e-cigarette regulation. E-cigarettes, virtually non-existent ten years ago, have skyrocketed in popularity, including among people who claim to use e-cigarettes as a tool to help them quit smoking altogether.

The 2009 Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration (FDA) authority to oversee the manufacture, marketing, distribution, and sale of regulated tobacco products such as cigarettes, tobacco in cigarettes, roll-your-own, and smokeless tobacco. But it left unregulated other tobacco products such as cigars, pipe and hookah tobacco, nicotine gels, and e-cigarettes.

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Implementing Health Reform: A Follow-Up Supreme Court Contraceptives Decision At Odds With Hobby Lobby


July 4th, 2014

On July 3, 2014, the Supreme Court decided its second contraceptive case of the 2013-2014 term, Wheaton College v. Burwell. The decision demonstrates why more Americans now believe that the justices are doing a poor job (27 percent) than believe they are doing an excellent or good job (26 percent combined), and why 76 percent of Americans believe that the justices decides cases based on their own personal and political opinions rather than legal analysis.

The Wheaton College decision seems to contradict directly the Hobby Lobby decision the Court had entered three days earlier. The Court offered virtually no justification for its change of position. Indeed, one wonders whether the men on the Court, in their haste to get out of town even bothered to read the scathing but well-reasoned dissent filed by Justice Sotomayor for the women of the Court, with which they did not engage.

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After Hobby Lobby: How Might Policymakers Mitigate The Decision’s Impact On Women And Families?


July 3rd, 2014

Editor’s note: In addition to Sara Rosenbaum, Adam Sonfield and Rachel Benson Gold also coauthored this post. 

On June 30, the U.S. Supreme Court handed down a ruling that has the potential to undermine an important provision of the Affordable Care Act (ACA) that establishes for women a federal guarantee of coverage for their full range of contraceptive methods, services, and counseling without any out-of-pocket costs. This guarantee is administered through private health plans, whether purchased in the individual market or made available through the insurers and plan administrators that provide group coverage.

The 5-4 ruling in Burrell v. Hobby Lobby Stores, written by Justice Samuel Alito on behalf of the Court’s conservative bloc, held that closely held for-profit corporations that assert a religious objection to some or all forms of contraception cannot be required to include such coverage in the health plans they sponsor for employees and their families. As emphasized by Justice Ruth Bader Ginsburg in her dissent (joined in whole by Justice Sotomayor and in part by Justices Kagan and Breyer), the Court’s decision could have serious and widespread consequences.

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The Supreme Court And The Contraception Mandate: A Temporary Setback For Contraception Coverage


June 30th, 2014

Editor’s note: See Health Affairs Blog for more coverage of the Supreme Court’s Hobby Lobby decision.

Today, the United States Supreme Court ruled that for-profit companies may avoid providing contraception coverage to employees if the companies sincerely object on religious grounds. At its narrowest interpretation, this decision is a significant but remediable setback for women’s reproductive health. At its broadest (but least likely interpretation), the decision has the potential to wreak havoc on public health regulation.

The legal challenges to the Affordable Care Act’s (ACA’s) contraception mandate have been well described in three previous Health Affairs Blog posts. To briefly recap, though, the ACA requires preventive services to be covered without copayments or other cost sharing in most employer-supported health plans. To implement this requirement, the Department of Health and Human Services (HHS) issued regulations that include all FDA-approved contraceptives, and a company that does not provide no-cost coverage of contraception is subject to substantial penalties.

Three groups of employers are exempt from the mandate: small businesses with less than 50 employees, purely religious employers, and “grandfathered” plans that have not changed meaningfully since the ACA was passed. Additionally, religiously affiliated non-profits (such as universities and hospitals) received a special accommodation from HHS by which women can receive contraception from third-party insurers at no extra cost to employees or the organization if the organization objects to covering contraception and identifies an alternate insurer.

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Correcting The Blind Spot In Accountability: The Role Of Pharmacy Care


June 25th, 2014

Editor’s note: In addition to William Shrank, this post is also coauthored by Andrew Sussman, Patrick Gilligan, and Troyen Brennan.

The Centers for Medicare and Medicaid Services (CMS) recently issued a Request for Information (RFI) to solicit suggestions about how to improve the Accountable Care Organization (ACO) programs. CMS stated that they seek recommendations about how the ACO program might evolve to “encourage greater care integration and financial accountability.”

The RFI explicitly stated that they seek information about how to better integrate Part D expenditures into ACO cost calculations to make pharmaceuticals part of the approach to care delivery and health care transformation.

The deadline for comments about encouraging Part D integration in ACOs has now passed. But the issue extends beyond ACOs. In addition, bundled payments and patient-centered medical home programs target hospitals and primary care providers to promote higher quality and lower cost care. All these programs have largely excluded prescription drug costs in their calculus, and offer no direct incentives for Part D plans to participate in and improve care.

Nonetheless, retail pharmacies and Part D plans have developed a number of strategies to participate. As CMS and policymakers reconsider ACO regulations to stimulate greater integration of prescription drug use in delivery system reform, we thought it important to offer a description of the marketplace response to payment reform activities at large.

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This Is Not Your Mother’s Payment Model: Reflections On The APM Pilot


June 18th, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation.

In early 1994, as I went about finding a practice to join after residency, every physician with whom I spoke discussed managed care at length. As a young family physician dedicated to prevention and early intervention, I was convinced that managed care answered many of the historical challenges faced by primary care physicians. At last we’d be able to pay for the social workers who could facilitate important mental health care and human services for our patients and for the group nutrition classes we wanted to run in our practices.

Yet just four years later, as I left private practice to return to academic medicine, managed care was virtually dead. All its promise had been undermined by a range of structural and environmental challenges.

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FDA Should Pass The Salt…Standards


June 16th, 2014

Editor’s note: In addition to Rep. Rosa DeLauro, Sen. Tom Harkin also coauthored this post.

For years, Americans have been inundated with messages about the dangers posed by the food we eat whether from fat, carbohydrates, or sugar. But another additive lurks in virtually every package and bag on the supermarket shelves, as well as practically every restaurant meal, and it is having a dire impact on our health.

That additive is sodium, and Americans are consuming far too much, with profoundly negative consequences on our health and well-being as a country. It is time for the U.S. Food and Drug Administration (FDA) to take serious and meaningful action to address this trend and issue federal standards to reduce the amount of salt in our foods.

Current dietary guidelines recommend that most individuals between the ages of 2 and 50 consume no more than 2,300 milligrams of sodium a day, or approximately one teaspoon of salt. For the roughly two-thirds of Americans in an at-risk population – seniors, African-Americans, those with high blood pressure, and individuals susceptible to hypertension, diabetes, or chronic kidney disease – only 1,500 milligrams is recommended.

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Agenda Overload In Primary Care: A Call To Protect The Real Capital Of Caring


May 15th, 2014

“When you go in to see a patient, you need to be focused. You need to have your agenda clearly in mind.”

As a physician educator offered this advice to hundreds of clinicians at a recent primary care update conference, heads nodded in agreement. It seemed like reasonable counsel given the wide range of complex goals of today’s primary care. But my heart sank as the address continued. Underlying the call for focus was a perspective that patients often bring up issues during a visit that distract us from priorities.

Both the sentiment expressed and the audience’s acquiescence indicate how far we have moved away from our patients’ agendas. I don’t think any of us in that convention center chose our careers thinking we would someday experience patients’ concerns as distractions in our work day. This incident was a sign to me that we need to chart a course back to the type of care that listens to and responds to patients.

The conference encapsulated a tension I had been feeling in my own practice for years. I was a family physician in what I consider an excellent, mission-driven community health center. We had motivated staff, interdisciplinary team care, electronic medical records, and many organizational efforts for quality improvement. Clinically, I found myself moving from room to room, pressured by time, trying to keep up with a multitude of health maintenance or quality metric items, and often feeling unable to engage with “yet another” issue that the patient in front of me wanted to talk about. While it was my goal and the goal of our practice to give compassionate, holistic care to patients, too often it seemed that the time and mental/emotional reserve to listen to patients were crowded out.

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Hobby Lobby, Conestoga Wood, The ACA, And The Corporate Person: A Historical Myth Bedevils The Law


April 18th, 2014

On March 25, 2014, the Supreme Court of the United States heard arguments in two cases—Sebelius v. Hobby Lobby Stores, Inc. and Conestoga Wood Specialties v. Sebelius—challenging the validity of the Affordable Care Act’s (“ACA”) mandate that employer-sponsored health plans cover all FDA-approved contraceptives (the “Contraceptive Mandate”). In each case, closely held plaintiff corporations contend that the Contraceptive Mandate illegally infringed upon the corporations’ freedom to exercise religion.

The cases attracted attention because the Supreme Court had agreed to hear yet another challenge to the validity of the ACA’s provisions, but it has been less noticed that both cases, and others like them, implicate a fundamental question that the Supreme Court has never decided; on what basis, if any, is a corporation a “person” entitled to assert the constitutional and statutory rights of natural persons. Without denying the significance of the challenge to the ACA’s Contraceptive Mandate, the Supreme Court’s failure to define a principled corporate person theory has had—and continues to have—important and pervasive implications for the American legal system beyond the present cases.

Typically, legal concepts creating and regulating societal rights and obligations, like the corporate personhood concept, come into being incrementally in an extended evolutionary process. That evolutionary process is characterized by a dialectic give and take in which the principles justifying—or precluding—application of the concept in a variety of different factual scenarios are gradually clarified, defined and developed through a series of judicial decisions. The problem confronting the Supreme Court as it considers the Hobby Lobby and Conestoga Wood cases is that the concept of corporate personhood did not develop gradually or in an evolutionary process in which the meaning of the concept was developed and defined. Instead, the concept of the corporate person was imposed on the law ipse dixit, that is, by judicial fiat and without definition, in a series of late nineteenth century Supreme Court cases.

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Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers (Updated)


April 18th, 2014

On February 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges. This significantly exceeds the White House’s original goal of 7 million enrollees. It is far more than the Congressional Budget Office’s recent projections of 6 million.

The number of actual enrollees will be smaller than this number. The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year. To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year. In the end, 6 to 7 million average enrollees is probably a reasonable estimate.

This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act. The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA. This number is probably high, but it is clear that the ACA has dramatically increased coverage of Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still).

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The New Nutrition Facts Panel: Public Health Improvement Or Distraction?


March 19th, 2014

Last month, the United States Food and Drug Administration announced long awaited proposed changes to the Nutrition Facts Panel (NFP), the nutrition information found on the back of packaged foods and beverages. The NFP is required to be on all packaged foods, with significant regulations on what is presented and how the information can be presented. Initially mandated in the first Bush Administration, the NFP offers a clear and consistent manner of presenting nutrition information—at least for those with the time and nutrition knowledge to benefit from the information.

The key questions behind the proposed changes are: will they be successful in altering consumer behavior, how might they be improved, and what overall role might they play in obesity prevention?

The NFP is clearly a source from which those already motivated and knowledgeable can easily access information and a base on which to build future approaches to addressing obesity. Put differently, this information will only work if people actively, directly choose to turn the package over, engage in information, and push past the many impulses pulling them towards the less healthy foods. The compelling nature of unhealthy foods means that individuals have to be particularly motivated, or the nutrition information has to be particularly compelling.

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Neighborhood Grocery Stores Combat Obesity, Improve Food Perceptions


March 12th, 2014

The Cummins et al article “New Neighborhood Grocery Store Increased Awareness of Food Access but Did Not Alter Dietary Habits or Obesity,” published in the February issue of Health Affairs, generated considerable media attention, with headlines claiming that grocery stores do not contribute to healthy diets or reductions in obesity.  However, the study offered no conclusive proof showing that access to grocery stores is not a part of the solution to preventing obesity.  In fact, the study showed clear signs of promise that the intervention was working in key aspects during the short time the researchers collected data.  Within just a few months after the new supermarket opened, for example, researchers documented significant improvement in residents’ perceptions about the choice and quality of fresh fruits and vegetables, along with improvements in their perception of healthy food accessibility.

The subject of the study, the Fresh Grocer in North Philadelphia, is a beautiful store with a bountiful fresh produce section. The supermarket, which is now thriving in one of the poorest neighborhoods in the country, was built from the ground up after a 15-year hiatus in which the surrounding community had no grocery store. Its opening has revitalized a historic African-American owned shopping plaza and reinvigorated the local neighborhood’s retail economy.

Has the store reduced the rate of obesity among local residents? This is a crucial question, but one that cannot be adequately deduced from the present study. All we know from this study’s findings is that obesity rates did not change significantly during the first six to nine months after the store’s opening – not surprising, given the many decades of gradual changes in eating habits that have led to the obesity epidemic.

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Howard Koh To Keynote Health Affairs Briefing Tomorrow On ACA And HIV/AIDS


March 10th, 2014

One of the least explored yet most important parts of the Affordable Care Act (ACA) are provisions that hold promise for addressing serious health care challenges facing the 1.1 million Americans who are living with HIV/AIDS — and others like them — most of whom are impoverished and uninsured.

Please join Health Affairs Founding Editor John Iglehart on Tuesday, March 11, in Washington, DC, for a Health Affairs briefing on our March issue where we will spotlight topics related to the ACA and people with HIV/AIDS. The briefing will be keynoted by Howard K. Koh, Assistant Secretary for Health, U.S. Department of Health and Human Services.

WHEN:
Tuesday, March 11, 2014
9:00 a.m. – Noon

WHERE:
National Press Club
529 14th Street NW, Washington, DC, 13th Floor (Metro Center)

REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_HIVAIDS

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Financial Orphan Therapies Looking For Adoption


March 6th, 2014

There exist scientifically promising treatments not being tested further because of insufficient financial incentives. Many of these therapies involve off-label uses of drugs approved by the Food and Drug Administration that are readily available and often inexpensive. Pharmaceutical companies—largely responsible for clinical drug development—cannot justify investing in such clinical trials because they cannot recoup the costs of these studies.  However, without prospective data demonstrating efficacy, such treatments will never be adopted as standard of care.

In an era of increasing health care costs and the need for effective therapies in many diseases, it is essential that society finds ways to adopt these “financial orphans.” We propose several potential solutions for the non-profit sector, pharmaceutical companies, health insurers, patient driven research and others to accomplish this goal.

Drug Development Today

Under today’s drug development model, the vast majority of clinical trials are sponsored by pharmaceutical companies, and the process is lengthy, expensive, and, some have argued, inefficient. The cost of developing a new FDA approved drug is estimated to exceed $1.2 billion, the average time from lead to market is typically over 10 years, and only 1 in 10 drugs entering a phase I study is finally approved. Thus pharmaceutical companies, seeking to recoup this investment, conduct a return on investment (ROI) calculation with attention to both scientific and financial considerations such as the chances of success and whether the therapy will be sufficiently profitable to justify the high cost of clinical development.

These considerations sometimes lead to inefficient outcomes from society’s perspective in which promising and potentially transformative therapies are not pursued because of improperly designed financial incentives. We call such therapies “financial orphans.”

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A Call For A Deeper, Cross-Sector Examination Of The Hunger-Health Link


February 18th, 2014

Evidence continues to build that hunger should be approached in some measure as a public health issue, and Hilary Seligman of the University of California, San Francisco and co-authors contribute to this trove of research in the January Health Affairs journal article “Exhaustion of Food Budgets at Month’s End and Hospital Admissions for Hypoglycemia.” Hunger-relief organizations across the country can attest to the long-observed pattern of a rise in demand for food distribution at the end of the month. In fact, meal providers and food pantries tailor their decisions about purchasing, staffing, and program design around the uptick in client need as the month comes to a close. Seligman et al correlate this surge in demand with an increase in hospitalization among low-income individuals the fourth week of the month (a 27 percent increase in hospitalization among low-income individuals for hypoglycemia, according to their study). These findings suggest the profound need to devise food policies and programs with public health in mind.

However, to effectively address hunger as a public health issue in particular, hunger-relief organizations, community health organizations, universities, government, and others must take a collective impact approach. This cross-sector approach to complex, systemic social issues fosters coordination among such groups so they can have a greater positive impact than if they were to operate independent of one another; it is being turned to with increasing frequency to create large-scale social change. Policy can encourage a collective impact approach; it is already happening in the case of hospitals, which under Section 3025 of the Affordable Care Act, are penalized a portion of their Medicare reimbursement if they have a higher than expected rate of acute care readmissions within 30 days of discharge. (See 42 CFR part 412P.)

New community and regional partnerships are beginning to develop in part because of this incentive. The Atlanta Community Food Bank, for example, which distributed 21.8 percent more food and grocery items this past fiscal year than the last, is in early discussions with the Atlanta Regional Commission, the city health department, regional hospitals, and universities. Together they aim to confront the need for better health education and sustained access to nutritious food among low-income individuals discharged from hospitals for chronic, diet-related disease like diabetes, congestive heart failure, and associated complications. This is precisely the type of alliance that could help address the issues laid out in “Exhaustion of Food Budgets…” Policymakers need to build on this kind of ingenuity taking place in the field – especially if those in the field are expected to do more with less. That will certainly be the case, as the recently enacted Farm Bill imposes $8.6 billion in cuts to SNAP over the next 10 years, increasing demand on hunger-relief organizations even further.

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Health Affairs “Community Development And Health” November 2014 Theme Issue: Announcement


February 18th, 2014

Health Affairs plans to publish an issue on the topic of “Community Development and Health” in November 2014. Details on the upcoming issue are available here. The deadline for submissions is June 1, 2014.

Papers will be competitively reviewed by editors, and, for those that are selected for external review, outside experts. We will make publication decisions based on these selection processes.

If you are interested in submitting a paper, please review our submissions procedures and guidelines. Contact senior deputy editor Sarah Dine (sdine@projecthope.org) or executive editor Don Metz (dmetz@projecthope.org) with any questions.

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Workplace Wellness Programs: Continuing The Discussion


January 27th, 2014

Editor’s note: One of the most-read Health Affairs articles last year was “Wellness Incentives In The Workplace: Cost Savings Through Cost Shifting To Unhealthy Workers,” by Jill R. Horwitz,.Brenna D. Kelly, and John E. DiNardo. The article engendered a Health Affairs Blog discussion between the authors and Ron Goetzel. (See here, here, here, and here.) Below is another installment of that discussion, from Ron Goetzel.

I have had several back and forth conversations with Professors DiNardo and Horwitz. I won’t bore the readers with a re-hash of old arguments. We don’t need to re-litigate the basic premises of our debate, from either point of view. Those interested in following that discussion can review our previous posts.

I would, however, like to respond to a central point made by DiNardo and Horwitz that employers should not interfere with the private lives of employees. I agree with this assertion to a certain point. It should be noted that many employers do “interfere” with employees’ private lives by not allowing them to smoke on premises, requiring them to wear seat belts when driving company vehicles, mandating that they wear protective gear (hard hats, work boots, gloves) at construction sites, and so forth.

Certainly, an employer cannot and should not tell workers what to eat or how much to exercise. However, an employer can provide guidance, education, skill building, and support programs to workers who wish to eat healthy foods and become more physically active. That, in my mind, is not interfering in workers’ lives but rather supporting their efforts at leading a healthy lifestyle.

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Implementing Health Reform: Filling In Details About The Shared Responsibility Requirement (Updated)


January 26th, 2014

Although the Department of Health and Human Services has more or less finished its Affordable Care Act private insurance reform rulemaking agenda for the time being, the Internal Revenue Service still has important regulations outstanding. On January 23, 2014, the Internal Revenue Service proposed a set of less important regulations that further elaborate on the details of the shared responsibility or minimum essential coverage requirement, often called the individual mandate. These proposed rules will supplement and fill a few gaps in the final regulations published in August of 2013, described in an earlier Health Affairs Blog post.

The shared responsibility requirement obligates individuals who are not subject to an exemption to maintain minimum essential coverage (MEC) or pay a tax penalty. This requirement was upheld as a legitimate exercise of the power of Congress to tax in National Federation of Independent Business v. Sebelius.

MEC includes individual coverage, employer coverage, grandfathered coverage, and coverage under a number of government programs, such as Medicaid and Medicare. MEC, however, neither includes all forms of individual insurance coverage nor coverage under all government programs. Under previous rules, for example, MEC does not include Medicaid coverage that does not provide comprehensive medical coverage but rather only covers specific services such as family planning services, tuberculosis-related coverage, pregnancy-related services, or emergency medical care.

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