March 28, 2024 • 16 mins
In Case You Missed It… In this episode of TMA's Practice Well Podcast, we cover several interesting and valuable topics aimed to help physicians across Texas thrive. We begin with a story on the significant reduction of administrative strain using virtual scribes in medical practice. We delve into how these scribes streamline notetaking and paperwork processes within Electronic Health Records (EHR), leading to improved time management and overall physicians' satisfaction.
Next, get the details on a notable decrease in the Medicare Physician Pay cut, achieved through high-pressure advocacy by TMA and others in organized medicine, brought some relief to physicians and their practice wellbeing. However, we emphasize the concerted efforts towards additional reform, as lack of suitable Medicare physician payments threatens physicians' practice viability and patient care access.
Lastly, we highlight the recent flexibilities announced by CMS due to a cyber-attack on Change Healthcare, which disrupted many practices' operations. We present various ways this is being addressed, from request acceleration of Medicare payments to alternative methods for submitting claims. This section serves to provide crucial advice during such disruptions and aid in navigating through them.
The episode wraps up with a reminder of the wealth of free resources provided for TMA members. Stay tuned to Practice Well for more valuable insights. Until next time, stay well.
Resource Links
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
Thank you for listening to TMA's Practice Well podcast. TMA,
helping you improve the health of all Texans.
Music.
Hi, I'm Cheryl Kroviak. I produce the TMA Practice Well podcast and manage the
TMA education center, where through on-demand webinars,
(00:26):
PDF publication, and CME to go podcast episodes, we strive to help Texas physicians thrive.
TMA, the Texas Medical Association, provides several timely curated newsletters and magazine issues.
Delivered to your email daily, look for TMT, Texas Medicine Today,
for top stories and association news, and Medical News Roundup,
(00:50):
or mainstream news that affects Texas physicians.
Texas Medicine Magazine delivers timely information on public health,
medical economics, and legislative affairs affecting Texas physicians and their patients.
With the hundreds of things pulling at our attention at any given time,
it's easy to miss that nugget of information that could make your life easier
(01:10):
or keep you from being caught unawares.
So, in case you missed them, here are three recent stories that Texas physicians
found most interesting.
Music.
Let's start with virtual scribes enhanced relationships between patients and physicians.
(01:31):
At a time when physicians face burnout, often due to administrative stress,
two new studies from Boston Brigham and Women's Hospital and Massachusetts General
Hospital found virtual scribes cut physician burden by 16% and enhanced relationships
between patients and 60% of physicians.
The American Medical Association Practice Transformation EHR Use Research Grant
(01:55):
Program supported the studies, which examined the experience of physicians who
use virtual scribes for note composition,
documentation, and paperwork within their electronic health records.
Those who used a scribe saw significant changes in note-taking time per appointment
and the amount of time they had to dedicate to work after hours.
In total, virtual scribes saved about five and a half minutes in EHR time for
(02:19):
appointments minutes, cutting that time from 35.1 minutes to 29.5 minutes.
Almost 40% of physicians said that they were very satisfied or satisfied with
the scribe service they had used, and 65% felt that a scribe service had enhanced their well-being.
24% said that the scribes improved their note quality.
(02:41):
Austin pediatrician Kelly Chalet, MD, says using a scribe has been the most
impactful strategy her practice has implemented against burnout.
She says EHR burden is so severe that the decision to use a virtual scribe came
almost out of necessity.
She said, my patients' care and their charts always come first,
but then all of my free time is consumed with administrative tasks.
(03:03):
Having a scribe on hand helps me navigate that enormous workload.
Dr. Jolay says her scribe, a registered nurse, virtually attends appointments
to document care notes, patient history, and to communicate prescription information
with medical assistants.
Dr. Jolay still prefers to manually read each of her inbox messages.
But after she reviews the content, her scribe answers patient questions,
(03:26):
sends visit reminders, and conducts a refill request.
Overall, Dr. Gillet said the extra help gave her practice room to breathe and
said this really helps to reduce the amount of work she's doing at home.
Virtual scribes can't do everything. You still need a physician to be in the
driver's seat to ensure documentation properly backs up patient care.
(03:47):
But at the very least, scribes ensure we don't have to take the longest route home.
Shannon Vogel, Associate Vice President of Health Information Technology,
states, in addition to replacing an in-office scribe with a virtual one,
there is an emerging trend with the use of ambient scribes.
An ambient scribe is an application that uses artificial intelligence to listen
(04:09):
to the patient-physician encounter and appropriately document the visit.
As with virtual scribes, the physician is responsible for reviewing and approving
the content before closing the note.
Remember that HIPAA requires practices to have a business associate agreement
in place with any virtual scribe that has access to electronic health information.
The U.S. Department of Health and Human Services requires the agreement to contain
(04:33):
description of the allowed and required uses of electronic health information.
Provide that business associates will not use or further disclose the information
other than as permitted or required by the contract or as required by law,
and document that the business associate used appropriate safeguards to prevent
unauthorized use or disclosure of the information, including implementing requirements
(04:56):
of the HIPAA Security Rule with regard to electronic protected health information.
Music.
This next piece brings some good news. Congress mitigates 2024 Medicare physician pay cut.
Congress recently passed legislation having the 3.4% Medicare physician pay
(05:20):
cut that took effect on January 1st, 2024, following a months-long high-pressure
advocacy campaign by the Texas Medical Association,
the American Medical Association, and others in organized medicine.
But TMA and its allies continue to push for additional reform,
given that any cut threatens physicians' practice viability and vulnerable patients' access to care.
(05:43):
TMA President-elect Ray Callas, MD, recently told Texas Medicine Today.
Every time we ask for a Band-Aid, we still get a scratch.
President Joe Biden signed into law on March 9th a $460 billion spending package,
averting a shutdown of some federal government agencies.
The package included a provision reducing the Medicare physician pay cut to 1.68%, now in effect.
(06:11):
However, physicians already have shouldered the burden of the higher 2024 cut
for more than two months.
TMA and others have repeatedly warned lawmakers of risk of practice closure,
early retirement, and reductions in health care services, office hours,
and Medicare patient panels.
For example, Haskell family physician C.
(06:33):
Wayne Cadenhead, M.D., closed his office doors for the last time in late December
of 2023, unable to withstand yet another Medicare physician pay cut.
I've had enough, he told Texas Medicine Today in his practice's final days.
These consequences are likely to continue under the new law,
with Medicare physician payments still falling short of rising practice costs.
(06:57):
The cut enacted via the 2024 Medicare physician fee schedule stems from a much-maligned
federal budget neutrality provision that requires any physician pay increase
or decrease to be offsetting,
as well as from congressional inaction on Medicare payment policy,
both of which further erode Medicare physician payment. payment.
(07:18):
Between 2001 and 2023, such pay decreased by 30% when adjusted for inflation,
even as Medicare payments to other sectors generally kept pace, according to the AMA.
Over the same period, the Consumer Price Index for physician services in U.S.
Cities increased 65%. TMA, AMA, and others remain focused on reforming Medicare
(07:42):
physician payment policy to prevent similar cuts in the future.
TMA will not let up in its efforts to protect Texas patients and physicians
from these ongoing harmful cuts, TMA President Rick Snyder, M.D.,
said in a January 19 statement.
Congress must act now to resolve this decades-old problem.
(08:03):
In pursuit of a long-term fix, TMA supports the bipartisan Strengthening Medicare
for Patients and Providers Act, House Resolution 2474 by U.S.
Representative Raul Ruiz, MD, which would provide annual inflationary updates
to the Medicare Physician Fee Schedule in line with the Medicare Economic Index,
(08:25):
a measure of practice cost inflation, among other reforms.
Music.
And the last piece, in case you missed it, CMS announces flexibilities following cyber attack.
CMS recently announced two flexibilities related to the Medicare's Merit-Based
(08:48):
Incentive Payment System, commonly referred to as MIPS, for the 2023 performance year,
citing the recent cyber attack on change health care and heeding advocacy by
organized medicine. Listen.
First, CMS extended the data submission period until April 15th at 7 p.m.
Central Time for all participants.
(09:09):
At stake is a pay cut of up to 9% in the 2025 payment year.
Second, the federal agency reopened applications for an extreme and uncontrollable
circumstance exception, also until April 15th at 7 p.m.
Central Time. MIPs participants impacted by the cyber attack may apply for the
(09:29):
exception to request reweighting of MIPs performance categories by the same deadline.
Federal officials have announced several flexibilities that aim to help physicians
in the wake of the cyber attack against Change Healthcare, which upset payment
and revenue cycle management operations for practices across the country.
Earlier in March, CMS announced an accelerated avenue of assistance for physicians
(09:50):
and practices impacted by the attack.
Practices may now request advanced Medicare payments in order to sustain practice
operations during this disruption.
Change Healthcare had anticipated that electronic payment functionality via
its payment platform would be available for connection beginning March 15th.
The company website also said Change Healthcare has experienced a cybersecurity
(10:15):
issue and we have multiple workarounds to ensure provider claims are addressed
and people have access to the medications and care they need.
The company's website provides resources for UnitedHealth Group,
UnitedHealthcare, Optum, and Change Healthcare stakeholders.
In addition to being a main source for the latest business and information update,
the page also contains links to other resources to support stakeholders in managing
(10:38):
any related impacts. PACs.
CMS had instructed Medicare Administrative Contractors, MACs,
to accept paper claims from physicians who need to use them and to expedite
physician requests to switch to new clearinghouses to work around the change healthcare outage.
HHS stated, while we recognize that electronic billing is preferable for everyone,
(10:59):
the MACs must accept paper submissions if a provider needs to file claims in that method.
Texas MAC Novitas recently shared instructions with the Texas Medical Association
experts on how physicians can send paper claims and work around ongoing issues
related to the cyber attack.
According to Novitas, paper claims processing requires a minimum 29-day payment
(11:21):
floor, which means payment cannot be released before the 29th day following receipt.
There is no automated editing for claims errors as there is with electronic
billing, so if a paper claim form contains mistakes, the Medicare contractor
will have to return the claim to the physician to make the correction for resubmission.
(11:42):
For electronic submissions, physicians can submit their claims through the direct
data entry or elect to change their network service vendor.
Novitas is expediting requests from healthcare professionals impacted by the
change healthcare issue as they come in.
Physicians can also enroll in Novitas portal, Novitasphere, which the contractor
(12:03):
says allows for claim submission and remittance retrieval.
The contractor also stated that due to Administrative Simplification Compliance
Act requirements, Medicare system settings for electronic-only billers need
to be manually updated to allow for paper submissions.
CMS has approved a waiver for those requirements for those impacted by the Change
(12:25):
Healthcare cyber attack.
CMS said it will issue guidance encouraging Medicare Advantage plans and Part
D sponsors to remove or relax prior authorization, other utilization management,
and timely filing requirements.
CMS is also encouraging Medicare Advantage plans to offer advanced funding to
healthcare professionals most affected by the cyber attack.
(12:47):
Additionally, CMS is strongly encouraging Medicaid and Children's Health Insurance
Program managed care plans to adopt similar strategies.
Physicians can submit requests for accelerated payment to their MAC for individual consideration.
These developments followed a March 1st letter to federal officials in which
the American Medical Association urged the federal government to take additional
(13:10):
steps to alleviate the damage caused by the cyber attack,
warning it could severely hamper physicians' abilities to care for patients.
A statement from the AMA said, given the combined financial impact of the change
health care hack and Medicare payment cuts to physician,
the AMA urged HHS to utilize any available emergency funds and authorities to
(13:34):
provide critical financial resources to physicians.
Ensuring they can continue to deliver essential health care services during
these challenging times, as well as facilitate expedited and direct communication
with physician practices. practices.
Physicians may continue to see disruptions in claims processing,
eligibility checks, or day-to-day practice operations due to ongoing system outages.
(13:58):
TMA experts recommend practices communicate with private health plans as well
to ensure they are accepting paper claims, and if not, refer them to HHS guidance
to make sure they are aware of CMS flexibilities.
The Texas Texas Department of Insurance and UnitedHealth Group,
which owns Change Healthcare through its Optum subsidiary, have offered claims
(14:20):
and payment flexibilities as well.
Concerned practices should conduct their own risk evaluation and, if necessary,
take steps to protect their network, which may include coordinating with their
electronic health record vendors to determine whether they should shut down
their exposure to Optum if they're using the Change Healthcare clearinghouse.
Additionally, practices should continue to evaluate updates from the company.
(14:45):
TMA experts also recommend physicians avoid delays in claims payment by using
alternative means of submission when appropriate.
Practices are encouraged to check with health plans to see if they can submit
claims via a physician's portal.
Music.
(15:05):
I hope this episode showcases the variety of information provided free for TMA members.
Check the episode description for the links to the articles from this episode.
And remember to like and follow to receive every episode from TMA Practice Well.
Until next time, stay well. all. TMA has a long, proud history of promoting
(15:27):
patient rights, advocating for physicians, and providing real solutions for your practice.
We can accomplish so much when we unite in one voice.
Call the TMA Knowledge Center at 1-800-880-7955 or visit textmed.org to find
out how you can join or renew your membership today.
Music.
Thank you for listening to TMA's Practice Well podcast. TMA,
helping you improve the health of all Texans.
Music.
Hi, I'm Cheryl Kroviak. I produce the TMA Practice Well podcast and manage the
TMA education center, where through on-demand webinars,
(00:26):
PDF publication, and CME to go podcast episodes, we strive to help Texas physicians thrive.
TMA, the Texas Medical Association, provides several timely curated newsletters and magazine issues.
Delivered to your email daily, look for TMT, Texas Medicine Today,
for top stories and association news, and Medical News Roundup,
(00:50):
or mainstream news that affects Texas physicians.
Texas Medicine Magazine delivers timely information on public health,
medical economics, and legislative affairs affecting Texas physicians and their patients.
With the hundreds of things pulling at our attention at any given time,
it's easy to miss that nugget of information that could make your life easier
(01:10):
or keep you from being caught unawares.
So, in case you missed them, here are three recent stories that Texas physicians
found most interesting.
Music.
Let's start with virtual scribes enhanced relationships between patients and physicians.
(01:31):
At a time when physicians face burnout, often due to administrative stress,
two new studies from Boston Brigham and Women's Hospital and Massachusetts General
Hospital found virtual scribes cut physician burden by 16% and enhanced relationships
between patients and 60% of physicians.
The American Medical Association Practice Transformation EHR Use Research Grant
(01:55):
Program supported the studies, which examined the experience of physicians who
use virtual scribes for note composition,
documentation, and paperwork within their electronic health records.
Those who used a scribe saw significant changes in note-taking time per appointment
and the amount of time they had to dedicate to work after hours.
In total, virtual scribes saved about five and a half minutes in EHR time for
(02:19):
appointments minutes, cutting that time from 35.1 minutes to 29.5 minutes.
Almost 40% of physicians said that they were very satisfied or satisfied with
the scribe service they had used, and 65% felt that a scribe service had enhanced their well-being.
24% said that the scribes improved their note quality.
(02:41):
Austin pediatrician Kelly Chalet, MD, says using a scribe has been the most
impactful strategy her practice has implemented against burnout.
She says EHR burden is so severe that the decision to use a virtual scribe came
almost out of necessity.
She said, my patients' care and their charts always come first,
but then all of my free time is consumed with administrative tasks.
(03:03):
Having a scribe on hand helps me navigate that enormous workload.
Dr. Jolay says her scribe, a registered nurse, virtually attends appointments
to document care notes, patient history, and to communicate prescription information
with medical assistants.
Dr. Jolay still prefers to manually read each of her inbox messages.
But after she reviews the content, her scribe answers patient questions,
(03:26):
sends visit reminders, and conducts a refill request.
Overall, Dr. Gillet said the extra help gave her practice room to breathe and
said this really helps to reduce the amount of work she's doing at home.
Virtual scribes can't do everything. You still need a physician to be in the
driver's seat to ensure documentation properly backs up patient care.
(03:47):
But at the very least, scribes ensure we don't have to take the longest route home.
Shannon Vogel, Associate Vice President of Health Information Technology,
states, in addition to replacing an in-office scribe with a virtual one,
there is an emerging trend with the use of ambient scribes.
An ambient scribe is an application that uses artificial intelligence to listen
(04:09):
to the patient-physician encounter and appropriately document the visit.
As with virtual scribes, the physician is responsible for reviewing and approving
the content before closing the note.
Remember that HIPAA requires practices to have a business associate agreement
in place with any virtual scribe that has access to electronic health information.
The U.S. Department of Health and Human Services requires the agreement to contain
(04:33):
description of the allowed and required uses of electronic health information.
Provide that business associates will not use or further disclose the information
other than as permitted or required by the contract or as required by law,
and document that the business associate used appropriate safeguards to prevent
unauthorized use or disclosure of the information, including implementing requirements
(04:56):
of the HIPAA Security Rule with regard to electronic protected health information.
Music.
This next piece brings some good news. Congress mitigates 2024 Medicare physician pay cut.
Congress recently passed legislation having the 3.4% Medicare physician pay
(05:20):
cut that took effect on January 1st, 2024, following a months-long high-pressure
advocacy campaign by the Texas Medical Association,
the American Medical Association, and others in organized medicine.
But TMA and its allies continue to push for additional reform,
given that any cut threatens physicians' practice viability and vulnerable patients' access to care.
(05:43):
TMA President-elect Ray Callas, MD, recently told Texas Medicine Today.
Every time we ask for a Band-Aid, we still get a scratch.
President Joe Biden signed into law on March 9th a $460 billion spending package,
averting a shutdown of some federal government agencies.
The package included a provision reducing the Medicare physician pay cut to 1.68%, now in effect.
(06:11):
However, physicians already have shouldered the burden of the higher 2024 cut
for more than two months.
TMA and others have repeatedly warned lawmakers of risk of practice closure,
early retirement, and reductions in health care services, office hours,
and Medicare patient panels.
For example, Haskell family physician C.
(06:33):
Wayne Cadenhead, M.D., closed his office doors for the last time in late December
of 2023, unable to withstand yet another Medicare physician pay cut.
I've had enough, he told Texas Medicine Today in his practice's final days.
These consequences are likely to continue under the new law,
with Medicare physician payments still falling short of rising practice costs.
(06:57):
The cut enacted via the 2024 Medicare physician fee schedule stems from a much-maligned
federal budget neutrality provision that requires any physician pay increase
or decrease to be offsetting,
as well as from congressional inaction on Medicare payment policy,
both of which further erode Medicare physician payment. payment.
(07:18):
Between 2001 and 2023, such pay decreased by 30% when adjusted for inflation,
even as Medicare payments to other sectors generally kept pace, according to the AMA.
Over the same period, the Consumer Price Index for physician services in U.S.
Cities increased 65%. TMA, AMA, and others remain focused on reforming Medicare
(07:42):
physician payment policy to prevent similar cuts in the future.
TMA will not let up in its efforts to protect Texas patients and physicians
from these ongoing harmful cuts, TMA President Rick Snyder, M.D.,
said in a January 19 statement.
Congress must act now to resolve this decades-old problem.
(08:03):
In pursuit of a long-term fix, TMA supports the bipartisan Strengthening Medicare
for Patients and Providers Act, House Resolution 2474 by U.S.
Representative Raul Ruiz, MD, which would provide annual inflationary updates
to the Medicare Physician Fee Schedule in line with the Medicare Economic Index,
(08:25):
a measure of practice cost inflation, among other reforms.
Music.
And the last piece, in case you missed it, CMS announces flexibilities following cyber attack.
CMS recently announced two flexibilities related to the Medicare's Merit-Based
(08:48):
Incentive Payment System, commonly referred to as MIPS, for the 2023 performance year,
citing the recent cyber attack on change health care and heeding advocacy by
organized medicine. Listen.
First, CMS extended the data submission period until April 15th at 7 p.m.
Central Time for all participants.
(09:09):
At stake is a pay cut of up to 9% in the 2025 payment year.
Second, the federal agency reopened applications for an extreme and uncontrollable
circumstance exception, also until April 15th at 7 p.m.
Central Time. MIPs participants impacted by the cyber attack may apply for the
(09:29):
exception to request reweighting of MIPs performance categories by the same deadline.
Federal officials have announced several flexibilities that aim to help physicians
in the wake of the cyber attack against Change Healthcare, which upset payment
and revenue cycle management operations for practices across the country.
Earlier in March, CMS announced an accelerated avenue of assistance for physicians
(09:50):
and practices impacted by the attack.
Practices may now request advanced Medicare payments in order to sustain practice
operations during this disruption.
Change Healthcare had anticipated that electronic payment functionality via
its payment platform would be available for connection beginning March 15th.
The company website also said Change Healthcare has experienced a cybersecurity
(10:15):
issue and we have multiple workarounds to ensure provider claims are addressed
and people have access to the medications and care they need.
The company's website provides resources for UnitedHealth Group,
UnitedHealthcare, Optum, and Change Healthcare stakeholders.
In addition to being a main source for the latest business and information update,
the page also contains links to other resources to support stakeholders in managing
(10:38):
any related impacts. PACs.
CMS had instructed Medicare Administrative Contractors, MACs,
to accept paper claims from physicians who need to use them and to expedite
physician requests to switch to new clearinghouses to work around the change healthcare outage.
HHS stated, while we recognize that electronic billing is preferable for everyone,
(10:59):
the MACs must accept paper submissions if a provider needs to file claims in that method.
Texas MAC Novitas recently shared instructions with the Texas Medical Association
experts on how physicians can send paper claims and work around ongoing issues
related to the cyber attack.
According to Novitas, paper claims processing requires a minimum 29-day payment
(11:21):
floor, which means payment cannot be released before the 29th day following receipt.
There is no automated editing for claims errors as there is with electronic
billing, so if a paper claim form contains mistakes, the Medicare contractor
will have to return the claim to the physician to make the correction for resubmission.
(11:42):
For electronic submissions, physicians can submit their claims through the direct
data entry or elect to change their network service vendor.
Novitas is expediting requests from healthcare professionals impacted by the
change healthcare issue as they come in.
Physicians can also enroll in Novitas portal, Novitasphere, which the contractor
(12:03):
says allows for claim submission and remittance retrieval.
The contractor also stated that due to Administrative Simplification Compliance
Act requirements, Medicare system settings for electronic-only billers need
to be manually updated to allow for paper submissions.
CMS has approved a waiver for those requirements for those impacted by the Change
(12:25):
Healthcare cyber attack.
CMS said it will issue guidance encouraging Medicare Advantage plans and Part
D sponsors to remove or relax prior authorization, other utilization management,
and timely filing requirements.
CMS is also encouraging Medicare Advantage plans to offer advanced funding to
healthcare professionals most affected by the cyber attack.
(12:47):
Additionally, CMS is strongly encouraging Medicaid and Children's Health Insurance
Program managed care plans to adopt similar strategies.
Physicians can submit requests for accelerated payment to their MAC for individual consideration.
These developments followed a March 1st letter to federal officials in which
the American Medical Association urged the federal government to take additional
(13:10):
steps to alleviate the damage caused by the cyber attack,
warning it could severely hamper physicians' abilities to care for patients.
A statement from the AMA said, given the combined financial impact of the change
health care hack and Medicare payment cuts to physician,
the AMA urged HHS to utilize any available emergency funds and authorities to
(13:34):
provide critical financial resources to physicians.
Ensuring they can continue to deliver essential health care services during
these challenging times, as well as facilitate expedited and direct communication
with physician practices. practices.
Physicians may continue to see disruptions in claims processing,
eligibility checks, or day-to-day practice operations due to ongoing system outages.
(13:58):
TMA experts recommend practices communicate with private health plans as well
to ensure they are accepting paper claims, and if not, refer them to HHS guidance
to make sure they are aware of CMS flexibilities.
The Texas Texas Department of Insurance and UnitedHealth Group,
which owns Change Healthcare through its Optum subsidiary, have offered claims
(14:20):
and payment flexibilities as well.
Concerned practices should conduct their own risk evaluation and, if necessary,
take steps to protect their network, which may include coordinating with their
electronic health record vendors to determine whether they should shut down
their exposure to Optum if they're using the Change Healthcare clearinghouse.
Additionally, practices should continue to evaluate updates from the company.
(14:45):
TMA experts also recommend physicians avoid delays in claims payment by using
alternative means of submission when appropriate.
Practices are encouraged to check with health plans to see if they can submit
claims via a physician's portal.
Music.
(15:05):
I hope this episode showcases the variety of information provided free for TMA members.
Check the episode description for the links to the articles from this episode.
And remember to like and follow to receive every episode from TMA Practice Well.
Until next time, stay well. all. TMA has a long, proud history of promoting
(15:27):
patient rights, advocating for physicians, and providing real solutions for your practice.
We can accomplish so much when we unite in one voice.
Call the TMA Knowledge Center at 1-800-880-7955 or visit textmed.org to find
out how you can join or renew your membership today.
Music.
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