Health Care Payers COVID19 Impact Assessment Lessons Learned And .

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DISCUSSION PAPERHealth Care Payers COVID-19Impact Assessment: LessonsLearned and Compelling NeedsMark McClellan, MD, PhD, Duke-Margolis Center for Health Policy, DukeUniversity; Rahul Rajkumar, MD, JD, Care Solutions at Optum; Marion Couch,MD, MBA, Cambia Health Solutions; Diane Holder, MS, UPMC Health Plan; MaiPham, MD, MPH, Anthem (formerly); Peter Long, PhD, Blue Shield of California;Rhonda Medows, MD, Providence St. Joseph Health and Ayin Health Solutions;Amol Navathe, MD, PhD, University of Pennsylvania; Lewis Sandy, MD, MBA,UnitedHealth Group; William Shrank, MD, MSHS, Humana; and Mark Smith, MD,MBA, University of California San FranciscoMay 17, 2021About the NAM series on Emerging Stronger AfterCOVID-19: Priorities for Health System TransformationThis discussion paper is part of the National Academy ofMedicine’s Emerging Stronger After COVID-19: Prioritiesfor Health System Transformation initiative, whichcommissioned papers from experts on how 9 key sectorsof the health, health care, and biomedical science fieldsresponded to and can be transformed in the wake of theCOVID-19 pandemic. The views presented in this discussionpaper and others in the series are those of the authorsand do not represent formal consensus positions of theNAM, the National Academies of Sciences, Engineering, andMedicine, or the authors’ organizations.Learn more: nam.edu/TransformingHealthIntroduction and Sector OverviewIn contrast with other high-income countries, healthcare insurance and payment in the United States ishighly fragmented. America’s multi-payer systemspans an array of entities, including publicly financedprograms (e.g., Medicare, Medicaid) and commercialinsurers and health plans. Figure 1 provides an overview of the different types of payers and populationsin the U.S. [1] This paper will focus on the perspectiveof payers covering Medicare, Medicaid, and adults withfully insured employer health plans, which togetherPerspectives Expert Voices in Health & Health Careencompass the majority of Americans.These payers aim to serve several functions in theU.S. health care system, including offering protectionagainst the financial impact of unexpected healthevents, providing patients with access to a broad setof health services delivered by a network of healthcare professionals, coordinating those services, andusing measurement and incentives to increase theaffordability and quality of care delivery [2]. Yet thecommon functions of payers can take many differentforms with regards to operational arrangements (e.g.,

DISCUSSION PAPERFIGURE 1 Overview of America’s Multi-Payer Landscapestand-alone plans versus joint ventures with deliveryorganizations), benefit design (e.g., covered services,cost distribution), and payment methodologies (e.g.,volume- versus population-based payments). A keyarea of change for payers over the past decade hasbeen the advent of so-called “value-based care,” inwhich payers in both the public and private sector havesought to transition away from fee-for-service (FFS) arrangements to alternative payment models (APMs)that link reimbursement to the quality and outcomesof care delivery [3].It is amidst this period of renovation to the architecture of the U.S. health care system that COVID-19struck. The public health emergency—which remainsongoing at the time of this paper’s publication—hashad tremendous consequences for the health of American society and the financial stability of the Americanhealth care system. During the spring of 2020, payerstook steps based on regulatory requirements and recommendations to expand access to health servicesfor both COVID-19 and non-COVID-19 health conditions (e.g., waiving administrative requirements, reimbursing telehealth). Many payers also independentlydeployed financial support and capital to stabilizeproviders, and leveraged their technological capabilities and community relationships to support outbreakresponse, from coordinating non-medical services tosupporting immunization campaigns.However, payers’ pandemic response capabilitiesand their obligations to regulators, employers, providers, and patients evolved as high caseloads persistedand the downstream consequences of COVID-19 began to manifest. For example, trends in medical spending and utilization shifted as outbreaks escalated overPage 2the course of 2020. Payers initially experienced costreductions due to care delays, but then experienced asubsequent increase in operating expenses due to thegrowing volume of COVID-19 patients and the resumption of deferred health services. Likewise, as insurance is an industry premised on forecasting and riskassessment, the fundamentally unpredictable natureof a pandemic created significant challenges for payeroperations in 2021 (e.g., pricing, enrollment).In this paper, leaders from the payer sector seek todescribe the experience of health insurers during COVID-19 and identify the key challenges and opportunitieslearned from the pandemic and beyond. It is importantto acknowledge that as an ongoing public health emergency, empirical evidence on health care costs andpayment policies for COVID-19 remains nascent at thistime, and data on the specific actions of payers mayvary according to differences in health insurance products, local market needs, and regulatory requirements.Nevertheless, one year into the pandemic, it is evidentthat the unprecedented disruption to the health caresystem as a result of COVID-19 provides a unique opportunity for payers to improve the efficiency and equity of health care financing in America. Consequently,the goal of this paper is to provide a preliminary reviewof payers’ experiences during COVID-19 to date, and tohighlight the key lessons for how payers and regulatorscan navigate the uncertainties of COVID-19 and leverage the newfound momentum for health care reform,with a particular focus on improving affordability andaccessibility.Published May 17, 2021

Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling NeedsFIGURE 2 Payer Responses to COVID-19 ChallengesThe Payer Response to COVID-19The COVID-19 pandemic imposed a sudden and significant shock to America’s fragmented health caresystem. While the volatility of COVID-19 did createchallenges for payers (e.g., actuarial forecasting), theunprecedented reduction in health care spending resulted in improved financial performance for manyhealth insurers during 2020. Many payers leveragedtheir resources and role to support patients, providers, and other stakeholders as the health care systemevolved at unprecedented speed. For example, insurers facilitated the management and delivery of bothCOVID-19-related and non-pandemic health servicesacross multiple care delivery partners. Likewise, healthplans worked to aggregate and coordinate the newfederal and state mandates, rules, waivers, and guidance regarding traditional health services (e.g., prescriptions, benefits) and COVID-19-related care (e.g.,testing, treatment). Furthermore, payers collaboratedwith providers and developed partnerships with othersectors (e.g., public health, community-based organizations) to support the implementation of new flexibilities, communicate key changes, and help patients, thepublic, and employers to navigate the rapidly shiftingdelivery environment.This section of the paper seeks to capture the primary areas of focus for the payer sector’s response tothe pandemic. While evidence on the scale and effectsNAM.edu/Perspectivesof payer actions is difficult to quantify at this stage,given that COVID-19 remains an evolving public healthemergency at the time of this paper’s publication, andit is challenging to generalize given the fragmentednature of America’s multi-payer environment, the authors seek to offer salient examples from their vantagepoint. The key aspects of payers’ COVID-19 responseinclude:1.2.3.4.5.6.Providing rapid and relevant information to keystakeholders;Ensuring patients retained access to health services despite disruptions to in-person delivery;Addressing the non-medical needs of patients,particularly in light of the pandemic’s disparateimpact on high-risk populations;Ensuring providers received adequate financialsupport amidst sudden revenue reductions andshifts toward virtual care;Supporting the delivery of pandemic-specificservices, including COVID-19 testing, treatments,and vaccinations, and the distribution of personal protective equipment (PPE); andProviding resource commitments and programsupport to address health inequities (see Figure2).Page 3

DISCUSSION PAPERAdapting to the Pandemic: Role-Shifting, Partnerships, and Program DevelopmentProviding Patients With Rapid and Relevant InformationAmidst an uncertain informational landscape, payersworked to synthesize evidence and provide outreachand education to help patients stay safe during thepandemic [4]. Within the public sector, the Centers forMedicare and Medicaid Services (CMS) posted regularupdates to frequently asked questions for beneficiaries, and issued proactive guidance to Medicare Advantage Organizations, Part D Sponsors, and MedicareMedicaid Plans about the flexibilities (e.g., changes tobenefits, waivers to cost-sharing) available to healthplans covering Medicare beneficiaries during the publichealth emergency [5]. Within the private sector, someinsurers established patient-facing web portals to compile real-time information regarding coverage optionsfor special enrollment, which often differed across individual, employer, Medicaid, and Medicare insurancemarkets [6].Health plans also leveraged their customer serviceteams to disseminate and answer coverage-specificquestions from patients and employers using multiplemodalities. For example, some payers deployed theirpatient services representatives to provide patientswith the latest information on applicable governmentmandates. Other payers organized virtual town halls,with a particular focus on outreach to high-risk patients(e.g., the elderly) [7]. Payers’ outreach efforts also extended beyond informational resources into directclinical assistance. Examples include supporting virtualclinical assessments and facilitating connections withproviders. Some plans even deployed care managersto hard-hit network hospitals to assist with post-acutecare coordination.Retaining Access to Health ServicesIn addition to complying with federally mandated coverage requirements for many components of COVID-19diagnosis and treatment, payers also sought to reducefinancial barriers to coverage for non-COVID-19 carefor the duration of the public health emergency [8,9].In the public sector, CMS required Medicare Advantageorganizations to waive certain referral requirementsand cost-sharing policies, all without 30-day notification periods, to enable beneficiaries to access necessary care. Likewise, some state Medicaid programsexpanded eligibility and benefits for long-term servicesand supports for seniors and patients with disabilitiesPage 4[10]. For employer-sponsored insurance, many planseliminated late fees, extended eligibility allowances forfurloughed employees, and offered premium deferralmechanisms to balance employers’ concerns of fiscalsustainability with the need to provide short-term relief to maintain members’ coverage [11,12]. However,waivers for coverage and cost-sharing did not extendto out-of-network billing for both COVID-19 and nonCOVID-19 health services. Additionally, the uptake ofthese policies varied across self-insured entities, whichaccount for the majority of covered workers and arebeyond the scope of this paper.A key area of focus for payers across the sector wasmitigating potential disruptions to patient access toprescription drugs (e.g., due to shortages or shelter-inplace restrictions) [13]. CMS issued guidance to Part Dsponsors, including reimbursement for out-of-networkpharmacies and permissions for home delivery andprior authorizations [14]. Within the private sector,many insurers (e.g., all 36 Blue Cross Blue Shield Association companies) temporarily waived early refill limitson 30-day maintenance medication prescriptions andextended prior authorizations on 90-day medicationsupplies [15,16].Addressing COVID-19-Related Social NeedsCOVID-19 exposed and exacerbated many longstanding health inequities in the U.S., with the pandemic disproportionately affecting racial and ethnic minoritiesand socioeconomically disadvantaged populations.Payers took multiple actions to respond to these inequities.First, at the policy level, CMS issued guidance thatthe agency would exercise enforcement discretion formid-year benefit enhancements by Medicare Advantage organizations, including benefits addressing socialneeds (e.g., meal delivery, transportation services) [17].While data on mid-year changes is still emerging, thenumber of Medicare Advantage plans offering SpecialSupplemental Benefits for the Chronically Ill more thantripled between 2020 and 2021 [18]. The majority ofstates also implemented new initiatives to address thesocial determinants of health through their Medicaidprograms, with some programs occurring in conjunction with insurers [19]. For example, Pennsylvania implemented new requirements for Medicaid ManagedCare Organizations to partner with community-basedorganizations, with implications for reimbursement.Second, some commercial payers took independentaction to address inequities, with select examplesfrom the sector summarized in Table 1 [9]. For exam-Published May 17, 2021

Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling NeedsTABLE 1 Payer Support for the Social Determinants of HealthMember NeedsExample of Payer ResponseService Coordination Several payers, including Anthem and Cigna, partnered with AuntBertha, a platform that identifies social services in the member’s localareaFood Insecurity Some payers, including Humana and AmeriHealth Cartas, deliveredmeals to members’ homesAnthem performed direct outreach to help eligible members enroll inSNAP Transportation Barriers Bright Health covered non-emergency medical transportation for itsmembersMental Health Services Several payers, including Aetna and Anthem, waived cost-sharing forcounseling and other mental health servicesMany payers developed population-specific resources, such as BlueShield CA’s BlueSky Initiative and Humana’s partnership with Papa ple, some payers developed a coordination functionto match high-need patients with relevant communityorganizations [20]. A few plans worked to augment financially strapped public assistance programs, suchas direct outreach efforts and enrollment assistancefor Supplemental Nutrition Assistance Program (SNAP)benefits and financial support for community organizations working on rapid rehousing solutions for thehomeless population. Other payers sought to addressthe challenge of food insecurity by coordinating thehome delivery of medically tailored meals and groceries during the pandemic, with a focus on reaching bothhigh-risk and COVID-19 positive patients. Additionally,plans worked to address the mental health burden ofthe pandemic by funding support programs (e.g., Crisis Text Line, domestic violence prevention programs)and coordinating virtual services for social connectionin specific populations (e.g., older adults experiencingloneliness) [9]. While these actions represent select examples of payer engagement, it is important to notethat there are limited data on the scope and impact ofpayer actions for health equity during the pandemic.Data collection and evaluation is needed to assessthe benefits and challenges of different pandemic-erapilots, and effectuating systemic change will requiretranslating philanthropic investments into structuralchanges in benefit design and payment policy, forwhich uptake to date has been slow [21].NAM.edu/PerspectivesFinancial Support for Health Care ProvidersClinicians and health care organizations faced unprecedented financial challenges in spring 2020 amidst asharp decline in visits that were paid on a FFS basis,as individuals complied with safer-at-home and physical distancing protocols, delaying visits to their healthcare providers [22]. The Paycheck Protection Programand other federal initiatives did provide substantial resources to hospitals and other providers to help ameliorate the resulting losses. However, with grants fromthe Provider Relief Fund favoring larger health systemsand Medicare’s Advanced Payments program providinglimited support to safety-net providers, many smaller,independent practices—which at baseline lack the levels of capital reserves possessed by hospitals and provider groups—continued to face severe cash shortages[23,24,25].Given the delays and flux in federal relief efforts, commercial payers were well-positioned to offer support toclinicians to meet payroll, operating expenses, and ongoing patient needs—particularly considering that thedecline in health care spending and utilization duringCOVID-19 had translated into improvements in insurers’ financial performance in terms of commercial payers’ gross margins and medical loss ratios [26,27]. Tothis end, health plans adopted an array of alternative financing strategies to infuse short-term capital into thecare delivery system. For example, some plans coordinated direct financial support for providers and hospitals through financing guarantees, advance payments,Page 5

DISCUSSION PAPERand opportunities to restructure contracts from FFS arrangements to value-based contracts (e.g., risk-sharingcapitated payments) [30]. For providers already operating under value-based contracts, some plans workedto provide up front payments of quality bonuses orexpected savings. In addition to providing infusions ofcash (the amounts of which varied between payers anddue to lack of data cannot be comprehensively reported), many plans committed to eliminating utilizationmanagement protocols or prior authorization in markets experiencing challenges with inpatient, intensivecare, or post-acute care capacity. Furthermore, someplans developed payment models that offered participating providers guaranteed revenue in exchange for acommitment to enter a value-based payment arrangement at a future date [16].Addressing COVID-19-Specific Delivery System NeedsPayers have worked to support the distribution of medical supplies and services throughout the pandemic,beginning with testing and tracing efforts. For testing,some plans have directly invested in diagnostic development and supported supply procurement, such asfunding the development of alternative reagents andmedical supplies for collecting patient samples (e.g.,polyester swabs and saline transport) [31]. For tracing,several plans have leveraged their technical capabilities to advance public health surveillance and create infrastructure to guide re-openings, including developingdata exchanges with local health departments to assistwith epidemiological mapping and to support testingand contact tracing functions [32]. Second, some payers have contributed resources and logistical expertiseto support the planning and distribution of medicalsupplies, such as PPE [33,34]. Third, some payers havecollaborated with the biopharmaceutical industry tosupport data sharing and evidence generation for thedevelopment of COVID-19 medical countermeasures,such as partnering to increase access to monoclonalantibodies and using claims data to identify high-riskpopulations for enrollment in COVID-19 vaccine trials[35,36]. Fourth, following the authorization of the firstCOVID-19 vaccines, some payers have played an activerole in supporting immunization campaigns in theirlocal markets, including helping to coordinate distribution and using claims data to support post-marketsafety surveillance [37].Addressing Systemic Health InequitiesCOVID-19 both exposed and exacerbated existing disparities in health outcomes, particularly along racialand ethnic lines. Consequently, several payers took ac-Page 6tion to address the pandemic’s disparate impact. Someplans made resource and financial commitments during the pandemic to support the communities thatwere bearing a disproportionate burden of COVID-19infections. Payer actions to address patients’ medical needs (e.g., by increasing access to health servicesfor chronic disease management), social needs (e.g.,coordinating supportive housing, meals), and COVID19-specific needs (e.g., PPE distribution, testing) soughtto address the environmental challenges contributingto health disparities where possible.However, payers also recognized that meaningfullyaddressing health disparities and structural racismwill require long-term, systemic action. Consequently,many plans adopted commitments to equity intendedto extend beyond the pandemic, with some payers already beginning to initiate partnerships with providersoriented around health equity (e.g., Blue Cross BlueShield of Illinois’ Health Equity Hospital Quality Incentive Pilot Program) [38].Regulatory Tailwinds: Federal Actions and PayerResponsesTransformative Flexibilities for Payment and Care DeliveryUnprecedented regulatory flexibilities and guidancefrom the U.S. Department of Health and Human Services (HHS) and CMS coupled with statutory mandatesand resources from COVID-19 relief legislation generated momentum across payers to promote alignmentin policy (e.g., coverage for COVID-19 care) and drivepivots in clinical practice (e.g., expansion of telehealth)to reduce barriers to accessing critical health care services during the pandemic.For example, with shelter-in-place orders shuttering the doors of many outpatient health care facilities,CMS granted waivers for telehealth to expand accessto patients while minimizing risk of exposure to COVID-19. When implementing flexibilities for telehealth,CMS worked with the Office of Civil Rights within HHSto enable the use of popular video-enabled mobile applications (e.g., FaceTime, Skype), which were not originally designed to be compliant with the standards setforth in the Health Insurance Portability and Accountability Act (HIPAA). Other key flexibilities include thetemporary relaxation of many site-of-care restrictionson health care delivery, from CMS’s “Hospital WithoutWalls” program to a commitment to reimburse servicesrelocated to off-campus sites at traditional outpatientprospective payment rates [39]. Beyond federal action,many state insurance commissioners and MedicaidPublished May 17, 2021

Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling Needsprograms also introduced new flexibilities and requirements for commercial health plans (e.g., requiringwaivers of cost-sharing, requiring guarantees of network adequacy) [40]. Additionally, special enrollmentperiods for state-based (in 2020) and federal (in 2021)insurance marketplaces enabled plans to expand access to health insurance for individuals who may havelost coverage during the pandemic [41].Health Plan ResponsesNew federal and state mandates, rules, waivers, andguidance supported a rapid transformation in thehealth care payment and delivery landscape. In somecases, commercial payers changed their policies due tonew requirements imposed by legislation and federaland state regulatory action. For example, the FamiliesFirst Coronavirus Response Act and Coronavirus Aid,Relief, and Economic Security (CARES) Act required allpayers in the U.S. to cover the cost of COVID-19 diagnostic testing without cost-sharing. Likewise, statesacross the country directed health plans to expandaccess to virtual care, including eliminating originatingsite requirements and reimbursing telehealth visits atparity with in-person visits.In addition to complying with regulatory requirements, some payers took further action. In some cases,commercial insurers implemented changes in healthplan design that regulators recommended, but did notrequire. For example, several Medicare Advantage organizations waived cost-sharing for both COVID-19 andnon-COVID-19 care for the duration of the pandemic,actions that CMS had encouraged but not required[42]. Many payers also temporarily waived prior authorization requirements with varying degrees of specificity, from indication-specific authorizations (e.g., behavioral health) to facility-level policies (e.g., transfers topost-acute care) [9]. In other cases, payers leveragedthe momentum of new state and federal flexibilities tointroduce changes with broader scope. For example,while Medicare’s March 2020 policies for telehealthare set to expire at the conclusion of the public healthemergency, select commercial insurers independentlyannounced in 2020 that their plans would permanentlyextend coverage of telehealth services [43]. Likewise, although Medicare’s advance payment program concluded in April 2020, several commercial insurers continued their provider refinancing and stimulus initiatives,and designed these programs to serve as on-ramps forpractices to transition into alternative payment models(APMs) after the public health emergency [44].The concerted actions of payers across the countrymay have played a key role in supporting the dramaticNAM.edu/Perspectivesincrease in the uptake of and appetite for telehealth inthe U.S. One analysis found private health care claimsfor telehealth services increased from 0.15% in April2019 to 13% in April 2020, a more than 8,000% increase [45]. Additionally, CMS reported that the weeklynumber of beneficiaries in FFS Medicare receiving telehealth services increased from 13,000 to nearly 1.7million during the pandemic [46]. While the increasedutilization of telehealth has not completely offset thedecrease in in-person visits, and levels of telehealth usehave declined significantly as the U.S. begins to removephysical distancing restrictions, nationwide telehealthusage still substantially exceeds pre-pandemic levels,particularly among large provider organizations ( 6clinicians) and within select specialties (e.g., behavioralhealth, endocrinology) [47,48]. Although the key driverof utilization growth was the realignment of financialincentives, many payers also made process and operational changes to support patient access to servicesand increase provider comfort with virtual care modalities. These strategies spanned member outreach initiatives, streamlined billing processes, and coverage forand integration of new digital health products, as summarized in Table 2.Regulators and industry experts reflecting on thescope of the payer sector’s COVID-19 activities described above have posited that the magnitude andduration of the pandemic have generated an impetus to drive lasting sector-wide change [49]. However,many pandemic-era policy flexibilities and operationalchanges are set to officially expire at the conclusion ofthe public health emergency, and the current lack ofcomprehensive policy proposals for long-term extension, coupled with the historical inertia of the healthcare system, present roadblocks to durable change. Totruly achieve a “new normal,” payers will need to makeforward-looking decisions that build upon pandemicera innovations in plan design (e.g., telehealth coverage, utilization controls), while policymakers will needto develop regulatory and legislative solutions that apply the momentum from COVID-19 to accelerate progress for pre-pandemic goals (e.g., transition to value).The next section outlines the challenges that payerswill have to address to achieve these goals, includingnavigating the financial aftershocks of the pandemic and managing evolving stakeholder expectationsabout plan policies.Key Pandemic-Era Challenges for PayersAlthough the pandemic accelerated long overduechanges to payment and delivery, the destabilizing na-Page 7

DISCUSSION PAPERTABLE 2 Payer Strategies to Support the Transition to Virtual CareFocus AreaPayer StrategiesPatient Barriers toAccess Provider Barriers toAccess Expanding ServiceOfferings Expanding DeliveryCapacity Integrating DigitalHealth Tools Communication: Member outreach initiatives and patient-facingwebsitesAccessibility: Online toolkits for sign up, scheduling, and remindersCommunication: Technical assistance, learning collaboratives,webinars, practice outreachAdministration: Clarification of billing processes, alignment of casemanagementCOVID-19: Triage, testing coordination, patient guidance andeducationNon-COVID-19: Chronic disease management, home visits and casemanagement, adaptation of specialty-specific servicesNetwork Growth: Increasing number of in-network providers;leveraging vendor platforms to alleviate strain on providersProvider Support: Financial support for alternative care sites (e.g.,Federally Qualified Health Centers)COVID-19: Mobile applications for symptom assessmentNon-COVID-19: Support tools for mental health (e.g., anxiety,depression)ture of the public health emergency has also exposedsystemic challenges and vulnerabilities for payers, andthe sustainability of payment and care changes implemented in the public health emergency is not yet clear.Health plans will need to navigate an uncertain marketwhile adjusting to the new expectations of patients,providers, and employers, whose behaviors and incentives have shifted markedly after COVID-19 upendednumerous health care norms.This section outlines the key short- and long-termchallenges for payers in the post-pandemic era, including:1.2.3.4.Navigating the actuarial uncertainty resultingfrom the uncertainty of enrollment;Managing evolving expectations for benefit design (e.g., cost-sharing, prior authorization);Monitoring the risk of fraud and disparities arising from new regulatory flexibilities; andEvaluating implications of COVID-19 for ratesetting and risk adjustment in value-based programs (see Figure 3).Uncertainty in Health Insurance CoverageAt its core, a viable insurance business requires accurate actuarial estimates of risk. In order to set premiums and service prices, payers need to predict whatenrollment will be, which pro

Health Care Payers COVID-19 Impact Assessment: Lessons Learned and Compelling Needs About the NAM series on Emerging Stronger After COVID-19: Priorities for Health System Transformation This discussion paper is part of the National Academy of Medicine's Emerging Stronger After COVID-19: Priorities for Health System Transformation initiative .

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