Social Security Disability: SSA Actions to Reduce Backlogs and Achieve More Consistent Decisions Deserve High Priority

Published by the Government Accountability Office on 1997-04-24.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                           United States General Accounting Office

GAO                        Testimony
                           Before the Subcommittee on Social Security, Committee
                           on Ways and Means, House of Representatives

For Release on Delivery
Expected at 9:00 a.m.
Thursday, April 24, 1997
                           SOCIAL SECURITY

                           SSA Actions to Reduce
                           Backlogs and Achieve More
                           Consistent Decisions
                           Deserve High Priority
                           Statement of Jane L. Ross, Director
                           Income Security Issues
                           Health, Education, and Human Services Division

Social Security Disability: SSA Actions to
Reduce Backlogs and Achieve More
Consistent Decisions Deserve High Priority
               Mr. Chairman and Members of the Subcommittee:

               Thank you for inviting me to testify on the Social Security Administration’s
               (SSA) management of the Disability Insurance (DI) and Supplemental
               Security Income (SSI) programs. In 1995, these programs paid benefits
               approaching $60 billion a year and served nearly 7 million working-age
               adults. As you are aware, SSA’s process has been overwhelmed with a large
               number of appealed cases, which grew from about 225,000 in fiscal year
               1986 to about 498,000 in fiscal year 1996.

               Today I will discuss actions that SSA undertook, beginning in 1994, to
               improve the timeliness, efficiency, and consistency of disability decisions.
               Its actions resulted from a realization that the lengthy and complicated
               decision-making process and the inconsistency of decisions between
               adjudicative levels compromise the integrity of disability determinations.
               More specifically, I will describe SSA’s actions to reduce the current
               backlog of cases appealed to the agency’s administrative law judges (ALJ).
               Then I will discuss how functional assessments, differences in procedures,
               and quality review contribute to inconsistent results between different
               decisionmakers and describe SSA’s strategy to obtain greater decisional
               consistency. My testimony is based on our reports and our ongoing studies
               of SSA’s disability programs being conducted for the Chairman of the
               Subcommittee. (See the list of related GAO products.)

               In summary, our work shows that while SSA has developed broad-based
               plans to improve the management of its disability programs, many
               initiatives are just beginning and their effectiveness can be assessed only
               after a period of full-scale implementation. For example, in the short term,
               SSA has taken action to try to deal with the backlog crisis, but it is still
               about 116,000 cases over its December 1996 goal of 375,000 cases. In the
               longer term, SSA needs to come to grips with the systemic factors causing
               inconsistent decisions, which underlie the current high level of appealed
               cases and, in turn, the backlog crisis. For example, we found that
               differences in assessments of functional capacity, different procedures,
               and weaknesses in quality reviews contribute to inconsistent decisions.
               Although SSA is on the verge of implementing initiatives to deal with these
               factors, we are concerned that other congressionally mandated workload
               pressures, such as significantly increasing the number of continuing
               disability reviews and readjudicating childhood cases, could jeopardize the
               agency’s ability to move ahead with its initiatives to reduce inconsistent

               Page 1                                                     GAO/T-HEHS-97-118
             Social Security Disability: SSA Actions to
             Reduce Backlogs and Achieve More
             Consistent Decisions Deserve High Priority

             SSA’s disability programs provide cash benefits to people with long-term
Background   disabilities. The DI program provides monthly cash benefits and Medicare
             eligibility to severely disabled workers; SSI is an income assistance
             program for blind and disabled people. The law defines disability for both
             programs as the inability to engage in substantial gainful activity because
             of a severe physical or mental impairment that is expected to last at least 1
             year or result in death.

             Both DI and SSI are administered by SSA and state disability determination
             services (DDS). SSA field offices determine whether applicants meet the
             nonmedical criteria for eligibility and at the DDSs, a disability examiner and
             a medical consultant (physician or psychologist) make the initial
             determination of whether the applicant meets the definition of disability.
             Denied claimants may ask the DDS to reconsider its finding and, if denied
             again, may appeal to an ALJ within SSA’s Office of Hearings and Appeals
             (OHA). The ALJ usually conducts a hearing at which applicants and medical
             or vocational experts may testify and submit new evidence. Applicants
             whose appeals are denied may request review by SSA’s Appeals Council
             and may further appeal the Council’s decision in federal court.

             Between fiscal years 1986 and 1996, the increasing number of appealed
             cases has caused workload pressures and processing delays. During that
             time, appealed cases increased more than 120 percent. In the last 3 years
             alone, average processing time for appealed cases rose from 305 days in
             fiscal year 1994 to 378 days in fiscal year 1996 and remained essentially the
             same for the first quarter of fiscal year 1997. In addition, “aged” cases
             (those taking 270 days or more for a decision) increased from 32 percent
             to almost 43 percent of the backlog.1

             In addition to the backlog, high ALJ allowances (in effect, “reversals” of DDS
             decisions to deny benefits2) have been a subject of concern for many
             years. Although the current ALJ allowance rate has dropped from
             75 percent in fiscal year 1994, ALJs still allow about two-thirds of all
             disability claims they decide. Because chances for award at the appeals
             level are so favorable, there is an incentive for claimants to appeal. For
             several years, about three-quarters of all claimants denied at the DDS
             reconsideration level have appealed their claims to the ALJ level.3

              Processing time represents total OHA workloads, which include appealed Medicare cases.
              ALJ decisions are said to be de novo, or “afresh.”
              About one-third of claimants denied at the initial DDS-level appeal, while the rest abandon their cases.

             Page 2                                                                           GAO/T-HEHS-97-118
                         Social Security Disability: SSA Actions to
                         Reduce Backlogs and Achieve More
                         Consistent Decisions Deserve High Priority

                         In 1994, SSA adopted a long-term plan to redesign the disability
                         decision-making process to improve its efficiency and timeliness. As a key
                         part of this plan, SSA developed initiatives to achieve similar decisions on
                         similar cases regardless of whether the decisions are made at the DDS or
                         the ALJ level. In July 1996, several of these initiatives, called “process
                         unification,” were approved for implementation by SSA’s Commissioner.
                         SSA expects that process unification will result in correct decisions being
                         made at the earliest point possible, substantially reducing the proportion
                         of appealed cases and ALJ allowance rates as well.

                         Because SSA expects that implementation of its redesigned disability
                         decision-making process will not be completed until after the year 2000,
                         SSA developed a Short Term Disability Project Plan (STDP) to reduce the
                         existing backlog by introducing new procedures and reallocating staff.
                         STDP is designed to expedite processing of claims in a way that will support
                         redesign and achieve some near-term results in reducing the backlog. SSA
                         expects that STDP’s major effect will come primarily from two
                         initiatives—regional screening unit and prehearing conferencing activities.
                         In the screening units, DDS staff and OHA attorneys work together to
                         identify claims that could be allowed earlier in the appeals process.
                         Prehearing conferencing shortens processing time for appealed cases by
                         assigning OHA attorneys to perform limited case development and review
                         cases to identify those that could potentially be allowed without a formal
                         hearing. The plan called for reducing the backlog to 375,000 appealed
                         cases by December 31, 1996.

                         Despite SSA attempts to reduce the backlog through its STDP initiatives, the
Despite SSA’s Efforts,   agency did not reach its goal of reducing this backlog to 375,000 by
SSA Still Faces a High   December 1996.4 SSA attributes its difficulties in meeting its backlog target
Backlog                  to start-up delays, overly optimistic projections of the number of appealed
                         cases that would be processed, and an unexpected increase in the number
                         of appealed cases. The actual backlog in December was about 486,000
                         cases and has risen in the last few months to 491,000 cases, still about
                         116,000 over the goal. Although SSA did not reach its backlog goal, about
                         98,000 more cases may have been added to the backlog if STDP steps had
                         not been undertaken. The contribution made by STDP underscores the need
                         for SSA to continue its short-term effort while moving ahead to address the
                         disability determination process in a more fundamental way in the long

                          SSA’s goal included Medicare claims, which ALJs also decide. However, the STDP initiatives focused
                         only on disability claims, which represented about 94 percent of the backlog in fiscal year 1996.

                         Page 3                                                                        GAO/T-HEHS-97-118
                                      Social Security Disability: SSA Actions to
                                      Reduce Backlogs and Achieve More
                                      Consistent Decisions Deserve High Priority

                                      In addition to the backlog problem, SSA’s decision-making process has
Decision-Making                       produced a high degree of inconsistency between DDS and ALJ awards, as
Process Yields High                   shown in table 1. Although award rates representing DDS decision-making
Degree of                             vary by impairment, ALJ award rates are high regardless of the type of
                                      impairment. For example, sample data showed that DDS award rates
Inconsistency                         ranged from 11 percent for back impairments to 54 percent for mental
Between DDSs and                      retardation. In contrast, ALJ award rates averaged 77 percent for all
                                      impairment types with only a smaller amount of variation among
ALJs                                  impairment types.

Table 1: Award Rates at DDS and ALJ
Levels by Impairment Type                                                                  DDS award rates        ALJ award rates
                                                                                                 (percent)              (percent)
                                      Physical                                                             29                       74
                                      Musculoskeletal                                                      16                       75
                                        Back cases                                                         11                       75
                                        Other musculoskeletal                                              23                       76
                                      Other physical                                                       36                       74
                                      Mental                                                               42                       87
                                      Illness                                                              39                       87
                                      Retardation                                                          54                       84
                                      All impairments                                                      30                       77
                                      Note: ALJ data are from an ongoing SSA study. Data include ALJ cases decided from September
                                      1, 1992, through April 30, 1995. Study samples excluded certain types of cases, such as
                                      children’s cases. DDS data for the same period and types of cases were obtained from SSA’s
                                      administrative database.

Disability Determinations             SSA’sprocess requires adjudicators to use a five-step sequential evaluation
Require Complex                       process in making their disability decisions (see table 2). Although this
Judgment                              process provides a standard approach to decision-making, determining
                                      disability often requires that a number of complex judgments be made by
                                      adjudicators at both the DDS and ALJ levels.

                                      Page 4                                                                    GAO/T-HEHS-97-118
                                     Social Security Disability: SSA Actions to
                                     Reduce Backlogs and Achieve More
                                     Consistent Decisions Deserve High Priority

Table 2: Five-Step Sequential
Evaluation Process for Determining                                                     Action or decision taken if answer to
Disability                                     Questions asked in the sequential                   question is:
                                     Step      process                                 Yes                No
                                     1         Is the claimant engaging in             Stop—claimant is   Go to step 2
                                               substantial gainful activity?           not disabled
                                     2         Does the claimant have an               Go to step 3       Stop—claimant is
                                               impairment that has more than a                            not disabled
                                               minimal effect on the claimant’s
                                               ability to perform basic work tasks
                                               and is expected to last at least 12
                                     3         Do the medical facts alone show that Stop—claimant is      Go to step 4
                                               the claimant’s impairment meets or   disabled
                                               equals the medical criteria for an
                                               impairment in SSA’s Listing of
                                     4         Comparing the claimant’s residual       Stop—claimant is   Go to step 5
                                               functional capacity with the physical   not disabled
                                               and mental demands of the
                                               claimant’s past work, can the
                                               claimant perform his or her past
                                     5         Based on the claimant’s residual        Claimant is not    Claimant is
                                               functional capacity and any             disabled           disabled
                                               limitations that may be imposed by
                                               the claimant’s age, education, and
                                               skill level, can the claimant do work
                                               other than his or her past work?

                                     As the application proceeds through the five-step process, claimants may
                                     be denied benefits at any step, ending the process. Steps 1 and 2 ask
                                     questions about the claimant’s work activity and the severity of the
                                     claimant’s impairment. If the reported impairment is judged to be severe,
                                     adjudicators move to step 3. At this step, they compare the claimant’s
                                     condition with a listing of medical impairments developed by SSA.
                                     Claimants whose conditions meet or are medically equivalent to the
                                     listings are presumed by SSA to be unable to work and are awarded
                                     benefits. Claimants whose conditions do not meet or equal the listings are
                                     then assessed at steps 4 and 5, where decisions must be made about the
                                     claimant’s ability to perform prior work and any other work that exists in
                                     the national economy. To do this, adjudicators assess the claimant’s
                                     capacity to function in the workplace.

                                     DDS and ALJ adjudicators exercise considerable judgment when making
                                     these functional assessments. They must consider and weigh all available

                                     Page 5                                                               GAO/T-HEHS-97-118
                                        Social Security Disability: SSA Actions to
                                        Reduce Backlogs and Achieve More
                                        Consistent Decisions Deserve High Priority

                                        evidence, including physician opinions and reported symptoms, such as
                                        pain. Mental impairment assessments include judgments about the
                                        claimant’s ability to understand, remember, and respond appropriately to
                                        supervision and normal work pressures. For physical impairments,
                                        adjudicators judge the claimant’s ability to walk, sit, stand, and lift. To
                                        facilitate this, SSA has defined five levels of physical exertion ranging from
                                        very heavy to sedentary. However, for those claimants unable to perform
                                        even sedentary activities, adjudicators may determine that a claimant can
                                        perform “less than a full range of sedentary” activities, a classification that
                                        often results in a benefit award.

                                        Our analysis found that differing functional assessments by DDSs and ALJs
DDSs and ALJs Differ                    are the primary reason for most ALJ awards. Since most DDS decisions use
Primarily Over                          all five steps of the sequential evaluation process before denying a claim,
Claimants’ Functional                   almost all DDS denial decisions appealed to ALJs included such a functional
                                        assessment. On appeal, the ALJ also follows the same sequential evaluation
Abilities                               process as the DDS and also assesses the claimant’s functional abilities in
                                        most awards they make.

                                        Data from SSA’s ongoing ALJ study indicate that ALJs are much more likely
                                        than DDSs to find that claimants have severe limitations in functioning in
                                        the workplace (see table 3).

Table 3: DDS and ALJ Differences in
Functional Assessment Classifications                                                                Percentage of awards
for Physical Impairment Awards                                                              Quality reviewers
                                        Level of physical exertion determined by                   using DDS Original awarding
                                        functional assessment                                       approach             ALJs
                                        Heavy work (or no limiting effect on physical
                                        effort)                                                                0                  0
                                        Medium work                                                          22                   1
                                        Light work                                                           56                   8
                                        Sedentary work                                                       15                  25
                                        Less than the full range of sedentary work                             6                 66
                                        Note: Data are for ALJ awards made from September 1992 through April 1995.

                                        Most notably, in the view of the awarding ALJs, 66 percent of the cases
                                        merited a functional capacity assessment of “less than the full range of
                                        sedentary” work—a classification that is likely to lead to an award. In

                                        Page 6                                                                     GAO/T-HEHS-97-118
Social Security Disability: SSA Actions to
Reduce Backlogs and Achieve More
Consistent Decisions Deserve High Priority

contrast, reviewers using the DDS approach found that less than 6 percent
of the cases merited this classification.

Functional assessment also played a key role in a 1982 SSA study, which
controlled for differences in evidence. This study indicated that DDS and
ALJ decisionmakers reached different results even when presented with the
same evidence.5 As part of the study, selected cases were reviewed by two
groups of reviewers—one group reviewing the cases as ALJs would and the
other reviewing the cases as DDSs would. Reviewers using the ALJ approach
concluded that 48 percent of the cases should have received awards, while
reviewers using the DDS approach concluded that only 13 percent of those
same cases should have received awards.

The use of medical expertise appears to influence the decisional
differences at the DDS and ALJ levels. At the DDS level, medical consultants
are responsible for making functional assessments. In contrast, ALJs have
the sole authority to determine functional capacity and often rely on
claimant testimony and the opinions of treating physicians. Although ALJs
may call on independent medical experts to testify, our analysis shows
that they do so in only 8 percent of the cases resulting in awards.

To help reduce inconsistency, SSA issued nine rulings on July 2, 1996,
which were written to address pain and other subjective symptoms,
treating source opinions, and assessing functional capacity.6 SSA also plans
to issue a regulation to provide additional guidance on assessing
functional capacity at both the DDS and ALJ levels, specifically clarifying
when a “less than sedentary” classification is appropriate.7 In addition,
based on the nine rulings, SSA completed nationwide process unification
training of over 15,000 adjudicators and quality reviewers between July 10,
1996, and February 26, 1997. In the training, SSA emphasized that it expects
the “less than sedentary” classification would be used rarely. In the longer
term, SSA plans to develop a simplified decision-making process, which
will expand the role of functional capacity assessments. Because
differences in functional capacity assessments are the primary reason for
inconsistent decisions, SSA should proceed cautiously with its plan to
expand the use of such assessments.

 Implementation of Section 304 (g) of Public Law 96-265, Social Security Disability Amendments of
1980: Report to the Congress by the Secretary of Health and Human Services, SSA, Department of
Health and Human Services (Jan. 1982). This report is commonly known as the “Bellmon Report.”
 Federal Register, 61 F.R. 34466-34492 (July 2, 1996).
 SSA told us that the notice of proposed rulemaking on the “less than sedentary” regulations is ready
for release but did not provide the date when it would be issued.

Page 7                                                                          GAO/T-HEHS-97-118
                        Social Security Disability: SSA Actions to
                        Reduce Backlogs and Achieve More
                        Consistent Decisions Deserve High Priority

                        Procedures at the DDS and ALJ levels limit the usefulness of the DDS
Procedures Limit Use    decision as a foundation for the ALJ decision. Often, ALJs are unable to rely
of DDS Decisions as a   on DDS decisions because they lack supporting evidence and explanations
Foundation for ALJ      of the reasons for denial, laying a weak foundation for the ALJ decision if
                        the case is appealed. Moreover, although SSA requires ALJs to consider the
Decisions               DDS medical consultant’s assessment of functional capacity, procedures at
                        the DDS level do not ensure that such assessments are clearly explained. In
                        a 1994 study, SSA found that written explanations of critical issues at the
                        DDS level were inadequate in about half of the appealed cases that turned
                        on complex issues.8 Without a clear explanation of the DDS decision, the
                        ALJ could neither effectively consider it nor give it much weight.

                        At the ALJ level, claimants are allowed to claim new impairments and
                        submit new or additional evidence, which also affects consistency
                        between the two levels. Moreover, in about 10 percent of cases appealed
                        to the ALJ level, claimants switch their primary impairment from a physical
                        claim to a mental claim. In addition, data from a 1994 SSA study show that
                        claimants submit additional evidence to the ALJ in about three-quarters of
                        the sampled cases and that additional evidence was an important factor in
                        27 percent of ALJ allowances.

                        To address the documentation issues, SSA plans to take steps to ensure
                        that DDS decisions are better explained and are based on a more complete
                        record so that they are more useful if appealed. On the basis of feedback
                        during the process unification training, SSA plans further instructions and
                        training in May 1997 for the DDSs on how and where in the case files they
                        should explain how they reached their decisions. SSA also plans to issue a
                        regulation clarifying the weight given to the DDS medical consultants’
                        opinions at the ALJ level.9

                        To deal with the potential effect of new evidence, SSA plans to return to the
                        DDSs about 100,000 selected cases a year for further consideration when
                        new evidence is introduced at the ALJ level. In cases where the DDS would
                        award benefits, the need for a more time-consuming and costly ALJ
                        decision would be avoided. SSA plans to implement this project in
                        May 1997. Moreover, SSA’s decision to limit such returns to about 100,000
                        cases may need to be reassessed in light of the potential benefits that
                        could accrue from this initiative.

                          Findings of the Disability Hearings Quality Review Process, Office of Program and Integrity Reviews,
                        SSA (Sept. 1994).
                         SSA told us that the notice of proposed rulemaking on the DDS medical consultants’ opinions is in
                        final clearance within SSA.

                        Page 8                                                                          GAO/T-HEHS-97-118
                         Social Security Disability: SSA Actions to
                         Reduce Backlogs and Achieve More
                         Consistent Decisions Deserve High Priority

                         Although SSA has several quality review systems to examine disability
Quality Reviews Do       decisions, none is designed to identify and reconcile factors that
Not Focus on             contribute to differences between DDS and ALJ decisions. For example,
Inconsistency            although ALJs are required to consider the opinion of the DDS medical
                         consultant when making their own assessment of a claimant’s functional
Between DDSs and         capacity, such written DDS opinions are often lacking in the case files.
ALJs                     Quality reviews at the DDS level do not focus effectively on whether or how
                         well these opinions are explained in the record, despite the potential
                         importance of such medical opinion evidence at the ALJ level. Moreover,
                         SSA reviews too few ALJ awards to ensure that ALJs give appropriate
                         consideration to the medical consultants’ opinions or to identify means to
                         make them more useful to the ALJs. Feedback on these issues could help
                         improve consistency by making the DDS decision a more useful part of the
                         overall adjudication process.

                         To improve consistency, SSA is completing work on a notice of proposed
                         rulemaking, with a target issue date of August 1997 for a final regulation,
                         to establish the basis for reviewing ALJ awards, which would require ALJs to
                         take corrective action on remand orders from the Appeals Council before
                         benefits are paid. SSA has just started conducting preliminary reviews of
                         ALJ awards, beginning with 200 cases a month. After the regulation is
                         issued, they plan to increase the number of cases per month. SSA has set a
                         first-year target of 10,000 cases to be reviewed, but this reflects only about
                         3 percent of approximately 350,000 award decisions made by ALJs in 1996.
                         Ultimately, SSA plans to implement quality review measures to provide
                         consistent feedback on the application of policy. By doing this, the agency
                         hopes to ensure that the correct decision is made at the earliest point in
                         the process.

                         At the same time that SSA is trying to begin implementation of its process
Competing Workloads      unification initiatives, it faces significantly increasing workloads at all
Could Jeopardize         levels of adjudication. In particular, efforts to improve decisional
Initiatives to Improve   consistency will compete with specific congressional mandates for time
                         and resources. For example, the Social Security Independence and
Consistency of           Program Improvements Act of 1994 and the Personal Responsibility and
Decisions                Work Opportunity Reconciliation Act of 1996 require hundreds of
                         thousands of more continuing disability reviews (CDR) to ensure that
                         beneficiaries are still eligible for benefits. By law, SSA will be required to
                         conduct CDRs for at least 100,000 more SSI beneficiaries annually through
                         fiscal year 1998. Last year, the Congress increased CDR requirements for
                         children on SSI, requiring them at least every 3 years for children under age

                         Page 9                                                      GAO/T-HEHS-97-118
               Social Security Disability: SSA Actions to
               Reduce Backlogs and Achieve More
               Consistent Decisions Deserve High Priority

               18 who are likely to improve and for all low-birthweight babies within the
               first year of life. In addition, SSA is required to redetermine, using adult
               criteria, the eligibility of all 18-year-olds on SSI beginning on their 18th
               birthdays and to readjudicate 332,000 childhood disability cases by
               August 1997. Finally, thousands of noncitizens and drug addicts and
               alcoholics could appeal their benefit terminations, further increasing
               workload pressures.

               Despite SSA’s Short Term Disability Project Plan, the appealed case
Concluding     backlog is still high. Nevertheless, because the backlog would have been
Observations   even higher without STDP, SSA will need to continue its effort to reduce the
               backlog to a manageable level until the agency, as a part of its long-term
               redesign effort, institutes a permanent process to ensure timely and
               expeditious disposition of appeals.

               In addition, SSA is beginning to move ahead with more systemwide changes
               in its redesign of the disability claims process. In particular, it is on the
               verge of implementing initiatives to redesign the process, including ones
               for improving decisional consistency and the timeliness of overall claims
               processing. However, competing workload demands could jeopardize SSA’s
               ability to make progress in reducing inconsistent decisions.

               We urge the agency to follow through on its initiatives to address the
               long-standing problem of decisional inconsistency with the sustained
               attention required for this difficult task. To do so, SSA, in consultation with
               this Subcommittee and others, will need to sort through its many priorities
               and do a better job of holding itself accountable for meeting its deadlines.
               Otherwise, plans and target dates will remain elusive goals and may never
               yield the dual benefits of helping to restore public confidence in the
               decision-making process and contributing to permanent reductions in

               Mr. Chairman, this concludes my prepared statement. At this time, I will be
               happy to answer any questions you or the other Subcommittee members
               may have.

               Page 10                                                      GAO/T-HEHS-97-118
               Social Security Disability: SSA Actions to
               Reduce Backlogs and Achieve More
               Consistent Decisions Deserve High Priority

               For more information on this testimony, please call Cynthia Bascetta,
Contributors   Assistant Director, at (202) 512-7207. Other major contributors are William
               Hutchinson, Senior Evaluator; Carol Dawn Petersen, Senior Economist;
               and David Fiske, Ellen Habenicht, and Carlos Evora, Senior Evaluators.

               Page 11                                                   GAO/T-HEHS-97-118
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(207005)      Page 12                                                    GAO/T-HEHS-97-118
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