Medicare and Medicaid: Meeting Needs of Dual Eligibles Raises Difficult Cost and Care Issues

Published by the Government Accountability Office on 1997-04-29.

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

                          United States General Accounting Office

GAO                       Testimony
                          Before the Special Committee on Aging, U.S. Senate

For Release on Delivery
Expected at 9:30 a.m.
Tuesday, April 29, 1997
                          MEDICARE AND

                          Meeting Needs of Dual
                          Eligibles Raises Difficult
                          Cost and Care Issues
                          Statement of William J. Scanlon, Director
                          Health Financing and Systems Issues
                          Health, Education, and Human Services Division

Medicare and Medicaid: Meeting Needs of
Dual Eligibles Raises Difficult Cost and Care
               Mr. Chairman and Members of the Committee:

               We are pleased to be here today to discuss several issues that arise in
               financing health care for people known as dual eligibles—Medicare
               beneficiaries who are also eligible for some form of Medicaid support. In
               1995, Medicare and Medicaid spending for the roughly 6 million dual
               eligibles totaled an estimated $106 billion, or almost a third of these
               programs’ expenditures combined. This dually eligible population is
               expected to grow, resulting in ever greater health financing expenditures
               and care challenges. In addition, dual eligibles are, by definition, poor, and
               many are in poor health, with over 20 percent residing in nursing homes.
               While the very poor and very sick could benefit from a coordinated system
               of care, at times they can encounter a fragmented and confusing array of

               My comments today will focus on three major areas: (1) the health
               characteristics of those who are eligible for both Medicare and Medicaid
               and the key structural differences between the two programs that serve
               this population, (2) benefit overlaps between these two programs and the
               associated shifting of care and costs between federal and state levels, and
               (3) states’ efforts to use managed care to serve this population. Our work
               is based on our recent products on efforts to reform Medicare posthospital
               benefit payments and Medicare and Medicaid managed care issues, an
               analysis of federal data on dually eligible beneficiaries, and other relevant
               research. (A list of related GAO products appears at the end of this

               In summary, the dually eligible population consists of people with a range
               of health needs—from the young to the very old and from the healthy to
               the disabled or chronically ill in nursing homes. Compared with
               Medicare-only beneficiaries, however, dually eligible beneficiaries are
               more likely to have poorer health status and require costly care, including
               long-term care. Meeting their needs under two programs that are
               administered under different rules complicates matters in both
               fee-for-service and managed care environments. The potential to cover
               posthospital and long-term care benefits under either program has
               resulted in costs being shifted between programs. Because the federal
               government pays the full cost of Medicare and shares the cost of Medicaid
               with the states, the greater financial burden generally falls on the federal

               Page 1                                                      GAO/T-HEHS-97-119
                           Medicare and Medicaid: Meeting Needs of
                           Dual Eligibles Raises Difficult Cost and Care

                           To better coordinate acute and long-term care needs while holding down
                           costs, some states are assessing the potential for enrolling their dually
                           eligible populations in a single managed care plan. However, differences in
                           Medicare and Medicaid requirements for commercial managed care
                           participation can create barriers to this approach. Because these barriers
                           are largely related to certain statutory beneficiary guarantees, including
                           beneficiaries’ freedom to choose their own provider, granting waivers
                           from federal requirements to states that are designing comprehensive
                           managed care programs remains a delicate issue.

                           The implications of managing the costs of care for this population are
                           significant at both the federal and state levels. The issue is important to
                           the federal government because it pays for Medicare as well as for over
                           half of Medicaid’s costs. It is also important to state governments, because
                           they have little control over federal decisions—such as the imposition of
                           new Medicare cost-sharing requirements—that make their budgets
                           vulnerable to unplanned fiscal liabilities. As states pursue greater
                           flexibility to design more efficient and effective service delivery programs
                           for this population through waivers of certain beneficiary protections
                           guaranteed by federal statute, federal and state governments’ rigorous
                           oversight of care delivery remains essential.

                           In concept, Medicare and Medicaid provide essential and complementary
Poor Health Status,        services to dually eligible beneficiaries. Medicare is the primary provider
Program Differences        of hospital, posthospital, and physician care, while Medicaid provides
Pose Challenges in         benefits beyond those covered by Medicare, such as prescription drugs
                           and long-term care. In practice, however, Medicare and Medicaid’s
Serving Dually             respective roles do not sort this out neatly, and the health financing needs
Eligible Population        of the dually eligible population surface numerous contradictions and
                           policy conundrums when attempts are made to mesh the two programs.

Poor Health Status         Dual eligibles are among the most vulnerable Medicare beneficiaries.
Characterizes the          Within this population, however, individuals’ health needs and associated
Condition of Many of the   medical costs can vary substantially. Although some individuals incur few
                           or no costs beyond those of the general population, many have
Dually Eligible            substantially greater health care needs and fewer personal resources to
                           meet those needs than the average Medicare beneficiary. By definition,
                           dual eligibles are poor: about 20 percent have annual income of less than
                           $5,000 a year; 80 percent have annual income of less than $10,000.

                           Page 2                                                     GAO/T-HEHS-97-119
                             Medicare and Medicaid: Meeting Needs of
                             Dual Eligibles Raises Difficult Cost and Care

                             Compared with Medicare-only beneficiaries, dually eligible beneficiaries
                             are more likely to

                         •   live in a nursing home or live alone;
                         •   have a serious and chronic condition, and physical or cognitive
                             impairment; and
                         •   have less access to a regular source of care and preventive services, and
                             higher use of emergency room care.

Medicare and Medicaid        Medicare is a federally financed health insurance program administered by
Display Key Structural       the Department of Health and Human Services’ Health Care Financing
Differences                  Administration (HCFA). It covers almost all Americans 65 years old and
                             older and certain individuals under 65 who are disabled or have chronic
                             kidney disease. The program provides protection with an acute care focus
                             under two parts. Part A covers inpatient hospital services, posthospital
                             care in skilled nursing facilities (SNF), and care in patients’ homes. Part B
                             covers primarily physician and other outpatient services. In fiscal year
                             1996, Medicare covered an estimated 38 million beneficiaries at a cost of
                             $197 billion.

                             Medicaid is a health insurance program financed and administered by both
                             the federal government and the states. Its beneficiaries include poor
                             children and their parents as well as low-income elderly, blind, and
                             disabled individuals. In addition to covering primary and acute care,
                             Medicaid covers outpatient prescription drugs and long-term care both in
                             the home and in nursing facilities.

                             Medicaid, however, is not 1, but over 50 separate programs.1 Although
                             federal law mandates coverage of certain medical services and population
                             groups, it also permits states to choose whether to cover additional
                             services or low-income population groups. Thus, under Medicaid, the
                             populations served and benefits provided vary across states. The
                             percentage of Medicaid expenditures covered by the federal government
                             also varies by state, depending on the state’s per capita income, with a
                             range from 50 to 83 percent. In 1996, the federal government paid 57
                             percent of the aggregate Medicaid costs of about $160 billion, which
                             provided health care coverage for about 37 million beneficiaries.

                              There are 56 programs, 1 in each of the 50 states, the District of Columbia, Puerto Rico, and the U.S.

                             Page 3                                                                            GAO/T-HEHS-97-119
                             Medicare and Medicaid: Meeting Needs of
                             Dual Eligibles Raises Difficult Cost and Care

                             Both programs have traditionally reimbursed providers through
                             fee-for-service arrangements, but both have been developing managed
                             care components in which beneficiaries obtain care from prepaid health
                             plans. Managed care plans in both programs cover beneficiaries under
                             terms that are different from those under fee-for-service arrangements.
                             For example, managed care organizations are paid a fixed monthly amount
                             for each enrollee to provide or arrange for medical services, which are
                             typically coordinated through a primary care physician. In addition,
                             Medicaid managed care programs differ among states. To implement these
                             programs, states typically seek approval from HCFA to waive certain federal
                             requirements. Named after sections of the Social Security Act that
                             authorize the waivers, 1915(b) program waivers and 1115 demonstration
                             waivers permit states to conduct managed care programs and experiment
                             with plan participation and eligibility rules that would otherwise be
                             prohibited by law.

Dual Eligibles Qualify for   Dually eligible individuals are Medicare beneficiaries first. According to
Medicare and Various         the level of support provided by Medicaid, the dually eligible population is
Levels of Medicaid Support   divided into two major groups: (1) those receiving Medicare cost-sharing
                             support and additional Medicaid health care benefits (“full-benefit”
                             individuals) and (2) those receiving help from Medicaid only to cover
                             out-of-pocket costs after payment by Medicare. Collectively, both groups
                             of dually eligible beneficiaries represent about 16 percent of the Medicare
                             population but 30 percent of Medicare expenditures. Similarly, they
                             account for about 17 percent of the Medicaid population but 35 percent of
                             Medicaid expenditures.

                             States vary dramatically in the proportion of Medicare beneficiaries also
                             enrolled in their Medicaid programs. According to one source, in 1993, two
                             states’ Medicaid programs covered more than 20 percent of their Medicare
                             beneficiary populations, whereas eight states’ Medicaid programs covered
                             fewer than 7 percent of their states’ Medicare beneficiaries.2 These
                             differences may reflect variation across states in demographic
                             composition, state eligibility criteria, outreach efforts, and data reporting

                             Full-benefit individuals—an estimated 5.4 million in 1995—compose the
                             largest group of Medicare beneficiaries covered by Medicaid.3 They qualify

                             Katie Merrell and others, “Medicare Beneficiaries Covered by Medicaid Buy-In Agreements,” Health
                             Affairs (Jan./Feb. 1997).
                              This testimony focuses primarily on the dual eligibles who qualify for full benefits.

                             Page 4                                                                             GAO/T-HEHS-97-119
Medicare and Medicaid: Meeting Needs of
Dual Eligibles Raises Difficult Cost and Care

for Medicaid primarily because they are “categorically eligible”—that is,
they are eligible for such cash assistance programs as Supplemental
Security Income (SSI)—or because they are “medically needy,” which
means they have incomes or assets above the levels that would make them
eligible for cash assistance but their medical expenses relative to their
incomes are so substantial that states qualify them for assistance.4

A much smaller group of Medicare beneficiaries—an estimated 562,000 in
19955—receives Medicaid coverage for certain Medicare financial
obligations and includes two subgroups. The first consists of Qualified
Medicare Beneficiaries—called QMBs. These people have incomes or assets
that exceed the thresholds set for full-benefit eligibility but have incomes
that are nevertheless at or below the federal poverty level. Medicaid pays
these beneficiaries’ Medicare monthly part B premiums and all
copayments and deductibles required under Medicare. The second
subgroup consists of Specified Low-Income Medicare
Beneficiaries—called SLMBs. These people have incomes slightly above the
federal poverty level; Medicaid pays their Medicare premiums but not
copayments or deductibles.

The Congress enacted the QMB and SLMB programs in 1988 and 1990,
respectively, out of concern for the financial hardship that Medicare
cost-sharing requirements could pose for low-income people not eligible
for Medicaid. As we reported in 1994 and others have stated more recently,
since the programs were implemented, many individuals eligible for
Medicaid’s cost-sharing support have not taken advantage of it.6 In 1995,
an estimated 37 percent of people eligible for the QMB program were not
enrolled, and an estimated 90 percent of people eligible for the SLMB
program were not enrolled.7

 States may also choose to provide Medicaid benefits to people with incomes up to 300 percent of SSI
levels in nursing homes or receiving home and community-based services under a waiver, or to people
with income between SSI levels and 100 percent of the poverty level who may not be receiving cash
 Precise numbers for these individuals are not readily available. For a recent estimate, see Judith
Feder, “Medicare/Medicaid Dual Eligibles: Fiscal and Social Responsibility for Vulnerable Populations”
(Georgetown University: Mar. 25, 1997).
 Medicare and Medicaid: Many Eligible People Not Enrolled in Qualified Medicare Beneficiary
Program (GAO/HEHS-94-52, Jan. 20, 1994).
Marilyn Moon and others, Protecting Low-Income Medicare Beneficiaries (The Urban Institute:
Nov. 1996).

Page 5                                                                         GAO/T-HEHS-97-119
                        Medicare and Medicaid: Meeting Needs of
                        Dual Eligibles Raises Difficult Cost and Care

                        Both Medicare and Medicaid devote substantial resources to providing
Benefit Overlaps        care to the dually eligible population. At the same time, both programs are
Foster Shifting of      under pressure to contain cost growth in their respective programs. This
Fee-for-Service Costs   makes the substitution of services provided—and the resulting shifting of
                        costs between federal and state levels—one alternative for limiting a
Between Programs        program’s fiscal liability. The net burden is likely to fall more heavily on
                        the federal government, as the payer for all Medicare and more than half of
                        Medicaid expenditures.

                        Dual eligibles can obtain similar services from both Medicare and
                        Medicaid, especially home health and nursing facility care. Since 1989,
                        when coverage guidelines were liberalized in response to court decisions,
                        the home health care benefit has been essentially transformed from one
                        focused on patients needing short-term care after hospitalization to one
                        that serves chronic, long-term care patients as well. Between 1989 and
                        1996, Medicare’s part A home health care payments rose sevenfold, from
                        $2.4 billion to $17.7 billion. As we testified before congressional
                        committees earlier this year,8 not only has the number of Medicare
                        beneficiaries receiving home health care increased dramatically, but so
                        has the intensity of visits for each beneficiary.9

                        Medicaid, as a payer for long-term and home-based care, can take
                        advantage of Medicare’s liberalized guidelines to help cover the costs of
                        long-term care for dual eligibles. This practice, often referred to as
                        “Medicare maximization,” involves Medicaid’s billing of Medicare
                        first—where feasible—on behalf of dual eligibles. This practice is
                        consistent with the Social Security Act, which requires that, when a
                        service is covered by both programs, Medicare is the primary payer. A
                        recent example is the enactment in 1996 of Minnesota’s Medicare
                        Maximization Initiative, a program designed to teach providers how to use
                        Medicare for home care services and supplies and equipment for
                        recipients who are dually eligible. In this way, Medicaid has been able to

                         We have testified before the Subcommittee on Health and Environment, House Committee on
                        Commerce: Medicare: Home Health Cost Growth and Administration’s Proposal for Prospective
                        Payment (GAO/T-HEHS-97-92, Mar. 5, 1997) and before the Subcommittee on Health, House
                        Committee on Ways and Means: Medicare Post-Acute Care: Home Health and Skilled Nursing Facility
                        Cost Growth and Proposals for Prospective Payment (GAO/T-HEHS-97-90, Mar. 4, 1997).
                         The number of Medicare beneficiaries receiving home health care more than doubled, from 1.7 million
                        in 1989 to about 3.9 million in 1996. During the same period, the average number of visits to home
                        health beneficiaries also more than doubled, from 27 to 72. In addition, we found that the proportion of
                        home health users receiving more than 30 visits increased from 24 percent in 1989 to 43 percent in
                        1993, and, during the same period, the proportion of those receiving more than 90 visits tripled, from
                        6 percent to 18 percent.

                        Page 6                                                                          GAO/T-HEHS-97-119
                                 Medicare and Medicaid: Meeting Needs of
                                 Dual Eligibles Raises Difficult Cost and Care

                                 reduce its costs by capitalizing on the movement of Medicare’s home
                                 health benefit from a post-acute focus to include long-term care benefits.

                                 Alternatively, when Medicare’s SNF coverage criteria for daily skilled care
                                 are applied more stringently, Medicare’s coverage of a dually eligible
                                 patient’s SNF stay may end earlier and Medicaid becomes the primary
                                 payer. Such a strict application of Medicare coverage criteria, while
                                 advantageous to Medicare, shifts some of the burden of financing SNF care
                                 to Medicaid.

                                 States are beginning to explore the use of managed care to serve their
States’ Desire to Use            dually eligible populations. However, using managed care prepaid health
Managed Care May                 plans presents another set of dilemmas. On the one hand, managed care, in
Conflict With Federal            principle, offers the potential for a single system of coordinated care to
                                 serve a population particularly likely to benefit from such a system. On the
Guarantees to                    other hand, managed care plans—both in Medicare and Medicaid—have
Medicare                         little experience serving a population with expensive medical and
                                 extensive long-term care needs. In addition, each of the respective
Beneficiaries                    programs has different terms for beneficiary and plan participation. Thus,
                                 as states consider enrolling dual eligibles in their managed care programs,
                                 they face certain barriers that require federal and state cooperation to
                                 overcome. With federal waivers from some statutory requirements, several
                                 states have removed key administrative obstacles, permitting the
                                 enrollment of the dually eligible population.

Differences in Managed           Medicare and Medicaid managed care programs are characterized by two
Care Participation Terms         key differences:
Complicate States’ Efforts
                             •   “Freedom-of-choice” guarantees. Under Medicare, beneficiaries can enroll
to Coordinate Care               in any managed care plan with a Medicare contract and are free to
                                 disenroll every 30 days and reenter the fee-for-service system or join
                                 another managed care plan. Under Medicaid, with HCFA-granted waivers a
                                 state can require beneficiaries to enroll in a limited number of state
                                 managed care plans and can also “lock in” their enrollment for as long as
                                 12 months.
                             •   Plan participation requirements. In both programs, managed care plans
                                 must enroll a certain number of commercial members because of the
                                 hypothesis that a health plan’s ability to attract private enrollees can serve
                                 as one assurance of quality. Medicare’s commercial membership threshold
                                 of 50 percent is higher than Medicaid’s, which is 25 percent—or waived

                                 Page 7                                                      GAO/T-HEHS-97-119
                               Medicare and Medicaid: Meeting Needs of
                               Dual Eligibles Raises Difficult Cost and Care

                               altogether in the case of states that have obtained special approval from

                               As states seek greater control of their health financing and care delivery
                               obligations, these program differences may serve as barriers to enrolling
                               dual eligibles in a single managed care plan. Medicare’s liberal
                               disenrollment policy, coupled with its requirement to enroll beneficiaries
                               in plans meeting the 50-percent commercial membership level,
                               complicates states’ ability to use managed care for their Medicaid
                               beneficiaries with Medicare status.

                               For example, a state’s ability to lock beneficiaries into a prepaid plan
                               providing both Medicare and Medicaid benefits for an extended period
                               may have the benefit of stabilizing the state’s fiscal liability for health care,
                               while offering the potential to coordinate care within a single network of
                               providers. But dually eligible beneficiaries who exercise their Medicare
                               right to leave the plan during the Medicaid lock-in period may expose the
                               state to the cost-sharing obligations incurred with a fee-for-service or
                               Medicare managed care provider and preclude the Medicaid plan’s
                               potential to organize a system of coordinated services. In addition, states
                               may have existing contractual relationships with Medicaid managed care
                               organizations that could serve the states’ dual eligibles, but their public
                               program membership exceeds the 50-percent threshold needed to comply
                               with Medicare’s rules for plans eligible to serve Medicare beneficiaries.

Beneficiary Protection in      With its focus on coordinated care, managed care provides states an
Managed Care More              option for moving their dually eligible population into a single plan
Critical for Dually Eligible   providing all or most required services. However, a Medicaid program’s
                               policy may preclude incorporating certain Medicare provisions—such as
Population                     the freedom to choose among all participating plans and to disenroll
                               monthly—which have been considered important beneficiary protections
                               in managed care. As our recent testimony before this Committee indicated,
                               the ability of plans to satisfy and retain beneficiaries is highly variable.11

                               The more complex and extensive needs of the dually eligible population
                               accentuate the importance of beneficiary protections. However, limited
                               experience on the part of states and plans serving—in a managed care

                                 The administration has proposed replacing Medicare and Medicaid’s commercial enrollment
                               requirements with enhanced quality monitoring and measurement systems, yet to be defined.
                                Medicare Managed Care: HCFA Missing Opportunities to Provide Consumer Information
                               (GAO/T-HEHS-97-109, Apr. 10, 1997).

                               Page 8                                                                      GAO/T-HEHS-97-119
                        Medicare and Medicaid: Meeting Needs of
                        Dual Eligibles Raises Difficult Cost and Care

                        setting—people with the demographic and health status traits of dual
                        eligibles makes it difficult to identify beneficiary protections that will be
                        effective and will minimize problems in coordinating these two programs.
                        For example, we recently reviewed states’ prepaid Medicaid programs
                        serving disabled beneficiaries12 and found that, of 17 states making
                        managed care available to disabled people, 12 had less than 20 percent of
                        their disabled beneficiaries enrolled. Of the six state programs requiring
                        some or all of their disabled population to enroll in prepaid managed care,
                        only one was more than 3 years old.

                        We also found that oversight mechanisms designed to track a plan’s
                        performance in delivering services to the average enrollee are not
                        well-suited to monitor service delivery to the severely disabled, who may
                        represent a small number of enrollees in a plan. About half of the 17 states
                        enrolling disabled beneficiaries in prepaid managed care continued to rely
                        on mechanisms such as beneficiaries’ freedom to disenroll from or switch
                        plans or on their access to grievance systems in lieu of more carefully
                        targeted formal quality assurance systems.

                        Several factors highlight the importance of dual eligibility in the coming
Several Concerns        years: a growing dually eligible population, the potential for new
About Dual Eligibles    cost-sharing obligations, and states’ continued requests for waivers to
Remain Issues for the   implement innovative managed care programs.

Future                  The demographics of the dually eligible beneficiaries will undoubtedly
                        continue to focus attention on the respective federal and state roles in
                        serving this population. The numbers of dual eligibles are expected to
                        increase, and the two groups that are likely to be dually eligible—the
                        oldest elderly and the nonelderly disabled—are growing segments of the
                        Medicare population.13

                        Among the various approaches being considered to contain the
                        unsustainable growth in Medicare costs is the option to increase
                        beneficiary cost sharing. However, if Medicare premiums and cost sharing
                        are increased, these costs will consequently rise for the states, as payers of
                        the dually eligibles’ financial obligations under Medicare.

                           Medicaid Managed Care: Serving the Disabled Challenges State Programs (GAO/HEHS-96-136,
                        July 31, 1996).
                          Nonelderly disabled beneficiaries made up about 10 percent of the Medicare population in 1991 but
                        are expected to make up nearly 18 percent in 2010. Similarly, beneficiaries aged 85 or older made up
                        8 percent of the Medicare population in 1991 but are expected to compose 11 percent of the Medicare
                        population in 2010.

                        Page 9                                                                        GAO/T-HEHS-97-119
               Medicare and Medicaid: Meeting Needs of
               Dual Eligibles Raises Difficult Cost and Care

               Finally, states are likely to continue seeking flexibility under HCFA’s waiver
               approval process to overcome existing barriers to dual eligibles’
               enrollment in managed care. How HCFA will treat freedom-of-choice issues,
               such as the beneficiaries’ right to disenroll monthly, and the “50-50”
               public/private membership rule remains an open question. Regardless of
               the approaches taken, our recent work in both Medicare and Medicaid
               managed care stresses repeatedly that, to ensure program accountability
               for the interests of both beneficiaries and the federal government, rigorous
               federal and state oversight of care and effective quality monitoring
               systems are essential.

               Mr. Chairman, this concludes my prepared statement. I will be happy to
               answer any questions you or the other Committee Members may have.

               For more information on this testimony, please call Kathryn G. Allen,
Contributors   Acting Associate Director, on (202) 512-7059. Other major contributors
               included Hannah F. Fein and Sally J. Kaplan.

               Page 10                                                     GAO/T-HEHS-97-119
Page 11   GAO/T-HEHS-97-119
Related GAO Products

              Medicaid Managed Care: Challenge of Holding Plans Accountable Requires
              Greater State Effort (GAO/HEHS-97-86, forthcoming).

              Medicare: Home Health Cost Growth and Administration’s Proposal for
              Prospective Payment (GAO/T-HEHS-97-92, Mar. 5, 1997).

              Medicare Post-Acute Care: Home Health and Skilled Nursing Facility Cost
              Growth and Proposals for Prospective Payment (GAO/T-HEHS-97-90, Mar. 4,

              Medicare HMOs: Potential Effects of a Limited Enrollment Period Policy
              (GAO/HEHS-97-50, Feb. 28, 1997).

              Medicare: HCFA Should Release Data to Aid Consumers, Prompt Better
              HMO Performance (GAO/HEHS-97-23, Oct. 22, 1996).

              Medicaid Managed Care: Serving the Disabled Challenges State Programs
              (GAO/HEHS-96-136, July 31, 1996).

              Medicare: Increased HMO Oversight Could Improve Quality and Access to
              Care (GAO/HEHS-95-155, Aug. 3, 1995).

              Medicaid: Spending Pressures Drive States Toward Program Reinvention
              (GAO/HEHS-95-122, Apr. 4, 1995).

              Medicare and Medicaid: Many Eligible People Not Enrolled in Qualified
              Medicare Beneficiary Program (GAO/HEHS-94-52, Jan. 20, 1994).

(101559)      Page 12                                                 GAO/T-HEHS-97-119
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