Veterans' Affairs: Observations on Selected Features of the Proposed Veterans' Millennium Health Care Act

Published by the Government Accountability Office on 1999-05-19.

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

                          United States General Accounting Office

GAO                       Testimony
                          Before the Subcommittee on Health, Committee on
                          Veterans’ Affairs, House of Representatives

Not to Be Released
Before 10:00 a.m.
Wednesday, May 19, 1999
                          VETERANS’ AFFAIRS

                          Observations on Selected
                          Features of the Proposed
                          Veterans’ Millennium Health
                          Care Act
                          Statement for the Record by Stephen P. Backhus, Director
                          Veterans’ Affairs and Military Health Care Issues
                          Health, Education, and Human Services Division

Veterans’ Affairs: Observations on Selected
Features of the Proposed Veterans’
Millennium Health Care Act
                  Mr. Chairman and Members of the Subcommittee:

                  We are pleased to contribute this statement for the record for the
                  Subcommittee’s deliberations on the draft bill entitled the Veterans’
                  Millennium Health Care Act, which would modify policies and practices of
                  the health care system operated by the Department of Veterans Affairs

                  In October 1995, VA began to transform its health care delivery structure
                  from operating hospitals to providing health care through integrated
                  networks of VA and non-VA providers to serve veterans more efficiently and
                  effectively. In 1996, the Veterans’ Health Care Eligibility Reform Act was
                  passed, requiring VA to enroll veterans for health care coverage by
                  congressionally mandated priority groups only to the extent that services
                  could be provided within VA’s resources. In January 1997, in response to
                  this and other factors, VA proposed a 5-year spending plan to reduce
                  per-patient costs by 30 percent, increase the number of VA patients by
                  20 percent, and reduce reliance on appropriations by 10 percent.

                  Through numerous reports and testimonies, we have discussed the
                  progress of VA’s ongoing transformation, as well as concerns about critical
                  challenges that VA faces (see the attached list of related GAO products). As
                  you requested, our statement today draws on our previous work to focus
                  on how the draft Veterans’ Millennium Health Care Act could affect VA’s
                  ongoing transformation, including our previously reported concerns about
                  its future progress. As agreed with your staff, we have limited our
                  comments to certain provisions of the bill that address

              •   the realignment of services at underused facilities,
              •   access to long-term care services,1 and
              •   cost sharing for medical care.

                  In summary, the draft bill’s facility service realignment, long-term care,
                  and cost-sharing provisions should help facilitate VA’s continuing
                  transformation of its health care system and address concerns that we
                  have previously reported to the Congress. These proposals, in combination
                  with VA’s enrollment process, provide a rational framework for helping VA
                  address the increasing health care needs of an aging population of
                  higher-priority veterans while operating within available resources.
                  However, even with this enabling legislation, achieving these multiple

                   We are using the term “long-term care” to refer to the services described in parts of the draft
                  legislation under the term “extended care” because “long-term care” is more frequently used in
                  current discussions of these services in VA, other federal agencies, and the private sector.

                  Page 1                                                                           GAO/T-HEHS-99-125
                 Veterans’ Affairs: Observations on Selected
                 Features of the Proposed Veterans’
                 Millennium Health Care Act

                 goals will be a challenge to VA because of their complexity and
                 far-reaching implications.

                 More specifically, the combination of proposed changes should help VA
                 provide care for veterans in more appropriate settings, as well as help VA
                 achieve its stated goals of reducing per-patient costs, increasing the
                 number of its patients, and reducing reliance on appropriations. Facility
                 realignment and cost-sharing provisions are consistent with options we
                 have suggested to help VA reduce budget pressures and generate the
                 resources needed to serve more veterans and provide enhanced benefits.
                 In addition, long-term care provisions appear designed to reduce
                 variability in veterans’ access to such care systemwide, which addresses,
                 in general, our concern about the potential adverse effect of VA’s
                 transformation on the equity of veterans’ access to care.

                 Over the last 6 decades, VA’s system has grown into our nation’s largest
Background       direct provider of health care, serving veterans at over 600 locations
                 nationwide. During that time, VA’s system focused primarily on hospital
                 care, using high technology and medical specialization. The system did not
                 keep pace, however, with such industry and societal changes as the
                 restructuring of health care to emphasize managed care and the evolving
                 medical needs of an aging veteran population.

                 VA’s transformation from a hospital-based operator to a health care
                 provider emphasizing outpatient care began in fiscal year 1996, when 22
                 regional offices, known as Veterans Integrated Service Networks (VISN),
                 were established to make basic budgetary, planning, and operating
                 decisions for veterans living within defined geographical areas.2 VA’s goal
                 is to develop local or regional networks of health care providers that offer
                 a continuum of care grounded in ambulatory, rather than hospital,
                 settings. VA is encouraging this transformation by allocating resources on
                 the basis of user populations rather than hospitals.

                 The Veterans’ Health Care Eligibility Reform Act, enacted in 1996,
                 furnishes tools that VA believes are key to a successful transformation,

             •   new eligibility rules that allow VA to treat veterans in the most appropriate

                  VA Health Care: Status of Efforts to Improve Efficiency and Access (GAO/HEHS-98-48, Feb. 6, 1998).

                 Page 2                                                                        GAO/T-HEHS-99-125
    Veterans’ Affairs: Observations on Selected
    Features of the Proposed Veterans’
    Millennium Health Care Act

•   a uniform benefits package for all eligible veterans that allows VA to
    provide a continuum of services,
•   expanded authority to purchase services from private providers when
    doing so benefits veterans, and
•   an enhanced ability to generate revenue by selling excess services to

    At that same time, the Congressional Budget Office and we concluded that
    these reforms could generate additional demand for services because
    more veterans would use outpatient services.3 The Congressional Budget
    Office also estimated that rising utilization could produce dramatic cost
    increases, potentially in the billions of dollars.

    To address such concerns, the Eligibility Reform Act required VA to
    implement an enrollment system to manage access in relation to available
    resources. The act established seven priority categories, with the highest
    priority given to veterans with service-connected conditions and the
    lowest priority given to higher-income veterans without such conditions.
    Each year, VA is to enroll veterans in those priority categories for which it
    has sufficient resources to provide care that is timely and acceptable in
    quality. The act also requires VA to maintain treatment capacity for
    veterans with special disabilities, including spinal cord injury, blindness,
    amputation, and mental illness.

    At VA’s request, the Congress also authorized VA to retain all medical care
    cost recoveries, beginning July 1, 1997, to increase its nonappropriated
    revenues.4 Such recoveries include collections from veterans’ private
    health insurance as well as copayments to VA. VA is to deposit these
    collections in a Medical Care Collections Fund and use them to
    supplement appropriations to meet veterans’ health care needs. VA may
    spend these funds in the year collected or in any subsequent year.

    VA’s health care system currently touches the lives of 15 percent, or about
    4 million, of our nation’s 25 million veterans. The rest rely on private
    insurance, other public programs, or their own resources to finance their
    health care needs.

     VA Health Care: Issues Affecting Eligibility Reform Efforts (GAO/HEHS-96-160, Sept. 11, 1996).
     In 1986, the Congress had authorized VA to recover third-party payments for medical care, but VA was
    required to turn over these collections to the Department of the Treasury.

    Page 3                                                                         GAO/T-HEHS-99-125
                             Veterans’ Affairs: Observations on Selected
                             Features of the Proposed Veterans’
                             Millennium Health Care Act

                             VA’s large, aged infrastructure could be the biggest obstacle confronting
Realigning Facilities’       the agency’s ongoing transformation efforts. VA spends a major portion of
Services Could               its health care budget—about 1 out of every 4 health care dollars—to
Benefit Veterans             operate, maintain, and improve its facilities.

                             At the Subcommittee’s March 10 hearing, we suggested that VA could
                             reduce significantly the amount of funds used to operate and maintain
                             unneeded or inefficient health care delivery locations and reinvest the
                             savings to enhance care provided to veterans.5 By systematically analyzing
                             health markets to identify unneeded delivery locations, VA could redirect
                             the operation and maintenance budgets of these locations to establish and
                             enhance community-based clinics and other service options for veterans.
                             Without such realignment of delivery locations, resources might be
                             increasingly shifted to operating and maintaining unneeded, aged assets at
                             the expense of veterans’ health care needs.

                             At the March 10 hearing, VA agreed to assess 106 markets in which it
                             operates 181 major delivery locations. VA owns 4,700 buildings and 18,000
                             acres of land at these locations. VA’s assessments will include a
                             determination of veterans’ health care needs, a survey of existing assets,
                             and an evaluation of alternatives for meeting veterans’ needs in the most
                             cost-effective manner.

                             The draft Veterans’ Millennium Health Care Act contains three key
                             features designed to benefit veterans through such facility services
                             realignment. The act requires

                         •   VA to develop enhanced-service plans to address veterans’ health care
                         •   VA’s stakeholders to participate in plan development, and
                         •   VA to use efficiency savings locally.

                             Developing enhanced-service plans would provide an appropriate
                             structure for VA to use when addressing its infrastructure challenge. The
                             proposed legislation requires that VA develop enhanced-service plans to
                             provide needed health care to veterans in markets where VA delivery
                             locations are ineffective or inefficient in providing services and alternative
                             health care providers are available. By requiring enhanced-service
                             planning, this proposal would address concerns that we raised during a
                             July 1997 hearing before this Subcommittee that VA was implementing

                             VA Health Care: Capital Asset Planning and Budgeting Need Improvement (GAO/T-HEHS-99-83,
                             Mar. 10, 1999).

                             Page 4                                                                   GAO/T-HEHS-99-125
                      Veterans’ Affairs: Observations on Selected
                      Features of the Proposed Veterans’
                      Millennium Health Care Act

                      changes at facilities without adequate planning.6 This proposal is also
                      consistent with guidelines that VA issued in April 1998 to help VA regional
                      offices improve their planning for service delivery changes.

                      Requiring stakeholders’ involvement in plan development is also an
                      essential element, as we noted during the July 1997 hearing. While facility
                      service realignments could provide significant benefits for veterans, they
                      could also have important consequences for a wide variety of
                      stakeholders, such as VA employees and residents of local communities.
                      For this reason, plans must be developed with comprehensive stakeholder
                      involvement to maximize benefits and minimize adverse impacts. The draft
                      bill proposes a process that VA has already used to develop a plan to
                      integrate medical services in Central Alabama.7

                      Requiring VA to use efficiency savings that are generated by facility service
                      realignments locally should provide incentives for developing effective
                      enhanced-use plans. This approach is consistent, for example, with a
                      suggestion we made concerning the potential savings that VA could realize
                      if it realigned the services of four hospitals in Chicago. In essence, we
                      suggested that savings could be used to enhance the services for veterans
                      in the Chicago area through establishing additional community-based
                      clinics or other services.8

                      VA faces major challenges in serving a rapidly aging veteran population.
Enhancing Long-Term   Veterans 65 and older constitute about 34 percent of the veteran
Care Services Could   population, or about 8.8 million veterans, and will make up 42 percent of
Benefit               the veteran population by 2010. This aging of the veteran population will
                      result in a growing need for long-term care.
Veterans              VA currently spends about $2 billion of its $18.4 billion health care budget
                      to provide long-term care services. Of this, nearly $1.7 billion is used for
                      care in 131 VA-operated nursing homes, contract nursing homes, and state
                      veterans’ nursing homes. The remaining $353 million is used for
                      noninstitutional care, including residential care and home- and

                       VA Health Care: Lessons Learned From Medical Facility Integrations (GAO/T-HEHS-97-184, July 24,
                       VA Health Care: VA’s Plan for the Integration of Medical Services in Central Alabama
                      (GAO/HEHS-98-245R, Sept. 23, 1998).
                       VA Health Care: Closing a Chicago Hospital Would Save Millions and Enhance Access to Services
                      (GAO/HEHS-98-64, Apr. 16, 1998).

                      Page 5                                                                         GAO/T-HEHS-99-125
    Veterans’ Affairs: Observations on Selected
    Features of the Proposed Veterans’
    Millennium Health Care Act

    community-based long-term care services, such as adult day health care,
    respite care, homemaker assistance, home health care, and other services.

    About 4 million veterans are currently enrolled in VA’s health care system.
    While VA’s uniform health care benefits package includes inpatient hospital
    care, outpatient care, and other related services, the package does not
    include long-term care, such as nursing home, domiciliary, and adult day
    health care. However, enrolled veterans are eligible to receive such
    services to the extent that resources are available. VA currently provides
    long-term care services to about 63,000 veterans a day, on average.

    The Federal Advisory Committee on the Future of VA Long-Term Care
    recently reported that VA currently meets about 20 percent of the need for
    long-term care nationally among veterans with service-connected
    conditions and those with low incomes.9 As a result, most veterans use
    other systems for long-term care services, such as Medicaid and
    Medicare.10 The Federal Advisory Committee also found that access to VA
    long-term care among veterans with service-connected conditions and
    those with low incomes varied greatly among VA’s 22 regions. We have
    voiced similar concerns in prior work about the lack of equitable access to
    a range of VA care, including primary outpatient care and more expensive
    services, such as nursing home care.11

    The draft Veterans’ Millennium Health Care Act contains three key
    features designed to enhance veterans’ access to long-term care:

•   requiring the development of a national program of long-term care
•   increasing the percentage of VA’s budget spent on noninstitutional
    long-term care services, and
•   mandating coverage for long-term care services for certain higher-priority

     In Mar. 1997, VA convened this Committee of long-term care experts to evaluate VA long-term care
    and develop a strategy for meeting veterans’ future needs. The Committee recommended 24 measures
    to enhance VA’s long-term care in its report, VA Long-Term Care at the Crossroads (Washington, D.C.:
    Department of Veterans Affairs, June 1998).
     For a discussion of other long-term programs, see Long-Term Care: Baby Boom Generation Presents
    Financing Challenges (GAO/T-HEHS-98-107, Mar. 9, 1998).
     VA Community Clinics: Networks’ Efforts to Improve Veterans’ Access to Primary Care Vary
    (GAO/HEHS-98-116, June 15, 1998), VA Health Care: Resource Allocation Has Improved, but Better
    Oversight Is Needed (GAO/HEHS-97-178, Sept. 17, 1997), and VA Health Care: More Veterans Are Being
    Served, but Better Oversight Is Needed (GAO/HEHS-98-226, Aug. 28, 1998).

    Page 6                                                                        GAO/T-HEHS-99-125
Veterans’ Affairs: Observations on Selected
Features of the Proposed Veterans’
Millennium Health Care Act

Requiring VA to establish a program that provides a comparable continuum
of long-term care services nationally is a reasonable way to ensure that
veterans have equitable access to care. It is consistent with the Federal
Advisory Committee’s recommendation that VA create financial incentives
and performance measures to ensure adequate access to long-term care
services, while preserving the flexibility of VA’s 22 regional offices to
develop and structure long-term care services. This proposal should also
help address our concerns about historical inequities in long-term care and
other services, inadequate monitoring of incentives in VA’s resource
allocation system that could lead to unintended outcomes, and the lack of
VA oversight of the equity of the 22 regional offices’ allocations of
resources to health care delivery locations.

Requiring VA to spend a greater percentage of its budget on
noninstitutional long-term care services is a reasonable strategy to address
the growing need for long-term care as the veteran population continues to
age, and it is consistent with the Federal Advisory Committee’s
recommendation to increase investment in these services to better meet
the long-term care needs of veterans. This approach is also consistent with
other long-term care programs’ evolution to expand noninstitutional
services to offer a continuum of less expensive services and more
efficiently serve veterans when care outside the nursing home is clinically
appropriate. An expansion of these services would enable VA to serve more
veterans in the home and in the community, as most people prefer, rather
than in institutions.

Mandating long-term care services for certain higher-priority veterans is
also consistent with eligibility reform legislation and addresses concerns
we have previously raised about targeting VA health care benefits to those
with the highest priority for services. The proposed legislation would
mandate long-term care services for veterans with 50 percent or more
service-connected disabilities and for others whose need for long-term
care is a result of a service-connected disability, essentially authorizing VA
to offer an enhanced benefit package for these veterans.

VA’s statutory enrollment process provides a mechanism for enhancing
benefit coverage for higher-priority veterans and managing the costs of
these enhancements within the limits of VA resources. This process
requires VA to determine the cost of meeting the needs of higher-priority
veterans and to target remaining resources to provide a basic benefits
package to as many lower-priority veterans as possible. Although the

Page 7                                                       GAO/T-HEHS-99-125
                         Veterans’ Affairs: Observations on Selected
                         Features of the Proposed Veterans’
                         Millennium Health Care Act

                         enrollment process provides the mechanism to adjust VA health care
                         delivery according to congressional priorities, the process is only in its
                         first year of operation. Enrolling veterans, projecting the costs of meeting
                         their health care needs, and managing according to the services required
                         and resources available is a complicated challenge that has far-reaching
                         implications for veterans’ access to care and the quality of that care.

                         In 1986, the Congress authorized VA to require higher-income veterans12
Enhancing Medical        without service-connected conditions to help offset the costs of their
Cost Sharing Could       medical care through copayments for both inpatient care (acute and
Benefit Veterans         long-term) and outpatient care. In 1990, the Congress added a copayment
                         requirement for outpatient medications used to treat non-service-
                         connected medical conditions. VA estimates that it billed about
                         $143 million in copayments in fiscal year 1998.

                         The draft bill contains provisions that would address VA cost sharing in
                         four areas:

                     •   prescription drugs,
                     •   outpatient services,
                     •   long-term care, and
                     •   certain high-cost supplies.

                         The draft bill would, for example, authorize the Secretary of VA to increase
                         the prescription drug copayment on the basis of regulations prescribed by
                         the Secretary. Currently, VA is required by law to charge a copayment of $2
                         for each 30-day or less supply of medication for the treatment of a
                         non-service-connected disability or condition. The proposal to permit VA to
                         increase the copayment for prescription drugs appears to be reasonable,
                         given VA’s rapidly escalating drug costs. Since the $2 copayment was
                         legislatively mandated, VA’s total prescription drug costs have more than
                         doubled. VA billed for about $64 million in copayments in fiscal year 1998.
                         Increasing the copayment amount for prescriptions is consistent with
                         options we have previously reported to the Congress for helping VA cope
                         with budgetary pressures. In 1996, for example, we suggested that the
                         Congress could offset VA spending for medications by increasing

                          Higher-income veterans are those whose incomes are above a statutory threshold—for example, a
                         veteran with no dependents with an income of $22,351 or greater. Income thresholds are higher for
                         veterans with dependents.

                         Page 8                                                                        GAO/T-HEHS-99-125
Veterans’ Affairs: Observations on Selected
Features of the Proposed Veterans’
Millennium Health Care Act

copayment amounts.13 Moreover, the draft proposal would provide VA
flexibility to adjust rates in a timely manner as conditions change.

The draft bill also proposes to give the Secretary the authority to establish
copayment amounts for outpatient services by regulation for veterans with
non-service-connected conditions who are above the low-income
threshold. VA billed for about $57 million in outpatient copayments in fiscal
year 1998. Currently, the law requires that VA charge a copayment to these
veterans of 20 percent of the estimated VA-wide average cost of an
outpatient visit. This copayment is currently about $46.

Giving the Secretary authority to change outpatient copayments appears
reasonable, given the transformation of VA outpatient services in recent
years. VA now provides many more expensive services in the outpatient
setting, like other health care providers, than it did when the current law
was enacted. Procedures at VA such as colonoscopy, arthroscopy, and
cystoscopy are now frequently performed in an outpatient setting. As a
result, the VA outpatient copayment amount has grown and is
disproportionately high for low-cost outpatient care, such as
immunizations. Authorizing VA to set a schedule of outpatient copayments
could help remove financial deterrents that might discourage the use of
preventive care. It could also enable VA to establish a copayment schedule
more similar to that used by other health care programs.14

The draft bill also proposes that VA increase cost sharing by charging
certain veterans a copayment for long-term care services of more than 21
days in any year. Veterans with 50 percent or more service-connected
disability and those who are receiving long-term care services for a
service-connected disability would be excluded from making copayments
under this proposal. VA would be required to develop a methodology for
determining copayment amounts on the basis of the income and assets of
the veteran and spouse, protecting the spouse from financial hardship, and
allowing the veteran to maintain a monthly allowance. Currently, VA bills
nursing home care at a rate equal to the Medicare inpatient deductible for
the first 90 days of care during any 365-day period. In addition, VA bills $5 a
day for nursing home care. In total, VA currently bills for about $4 million
from these sources.

 VA Health Care: Opportunities to Significantly Reduce Outpatient Pharmacy Costs
(GAO/HEHS-97-15, Oct. 11, 1996).
 In general, veterans are subject to less cost sharing than is required under most public and private
health benefit programs. See VA Health Care: Comparison of VA Benefits With Other Public and
Private Programs (GAO/HRD-93-94, July 29, 1993).

Page 9                                                                           GAO/T-HEHS-99-125
                   Veterans’ Affairs: Observations on Selected
                   Features of the Proposed Veterans’
                   Millennium Health Care Act

                   The proposal to revise the structure of long-term care copayments appears
                   reasonable because it would give VA flexibility to determine the most
                   appropriate copayment amount for these services by taking into account a
                   veteran’s financial resources while protecting the financial independence
                   of a veteran’s spouse living in the community. Because these funds would
                   be directed to an earmarked fund for long-term care services, these
                   copayments might also provide additional long-term care services to
                   veterans. In 1992, we suggested a copayment approach using similar
                   principles to offset long-term costs.15 These principles are already used in
                   VA state homes and in state Medicaid programs.

                   The draft bill also proposes to establish copayments for certain high-cost
                   items, such as hearing aids, eyeglasses, certain electronic equipment, and
                   other items for non-service-connected conditions. Wheelchairs and
                   artificial limbs would be excluded from these copayments. Currently, VA is
                   not required to collect copayments for these items.

                   Requiring some veterans to pay a copayment for hearing aids, eyeglasses,
                   certain electronic equipment, and other costly items seems reasonable.
                   Total VA expenditures for these prosthetic items are expected to increase
                   from $420 million in fiscal year 1998 to about $524 million in fiscal year
                   2000. During the course of our ongoing review of VA’s enrollment process,
                   several VA network directors commented that they are experiencing
                   increased demand from veterans whose primary care is provided
                   elsewhere but who obtain from VA services not covered by their private
                   insurance or Medicare, such as eyeglasses and hearing aids. Giving VA the
                   authority to establish copayment amounts would provide flexibility to
                   generate additional revenues to enhance veterans’ health care while still
                   affording veterans a substantial health care benefit, because the costs for
                   such items, according to VA officials, are not routinely covered by other
                   health care programs.

                   In conclusion, the Veterans’ Millennium Health Care Act provides a
Concluding         rational framework for addressing such important needs as
               •   enhancing services at underused facilities,
               •   enhancing long-term care services for an aging veteran population, and
               •   providing VA flexibility to generate additional revenues to offset budget
                   pressures and serve more veterans.

                    VA Health Care: Offsetting Long-Term Care Costs by Adopting State Copayment Practices
                   (GAO/HRD-92-96, Aug. 12, 1992).

                   Page 10                                                                    GAO/T-HEHS-99-125
Veterans’ Affairs: Observations on Selected
Features of the Proposed Veterans’
Millennium Health Care Act

Most importantly, the draft bill strives to achieve these objectives in a
manner that is consistent with the overall goal of VA’s enrollment process,
which is to manage veterans’ access to health care in relation to available

Page 11                                                    GAO/T-HEHS-99-125
Related GAO Products

              Veterans’ Affairs: Progress and Challenges in Transforming Health Care
              (GAO/T-HEHS-99-109, Apr. 15, 1999).

              Major Management Challenges and Program Risks: Departments of
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              Major Management Challenges and Program Risks: Department of
              Veterans Affairs (GAO/OCG-99-15, Jan. 1999).

              Veterans’ Health Care: Challenges Facing VA’s Evolving Role in Serving
              Veterans (GAO/T-HEHS-98-194, June 17, 1998).

              VA Health Care: Assessment of VA’s Fiscal Year 1998 Budget Proposal
              (GAO/T-HEHS-97-121, May 1, 1997).

              Department of Veterans Affairs: Programmatic and Management
              Challenges Facing the Department (GAO/T-HEHS-97-97, Mar. 18, 1997).

              Veterans’ Health Care: Challenges for the Future (GAO/T-HEHS-96-172, June 27,

              VAHealth Care: Challenges and Options for the Future (GAO/T-HEHS-95-147,
              May 9, 1995).

              VAHealth Care: Retargeting Needed to Better Meet Veterans’ Changing
              Needs (GAO/HEHS-95-39, Apr. 21, 1995).

(406170)      Page 12                                                      GAO/T-HEHS-99-125
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