Report on ACSPA/ACS activities, June 2015

The Board of Directors of the American College of Surgeons Professional Association (ACSPA) and the Board of Regents (B/R) of the American College of Surgeons (ACS) met June 5–6 at the College’s headquarters in Chicago, IL. The following is a summary of their discussions and actions.

ACSPA

At the time of the meeting, the American College of Surgeons Professional Association’s political action committee (ACSPA-SurgeonsPAC) has raised $267,483 in both personal and corporate funds from 825 members of the College and staff; the average contribution is $324. Of the total raised, $248,414 is personal (hard) dollars and $19,069 is corporate (soft) dollars.

During the 2015–2016 election cycle, SurgeonsPAC has disbursed $198,000 to 42 candidates, leadership PACs, and party committees. Of the amount given, 66 percent went to Republicans and 34 percent to Democrats.

In March, the SurgeonsPAC sponsored a “Pizza and Politics” reception in conjunction with the 2015 Residents as Teachers and Leaders Course. Brian Gavitt, MD, the Resident and Associate Society of the American College of Surgeons (RAS-ACS) PAC Board Representative, and SurgeonsPAC staff led a discussion on the importance of surgical advocacy and political engagement. Attendees networked and learned more about political advocacy.

SurgeonsPAC launched its first PAC Captain Program on May 26. This six-week, peer-to-peer campaign, aimed at disseminating SurgeonsPAC’s message to a broader audience, ended in early July. More than 40 PAC Captains participated in the program launch. These PAC Captains will remain our “champions” in the states, working to increase the SurgeonsPAC membership base throughout the 2015–2016 election cycle.

The 2015 goals of the ACSPA-SurgeonsPAC include:

  • Launch additional peer-to-peer focused solicitations, focused on lapsed and low donors, as well as surgeons who have not contributed, using Health Policy and Advocacy Councilors and other SurgeonsPAC advocates.
  • Increase awareness of PAC efforts to achieve a market share goal of 10 percent.
  • Increase RAS-ACS SurgeonsPAC involvement throughout the country with a goal of 100 percent participation. Efforts and related events would be carried out in coordination with the RAS committee and Dr. Gavitt.

ACS

The Board of Regents (B/R) approved the addition of two new Regents’ seats for representatives of specialties that are certified under the auspices of the American Board of Surgery (ABS). The B/R will, therefore, have 14 instead of 12 members from the ABS community, plus an additional nine members from each specialty board.

The subspecialties recognized by the ABS include:

  • Burn and critical care surgery
  • Gastrointestinal surgery
  • General surgery
  • Pediatric surgery
  • Surgical oncology
  • Transplantation
  • Trauma
  • Vascular surgery

One new position will be filled in 2015, and the other in 2016. The Nominating Committee of the Board of Governors will convene this  fall to select the nominee for the 2015 pending vacancy.

Advocacy and Health Policy

The ACS Division of Advocacy and Health Policy (DAHP) continues to support surgeons’ interests at the federal and state levels, advocating on the following issues.

The Critical Access Hospital Relief Act (96-hour rule)

The Centers for Medicare & Medicaid Services (CMS) recently indicated it would begin enforcing a long forgotten regulation requiring that physicians who admit patients to Critical Access Hospitals (CAHs) certify that it is reasonable to anticipate that each will be discharged or transferred within 96 hours. Previously, CAHs operated under a similar but separate condition of participation that required patient stays to be less than 96 hours on average. CMS’ recent action will prevent surgeons from being able to admit many patients for procedures routinely performed in CAHs and will force many rural patients to travel further from home for treatment.

To address the issue, Rep. Adrian Smith (R-NE) and Sens. Pat Roberts (R-KS) and Jon Tester (D-MT) have introduced legislation to eliminate the certification requirement for admitting physicians while maintaining the long-enforced 96-hour average stay requirement. The College has endorsed the Critical Access Hospital Relief Act (H.R.169/S.258).

CAH 96-hour rule and EMTALA

ACS staff received questions from rural surgeons regarding compliance with the 96-hour rule in emergency cases as it related to the Emergency Medical Treatment and Labor Act (EMTALA). To help resolve these issues, the ACS scheduled a call with experts from CMS to (a) ensure that they understood that their regulations were in conflict with the reality of practice in the rural setting and (b) to highlight that the regulations for which the agency is responsible could be forcing CAHs to provide care to Medicare patients without payment.

CMS confirmed the outcomes created by the two regulations (the 96-hour rule and EMTALA) taken together. Specifically, CMS stated that if a CAH has the capability to perform surgeries that would result in a patient stay of longer than 96 hours, and if the patient requires that operation in order to be stabilized, then transferring a patient with an emergency medical condition (EMC) to a different facility simply because a physician cannot certify that the patient will be in the hospital for less than 96 hours could result in an EMTALA violation for the CAH.

In addition, if a CAH performs surgeries on non-Medicare patients that commonly result in patient stays of longer than 96 hours, even if the patient does not have an EMC (and thus there are no EMTALA implications), transferring the patient because of the 96-hour rule could jeopardize the CAH’s Medicare status because of a potential violation of the CAH’s Medicare Conditions of Participation, sometimes resulting in the CAH not being paid for an expensive surgery performed there. Importantly, the 96-hour certification criteria relates to the CAH payment and does not prohibit surgeons from submitting claims to Medicare for professional services.

Given this response from CMS, the best remedy for this situation is passage of the Critical Access Hospital Relief Act of 2015. The bill, introduced in the Senate as S. 258 and in the House as H.R. 169, removes the 96-hour certification requirement, which would alleviate the problems rural surgeons have expressed. The ACS strongly supports this legislation and has included it in our legislative agenda at the annual Advocacy Summit for the past two years.

Cancer

At the time of the Board meeting, the DAHP was working with the Commission on Cancer (CoC) to host a congressional briefing on June 9. This second briefing hosted by the CoC focused on accreditation. The briefing featured CoC Chair Daniel McKellar, MD, FACS, and CoC Legislative Committee Chair James Hamilton, MD, FACS, as well as a patient treated at a CoC-accredited facility. The briefing was scheduled to complement the annual One Voice Against Cancer (OVAC) lobby day.

Reps. Charlie Dent (R-PA), Joe Courtney (D-CT), Michael Fitzpatrick (R-PA), and Donald Payne (D-NJ), introduced the Removing Barriers to Colorectal Cancer Screening Act, H.R. 1220. This bill would correct an oversight in current law that requires Medicare beneficiaries to make a copayment when a colonoscopy also involves a polyp removal. The College advocated for including this legislation in the 21st Century Cures Act, which the House passed soon after the Board meeting.

Rep. Anna Eshoo (D-CA) introduced the American Cures Act (H.R. 2104), which seeks to expand support for future cancer and other health care research at the National Institutes of Health (NIH), the Centers for Disease Control, the Department of Defense (DoD) Health Program, and the Veterans Medical and Prosthetics Research Program. Sen. Richard Durbin (D-IL) introduced companion legislation, S.289. The College supports these bills, which would create a trust fund to support a mandatory funding stream for this type of research.

Reps. Jackie Speier (D-CA) and Cynthia Lummis (R-WY) introduced the Breast Cancer Research Stamp Reauthorization Act, H.R. 2191, which would extend by four years the U.S. Postal Service’s authority to issue a fundraising stamp for breast cancer research. The Breast Cancer Research Stamp is available for purchase at 11 cents more than the cost of a regular first-class stamp. The revenues cover the post office’s administrative costs and fund breast cancer research programs at the NIH and the DoD. Sens. Dianne Feinstein (D-CA) and Mike Enzi (R-WY) introduced the Senate version, S.1170. The ACS supports these bills.

Medical liability reform

The legislation described in earlier reports and that repealed the sustainable growth rate (SGR) formula—the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA)—also included ACS-supported legislation known as the Standard of Care Protection Act. This legislation clarifies that no standard or guideline in federal health programs, including Medicare, Medicaid, or the Affordable Care Act, may be used to establish the standard of care that a health care professional must provide to a patient; therefore, these mandates cannot be used as a cause of action in liability lawsuits.

The Saving Lives, Saving Costs Act was recently reintroduced by Rep. Andy Barr (R-KY), and for the first time, a companion bill was introduced by Sen. John Barrasso (R-WY). This bill was first introduced last Congress by Reps. Barr and Ami Bera (D-CA), and combines elements of pretrial screening panels and safe harbors for adhering to practice guidelines to provide liability protections, promote evidence-based medicine, and improve patient safety. The College worked with the bill’s sponsors to make refinements and improvements, including removal of a “loser pays” provision.

In December, the DAHP and the ACS Legislative Committee released a new primer, Surgeons and Medical Liability: A Guide to Understanding Medical Liability Reform. This document explores the history and inefficiency of the nation’s medical liability system and analyzes both traditional and alternative reform proposals. The primer informs Fellows of ongoing challenges and outlines opportunities for implementation of alternative reforms that have been proposed or studied at the local, state, and federal levels. This document is expected to be followed later this year by a Surgeon’s Guide to a Medical Liability Lawsuit and early next year by a Surgeon’s Guide to Avoiding Medical Liability Litigation.

Trauma funding

The House Energy and Commerce Committee approved two pieces of trauma legislation, sending them to the full House for consideration. H.R. 648, the Trauma Systems and Regionalization of Emergency Care Reauthorization Act, would reauthorize the trauma systems planning grants and the regionalization of emergency care pilot projects; H.R. 647, the Access to Life-Saving Trauma Care for All Americans Act, would provide critically needed federal funding to help cover uncompensated costs in trauma centers, support core mission trauma services, provide emergency funding to trauma centers, and address trauma center physician shortages. Both of these bills then passed the full House under suspension rules.

On March 17, Sen. Jack Reed (D-RI) introduced the Senate companion bill, S. 763, to H.R. 648. At press time, Sen. Patty Murray (D-WA) was expected to introduce the Senate companion bill to the trauma centers legislation. In addition, the ACS is meeting with members of the House and Senate Appropriations Committees to ask that they include funding for these programs, which have been unfunded since 2005.

The Coalition for National Trauma Research (CNTR) advocated for $30 million in fiscal year (FY) 2016 Defense Appropriations to create and fund research topics through a coordinated, multi-institutional, clinical research network to advance military-relevant topics in trauma care and trauma systems that will allow the Department of Defense to maintain the advancements and skill sets critical to moving this area of research forward, even as combat deployments decrease. The ACS Committee on Trauma (COT) is a founding member of CNTR and supports the establishment of a National Trauma Clinical Research Program, which would fund research to improve treatment for the most deadly and commonly seen battlefield injuries, many of which also affect civilians. Research would be conducted through multi-institution clinical studies at a network of civilian and military trauma centers established through this initiative. The request was sent to the committees from several members of Congress, but it is not known if the funds will be included in the bill.

Regulatory and policy issues

The ACS has long highlighted issues related to the Berenson-Eggers Type of Service (BETOS) coding system. CMS and other agencies have used the BETOS coding system primarily to track resource utilization and to analyze growth in Medicare expenditures. In recent years, it also has been used to study the effect of bundled payments, accountable care organizations, and other alternative payment methodologies. Given increased national requirements for the development of new approaches to Medicare payment for provider services, the BETOS coding system could play a larger role in provider reimbursement in the future; however, many aspects of the BETOS classifications are outdated, inconsistent, or no longer optimal. On May 8, the ACS submitted a letter to CMS with detailed recommendations on how to improve and modernize the BETOS coding system. The ACS will continue to work with CMS and the AMA Relative Value Scale Update Committee with the goal of overcoming weaknesses of the BETOS classification system to develop a more reliable and useful research and payment policy tool.

CMS released the Medicare physician fee schedule (MPFS) proposed rule in early July, with plans to release the final rule in early November. At press time, ACS staff was reviewing the proposed rule and developing comments based on feedback from the ACS General Surgery Coding and Reimbursement Committee and the Performance Measures Committee.

CMS released its fiscal year (FY) 2016 Inpatient Prospective Payment System (IPPS) proposed rule on April 17. Under the proposed rule, average inpatient payments would increase by about 0.3 percent in FY 2016 (October 1, 2015–September 30, 2016). This update is contingent on hospitals reporting specified quality data established in the Hospital Inpatient Quality Reporting Program. The proposed rule also includes potential changes to programs that apply incentives and/or penalties to inpatient hospitals. These include the Hospital Value-Based Purchasing Program and others aimed at reducing unnecessary readmissions and the prevalence of hospital-acquired conditions. CMS also proposed changes to policy and operational issues surrounding the potential expansion of its Bundled Payments for Care Improvement initiative (BPCI), which links payments for multiple services. ACS staff submitted comments to CMS in June.

CMS released the proposed Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) rule this summer. The proposed rule would increase Medicare payment for health care services delivered in most outpatient department sites of care by an estimated 2.1 percent for CY 2015.

The ACS continues to provide educational materials and resources on the Physician Quality Reporting System (PQRS) to Fellows and office staff through the website, meetings, and publications. The April 2015 issue of the Bulletin provides an overview of the PQRS programs and College resources that assist members in complying with 2015 PQRS program requirements.* The PQRS section of the website is continuously updated with new information, including how to report measures via claims, registries, and electronic health records.

In addition, CMS has made Quality and Resource Use Reports (QRURs) available to help solo practitioners and group practices understand their performance in relation to Medicare’s quality and cost metrics. ACS staff created a Web page on QRURs that includes educational material and resources to help Fellows access and understand their report. The ACS and CMS also hosted a webinar, available on the ACS QRUR website, on how to interpret reports.

The Physician Clinical Registry Coalition is a group of more than 20 medical society-sponsored or physician-led registries advocating for public policies that facilitate registry development and remove regulatory burdens. In February 2015, the College worked with the coalition to develop a resource titled Guidance on Legal Challenges and Regulatory Obligations for Clinical Data Registries, which provides guidance on privacy issues, data ownership, device reporting, liability risk, and legal discovery.

State Affairs

Last year, ACS State Affairs staff assessed which states require that insurers provide coverage for bariatric surgery, particularly through the state health exchanges created in the ACA. This assessment showed that 28 states do not require bariatric surgery coverage, and that of those states, about half were states had created exchanges, and about half were part of the federal exchange. The ACS has been partnering with the American Society of Metabolic and Bariatric Surgeons to address the issue with CMS.

The popular Chapter Lobby Day Grant Program entered its fifth year in 2015; a total of 12 chapters received grants for their lobby days, including Alabama, Brooklyn/Long Island, California, Connecticut, Florida, Georgia, Indiana, Kansas, Massachusetts, Michigan, Tennessee, and Virginia. The chapters applied various models to conduct the activities, including dinners with legislative leaders, receptions for legislators and state Supreme Court justices, and briefings and visits with legislators in the capitol.

Division of Education

The ACS Division of Education continues to provide learning opportunities to surgeons in practice, training, and medical school and leads several other important activities related to surgical education.

For example, the ACS, the Association of Program Directors in Surgery, and the Association of Surgical Educators (ASE) have developed an innovative, modular Surgery Resident Prep Curriculum, which relies heavily on simulation. It is currently being pilot tested at 47 institutions across the country with a formal launch scheduled for 2016.

The ACS and ASE also have developed a Medical Student Core Surgery Curriculum, a simulation-based modular curriculum addressing the cognitive skills of medical students during the core surgery clerkship. The goal is to formally launch the program in 2017.

The Committee on Ethics continues to pursue projects identified during its 2014 strategic planning meeting. Specifically, the ACS Division of Education and MacLean Center for Clinical Medical Ethics at the University of Chicago, IL, have established a new Fellowship in Surgical Ethics, which the B/R approved in February 2015. The program will prepare surgeons for careers that combine clinical surgery with scholarly studies in surgical ethics.

Furthermore, the College has selected Alberto R. Ferreres, MD, PhD, MPH, FACS, to serve as Editor of a new book, Ethical Issues in Surgical Care, which will establish boundaries of the important domains and organize the essential components of surgery ethics.

Division of Member Services

The B/R accepted resignations from eight Fellows from the following specialties:

  • Neurological surgery (one)
  • Obstetrics and Gynecology (two)
  • Ophthalmic surgery (two)
  • Otolaryngology (one)
  • Plastic and Reconstructive (one)
  • Urologic (one)

The B/R also approved a change in status from Active (dues paying) to Retired for 72 Fellows, and from Senior (non-dues paying) to Retired for 12 Fellows, for a total of 84 Fellows.

The College’s Nigerian Fellows have requested the formation of a Nigeria Chapter. Emmanuel A. Ameh, MB, BS, FACS, FWACS, is the current Governor for Nigeria. Provisional officers include:

  • Stanley N. C. Anyanwu, MB, BS, FACS, President
  • Bello Bala Shehu, MB, BS, FACS, Vice President
  • Lukman Olajide Abdur-Rahman, MB, BS, FACS, Treasurer
  • Samuel Adesina Ademola, MB, BCh, FACS, Secretary
  • Adesoji O. Ademuyiwa, MB, BS, FACS, Councilor-At-Large

The Nigeria Chapter is the College’s 41st international chapter, bringing the total number of chapters to 108, with 67 domestic (including two Canadian chapters) and 41 international.

Division of Research and Optimal Patient Care

A total of 630 hospitals participate in ACS National Surgical Quality Improvement Program (NSQIP®); 564 of those sites participate in adult ACS NSQIP. The Essentials option, which is the conventional sampling frame, has the highest enrollment of all the adult participation options with 269 sites; however, the Procedure Targeted option, which allows hospitals to “target” the sampling to a list of focused procedures of their choosing, has 233 hospitals and is experiencing the highest level of growth. The Pediatric option represents slightly more than 10 percent of participation.

The following is a breakdown of participating sites by ACS NSQIP option:

  • Small and Rural: 41
  • Procedure Targeted: 233
  • Essentials: 269
  • Measures (National Quality Forum-endorsed measures only): 12

ACS NSQIP continues to enhance its feedback reports, specifically the real-time, risk-adjusted reporting capabilities, in an effort to improve the relevance of data. As of July 2015, a new Accelerated-on-Demand application provides risk- and shrinkage-adjusted rates using a more accurate and more robust methodology. This new application has the same look and feel of the old application but reports “rates” rather than “odds ratios,” providing a better application of the data.

The 2015 ACS NSQIP National Conference took place July 25–28 at the Hilton Chicago. A major theme at the conference’s 10th anniversary was recognition of ACS NSQIP hospitals and providers and their dedication to improving the care of the surgical patient.

At present, 787 health care institutions participate in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Of those centers, 621 are fully accredited, 45 are data collection centers, and 115 are initial applicants. The MBSAQIP was again selected as a PQRS Qualified Clinical Data Registry in March 2015 for the current reporting year.

Kamal M. F. Itani, MD, FACS, will again chair the biennial Clinical Trials Methods Course, November 6–10, at the ACS headquarters in Chicago. This five-day intensive course is based on four successfully conducted and published clinical trials, which are used to teach the methodology of design and implementation of a controlled clinical trial. A combination of didactic lectures and hands-on breakout sessions will be used to apply concepts learned throughout the course, including the development of concepts and skills in the design, implementation, and analysis of randomized clinical trials’ funding mechanisms and budget development; outcomes (medical and patient-centered); and dissemination of results through publications.

The ACS and the Armstrong Institute for Patient Safety and Quality are developing a surgeon leadership course. A one-day event was piloted at the ACS Clinical Congress 2014. The course intended primarily to introduce quality improvement and data review, present engagement strategies and quality improvement models, and discuss strategies for overcoming barriers. The course will be offered again at Clinical Congress 2015.

Cancer Programs

The Commission on Cancer (CoC) engaged in the following activities recently:

  • A cumulative total of 1,507 cancer programs in the U.S. and Puerto Rico were accredited by the CoC. CoC accreditation encourages hospitals, treatment centers, and other facilities to improve their quality of care through various cancer-related programs and activities.
  • A total of 481 cancer program accreditation surveys were conducted in 2014.
  • 33 new cancer programs joined the Accreditation Program in 2014.
  • 75 cancer programs received the Outstanding Achievement Award.
  • 73 percent of CoC-accredited cancer programs participated in the Rapid Quality Reporting System.
  • CoC leadership and ACS Fellows who are members of Optimizing Surgical Treatment of Rectal Cancer are developing standards and performance measures that will form the basis of a Rectal Cancer Accreditation module. The work is modeled on European success with decreasing disparities in the quality of rectal cancer care by promoting proper surgical technique, evidence-based treatment, and a multidisciplinary team approach to care.

The National Cancer Data Base (NCDB) Cancer Program Practice Profile Reports (CP3R) have been expanded to include three new quality measures and one replacement quality measure. Two cervical, one non-small cell lung, and one rectal measure were released in March 2015. CP3R currently reports 15 quality measures across six primary sites.

The Quality Integration Committee approved nine new quality measures to be added to the NCDB reporting tools. Three bladder, one pediatric, and five melanoma measures were proposed and approved. These measures were developed in conjunction with the Society of Urologic Oncology/American Urologic Association Pediatric Accreditation Committee, and the Society of Surgical Oncology.

The CoC’s second annual legislative briefing, Accreditation Makes a Difference, took place June 9 and included remarks from the CoC leadership and from the patient perspective regarding the importance of receiving care from an accredited program.

In addition, One Voice Against Cancer Lobby Days took place June 8–9.

Survey Savvy took place June 18–19 in Chicago with approximately 225 participants in attendance. Accreditation 101 will be held September 22 in Baltimore, MD.

The National Accreditation Program for Breast Centers has verified more than 630 breast centers in the U.S. A total of 28 new programs have been added in 2015. Reaccreditation rates for 2015 remain at 99 percent. Approximately 20 percent of centers request to be surveyed with their CoC program. Plans for expansion to international sites in 2015 include two Canadian breast centers and five centers from the U.K.

The CoC’s Advocacy and Outreach Committee was reorganized to add representation from major breast cancer advocacy groups, including:

  • Young Survivors Coalition
  • Living Beyond Breast Cancer
  • Lymphedema Network
  • Inflammatory Breast Cancer Research Foundation
  • Susan G. Komen for the Cure
  • American Cancer Society

American College of Surgeons Foundation

The Kenneth L. Mattox International Lectureship and Scholar Program in Acute Care Surgery (KLM Program) is proposed as a joint initiative of the ACS and the COT. The program honors Kenneth L. Mattox, MD, FACS, for his national and international contributions to acute care surgery and his many decades of ACS leadership. The award also extends the ACS vision and the reputation of COT internationally, while mentoring academic surgeons for leadership positions in acute care surgery. This proposal was endorsed unanimously by the COT Executive Committee.

The ACS COT will confer one or more Mattox awards each year, contingent on the ultimate success of the fund-seeking effort and investment return. These awards may be granted to surgeons practicing in the U.S. and Canada, as well as to surgeons practicing outside North America. The COT, in conjunction with the ACS Executive Director and B/R, will guide the selection process for the Mattox Awards in Acute Care Surgery. Responsibilities of the recipient may include travel to international ACS chapters for scholarly and promotional purposes; travel support to international surgeons to visit American academic centers and participate in scholarly programs; development of reports and publications for presentation at Clinical Congress; and/or a COT-sponsored Mattox Lectureship.

Journal of the American College of Surgeons (JACS)

The JACS continuing medical education (CME) website is now fully integrated into the College’s membership database, and is easily accessible after login. The new JACS CME platform, developed by the College’s Information Technology area, is mobile-ready for smartphones, iPads, and tablets. JACS CME is a quick and convenient way for ACS members to earn credit for Maintenance of Certification.

In the last year, 3,660 Fellows earned credit toward maintenance of certification from the JACS CME program, with 84,348 CME credits granted.

There are now more than 1,000 followers of @JAmCollSurg on Twitter—a 50 percent increase since the beginning of the year.

The app for reading JACS on smartphones, iPads, and tablets has been downloaded almost 9,000 times since the app launched in October 2014.

A few examples of media coverage of JACS articles from the recent months include the following:

  • “Too few breast cancer patients getting radiation after mastectomy: Study,” U.S. News & World Report, discussing an article in the April 2015 issue
  • “Patients bounce back faster from surgery with hospitals’ new protocol,” Wall Street Journal, also regarding an article in JACS’ April 2015 issue
  • “Blood transfusion during flight to trauma center boosts survival: Study,” Medline Plus, covering an article in JACS in May 2015
  • “Worse survival after lung cancer surgery for residents of poor neighborhoods,” Reuters, discussing an article published online April 15, 2015

*Gokak S. Surgeons can avoid PQRS and value-based modifier payment penalties. Bull Am Coll Surg. 2015;100(4):40-44. Available at: bulletin.facs.org/2015/04/surgeons-can-avoid-pqrs-and-value-based-modifier-payment-penalties/. Accessed August 14, 2015.

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