Advocacy in action: Bariatric and metabolic surgery

The leading public health concern for the industrialized world is obesity. It has been well demonstrated that obesity adversely affects all body organs, decreases the effectiveness of medical interventions, and raises the cost of medical care. In many ways, the first responders to this concern have been bariatric surgeons. Early in the approach to obesity as a disease, and similar to the experience in other fields of medicine, such as oncology or cardiology, surgery has been central in the treatment algorithm. Bariatric surgery, a subspecialty of metabolic surgery, has been a model of invention, assessment, and scientific advancement.

Obesity is only one expression of the metabolic syndrome, a body-wide defect of metabolism that also encompasses diabetes, dyslipidemias, hypertension, renal failure, blindness, amputations, and other diseases. The broader serious threat of these metabolic diseases should be the long-term focus of our advocacy in order to succeed in the adoption of metabolic surgery. The demonstrated safety and efficacy of bariatric and metabolic surgery has led to wider acceptance of surgery as a tool to combat obesity and metabolic diseases. These gains can be directly attributable to changes in procedure selection, fellowship training, minimally invasive operative approaches, and hospital and surgeon accreditation.1 Acceptance of bariatric and metabolic surgery has been demonstrated in its recognition by the medical societies that contributed to the Diabetes Surgery Summit II guidelines and by the 37 percent growth in bariatric procedures between 2011 and 2016—an estimated total increase of 216,000 procedures annually.2,3 Nonetheless, bariatric and metabolic surgery is performed on only 1 percent of the affected population annually.

Public acceptance of surgical treatment of obesity has been shown to be low. A national survey demonstrated that although the public views obesity as a significant health concern equivalent to cancer, fully 89 percent of patients with a body mass index (BMI) >30 kg/m2 did not consider themselves obese, and 40 percent had not sought further medical discussion of their weight.4 These views may be reflective of the lack of universal insurance coverage for bariatric surgery and a focus on less-invasive medical treatment and pharmaceuticals, which have been shown to be markedly less effective and durable than bariatric surgery.5 Finally, although faulty beliefs that bariatric surgery carries an excessive cost and high risk have been shown to be unfounded, these perceptions linger in the minds of the general public.6

To meet the need and demand for treatment of obesity and its comorbidities, surgeons, physicians, allied health professionals, industry partners, and patients have sought to advocate for a patient’s right to access the wide range of medical and surgical treatments. Through these efforts, access to metabolic surgery has expanded, allowing many patients to increase their quality of life and longevity. Yet access to care remains a challenge for many patients in need. No universal insurance coverage is available for bariatric surgery. This situation is inconsistent with the documented improvements in medical costs for bariatric surgery and its very low risk.6 As detailed herein, persistent, vigilant, and evidence-based advocacy through this professional and patient alliance is required to meet our mutual goal of providing care to those patients affected by obesity.

Advocacy principles

Surgeons are natural advocates for their field. They possess a firsthand understanding of the consequences and treatment of disease, as well as evidence-based knowledge of the best practices for long-term patient care. Defining clear principles for treatment advocacy aids in meeting the needs of patients, advancing the medical field, and increasing treatment utilization. These are the five A’s of advocacy for metabolic bariatric surgery: Acceptance of disease, Assessment of intervention, Access to care, Accuracy of progress, and Advancing the cause.

Acceptance of disease

A great step forward in scientific acceptance of obesity as a disease was the resolution put forth in 2013 by the American Medical Association (AMA).7 Clinicians on the front lines of treating obesity have long recognized that obesity is a disease; however, the AMA’s affirmation of that perspective was a landmark event. Acceptance of obesity as a disease has increased as all medical disciplines have come to recognize obesity’s vast negative health impact. General surgeons know that obesity can lead to recurrence of hernias and gastrointestinal reflux disease following surgery; transplant surgeons can only place patients on the list for organ donations if they have a BMI <35 kg/m2; an orthopaedic surgeon may decide not to perform a total joint replacement on obese patients because they are at greater risk for surgical site infection, joint dislocation, and decreased implant longevity.8 Because obesity affects all medical disciplines, it is incumbent upon the entire house of medicine to be engaged in decreasing the burden of this disease.

Acceptance of obesity treatment is aided by “mainstreaming” bariatric surgery through surgeon organizing, both nationally and across disciplines. The American Society for Metabolic and Bariatric Surgery (ASMBS) has made a concerted effort over the last few years to become an institutional partner of the National Quality Forum, AMA, Arnold P. Gold Foundation, Medical Group Management Association, and the Choosing Wisely Campaign.

Better understanding of the disease of obesity, particularly acceptance of the tenet that physiology is primary and psychology secondary in disease progression, has been paramount. The Biggest Loser study by Fothergill and colleagues demonstrated unequivocally that despite best efforts at dietary counseling and physical exertion, the 16 initial participants in the television competition all regained weight close to or greater than the amount they had lost.9 It is theorized that weight loss amplifies weight-mediated hormonal signaling, physiologically impelling the body to return to its original set point. Outcome observations following The Biggest Loser study showed that patients with clinical obesity need treatment that goes beyond motivation and inspiration.

Assessment of intervention

As W. Edwards Deming stated, “If you can’t measure it, you can’t manage it.”10 This approach holds true for the work of advocacy. Accurate assessment of national insurance coverage is critical to determine progress and focus resources in needed areas. Figures 1A-B, 2, and 3A-B, demonstrate the gains made over the last decade. However, as the figures demonstrate, more needs to be done to achieve Medicaid coverage in Mississippi and Montana; state employee coverage in Idaho, Georgia, Louisiana, Montana, South Carolina, and Wisconsin; and to raise overall commercial coverage to 100 percent. Of note, insurance coverage decisions can change quickly, and in Georgia and Louisiana, state employees were covered on a pilot basis, which allowed some surgeons to perform a set number of cases for selected patients. Medicare has paid for Roux-en-Y gastric bypass (RYGB), gastric banding, and duodenal switch since 2006.11 The special circumstance of Medicare coverage for sleeve gastrectomy is discussed later in this article.

Figure 1A–B. Medicaid bariatric surgery coverage by state in 2005 and 2014

Figure 1A–B. Medicaid bariatric surgery coverage by state in 2005 and 2014

Source: ASMBS

Figure 2. National bariatric surgery coverage for employees by state 2018

Figure 2. National bariatric surgery coverage for employees by state 2018

Source: ASMBS

Figure 3A–B. National bariatric surgery commercial insurance coverage by state in 2005 and 2010

Figure 3A–B. National bariatric surgery commercial insurance coverage by state in 2005 and 2010

Source: ASMBS

Access to care

Advocating for access to care requires coordination and expertise. ASMBS established several organizational efforts to address this need, recognizing that many coverage issues are local and require swift action. To accomplish these goals, the ASMBS formed an Access to Care Committee (ATCC), STAR program, and state chapters. The ATCC is a starting point for coordinated, strategic advocacy campaigns and maintains a network of state access-to-care advocates (STARs) who monitor threats to access within their geographic area and then develop advocacy action plans.

Through an ASMBS presidential initiative, the ASMBS chartered a nationwide network of state chapters, which resulted in all 50 states having a chapter by 2015 (see Figure 4). The state chapters have been encouraged to collaborate on educational, quality improvement, and access issues. For example, through the ASMBS Pennsylvania State Chapter, a coordinated effort by surgeon-advocates enabled a discussion about bariatric coverage for state employees with key members of the state government, resulting in benefit coverage. During monthly phone calls and annual state chapter meetings, advocacy strategy is reviewed and implemented. In addition, the ASMBS and American College of Surgeons (ACS) chapters have often co-located their offices to take advantage of natural synergies.

Figure 4. ASMBS state chapters

Figure 4. ASMBS state chapters

Source: ASMBS

Accuracy of progress

As in all fields of surgery, safety and efficacy of intervention must be detailed to patient and payor alike to gain acceptance. The immense value of a clinical data registry is profound, allowing for accurate assessment of both safety and efficacy. Claims data, which Medicare uses, do not include clinically important variables such as BMI and are limited to a single payor. In 2006, the Centers for Medicare & Medicaid Services (CMS) required hospital accreditation and recognized its value through a data registry coupled with standards, resources, and site visits. In 2013, CMS acknowledged the tremendous improvement in quality demonstrated in bariatric surgery since 2006 by no longer requiring accreditation for Medicare patients. It should be noted that the following year, CMS recognized the ACS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry as the only national Qualified Clinical Data Registry for the Physician Quality Reporting System in bariatric surgery.

Since 2002, mortality associated with bariatric surgery has declined at a rate that is unique to the field of surgery, from 1 percent to 0.1 percent.12 The value of accreditation has been demonstrated repeatedly to decrease costs and surgical complications.1,13 The benefits of bariatric surgery have been demonstrated through improvements in quality and quantity of life.5,14,15 Reporting of accurate outcomes has been instrumental in securing further acceptance of the safety and efficacy of bariatric surgery through partnership of the ASMBS and the ACS in establishing the MBSAQIP.

Advancing the cause

To meet the many challenges and remain an enduring effort, new avenues for advocacy must be explored, and bariatric surgeons must be seen as the stewards of care for patients with obesity. Bariatric surgeons should be advocates for acceptance of obesity as a disease; leaders of the multidisciplinary bariatric team; providers of a continuum of care; architects of health policy; and investigators into the causes of obesity, its prevention, consequences, and treatment.

Augmenting advocacy

Specifically, the ASMBS has created three means of augmenting advocacy: the production of a video for the lay public; the formation of an ObesityPAC (political action committee); and the Obesity Care Advocacy Network and Obesity Summit for referral of health care professionals.16-18 Plans have been discussed to establish a foundation to advocate for obesity awareness, prevention, and treatment, which would draw on resources from all medical disciplines, industries, patients, and government.

“It Starts Today” video

A video detailing the stories of three patients provides a narrative for acceptance of bariatric surgery and can be used by anyone.16 “It Starts Today” explains the ways in which bariatric surgery improves the health and welfare of a nurse, a military veteran, and a former National Football League (NFL) player. The video shows that bariatric surgery works and that obesity is not due to lack of medical knowledge (as illustrated by the nurse), discipline (military veteran), or physical activity (NFL player). The video ends with a call to action to visit the ASMBS website to learn more and make use of bariatric surgery access resources.

ObesityPAC

The ObesityPAC was formed in 2015 as an ASMBS presidential initiative of the lead author of this article, John Morton, MD, FACS. The ObesityPAC represents the interests of bariatric and metabolic surgeons as the official political action committee of the ASMBS. The mission of ObesityPAC is to “preserve, protect, and defend the inalienable right of the patient with obesity to have safe, effective, equitable, and affordable access to care in all of the United States.”17 ObesityPAC has afforded local surgeons an opportunity to interact with politicians in their regions and districts, enabling direct one-on-one advocacy that would be difficult without monetary support. To both garner support and initiate dialogue, the ObesityPAC sponsors a donor event at each annual ObesityWeek, wherein a local elected official is given ObesityPAC support and speaks on issues related to obesity. For example, Sen. Bill Cassidy (R-LA) was invited to speak in New Orleans in 2016 at ObesityWeek. In the future, the ObesityPAC will work closely with other PACs, such the ACS Professional Association-SurgeonsPAC, to maximize influence.

Obesity Care Advocacy Network and Obesity Summit

Partnering with other health care professional societies is an important component of our advocacy efforts. The Obesity Care Advocacy Network (OCAN) is composed of the patient advocacy organization (Obesity Action Coalition) and representatives of four major societies: ASMBS, The Obesity Society, Obesity Medical Association, and the Academy for Nutrition and Dietetics. The membership of these five organizations is approaching 200,000 members and represents the entire continuum of care for obesity. OCAN can use this vast membership to effect change on behalf of patients with obesity. Additional partners—including the ACS, Society of American Gastrointestinal and Endoscopic Surgeons, Society for Surgery of the Alimentary Tract, and the American Gastroenterology Association—have been recruited for assistance with other initiatives.

Finally, in 2014, Ninh T. Nguyen, MD, FACS (a coauthor of this article), and Dr. Morton led a large-scale effort to involve the entire house of medicine in addressing the obesity challenge. This effort, the Obesity Summit for the Provision of Care, has featured more than 35 different medical societies annually, including the AMA, American Heart Association, and American Academy for Orthopaedic Surgery.18 The summit has resulted in six collaborative documents and inaugurated movements within the other societies to treat obesity.19-24

Case studies in advocacy

Three examples of advocacy in action for bariatric surgery follow, including the 1991 National Institutes of Health (NIH) Consensus Conference, the Essential Health Benefit (EHB) Coverage in Colorado, and CMS coverage of sleeve gastrectomy.

1991 NIH Consensus Conference

Metabolic surgery pioneers, such as Henry Buchwald, MD, FACS, and Walter Pories, MD, FACS, realized the benefits of bariatric surgery extended beyond simple weight loss.25,26 As better understanding of obesity’s pathophysiology and its remission was gained, acceptance of metabolic bariatric surgery increased. However, use still lagged, partly because the health care professionals clung to the belief that obese patients should self-treat and not be offered treatment—that obese patients had caused their own health consequences. These beliefs run counter to scientific evidence and accepted principles of treatment for patients who also make unhealthy lifestyle choices, such as overuse of alcohol necessitating liver transplantation or tobacco use necessitating lung resection.

To further delineate indications, risks, and benefits of bariatric surgery, the NIH convened a consensus panel of experts in March 1991.27 Early practitioners of bariatric and metabolic surgery were panel participants, including Drs. Buchwald and Pories, who were joined by Robert Brolin, MD, FACS; John Halverson, MD, FACS; and Edward Mason, MD, FACS. This august panel created specific indications for bariatric procedures and set practice standards. This collective advocacy effort evolved the surgical specialty to move beyond weight loss to metabolic benefits and established clear indications and resources for bariatric surgery.

Essential health benefit coverage

The Affordable Care Act (ACA) of 2013 was the largest health care reform package since Medicare was created in 1965. The ACA had specific components that addressed obesity, including a requirement for restaurant chains to post calorie counts, coverage for weight-loss counseling, and a state-by-state EHB requirement. Determination of coverage for bariatric surgery within each state EHB was variable. Some states included a bariatric surgery benefit in their EHB, while others did not (see Figure 5). As a consequence, the U.S. now has a disparate patchwork of state treatment options, with 27 states offering bariatric surgery and 23 states excluding this option.

Figure 5. Essential health benefit coverage for bariatric surgery by state 2014

Figure 5. Essential health benefit coverage for bariatric surgery by state 2014

Source: ASMBS

With Dr. Morton’s leadership, in 2013, the ASMBS created the No State Left Behind initiative to directly advocate with governors, state insurance commissioners, and state legislators for EHB coverage of bariatric surgery.28 No State Left Behind provided talking points, sample letters, state-specific obesity data, and summaries of information regarding safety and effectiveness. These efforts resulted in Colorado adding bariatric surgery to the state EHB. Disparities in coverage continue to exist despite evidence that adding the benefit has minimal impact on overall cost.29 Unfortunately, states without bariatric surgery coverage are those with the highest rates of obesity, a punishing deficit that falls disproportionately on the sufferers of the disease of obesity and perpetuates this health disparity.

CMS coverage of sleeve gastrectomy

Laparoscopic sleeve gastrectomy has become the most prevalently performed bariatric surgery.3 The explosive growth of the sleeve gastrectomy can be attributed in part to insurance coverage, as well as to patient and surgeon preference. As in many coverage decisions, CMS played a large role. Until 2012, CMS did not cover sleeve gastrectomy and, in 2014, all Medicare administrative contractors (MACs) covered sleeve gastrectomy.30 How did this happen?

Through a collaborative effort, data regarding the safety and efficacy of the sleeve gastrectomy were presented to CMS after the National Care Determination (NCD) was opened. In addition, all advocacy efforts included a team approach with bariatric surgeons, bariatric patients, specialty society partners, and industry. The NCD was opened to examine coverage of the sleeve gastrectomy, apparently at the behest of one Medicare patient who was awaiting renal transplantation and desired a sleeve gastrectomy. This scenario underscores the value and power of patient involvement. Surprisingly, initial review of the large evidence base for sleeve gastrectomy did not result immediately in coverage, as CMS declined to change the NCD, but instead allowed for MACs to make a Local Care Determination.

ASMBS, led by Robin Blackstone, MD, FACS, and Dr. Morton, petitioned each MAC individually and managed to secure coverage throughout the U.S. Initially, local barriers such as age restrictions remained, but to date, all restrictions have been removed. The narrative regarding achievement of coverage of the sleeve gastrectomy is reflective of best practices in advocacy, including data gathering, professional group collaboration, patient involvement, and persistence.

Conclusions

Although much progress has been made in coverage for bariatric surgery, challenges remain. All commercial, Medicaid, and state employee insurance policies should provide uniform bariatric surgery coverage. In addition, restrictive practices (such as high deductibles, special insurance riders for bariatric surgery, required timed preoperative weight loss) should be removed to provide benefits to all patients suffering from obesity and its comorbidities. We must continue to demonstrate and advocate for acceptance of the safety and effectiveness of metabolic surgery, not only to insurance carriers, but to referring physicians, legislators, and patients themselves. Until the profession focuses on getting patients to demand this care, use of the powerful tool of metabolic surgery will remain sluggish.

The metabolic syndrome, a body-wide defect of metabolism, should be the longer-term focus of our advocacy to increase patient access to care and acceptance of metabolic surgery. To provide care to our patients in need, the metabolic bariatric surgery community needs to advocate consistently and vigilantly. In addition, metabolic surgeons must collaborate with all specialties that treat obesity to improve education, treatment, and advocacy. Challenges remain, but surpassing obstacles is what the daring do and what is required for all involved in the care of the patient with obesity.

Acknowledgment

This work was supported by the American College of Surgeons (ACS). The authors declare that they have no relevant conflict of interest.

We are grateful to the ACS for their generous sponsorship of the Metabolic Surgery Symposium and associated journal publication development. We thank Jane N. Buchwald, Chief Scientific Research Writer, Medwrite Medical Communications, Maiden Rock, WI, for manuscript editing and publication coordination. And we thank Patrick Beebe and Donna Coulombe, ACS Executive Services, for their expert organization of the Metabolic Surgery Symposium.


References

  1. Azagury D, Morton J. Bariatric surgery outcomes in U.S. accredited vs non-accredited centers: A systematic review. J Am Coll Surg. 2016;223(3):469-477.
  2. Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the treatment algorithm for type 2 diabetes: A joint statement by international diabetes organizations. Diabetes Care. 2016;39(6):861-877.
  3. English WJ, DeMaria EJ, Brethauer SA, et al. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surg Obes Relat Dis. 2018;14(3):259-263.
  4. Rosenthal RJ, Morton J, Brethauer S, et al. Obesity in America. Surg Obes Relat Dis. 2017;13(10):1643-1650.
  5. Schauer PR, Bhatt DL, Kirwan JP, et al; STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. N Engl J Med. 2017;376(7):641-651.
  6. Gulliford MC, Charlton J, Booth HP, et al. Costs and outcomes of increasing access to bariatric surgery for obesity: Cohort study and cost-effectiveness analysis using electronic health records. Value Health. 2017;20(1):85-92.
  7. American Medical Association. House of Delegates Resolution 420: Recognition of obesity as a disease. Presented at: House of Delegates Annual Meeting; 2013. Available at: www.npr.org/documents/2013/jun/ama-resolution-obesity.pdf. Accessed June 1, 2018.
  8. Goodnough LH, Finlay AK, Huddleston JI 3rd, Goodman SB, Maloney WJ, Amanatullah DF. Obesity is independently associated with early aseptic loosening in primary total hip arthroplasty. J Arthroplasty. 2018;33(3):882-886.
  9. Fothergill E, Guo J, Howard L, et al. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity (Silver Spring). 2016;24(8):1612-1619.
  10. Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Educational Services; 1994.
  11. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for bariatric surgery for treatment of co-morbid conditions related to morbid obesity (100.1). December 17, 2013. Available at: https://go.cms.gov/2Up9BAt. Accessed April 16, 2019.
  12. Young MT, Jafari MD, Gebhart A, Phelan MJ, Nguyen NT. A decade analysis of trends and outcomes of bariatric surgery in Medicare beneficiaries. J Am Coll Surg. 2014;219(3):480-488.
  13. Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260(3):504-509.
  14. Mazer LM, Azagury DE, Morton JM. Quality of life after bariatric surgery. Curr Obes Rep. 2017;6(2):204-210.
  15. Adams TD, Davidson LE, Litwin SE, et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med. 2017;377(12):1143-1155.
  16. American Society for Metabolic and Bariatric Surgery. It Starts Today. Available at: https://asmbs.org/video-it-starts-today-obesity-surgery-helps-people-reclaim-their-lives. Accessed March 22, 2019.
  17. American Society for Metabolic and Bariatric Surgery. About ObesityPAC. Available at: https://asmbs.org/obesitypac. Accessed March 22, 2019.
  18. American Society for Metabolic and Bariatric Surgery. Obesity Summit. Available at: https://asmbs.org/obesity-summit. Accessed March 22, 2019.
  19. Yarborough CM, Brethauer S, Burton WN, Fabius RJ, et al. Obesity in the workplace: Impact, outcomes, and recommendations. J Occup Environ Med. 2018;60(1):97-107.
  20. Ligibel JA, Alfano CM, Hershman DL, et al. American Society of Clinical Oncology summit on addressing obesity through multidisciplinary provider collaboration: Key findings and recommendations for action. Obesity (Silver Spring). 2017;25(Suppl 2):S34-S39.
  21. 21. Springer BD, Carter JT, McLawhorn AS, et al. Obesity and the role of bariatric surgery in the surgical management of osteoarthritis of the hip and knee: A review of the literature. Surg Obes Relat Dis. 2017;13(1):111-118.
  22. Bays HE, Jones PH, Jacobson TA, et al. Lipids and bariatric procedures, part 1 of 2: Scientific statement from the National Lipid Association (NLA), American Society for Metabolic and Bariatric Surgery (ASMBS), and Obesity Medicine Association (OMA): Full Report. J Clin Lipidol. 2016;10(1):33-57.
  23. Bays H, Kothari SN, Azagury DE, et al. Lipids and bariatric procedures, part 2 of 2: Scientific statement from the American Society for Metabolic and Bariatric Surgery (ASMBS), the National Lipid Association (NLA), and Obesity Medicine Association (OMA). Surg Obes Relat Dis. 2016;12(3):468-495.
  24. Kominiarek MA, Jungheim ES, Hoeger KM, Rogers AM, Kahan S, Kim JJ. American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy. Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society. Surg Obes Relat Dis. 2017;13(5):750-757.
  25. Pories, WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222(3):339-352.
  26. Buchwald H, Varco RL, Matts JP, et al. Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia. Report of the Program on the Surgical Control of the Hyperlipidemias (POSCH). N Engl J Med. 1990;323(14):946-955.
  27. National Institutes of Health. National Institutes of Health Consensus Development Conference Statement March 25–27, 1991: Gastrointestinal surgery for severe obesity. Available at: https://consensus.nih.gov/1991/1991gisurgeryobesity084html.htm. Accessed March June 2018.
  28. American Society for Bariatric and Metabolic Surgery. EHB Access Tool Kit. Available at: https://asmbs.org/resources/ehb-access-toolkit. Accessed March 22, 2019.
  29. English W, Williams B, Scott J, Morton J. Covering bariatric surgery has minimal effect on insurance premium costs within the Affordable Care Act. Surg Obes Relat Dis. 2016;12(5):1045-1050.
  30. Centers for Medicare & Medicaid Services. Decision Memo for Bariatric Surgery for the Treatment of Morbid OBESITY (CAG-00250R2). Available at: https://go.cms.gov/2UtMWqW. Accessed April 3, 2019.

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