The introduction of independent sector providers (ISPs) in England was associated with an increase in NHS-funded hip replacements. As ISPs opened closer to areas than the nearest NHS trust hospital, those areas saw faster growth in the number of hip replacements among residents. This suggests patients responded to the availability of closer treatment options by having more NHS-funded hip replacements. The additional demand from ISPs being located nearby was estimated to increase annual hip replacements in an area by 0.2-1.2 cases, similar to adding 100 more elderly residents. Further analysis of joint registry and hospital data may help determine if the increased demand came from new hip replacement patients or substitutions from private to NHS funding.
John Ribchester: Community integrated health careNuffield Trust
Whitstable Medical Practice has developed a model of community integrated healthcare to address the growing health needs of its aging population. The practice has expanded services to include diagnostics, outpatient clinics, therapies, screening, and minor procedures delivered on site or through partnerships. This has resulted in cost savings up to 63% compared to traditional referrals, shorter wait times, and improved patient experience. The practice has also strengthened partnerships to coordinate long-term condition management, urgent care, and rehabilitation services. While this model has benefits, expanding it would require overcoming obstacles such as practice consolidation, facility upgrades, and gaining support from clinical commissioning groups and other stakeholders.
Anita Charlesworth: Spending on Health 2011-2015Nuffield Trust
The document summarizes government spending plans and health spending in the UK from 2010-2015. It finds that overall health funding is increasing by an average of 0.1% per year over this period. However, it also notes that annual real terms growth in public health spending needs to be around 2% just to maintain current services, representing a significant efficiency challenge. It outlines some strategies for improving efficiency in the NHS, including the Quality, Innovation, Productivity and Prevention program which aims to achieve over £3 billion in annual productivity savings through various means.
Long Term Conditions: Long Term Conditions What’s wrong and what do we need?Mohammad Al-Ubaydli
This document discusses challenges facing long-term condition (LTC) care in the NHS East of England region. It notes that funding cuts are projected, while demand is increasing. Current LTC care is seen as too medicalized and not personalized enough. Variation in services and costs between areas is also a problem. To address these issues, the document advocates for a more personalized, integrated approach centered around self-care and personal health planning. It proposes alternative payment models, like a "pathway hub" provider managing entire care pathways and budgets. The overall vision is to empower patients and provide the right care at the right time in a sustainable way.
Xavier Chitnis & Michael Cooke: Marie Curie service impactNuffield Trust
This document summarizes a study that evaluated the impact of the Marie Curie Nursing Service (MCNS) on place of death, hospital use, and costs at end of life. The study used a matched control group to compare outcomes for over 30,000 MCNS patients to over 1 million people who did not receive MCNS care. The results showed that MCNS patients were much more likely to die at home, had lower hospital use and costs, and spent less time in the hospital in their last 3 months of life compared to the control group. The impact was greater for those without cancer histories. The study provides evidence that home-based nursing care can help more people die at home while reducing hospital costs.
Holly Holder: Caring for older people in societyNuffield Trust
The document discusses caring for aging populations and compares approaches in Japan and England. It notes that Japan has the oldest population in the world and introduced significant reform to its long-term care system in 2000. Key aspects of Japan's system include universal compulsory insurance for those over 40 that provides home care and day services based on need for those over 65. England assesses eligibility based on a means and needs test and provides less support, with 44% of social care for the elderly being self-funded. Both countries are undergoing reforms to address the challenges of caring for growing older populations.
Mike Richards: Ratings in the hospital inspection programmeNuffield Trust
The document outlines the Care Quality Commission's (CQC) proposed approach to introducing ratings as part of their new hospital inspection program. Key points include:
- Ratings will use a four point scale of Outstanding, Good, Requires Improvement, and Inadequate.
- Ratings will be determined based on information from inspections, data, and other sources across five key domains of safety, effectiveness, caring, responsiveness, and well-led.
- Services and trusts will receive ratings in each domain as well as overall ratings.
- Examples are provided of how ratings might be applied based on inspection findings.
Simon Brownleader & Ashraf Ullah: GP NetworksNuffield Trust
This document describes the Tower Hamlets Networks program which established 8 geographical networks of 4-5 practices each in Tower Hamlets, London. The networks received funding for staff and programs to improve care for conditions like diabetes, COPD, and immunizations. Data shows the networks have improved outcomes like higher MMR immunization rates and lower average HbA1c and COPD admission rates compared to prior years. Key factors in their success include trust, data sharing, peer support, incentives, and education between networked practices.
Sarah Purdy: What does evidence look like?Nuffield Trust
The document summarizes evidence on interventions that can reduce avoidable hospital admissions. It finds that primary care interventions with continuity of care, appropriate practitioner-to-patient ratios, and structured hospital discharges are effective. Case management works for mental health but its effects are uncertain for other groups. Specialist clinics, self-management programs, and palliative care coordination can reduce cardiac and respiratory admissions. However, the evidence on other interventions like telemedicine, medication reviews, and integrated care models is mixed. Overall, the most supported interventions emphasize traditional high-quality care, patient education, and care coordination.
John Ribchester: Community integrated health careNuffield Trust
Whitstable Medical Practice has developed a model of community integrated healthcare to address the growing health needs of its aging population. The practice has expanded services to include diagnostics, outpatient clinics, therapies, screening, and minor procedures delivered on site or through partnerships. This has resulted in cost savings up to 63% compared to traditional referrals, shorter wait times, and improved patient experience. The practice has also strengthened partnerships to coordinate long-term condition management, urgent care, and rehabilitation services. While this model has benefits, expanding it would require overcoming obstacles such as practice consolidation, facility upgrades, and gaining support from clinical commissioning groups and other stakeholders.
Anita Charlesworth: Spending on Health 2011-2015Nuffield Trust
The document summarizes government spending plans and health spending in the UK from 2010-2015. It finds that overall health funding is increasing by an average of 0.1% per year over this period. However, it also notes that annual real terms growth in public health spending needs to be around 2% just to maintain current services, representing a significant efficiency challenge. It outlines some strategies for improving efficiency in the NHS, including the Quality, Innovation, Productivity and Prevention program which aims to achieve over £3 billion in annual productivity savings through various means.
Long Term Conditions: Long Term Conditions What’s wrong and what do we need?Mohammad Al-Ubaydli
This document discusses challenges facing long-term condition (LTC) care in the NHS East of England region. It notes that funding cuts are projected, while demand is increasing. Current LTC care is seen as too medicalized and not personalized enough. Variation in services and costs between areas is also a problem. To address these issues, the document advocates for a more personalized, integrated approach centered around self-care and personal health planning. It proposes alternative payment models, like a "pathway hub" provider managing entire care pathways and budgets. The overall vision is to empower patients and provide the right care at the right time in a sustainable way.
Xavier Chitnis & Michael Cooke: Marie Curie service impactNuffield Trust
This document summarizes a study that evaluated the impact of the Marie Curie Nursing Service (MCNS) on place of death, hospital use, and costs at end of life. The study used a matched control group to compare outcomes for over 30,000 MCNS patients to over 1 million people who did not receive MCNS care. The results showed that MCNS patients were much more likely to die at home, had lower hospital use and costs, and spent less time in the hospital in their last 3 months of life compared to the control group. The impact was greater for those without cancer histories. The study provides evidence that home-based nursing care can help more people die at home while reducing hospital costs.
Holly Holder: Caring for older people in societyNuffield Trust
The document discusses caring for aging populations and compares approaches in Japan and England. It notes that Japan has the oldest population in the world and introduced significant reform to its long-term care system in 2000. Key aspects of Japan's system include universal compulsory insurance for those over 40 that provides home care and day services based on need for those over 65. England assesses eligibility based on a means and needs test and provides less support, with 44% of social care for the elderly being self-funded. Both countries are undergoing reforms to address the challenges of caring for growing older populations.
Mike Richards: Ratings in the hospital inspection programmeNuffield Trust
The document outlines the Care Quality Commission's (CQC) proposed approach to introducing ratings as part of their new hospital inspection program. Key points include:
- Ratings will use a four point scale of Outstanding, Good, Requires Improvement, and Inadequate.
- Ratings will be determined based on information from inspections, data, and other sources across five key domains of safety, effectiveness, caring, responsiveness, and well-led.
- Services and trusts will receive ratings in each domain as well as overall ratings.
- Examples are provided of how ratings might be applied based on inspection findings.
Simon Brownleader & Ashraf Ullah: GP NetworksNuffield Trust
This document describes the Tower Hamlets Networks program which established 8 geographical networks of 4-5 practices each in Tower Hamlets, London. The networks received funding for staff and programs to improve care for conditions like diabetes, COPD, and immunizations. Data shows the networks have improved outcomes like higher MMR immunization rates and lower average HbA1c and COPD admission rates compared to prior years. Key factors in their success include trust, data sharing, peer support, incentives, and education between networked practices.
Sarah Purdy: What does evidence look like?Nuffield Trust
The document summarizes evidence on interventions that can reduce avoidable hospital admissions. It finds that primary care interventions with continuity of care, appropriate practitioner-to-patient ratios, and structured hospital discharges are effective. Case management works for mental health but its effects are uncertain for other groups. Specialist clinics, self-management programs, and palliative care coordination can reduce cardiac and respiratory admissions. However, the evidence on other interventions like telemedicine, medication reviews, and integrated care models is mixed. Overall, the most supported interventions emphasize traditional high-quality care, patient education, and care coordination.
Carol Propper: Reform and demand response in the NHS Nuffield Trust
- The document analyzes the impact of increased choice in the British National Health Service on the responsiveness of patient demand to hospital quality.
- It uses data on patients undergoing coronary artery bypass graft (CABG) surgery before and after a 2006 reform that expanded choice of hospitals.
- The reform mandated that patients be offered a choice of 5 hospitals, rather than being referred only to their local hospital. Prices were also standardized across hospitals.
- The results find that while average patient demand responsiveness did not change with the reform, sicker patients became more responsive to hospital mortality rates with increased choice. Responsiveness to wait times decreased slightly.
John Macaskill-Smith: General practice models in New ZealandNuffield Trust
The document provides an overview of the New Zealand health system and discusses some of its key challenges and drivers for change. It notes that the NZ population is 4.2 million served by a largely devolved system including a central ministry, 20 regional health boards, and private providers. While performance is generally good compared to other OECD countries, challenges include an aging population increasing demands, rising costs, and fragmentation across the system. Key drivers for change include addressing these population trends, workforce needs, financial sustainability, and improving facilities.
Holly Holder & Ian Blunt: Integrated care pilot evaluationNuffield Trust
The document evaluates the first year of the Inner North West London Integrated Care Pilot (ICP), which aims to improve coordination of care for older adults and those with diabetes. It finds that the ICP made substantial progress establishing governance structures and engaging organizations across health and social care. However, most patients did not experience changes in year one and it was too early to see impacts on health services or outcomes. The evaluation highlights the complexity of implementing large-scale transformation and that longer-term evaluation is needed to assess changes in care and health impacts.
Jon Sussex: Capacity, choice and private ownership Nuffield Trust
1. NHS-funded hip replacements increased by 40% between 2003-2011, with the independent sector providing 62% of the additional procedures.
2. Growth was faster when an independent sector provider was located nearer to the patient than the nearest NHS provider.
3. Some patients who previously would have paid privately switched to NHS-funded care at independent sector providers, resulting in some deadweight loss to taxpayers.
Gavin MacColl: Anticipatory care planning in primary careNuffield Trust
This document discusses SPARRA (Scottish Patients at Risk of Readmission & Admission), a risk prediction algorithm, and its use in identifying high-risk patients for anticipatory care planning (ACP) in primary care practices. It provides an overview of SPARRA, how practices can use SPARRA risk scores to target patients for ACPs, and details on evaluating ACPs and related Quality and Outcomes Framework indicators. The document also addresses practical considerations for practices in accessing SPARRA data and limitations of the current SPARRA model.
Richard Disney: Questions on quality, choice and demandNuffield Trust
This document summarizes and comments on a paper examining the impact of mandated hospital choice for coronary artery bypass graft surgery in England after 2006. It finds that allowing patients to choose higher-quality hospitals reduced mortality by 3%. The document then provides several pedantic comments and questions about the data and analysis, including questioning the measures of hospital quality, mortality rates, and generalizability given the small number of specialist hospitals studied. It also raises issues about how patient choice is actually exercised and the role of spatial competition between hospitals.
Mayumi Hayashi: Lessons from Japan on social care reformNuffield Trust
In this slideshow, Dr Mayumi Hayashi, Leverhulme Early Career Fellow, Institute of Gerontology, King’s College London, gives an overview of social care reforms in Japan, and outlines the achievements, challenges and lessons for England.
William Shrank: Payment reform activities at CMSNuffield Trust
The document discusses activities at the CMS Innovation Center to test new payment and service delivery models. It outlines several initiatives to improve care coordination, such as ACO models and medical home programs. It also discusses initiatives to improve care quality like Partnership for Patients and reduce costs through bundled payments. Rapid-cycle evaluation is highlighted as important to provide feedback to support continuous quality improvement and identify successful models to scale nationally.
Hugh Gravelle: The impact of care quality on patient choiceNuffield Trust
Patients in England are more likely to choose general practices with higher clinical quality as measured by Quality and Outcomes Framework (QOF) points. A 1 standard deviation increase in QOF points is associated with a 20% increase in demand for a practice. While the effect of quality on an individual's choice is small, the large number of potential patients means quality has a large effect on total demand for a practice. Quality is the main driver of choice, more so than distance, practice characteristics, or patient attributes. This provides incentive for practices to improve quality to attract more patients.
Ian Duncan: Predictive risk in a US pharmacyNuffield Trust
Three predictive modeling examples are described:
1. Targeting non-adherent customers to improve medication adherence.
2. Stratifying end-of-life patients in accountable care organizations to prevent over-medicalized end-of-life care.
3. Identifying Medicare and health insurance exchange patients for wellness visits and risk assessments to improve health outcomes and quality measures.
Paul Burstow: The need for care reform in EnglandNuffield Trust
In this slideshow, Rt Hon Paul Burstow MP, Minister of State for Care Services (2010-2012), explains the need for social care reform in England due to an ageing population and the challenges ahead.
Elaine Kelly public payment and private provisionNuffield Trust
1) Public health spending in the UK rose faster in the 2000s than in previous decades, while growth of private spending slowed after 2007. The share of NHS-funded treatment provided by non-NHS providers also increased during this period.
2) Analysis of hip and knee replacements showed they increased substantially on the NHS between 2003-2012, with non-NHS providers responsible for over half of the rise. Some increase was due to demographics but there was also evidence of substitution from private to NHS funding.
3) Reforms opened up more NHS-funded care to non-NHS providers but the NHS remained the predominant provider, and further growth of non-NHS providers may be limited by NHS demand and
Masahiko Hayashi: Long-term care insurance in JapanNuffield Trust
In this slideshow, Masahiko Hayashi, Deputy Assistant to the Minister for International Affairs, Ministry of Health, Labour and Welfare, Japan, provides an overview of long-term care insurance in Japan and considers its’ future.
Judith Smith: Commissioning for long-term conditionsNuffield Trust
1) The study explored how NHS commissioning can assure high quality care for people with long-term conditions through ethnographic research in three commissioning communities over two years.
2) The research found that commissioning in practice is messier than assumed, involves coordination and facilitation beyond a neat annual cycle, and commissioners play roles in implementation support.
3) The implications are that commissioning long-term conditions requires extensive relational work that may not align with the commissioning cycle and that there are critical enablers like skilled managers and clinicians that support effective commissioning practices.
Primary care in Europe: can we make it fit for the future?Nuffield Trust
Primary care provides essential health services but current models are struggling to adapt to changing needs. New models are emerging in Europe to make primary care more comprehensive, coordinated, accessible and sustainable. These include larger group practices, multidisciplinary teams, and integrated community health centers. Redesigning primary care requires principles like continuity, early access to expertise, and payment systems that support coordination and population health.
John Billings: Developing a new predictive risk modelNuffield Trust
This document discusses the development of a new predictive risk model. It describes predicting future costs and emergency admissions using data from inpatient, A&E, outpatient and GP databases. It shows the tradeoff between predictive accuracy and number of patients flagged as risk scores are varied, with higher cutoffs improving positive predictive value but reducing sensitivity. The model achieved good discrimination with an ROC C statistic of 0.78.
Andrew Street: Market mechanisms in health care Nuffield Trust
Professor Andrew Street discusses competition and market mechanisms in healthcare. He notes that competition does not necessarily mean privatization, and competitive effects depend on other system features. Competition is also not directly observable and its impact varies based on factors like pricing structures, patient choice, and degrees of collaboration between organizations. Overall, Professor Street examines how competition operates in healthcare and that its effects must be considered in context of the overall system design.
Adam Steventon: How can predictive risk models help?Nuffield Trust
This document discusses how predictive risk models can help evaluate interventions in observational studies. It notes challenges with observational studies, such as regression to the mean and lack of control groups. It proposes several solutions to address these challenges, including before-after studies, regression adjustment, matching controls, and regression discontinuity designs. Matched controls are described as a way to reduce dependence on regression model specification by "data pre-processing" to compare intervention patients to similar control patients. The document concludes by surveying the current state of telehealth studies, finding most are descriptive or use before-after designs, with few employing more rigorous controlled designs.
Tom Youldon: Creating a fair playing fieldNuffield Trust
Monitor's first major report as sector regulator examines how to create a fair playing field for competition in healthcare. The report identifies three areas that can distort the level playing field: participation costs, financial costs, and operational restrictions. It provides recommendations to address issues in commissioning, increase stability and support for providers, and ensure transparency and accountability. The goal is to enable a range of NHS providers to offer high quality services to patients on equitable terms.
Matt James: Choice and independent hospitalsNuffield Trust
The document summarizes Private Healthcare Information Network (PHIN), a new not-for-profit organization that collects data from independent hospitals in the UK to publish comparative information for patients, policyholders, and GPs. PHIN launched in April 2013 with a website providing searchable data on 183 independent hospitals. While initial data is limited, PHIN aims to expand the data over time to cover additional hospitals and providers. The document also discusses trends in the independent healthcare sector in the UK and findings that quality in the independent sector holds up well compared to NHS hospitals for procedures like hip replacements.
State of the Musculoskeletal Service Line: What's New in 2013 and Beyond?Wellbe
Long a bastion of growth and profitability, the orthopedic service line has historically served as a reliable source of surgical volumes and attractive per case economics for hospitals and health systems.
However, the rate of profitable volume growth is progressively challenged by several recent trends, including soaring implant costs, wavering reimbursement, and intensifying competition, which includes the migration of care to ambulatory centers.
In addition, in the wake of the Patient Protection and Affordable Care Act (PPACA) of 2010, hospitals will increasingly be held accountable for delivering high-quality, low-cost orthopedic care. In this rapidly changing environment, the orthopedic service line will require careful management to ensure its continued success.
This presentation explores the most important business and structural challenges to musculoskeletal healthcare delivery, covering topics such as the impact of healthcare reform; physician alignment tactics; and strategies for organization, staffing, and structure.
Speaker Biographies:
Ms. Krista L. Fakoory, Manager
Ms. Fakoory has been providing healthcare management consulting services since 2006. Her background includes strategic and service line business planning, hospital/physician alignment, provider compensation planning, and merger and acquisition assistance. She has particular expertise in developing comprehensive orthopedic programs, strategic planning for physician-owned ambulatory surgery centers, and designing alignment models between health systems and independent orthopedic surgeons.
Mr. Todd W. Godfrey, Senior Manager
With nearly 15 years of healthcare experience, Mr. Godfrey has a focused background in musculoskeletal services. He regularly advises clients on performance-based incentives between surgeon and health systems as organizations position their musculoskeletal service line to assume risk and manage populations.
- Slit lamp examination (including fundus)
- Perform biometry and focimetry
- Decide appropriateness for surgery
- Perform auto-refraction
- Discuss desired post-operative refractive status
with the patient (including current type of
spectacle correction) to enable the choice of lens
implant
- Perform ECG and blood tests
- Identify 2nd eye surgery where appropriate
Benefits
- reduces duplication of tasks
- reduces waiting time for patients
- frees up nursing time for other duties
- ensures all key tasks are completed in one visit
- improves patient experience
- reduces overall time in clinic
09
Carol Propper: Reform and demand response in the NHS Nuffield Trust
- The document analyzes the impact of increased choice in the British National Health Service on the responsiveness of patient demand to hospital quality.
- It uses data on patients undergoing coronary artery bypass graft (CABG) surgery before and after a 2006 reform that expanded choice of hospitals.
- The reform mandated that patients be offered a choice of 5 hospitals, rather than being referred only to their local hospital. Prices were also standardized across hospitals.
- The results find that while average patient demand responsiveness did not change with the reform, sicker patients became more responsive to hospital mortality rates with increased choice. Responsiveness to wait times decreased slightly.
John Macaskill-Smith: General practice models in New ZealandNuffield Trust
The document provides an overview of the New Zealand health system and discusses some of its key challenges and drivers for change. It notes that the NZ population is 4.2 million served by a largely devolved system including a central ministry, 20 regional health boards, and private providers. While performance is generally good compared to other OECD countries, challenges include an aging population increasing demands, rising costs, and fragmentation across the system. Key drivers for change include addressing these population trends, workforce needs, financial sustainability, and improving facilities.
Holly Holder & Ian Blunt: Integrated care pilot evaluationNuffield Trust
The document evaluates the first year of the Inner North West London Integrated Care Pilot (ICP), which aims to improve coordination of care for older adults and those with diabetes. It finds that the ICP made substantial progress establishing governance structures and engaging organizations across health and social care. However, most patients did not experience changes in year one and it was too early to see impacts on health services or outcomes. The evaluation highlights the complexity of implementing large-scale transformation and that longer-term evaluation is needed to assess changes in care and health impacts.
Jon Sussex: Capacity, choice and private ownership Nuffield Trust
1. NHS-funded hip replacements increased by 40% between 2003-2011, with the independent sector providing 62% of the additional procedures.
2. Growth was faster when an independent sector provider was located nearer to the patient than the nearest NHS provider.
3. Some patients who previously would have paid privately switched to NHS-funded care at independent sector providers, resulting in some deadweight loss to taxpayers.
Gavin MacColl: Anticipatory care planning in primary careNuffield Trust
This document discusses SPARRA (Scottish Patients at Risk of Readmission & Admission), a risk prediction algorithm, and its use in identifying high-risk patients for anticipatory care planning (ACP) in primary care practices. It provides an overview of SPARRA, how practices can use SPARRA risk scores to target patients for ACPs, and details on evaluating ACPs and related Quality and Outcomes Framework indicators. The document also addresses practical considerations for practices in accessing SPARRA data and limitations of the current SPARRA model.
Richard Disney: Questions on quality, choice and demandNuffield Trust
This document summarizes and comments on a paper examining the impact of mandated hospital choice for coronary artery bypass graft surgery in England after 2006. It finds that allowing patients to choose higher-quality hospitals reduced mortality by 3%. The document then provides several pedantic comments and questions about the data and analysis, including questioning the measures of hospital quality, mortality rates, and generalizability given the small number of specialist hospitals studied. It also raises issues about how patient choice is actually exercised and the role of spatial competition between hospitals.
Mayumi Hayashi: Lessons from Japan on social care reformNuffield Trust
In this slideshow, Dr Mayumi Hayashi, Leverhulme Early Career Fellow, Institute of Gerontology, King’s College London, gives an overview of social care reforms in Japan, and outlines the achievements, challenges and lessons for England.
William Shrank: Payment reform activities at CMSNuffield Trust
The document discusses activities at the CMS Innovation Center to test new payment and service delivery models. It outlines several initiatives to improve care coordination, such as ACO models and medical home programs. It also discusses initiatives to improve care quality like Partnership for Patients and reduce costs through bundled payments. Rapid-cycle evaluation is highlighted as important to provide feedback to support continuous quality improvement and identify successful models to scale nationally.
Hugh Gravelle: The impact of care quality on patient choiceNuffield Trust
Patients in England are more likely to choose general practices with higher clinical quality as measured by Quality and Outcomes Framework (QOF) points. A 1 standard deviation increase in QOF points is associated with a 20% increase in demand for a practice. While the effect of quality on an individual's choice is small, the large number of potential patients means quality has a large effect on total demand for a practice. Quality is the main driver of choice, more so than distance, practice characteristics, or patient attributes. This provides incentive for practices to improve quality to attract more patients.
Ian Duncan: Predictive risk in a US pharmacyNuffield Trust
Three predictive modeling examples are described:
1. Targeting non-adherent customers to improve medication adherence.
2. Stratifying end-of-life patients in accountable care organizations to prevent over-medicalized end-of-life care.
3. Identifying Medicare and health insurance exchange patients for wellness visits and risk assessments to improve health outcomes and quality measures.
Paul Burstow: The need for care reform in EnglandNuffield Trust
In this slideshow, Rt Hon Paul Burstow MP, Minister of State for Care Services (2010-2012), explains the need for social care reform in England due to an ageing population and the challenges ahead.
Elaine Kelly public payment and private provisionNuffield Trust
1) Public health spending in the UK rose faster in the 2000s than in previous decades, while growth of private spending slowed after 2007. The share of NHS-funded treatment provided by non-NHS providers also increased during this period.
2) Analysis of hip and knee replacements showed they increased substantially on the NHS between 2003-2012, with non-NHS providers responsible for over half of the rise. Some increase was due to demographics but there was also evidence of substitution from private to NHS funding.
3) Reforms opened up more NHS-funded care to non-NHS providers but the NHS remained the predominant provider, and further growth of non-NHS providers may be limited by NHS demand and
Masahiko Hayashi: Long-term care insurance in JapanNuffield Trust
In this slideshow, Masahiko Hayashi, Deputy Assistant to the Minister for International Affairs, Ministry of Health, Labour and Welfare, Japan, provides an overview of long-term care insurance in Japan and considers its’ future.
Judith Smith: Commissioning for long-term conditionsNuffield Trust
1) The study explored how NHS commissioning can assure high quality care for people with long-term conditions through ethnographic research in three commissioning communities over two years.
2) The research found that commissioning in practice is messier than assumed, involves coordination and facilitation beyond a neat annual cycle, and commissioners play roles in implementation support.
3) The implications are that commissioning long-term conditions requires extensive relational work that may not align with the commissioning cycle and that there are critical enablers like skilled managers and clinicians that support effective commissioning practices.
Primary care in Europe: can we make it fit for the future?Nuffield Trust
Primary care provides essential health services but current models are struggling to adapt to changing needs. New models are emerging in Europe to make primary care more comprehensive, coordinated, accessible and sustainable. These include larger group practices, multidisciplinary teams, and integrated community health centers. Redesigning primary care requires principles like continuity, early access to expertise, and payment systems that support coordination and population health.
John Billings: Developing a new predictive risk modelNuffield Trust
This document discusses the development of a new predictive risk model. It describes predicting future costs and emergency admissions using data from inpatient, A&E, outpatient and GP databases. It shows the tradeoff between predictive accuracy and number of patients flagged as risk scores are varied, with higher cutoffs improving positive predictive value but reducing sensitivity. The model achieved good discrimination with an ROC C statistic of 0.78.
Andrew Street: Market mechanisms in health care Nuffield Trust
Professor Andrew Street discusses competition and market mechanisms in healthcare. He notes that competition does not necessarily mean privatization, and competitive effects depend on other system features. Competition is also not directly observable and its impact varies based on factors like pricing structures, patient choice, and degrees of collaboration between organizations. Overall, Professor Street examines how competition operates in healthcare and that its effects must be considered in context of the overall system design.
Adam Steventon: How can predictive risk models help?Nuffield Trust
This document discusses how predictive risk models can help evaluate interventions in observational studies. It notes challenges with observational studies, such as regression to the mean and lack of control groups. It proposes several solutions to address these challenges, including before-after studies, regression adjustment, matching controls, and regression discontinuity designs. Matched controls are described as a way to reduce dependence on regression model specification by "data pre-processing" to compare intervention patients to similar control patients. The document concludes by surveying the current state of telehealth studies, finding most are descriptive or use before-after designs, with few employing more rigorous controlled designs.
Tom Youldon: Creating a fair playing fieldNuffield Trust
Monitor's first major report as sector regulator examines how to create a fair playing field for competition in healthcare. The report identifies three areas that can distort the level playing field: participation costs, financial costs, and operational restrictions. It provides recommendations to address issues in commissioning, increase stability and support for providers, and ensure transparency and accountability. The goal is to enable a range of NHS providers to offer high quality services to patients on equitable terms.
Matt James: Choice and independent hospitalsNuffield Trust
The document summarizes Private Healthcare Information Network (PHIN), a new not-for-profit organization that collects data from independent hospitals in the UK to publish comparative information for patients, policyholders, and GPs. PHIN launched in April 2013 with a website providing searchable data on 183 independent hospitals. While initial data is limited, PHIN aims to expand the data over time to cover additional hospitals and providers. The document also discusses trends in the independent healthcare sector in the UK and findings that quality in the independent sector holds up well compared to NHS hospitals for procedures like hip replacements.
State of the Musculoskeletal Service Line: What's New in 2013 and Beyond?Wellbe
Long a bastion of growth and profitability, the orthopedic service line has historically served as a reliable source of surgical volumes and attractive per case economics for hospitals and health systems.
However, the rate of profitable volume growth is progressively challenged by several recent trends, including soaring implant costs, wavering reimbursement, and intensifying competition, which includes the migration of care to ambulatory centers.
In addition, in the wake of the Patient Protection and Affordable Care Act (PPACA) of 2010, hospitals will increasingly be held accountable for delivering high-quality, low-cost orthopedic care. In this rapidly changing environment, the orthopedic service line will require careful management to ensure its continued success.
This presentation explores the most important business and structural challenges to musculoskeletal healthcare delivery, covering topics such as the impact of healthcare reform; physician alignment tactics; and strategies for organization, staffing, and structure.
Speaker Biographies:
Ms. Krista L. Fakoory, Manager
Ms. Fakoory has been providing healthcare management consulting services since 2006. Her background includes strategic and service line business planning, hospital/physician alignment, provider compensation planning, and merger and acquisition assistance. She has particular expertise in developing comprehensive orthopedic programs, strategic planning for physician-owned ambulatory surgery centers, and designing alignment models between health systems and independent orthopedic surgeons.
Mr. Todd W. Godfrey, Senior Manager
With nearly 15 years of healthcare experience, Mr. Godfrey has a focused background in musculoskeletal services. He regularly advises clients on performance-based incentives between surgeon and health systems as organizations position their musculoskeletal service line to assume risk and manage populations.
- Slit lamp examination (including fundus)
- Perform biometry and focimetry
- Decide appropriateness for surgery
- Perform auto-refraction
- Discuss desired post-operative refractive status
with the patient (including current type of
spectacle correction) to enable the choice of lens
implant
- Perform ECG and blood tests
- Identify 2nd eye surgery where appropriate
Benefits
- reduces duplication of tasks
- reduces waiting time for patients
- frees up nursing time for other duties
- ensures all key tasks are completed in one visit
- improves patient experience
- reduces overall time in clinic
09
This document provides an executive summary of a national review of adult elective orthopaedic services in England led by Professor Tim Briggs. The review found significant undesirable variation in orthopaedic practice and outcomes across the country. Emerging themes included low surgeon volume, failure to follow evidence on implants, and variation in pathways, management models, and commissioning relationships. The review aims to improve quality and reduce costs by reducing unwarranted variation and encouraging best practice. Over 200 hospitals were visited and individual reports provided. The methodology was effective and could be applied to other specialties.
Elaine kelly public payment and private provisionNuffield Trust
1) Public health spending in the UK rose faster in the 2000s than in previous decades, while growth of private spending slowed after 2007. The share of NHS-funded treatment provided by non-NHS providers also increased during this period.
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Elaine Kelly: Growth in NHS-funded elective care
1. Introduction Background Results Mechanisms Conclusions
More hips, please. Independent sector provision and the
growth in NHS-funded elective care
Elaine Kelly & George Stoye
Nueld Trust Workshop
13th September 2013
1/27
2. Introduction Background Results Mechanisms Conclusions
Introduction
The past decade of health care policy reforms have increased the role of
competition in NHS-funded care.
Existing work has concentrated on the patient choice reforms of 2006
and 2008. [Cooper et al, 2011; Gaynor et al, 2012 a,b]
This paper focuses on a separate but related set of reforms that
increased the access of independent sector providers (ISP) to markets for
NHS-funded elective secondary care.
How did this aect the market for both NHS and privately funded hip
replacements?
2/27
3. Figure : Total number of NHS-funded hip replacements in England, by provider type
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
HipReplacements
Financial Year
ISP NHS Trusts
The total number of NHS-funded hip replacements increased by 40% between
2003/04 and 2010/11.
After 2006/07, most of this growth is accounted for by ISPs.
4. Figure : Mean hip NHS-funded replacements per Middle Super Output Area by
nearest provider type in 2010/11
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11
MeanhipreplacementsperMOSA/year
NHS ISP
Growth was fastest in areas where an ISP was located closer than the nearest NHS
trust by 2010/11.
5. Introduction Background Results Mechanisms Conclusions
Research Questions
How did the introduction of ISPs aect the market for NHS-funded hip
replacements?
1 Why did the number of hip replacements increase faster in areas where
ISPs were located relatively close by?
2 What explains the increase in the number of NHS-funded hip
replacements?
New procedures
Substitution from privately funded procedures
5/27
6. Introduction Background Results Mechanisms Conclusions
Independent Sector Provider reforms
1 Independent Sector Treatment Centres (ISTCs)
First introduced in 2003, expanded in 2006.
Privately owned but typically treat just NHS-funded patients.
Objectives [Naylor Gregory, 2009]:
Wave 1: to address capacity constraints and reduce waiting times
Wave 2: increasing competition for NHS providers, providing more choices
for patients, and fostering innovation.
2 Any Qualied Providers (AQPs)
In mid 2007, choice of providers in orthopaedics expanded to cover
existing facilities, such as private hospitals, through the Extended Choice
Network.
Treat privately funded and NHS-funded patients.
Extended to other specialties when 2nd choice reform was introduced in
2008.
6/27
7. Figure : NHS-funded hip replacements conducted by ISPs, by quarter and ISP type
0500100015002000
NumberISPHipProcedures
2003q2
2004q2
2005q2
2006q2
2007q2
2008q2
2009q2
2010q2
2011q2
Time
ISTC sites AQP sites
ISTC volumes started to increase as ISTCs began to open. Levelled o after 2008.
AQP volumes increased rapidly after the second choice reform was introduced.
8. Figure : Number of ISP sites by year and ISP type
0
20
40
60
80
100
120
Sites 1 pat Sites 20 pats Sites 1 pat Sites 20 pats
ISTC AQP
NumberofISPSites
2003/4
2004/5
2005/6
2006/7
2007/8
2008/9
2009/10
2010/11
More AQP sites, but ISTC procedures more concentrated across sites.
In 2010/11, average NHS-funded hip replacements per site were 65 for AQPs and
160 for ISTCs.
9. Figure : Mean number of hip replacements per MSOA/year, by nearest provider
type in 2010/11
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11
MeanhipreplacementsperMSOA/year
Financial Year
NHS ISTC AQP
Relative growth is much faster in areas where an ISTC is the nearest provider than
where AQPs are the nearest provider.
Shift in entire distribution, not just the mean.
10. Introduction Background Results Mechanisms Conclusions
Why might introducing ISPs aect the number of
NHS-funded procedures?
1 Supply: extra potential capacity relaxes supply constraints.
An initial objective of the ISTC programme [Naylor Gregory, 2009]
2 Demand: ISPs provide an option that potential patients prefer to:
1 No procedure.
2 Privately funded treatment
This paper focuses on establishing whether there was a demand response.
Diculty: all areas/patients can access ISPs through the 2008 choice
reforms.
Solution: exploit variation in intensity of treatment or exposure by
relative distance between the nearest ISP and the nearest NHS trust.
10/27
11. Introduction Background Results Mechanisms Conclusions
Why does the growth rate of hip replacement vary by
distance to ISP?
1 Endogenous placement: ISPs located in areas where higher growth is
anticipated/removing supply constraints
2 A demand response:
Patients prefer treatment closer to home [Beckert et al, 2012; Sivey 2012].
Analysis examines ISP placement and the number of hip replacements at
the Middle Super Output Area (MSOA) level.
Data on NHS-funded hip replacements from the inpatient Hospital
Episode Statistics (HES).
6,710 MSOAs in England (ave pop 7,200). MSOAs are a statistical
construct, no administrative jurisdictions.
Dene MSOA as treated if there is an ISP that performs hip
replacements nearer than the NHS trust.
11/27
12. Introduction Background Results Mechanisms Conclusions
What are the determinants of ISP placement?
The odds of MSOA m having an ISP closer than the nearest NHS trust in
2010/11 is given by the following specication:
ISPclose10m = θo +θ1WaitTimesm +θ2nTrustm +θ3SDm +em (1)
WaitTimesm includes waiting times of nearest trust and residents of the
MSOA, and MSOA admittances for hip replacements in 2003/04.
nTrustm are characteristics of the nearest trust to MSOA m; SDm are
socio-demographic characteristics (all pre 2005)
Results aim to indicate:
The extent to which ISP placement reects population need/supply
constraints
Any sources of random variation in placement that could be used for
identication
12/27
13. Table : Odds of having an ISP closer than the nearest NHS trust in 2010/11
Type of ISP Closer than the Nearest Trust
ISP ISP ISP ISTC only AQP only
(1) (2) (3) (4) (5)
Nearest Trust Wait Time 2003 (SD) 1.352*** 1.195** 1.141 1.284 1.124
(0.102) (0.0900) (0.117) (0.272) (0.128)
MSOA Wait Time 2003 (SD) 0.983 0.963 0.943 0.927 0.955
(0.0356) (0.0355) (0.0451) (0.0742) (0.0493)
Average hip replacements in 2003 and 2004 0.972* 0.927*** 0.939** 1.013 0.938**
(0.0159) (0.0176) (0.0242) (0.0370) (0.0257)
Distance to Nearest Trust (km) 1.120*** 1.078*** 1.054 1.064**
(0.0270) (0.0294) (0.0408) (0.0300)
Distance to Nearest Trust Squared (km) 0.997*** 0.998** 0.999 0.999
(0.000760) (0.000768) (0.000941) (0.000789)
IMD score (2004) 0.967*** 0.976 1.063*** 0.941***
(0.0117) (0.0179) (0.0185) (0.0198)
Private hospital closer 29.25*** 3.573*** 33.56***
(7.843) (1.292) (9.935)
NHS `hospital' (30 beds) closer 2.028*** 2.146*** 1.915***
(0.384) (0.624) (0.386)
Nearest trust Socio-demographics No Yes Yes Yes Yes
Observations 6,710 6,710 6,710 6,710 6,710
Pseudo R-squared 0.0127 0.0731 0.404 0.119 0.413
Notes: *** denotes signicance at 1%, ** at 5%, and * at 10% level. Observations are at the MSOA level.
Presence of existing hospital facilities is strongest determinant of ISP location
Adding PCT FE strengthens relationship with private hospital location. (OR increases
to 9.6 in col 4 and 138.7 in col 5)
14. Introduction Background Results Mechanisms Conclusions
Estimating a demand response
Within PCTs, relative distance to an ISP should not aect hip
replacement numbers through supply.
Placement related to nearest trust waiting times but not MSOA waiting
times (not related to local pre-existing need).
Administrative constraints should operate at PCT level, not MSOA level.
However, relative distance to an ISP should aect patient demand.
14/27
15. Table : Treatment and Control Group Denitions
Financial % MSOA % of MSOA hip rep % ISP pats
Year ISP close conducted by ISPs live close
ISP closer ISP Further
2003/4 2.7 1.1 0.1 35.0
2004/5 7.3 2.4 0.9 16.2
2005/6 8.6 3.9 1.9 17.9
2006/7 3.6 13.8 3.2 17.4
2007/8 12.8 13.8 5.6 29.2
2008/9 19.4 18.1 8.5 36.5
2009/10 22.3 17.7 10 36.8
2010/11 28.2 24.4 14.1 45.2
The proportion of areas treated by an ISP increases as more ISPs open
Patients are more likely to receive care from an ISP if they live in treated areas.
But, most ISP patients do not live in treated areas.
16. Introduction Background Results Mechanisms Conclusions
Fixed Eects Specication
Number of residents in MSOA m that receive a NHS-funded hip
replacement (conducted by an NHS trust or an ISP) in year t:
Hipsmt = α +βISPmt +γm + µt +Xmt +εmt (2)
The coecient of interest is β, the eect of introducing an ISP close to
MSOA m on number of residents admitted for NHS-funded hip
replacements.
Xmt includes time varying MSOA measures of population age
composition, admissions for fractured neck of femur, and the
unemployment rate. εmt clustered at the PCT level.
Identifying assumption: conditional on Xmt, ISPmt uncorrelated with εmt.
16/27
17. Table : Fixed eects estimates of the impact of ISP introduction on number of
admittances for elective hip replacements per MSOA
Type of ISP Closer: ISP ISTC AQP ISTC20 AQP20
(1) (2) (3) (4) (5)
ISP closer than nearest NHS Trust 0.222** 0.447 0.174* 1.189*** 0.825***
(0.0983) (0.326) (0.0976) (0.392) (0.168)
Pop 65-79 (thousands) 9.838*** 9.860*** 9.866*** 9.423*** 9.579***
(0.867) (0.863) (0.867) (0.860) (0.864)
Pop 80+ (thousands) 9.806*** 9.815*** 9.818*** 9.695*** 9.721***
(1.253) (1.255) (1.256) (1.256) (1.264)
FNOF admits 0.0581*** 0.0579*** 0.0581*** 0.0582*** 0.0586***
(0.0161) (0.0161) (0.0161) (0.0162) (0.0162)
FNOF admits squared -0.00377*** -0.00375*** -0.00376*** -0.00378*** -0.00377***
(0.00123) (0.00124) (0.00123) (0.00123) (0.00123)
Unemployment Rate -8.207 -8.176 -8.214 -9.216 -9.151
(6.126) (6.115) (6.134) (6.037) (6.082)
Year Fixed Eects Yes Yes Yes Yes Yes
MSOA Fixed Eects Yes Yes Yes Yes Yes
Demographics Yes Yes Yes Yes Yes
Observations 46,970 46,970 46,970 46,970 46,970
R-squared 0.121 0.121 0.121 0.123 0.124
Notes: *** denotes signicance at 1%, ** at 5%, and * at 10% level. Observations are at the MSOA year level. The dependent
variable in all columns is the number of admissions for an NHS-funded elective hip replacement amoungst MSOA residents.
18. Introduction Background Results Mechanisms Conclusions
Summary
The introduction of ISPs is associated with an increase in demand for
hip replacements.
For large ISPs introduced nearer than the nearest trust, ISTCs add 1.2
and AQPs 0.8 to annual hip replacements per MSOA.
Relative to a baseline level of hip replacements in 2003/04 of 7.
Equivalent to adding an additional 100 people aged 65+ to the MSOA
population.
Propensity score matching estimates provide a similar set of results.
Potential to use location of existing health care facilities as an IV.
18/27
19. Introduction Background Results Mechanisms Conclusions
Where is the additional demand for NHS treatment coming
from?
The increase in demand for hip replacements may operate through:
A rise in the number of people having hip replacements
Substitution from privately funded to NHS-funded hip replacements
Combine HES with hospital level data from the National Joint Registry
(NJR), to estimate relationships between NHS, ISP and private pay
volumes.
Caution: much more work needed on separating demand from supply.
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20. Introduction Background Results Mechanisms Conclusions
Data Construction I
HES contains:
Number of patients treated in NHS hospitals
Number of NHS-funded patients treated in AQPs and ISTCs.
NJR contains:
Number of patient treated in NHS hospitals
Total number of patients treated in private hospitals, including those
operating as AQPs and ISTCs.
Private patients = Hip replacements in private hospitals (NJR) − hip
replacements conducted at ISTCs (NJR)− NHS-funded hip replacements
conducted by AQPs (HES)
Note: measurement error in the number of private procedures.
will be improved with access to patient level data (agreed in principle).
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21. Introduction Background Results Mechanisms Conclusions
Data Construction II
The NJR has no information on where patients live, therefore assign
patients to areas on the basis of hospital location.
Collapse number of procedures by provider type and NHS/private pay by
Primary Care Trust and nancial year.
Use data from 2007/08 to 2010/11, due to concerns about quality of
data in earlier years.
Drop negative private pay volumes.
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22. Introduction Background Results Mechanisms Conclusions
NJR-HES Sample
Table : PCTs that contain Independent Sector Providers and estimated privately
funded hip procedures 2007/08 to 2010/11
PCTs with ISPs No of hip reps on private sites
ISTCs AQPs All NHS-funded Est pr pay
NJR HES NJR HES
2007/8 14 31 18,387 4,222 14,165
2008/9 19 48 22,198 6,794 15,404
2009/10 20 60 21,511 7,830 13,681
2010/11 22 77 22,975 11,665 11,310
Private hospitals treated more patients in 2010/11 than 2007/08.
Increased numbers of NHS-funded patients compensated for falls in private pay
patients.
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23. Introduction Background Results Mechanisms Conclusions
Estimation
Private pay hip replacements and ISTCs
We assume that the supply of ISTC hips is determined by the ISTC
contract and therefore does not respond to private pay volumes.
Private pay hip operations in PCT p and nancial year t is given by:
PPHipspt = α +ρISTCpatspt +γp + µt +Zpt +εpt (3)
Private pay hip replacements and AQPs
We assume that private hospitals strictly prefer to treat private patients
over NHS-funded patients because they receive more for their care.
AQPpatspt = α +σPPHipspt +γp + µt +Zpt +εpt (4)
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24. Table : Fixed eects estimates of the impact of ISP introduction on number of
admittances for elective hip replacements per PCT of treatment
Priv Funded Ops AQP NHS Ops NHS Trust Ops
(1) (2) (3) (4) (5) (6)
HES ISTC hips -0.155 -0.149 -0.147** -0.144**
(0.0995) (0.0958) (0.0628) (0.0618)
Est private pay hips -0.664*** -0.338***
(0.141) (0.0842)
HES AQP hips -0.0749 -0.207*
(0.0653) (0.109)
Sample All Balanced All Balanced All Balanced
PCT Year FE Yes Yes Yes Yes Yes Yes
Age Composition Yes Yes Yes Yes Yes Yes
Observations 515 484 515 484 532 520
R-squared 0.112 0.165 0.664 0.484 0.043 0.052
Number of PCTs 135 121 135 121 136 130
Notes: *** denotes signicance at 1%, ** at 5%, and * at 10% level. Observations are at the PCT year level.
Strong evidence of substitution between private pay and AQP procedures, but not
between private pay and ISTC procedures.
Small negative eects of ISTC and AQP procedures on NHS trust procedure numbers
25. Introduction Background Results Mechanisms Conclusions
Summary
Number of NHS-funded hip replacements increased by 40% between
2003/04 and 2010/11, with ISPs accounting for almost two-thirds of the
rise.
Hip replacements increased faster in areas that were closer to an ISP
than the nearest NHS trust.
Fixed eects and matching estimates suggest that this was consistent
with a demand response.
Data on private pay patients from the NJR indicates strong evidence of
substitution between private pay and NHS-funded AQP procedures.
Consistent with private hospitals treating NHS patients to help
compensate for a decline in demand from private patients.
Increases in ISTC and AQP procedures tend to reduce procedures
conducted by NHS trusts.
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26. Introduction Background Results Mechanisms Conclusions
Implications
1 For patients
ISPs contributed two-thirds of the total increase in hip replacements,
contributing a substantive increase in supply.
Patients beneted more in areas located nearer to an ISP than the
nearest trust.
2 For ISPs
ISTC sites provided an unambiguous increase in revenue, as there is not
much evidence of substitution
For AQPs, NHS-funded patients have compensated for falls in demand
from private patients.
In the long run could ISPs crowd out private pay patients?
3 For NHS trusts.
There is some evidence that ISP operations led to a fall in NHS trust
operations.
Unclear what this means for NHS trust nances, given likely substitution
to other activity.
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27. Introduction Background Results Mechanisms Conclusions
Future Work
Add data from 2011/12 and 2012/13.
Patient level data from the National Joint Registry (removing the need
to estimate private pay patients).
Use the presence of existing health care facilities as an instrument for
ISP location.
More theoretical and empirical work separating the supply of health care
from demand for health care.
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