Apr 17, 2017
Washington Healthcare Update
This Week: Congress is in recess…While there have been discussions about health care reform, the focus is turning to funding the government after April 28…CMS finalized the marketplace rule.
4. State Activities
5. Regulations Open for Comment
Reps. Rodgers, Tsongas Garner Bipartisan Support for Teaching Health Center GME Program
Reps. Cathy McMorris Rodgers (R-WA) and Niki Tsongas (D-MA) are garnering
support for reauthorizing at least three years of funding for the
Teaching Health Center Graduate Medical Education (GME) program—a program
that helps teaching health centers train providers. More than 90 lawmakers
have signed onto a dear-colleague letter to House Energy & Commerce
Osteopathic physicians say the program, while small compared to Medicare
GME grants, could be a model for reforming Medicare GME because the program
is transparent and has succeeded in training and retaining physicians in
medically underserved areas.
The program, which is run by the Health Resources and Services
Administration, expires after Sept. 30. It is on a long list of programs
that expire this year, and the American Osteopathic Association hopes to
bring attention to the program to increase the chances that it will be
included in expected legislation reauthorizing many of the expiring
programs at the end of the year.
HRSA’s teaching health center GME program is designed to train primary care
providers in areas of the country that need it most. The Medicare GME
program includes direct and indirect payments to hospitals, and lawmakers
have criticized indirect Medicare GME because hospitals do not have to use
the money for training doctors.
John Sealey, an osteopathic surgeon and director of medical education at
Authority Health in Detroit, said the Teaching Health Center GME program
requires health centers to account for every dollar they spend. The program
works well because it lets health centers use the money to tailor the
training of residents to the areas they serve. The health center programs
must meet the same criteria as traditional Medicare GME, Sealey said, but
the funding can also be used for additional training, such as the
population health certificate that Authority Health created. To be
certified in population health, physicians must visit homeless shelters and
food banks to help them deal with the root causes of health problems for
patients in their area, such as hunger and poor diets.
Lawmakers Ask for Mental Health Program Funding
The co-authors of the bipartisan legislation Helping Families in Mental
Health Crisis Act are asking appropriators to fund the programs authorized
by the new law. Reps. Tim Murphy (R-PA) and Eddie Bernice Johnson (D-TX)
sent a letter to House Appropriations Chairman Tom Cole and ranking member
Rosa DeLauro asking that the committee consider funding the programs the
mental health reform legislation included in the 21st Century Cures Act.
“Treatment delayed is treatment denied—waiting to fund this law will
contribute to more crime, violence, homelessness, and the daily loss of 959
Americans as a result of a mental illness,” the letter states.
To see the letter, click
Senate Bill Aims to Increase Number of Doctors in Rural Areas
A bipartisan group of senators unveiled a bill to increase the number of
doctors in rural and other medically underserved areas. The legislation,
which has been endorsed by major health organizations, would allow
international doctors trained in the United States to remain in the country
if they practice in underserved areas.
The bill—sponsored by Sens. Amy Klobuchar (D-MN), Susan Collins (R-ME) and
Heidi Heitkamp (D-ND)—extends the “Conrad 30” program that allows 30
doctors per state to remain in the country without having to return home if
they agree to practice in an underserved area for three years. The measure
allows for the program to be expanded beyond 30 slots if certain thresholds
are met. The bill also allows the spouses of doctors to work and provides
worker protections to prevent the doctors from being mistreated. The
legislation has been endorsed by the American Medical Association,
the American Hospital Association and the Association of American Medical
For more information,
MedPAC Finalizes Draft Recommendations to Curb Part B Drug Prices
On April 6, congressional Medicare advisers finalized recommendations for
Congress aimed at reducing growth in Part B drug spending.
The vote was unanimous in favor of the recommendations, but a few Medicare
Payment Advisory Commission (MedPAC) members said they dislike some of the
policies, and the option to allow a third-party arbiter to determine prices
for drugs that do not have competition caused the most debate.
The commission recommended modifying the reimbursement for Part B drugs
that are paid for based on wholesale acquisition cost (WAC)—a
manufacturer’s undiscounted price to wholesalers or direct purchasers.
Under the proposals, the payment rate for WAC-priced drugs would be reduced
to WAC plus 3 percent, down from the current rate of WAC plus 6 percent.
MedPAC recommended requiring all Part B drug manufacturers to submit annual
average sales price data. Currently, only Medicare Part B drug
manufacturers with Medicaid drug rebate agreements are required to submit
annual average sales price data.
For drugs that are paid for based on average sales price, physicians and
hospital outpatient departments are typically paid the ASP of a drug, plus
a 6 percent add-on. The proposals would require manufacturers to pay
Medicare a rebate with the ASP for their product if it exceeds an inflation
benchmark such as the consumer price index.
The commission also recommended creating a voluntary Drug Value Program
that would be phased in by 2022. Under the program, private vendors would
negotiate lower Part B drug prices.
The Pharmaceutical Research and Manufacturers of America and the Community
Oncology Alliance oppose the recommendations, which they say threaten
patient access to therapies.
Trump Administration Finalizes Obamacare Stabilization Rule
On April 13, HHS released a final rule it says will help stabilize
Obamacare’s insurance markets as the administration plans a broader repeal
strategy. The rule implements a series of policies tightening enrollment
The final rule makes several policy changes to improve the market and
promote stability, including:
2018 Annual Open Enrollment Period:
The final rule adjusts the
annual open enrollment period for 2018 to more closely align with
Medicare and the private market. The next open enrollment period will
start on Nov. 1, 2017, and run through Dec. 15, 2017, encouraging
individuals to enroll in coverage prior to the beginning of the year.
Reduce Fraud, Waste and Abuse:
The final rule promotes program integrity by requiring individuals to
submit supporting documentation for special enrollment periods and
ensures that only those who are eligible are able to enroll. It will
encourage individuals to stay enrolled in coverage all year, reducing
gaps in coverage, resulting in fewer individual mandate penalties and
helping to lower premiums.
Promote Continuous Coverage:
The final rule promotes personal responsibility by allowing issuers to
require individuals to pay back past due premiums before enrolling into
a plan with the same issuer the following year. This is intended to
address gaming and encourage individuals to maintain continuous
coverage throughout the year, which will have a positive impact on the
Ensure More Choices for Consumers: For the 2018 plan year and
beyond, the final rule
allows issuers additional actuarial value flexibility to develop more
choices with lower premium options for consumers, and to continue
offering existing plans.
Empower States & Reduce Duplication:
The final rule reduces waste of taxpayer dollars by eliminating
duplicative review of network adequacy by the federal government. The
rule returns oversight of network adequacy to states that are best
positioned to evaluate network adequacy.
To see the rule,
CMS Announces Oncology Care Model Stakeholder Feedback Opportunity
Oncology Care Model (OCM) team
will be hosting the OCM Stakeholder Public Forum on Thursday, May 11, 2017, from 1-4 p.m. EDT. CMS invites all
interested OCM stakeholders to attend the public forum, with the goal of
hearing feedback about OCM.
The forum will include a brief introduction from the OCM team followed by
discussion. An agenda will be sent to registrants two weeks prior to the
forum and will include gathered topics that may be submitted via the text
field in the registration link below. Attendees may attend virtually or
in-person at the Centers for Medicare & Medicaid Services Central
Office located at 7500 Security Boulevard, Baltimore, Maryland 21244.
Space is limited, so if planning to attend in person, registration is
suggested as soon as possible. Each organization is requested to limit its
in-person attendance to two individuals. In-person attendees are on a
first-come, first-serve basis. Registration will close one week in advance
of the forum. Persons who are not registered will not be permitted to enter
the CMS Central Office and thus will be unable to attend the forum.
Registration is available via this link
until 5 p.m. EDT, May 4, 2017.
For questions or additional event information, email
CMS Releases 2015 Data on Geographic Variation in the Medicare Program
On April 11, CMS posted the annual release of the Geographic Variation
Public Use File with data for 2015. The Geographic Variation Public Use
File is a series of downloadable tables and reports that contain
demographic, spending, utilization and quality indicators for the Medicare
fee-for-service population. It presents data at the state (including the
District of Columbia, Puerto Rico and the Virgin Islands), hospital
referral region (HRR) and county levels.
This public use file can be
VHA Introduces Scheduling Transparency Website
On April 12, the Veterans Health Administration (VHA) released a website that shows
how long patients are waiting for appointments at VA hospitals and clinics
and provides quality information comparing VA centers with private-sector
The website, developed in-house, is the only one of its kind in the
country. While it does not allow patients to schedule appointments
themselves, it eventually will be linked directly to a new VA scheduling
system, said Poonam Alaigh, the department’s acting undersecretary for
The system lists average wait times for different specialties and is adding
comparative data on hospitals in cities and towns, as well as Yelp-style
reviews by veterans.
In a demo in Washington, VA officials showed that patients had average
waits of 11 to 56 days at eight VA primary care clinics in Phoenix. Noting
that 56 days was a long wait, Alaigh said transparency could inspire
competition and improvement in the system.
The site was to be officially released May 1. It showed that veterans
currently have about 3,000 pending urgent referrals to specialists. When
the VA started attacking that problem in November 2015 by simplifying the
department’s byzantine scheduling system, there were more than 57,000 in
that category, Alaigh said.
White House Calls for Agencies to Shrink Their Workforces
On April 12, the White House directed federal agencies to make deep
personnel cuts over the next year. Agency heads are to receive a 14-page
memorandum outlining changes. The memo, which replaces the federal hiring
freeze Trump enacted in January, outlines cuts based on Trump’s skinny
budget, released last month. The budget proposal called for deep cuts to
domestic programs and an increase in military spending.
The memo tells agencies to submit a plan by June 30 that will save money
and reduce their staffs. They must also come up with an agency reform plan
to shrink personnel to accommodate long-term budget reductions.
Office of Management and Budget Director Mick Mulvaney said some agencies
such as the Defense Department and Veterans Affairs will add staff.
The memo says that agencies should eliminate programs that are duplicative,
nonessential to the agency’s mission or are already carried out in some
form by state and local government.
Mulvaney insisted the process could be bipartisan and include public input.
Adapt Pharma Expands Free Nasal Spray Program to Colleges and
On April 10, Adapt Pharma
it is donating 20,000 cartons of the anti-opioid-overdose nasal spray
Narcan to colleges and universities.
The new effort was announced by the company and former President Bill
Clinton in Little Rock, Arkansas, at the Clinton Health Matters Activation
Summit. It builds on an effort by the initiative and the company, focused
on K-12 schools, which has already led to the donation of 3,300 doses of
the spray to high schools in 33 states.
The Centers for Disease Control and Prevention has said that heroin
use in the last decade has more than doubled among young adults aged 18 to
25—a rise that has coincided with an increase in heroin deaths.
The spray can be used for the emergency treatment of known or suspected
opioid overdoses. Each carton contains two doses.
Colleges and universities can sign up to participate here.
4. State Activities
California: New Figures Show Higher Vaccination Rates in Children
California public health officials recently reported the highest
kindergarten vaccination rates in more than 15 years.
show nearly 96 percent of kindergartners in the 2016-17 school year were
vaccinated, a three-point jump from the previous school year.
A law passed last year nixed the state’s “personal-belief” provision that
allowed parents to refuse vaccinating their kids for virtually any reason,
and all children without medical exemptions must now be vaccinated before
starting school. Vaccination rates had dropped in recent years as more
parents opted out, but a measles outbreak at Disneyland in early 2015 drew
national attention to the issue.
Florida: Trump Administration Gives Florida Nearly $1 Billion in Supplemental Medicaid Payments
The Trump administration has increased by nearly $1 billion the amount of
supplemental Medicaid payments Florida is set to receive in the upcoming
Florida Gov. Rick Scott praised the administration, saying in a statement
that “it is great to have a partner in Washington who is willing to work
with us to help our state.”
The former Obama administration had pared back the amount of money Florida
received for its Low Income Pool (LIP) from a high of $2 billion to $608
million in 2015, and set an expiration date of June 30 after the state
refused to expand Medicaid. The administration maintained that supplemental
Medicaid spending programs were not a good use of tax dollars and that
providing people access to health care coverage was a better use of the
Scott sued the Obama administration in federal court to force it to
continue Florida’s supplemental Medicaid funding but eventually dropped it.
The governor has been working closely with the Trump administration to
continue LIP funding. The approval comes as the Florida Legislature works
on its budget for the upcoming fiscal year, which begins July 1.
Kentucky: Consultants Prepare Draft Documents for Kentucky Medicaid Expansion
Consultants that helped create Kentucky’s new Medicaid expansion model are
developing key operational details for the program. New
draft documents were prepared by Deloitte Consulting for
SVC—the Indiana-based consulting firm founded by now-CMS Administrator Seema Verma.
Kentucky initially opted for the traditional expansion under Democratic
Gov. Steve Beshear that covered more than 400,000 people. Gov. Matt Bevin
has asked federal officials for several changes that could curtail
enrollment. Among other things, Bevin’s plan would institute premiums for
the entire expansion population—ranging from $1 to $15 per month, depending
on income—a work requirement, penalties for using the ER inappropriately,
HSA-style accounts, and a waiver of non-emergency medical transportation
Massachusetts: Massachusetts Seeking Waiver to ACA’s Employer Mandate
Massachusetts is seeking a waiver to the ACA’s employer mandate, and to
allow a state-based reinsurance and risk adjustment program to stabilize
the health insurance market. The state wants HHS Secretary Tom Price and
CMS Administrator Seema Verma to relax reporting and tax requirements
immediately to allow more state flexibility to build on its coverage
successes. The state is asking Verma to allow states to implement their own
employer-sponsored coverage alternative, including swapping out the federal
employer mandate for a state-based approach. The state also wants more
control over its merged nongroup and small group markets and the
state-specific way of rating factors. Massachusetts wants more control over
risk adjustment, reinsurance, health insurance coverage standards and
operation of the state’s marketplace, as well.
Massachusetts would also like to waive small business taxes and allow
states to allocate them based on their own criteria.
Oklahoma: Oklahoma Weighs Heavy Cuts to Provider Pay, Medicaid Benefits
Oklahoma’s Medicaid agency is considering cutting provider reimbursement
rates by 25 percent and eliminating several optional benefits amid ongoing
budget issues, officials said April 11.
This is the second straight year that Oklahoma is considering a 25 percent
cut to provider rates. Oklahoma ultimately avoided painful cuts to provider
rates and benefits last year, but a dire outlook for fiscal year 2018 is
forcing the state to reconsider.
Oklahoma will consider eliminating or reducing benefits related to
pharmacy, behavioral health treatment, dialysis, adult organ transplants,
hospice services and private duty nursing services, among others.
Cutting provider reimbursement rates by 25 percent would put physician
payment levels at 65 percent of Medicare rates, officials said. The
reductions would affect all provider types, including hospitals, nursing
facilities and pharmacy.
Pennsylvania: CMS Announces $10 Million for Pennsylvania’s Medicare
Rural Health Model
On April 11, CMS announced that $10 million in startup funds is now
available for the Pennsylvania Department of Health to set up its new
alternative payment model for Medicare in rural hospitals. The model will
be tested over seven years, four of which will be partially funded by CMS.
HHS Secretary Tom Price is authorizing the initial $10 million for the
Pennsylvania Rural Health Model through CMS’s innovation center; after 12
months, Pennsylvania can apply for an additional $15 million to continue
The model was launched Jan. 12 and testing will run through the end of
2023. The demonstration aims to forge a large-scale payer and rural
hospital network, according to the CMS model summary.
The new model would move away from Medicare fee-for-service and set a
prospective budget for all Medicare payers for each participating rural
hospital. The budget is based on the total net revenues historically paid
to these hospitals for inpatient and outpatient care. Under the model,
payers will each pay their part of the global budget to the hospitals. The
overall budget for each hospital must be approved by CMS.
The idea is to let hospitals better predict their costs so they can start
investing in better care. The rural hospitals that join the effort will
have to bring their stakeholders and communities into long-term planning
for higher quality care and preventive care. The state will help the
hospitals adapt their systems for the new payment model.
Six rural hospitals will take part in 2018, at least 18 in 2019 and at
least 30 in subsequent years. Pennsylvania agreed to have each rural
hospital’s global budget represent 75 percent of that hospital’s net
revenue by 2018 and at least 90 percent of their net revenue for the rest
of the testing period.
Pennsylvania will also try to bring Medicaid payers into the model,
according to CMS. The state is aiming to save $25 million in Medicare
hospital costs throughout the seven-year period, and the per-person
Medicare yearly inflation rate must be budget neutral.
Texas: House Committee Considers Bill to Provide Information on
The Texas House public health committee recently heard testimony on a bill that
would require schools to provide more detailed information about
vaccination levels amid growing rates of unvaccinated children. Bill
supporters say that the data about school vaccination rates would provide
transparency to parents worried about the spread of chidlhood diseases. But
parents who do not vaccinate their children said the bill would foster
bullying and discrimination against their children. Since 2003, when the
state made it easier for people to opt out of vaccines, the number of
unvaccinated children in Texas has climbed to nearly 45,000.
5. Regulations Open for Comment
FDA Considers Establishing New Office of Patient Affairs
The FDA is considering establishing a new Office of Patient Affairs that
would centralize its work on patient involvement in the review and approval
of drugs and medical devices, according to a
March 14 notice
in the Federal Register.
Comments on the new office are due by June 12, 2017.
FDA Proposes 1,000 Medical Devices to Exempt From Premarket
On March 14, FDA took one of its first actions to begin implementing the
21st Century Cures Act, by
more than 1,000 medical devices it will exempt or partially exempt from the
premarket review process. The devices on the list are sufficiently well
understood and do not present risks that require premarket notification to
provide a reasonable assurance of safety and effectiveness, FDA said. The
agency will finalize the list after a 60-day public comment period.
Comments are due by May 15, 2017.
FDA Extends Comment Period on Biosimilar Interchangeability Guidance
FDA is extending the public comment period for its
outlining how biosimilar sponsors can demonstrate that their products are
interchangeable with other biologics, following extension requests from top
The agency laid out in a January 2017 draft guidance its first attempt at
codifying the requirements that sponsors must satisfy to demonstrate
interchangeability. The agency said it would make case-by-case
determinations of interchangeability, but indicated it would require
studies measuring the impact of switching on clinical pharmacokinetics and
The Biotechnology Innovation Organization (BIO), Pharmaceutical Research
and Manufacturers of America and Covington & Burling all requested
comment period extensions, according to documents posted on
The comment period, which was set to close on March 20, will be extended 60
days until May 19.
CMS Releases Proposed Hospital Pay Rule
In a new proposed
2018 Medicare payment rule, CMS
says it will look to cut hospital industry regulations and streamline
oversight, and it’s asking hospitals themselves for help. The agency is
soliciting ideas for changes to rules and procedures governing acute-care
and long-term care hospitals. The initiative aims to “relieve regulatory
burdens for providers,” as well as promote flexibility and innovation, CMS
said in a statement.
The new proposed rule would suspend for one year a provision penalizing
long-term care hospitals that receive more than 25 percent of patients from
a single acute-care hospital. It would also reduce certain quality
reporting requirements for hospitals that have implemented electronic
CMS projects the rule would increase Medicare spending on inpatient
hospital services by $3.1 billion in 2018, with operating payments to
hospitals increasing 2.9 percent. Long-term care hospitals’ Medicare
payments are projected to decrease by $173 million, or 3.75 percent, over
the same period.
Comments on the rule must be submitted no later than 5 p.m. EDT on June 13,
MACPAC Weighs in on Capitated Rates and Medicaid
Analysts from the Medicaid and CHIP Payment and Access Commission (MACPAC)
say that lawmakers who want to convert federal Medicaid funding into
per-person payments can look at how states negotiate capitated rates with
managed care plans and the budget neutrality of waivers with CMS to forge a
system that would work well for states and the federal government.
Twenty-six states currently run their Medicaid programs through some kind
of capitated system. However, the system works differently in each state,
and it also works on different levels: There is the federal level, where
CMS negotiates budget-neutral 1115 waivers with states to allow them to run
their programs through capitated managed care systems. Then there is the
private insurer level, where managed care plans negotiate contracts with
The federal government, states and managed care plans enter into these
contracts so they can benefit from them, MACPAC says, and lawmakers need to
keep in mind that the contracts are voluntary—which makes them
fundamentally different than how mandatory contracts under a capped system
would look. States enter into both 1115 waiver agreements and managed care
contracts because they want to. Therefore, they have negotiating leverage
with both CMS and insurers. Such leverage would not exist if states are
forced into per-capita caps.
The MACPAC report makes the case that in order for a national per-capita
cap system to work, federal lawmakers need to establish: fair and
transparent guidelines for negotiations between the states and federal
government; regular review of rates and rate-setting measures to make sure
they are adequate; and detailed agreements that clearly define the
responsibilities of both CMS and the states.
These approaches, the analysts write, may help Congress as they try to make
a single, cohesive policy for states that have developed their own distinct
Medicaid programs that so far haven’t needed to mix with or consider other
states’ policies or programs.
The report incorporates questions raised by MACPAC members at the
commission’s March meeting on potential unintended consequences of
per-capita caps on state policy. A few advisers on the panel warned that
per-capita caps may stick states into a rigid system that wouldn’t allow
for the current practice of fluid, as-needed rate adjustments or
negotiations between CMS, states and the managed care plans that administer
Medicaid in most states.
Throughout the AHCA debate, beneficiary advocates have argued that a
per-capita allotment would destroy the federalist structure of Medicaid.
For more information,
MACPAC Report Finds 5 States to Run Out of CHIP Funds at Beginning of Fiscal Year 2018
Four states and the District of Columbia will run out of their federal
funds for the Children’s Health Insurance Program (CHIP) at the
start of fiscal 2018 if Congress does not reauthorize the money, the
Medicaid and CHIP Payment and Access Commission reports. By the second
quarter, 29 more states would exhaust their program funding, the report
Under current law, if states have not spent all the federal CHIP funds they
are entitled to, that money can be redistributed to other states that have
fallen short. Therefore, states with fiscal 2017 funding still available
will see their payments reduced by one-third, MACPAC reports.
Arizona, California, D.C., Minnesota and North Carolina will overspend on
the program this fiscal year, but will receive payments from other
underspending states to cover their shortfall until fiscal 2018.
Once the new fiscal year starts on Oct. 1, leftover funds from this fiscal
year—estimated to be about $4.2 billion—can be passed around to states that
come up short.
States that run their CHIP separate from Medicaid can stop coverage for
children—calculated as 3.7 million in fiscal 2015—under the program, if
federal funding runs out. These children would be eligible for subsidized
plans on the ACA state exchanges or for employer-sponsored insurance,
according to the MACPAC report. About 1.1 million children would lose
coverage and if a state shuts down their program they wouldn’t have to pay
many of the costs for children insured on the exchanges or on their
parents’ employer-sponsored plans.
States that run a CHIP-Medicaid expansion program will receive their
traditional Medicaid federal funding rate instead of the enhanced rate
mandated for CHIP, the report states. Although by law states wouldn’t be
allowed to roll back eligibility levels through fiscal 2019 at the
earliest, MACPAC warns that states might ultimately block access to care as
they try to save money through cutting payment rates for providers or
adding new prior authorization requirements.
To see the report,
New Report Shows FDA Approving More Drugs Than its European Counterpart
published in the New England Journal of Medicine, FDA has recently
approved more new therapeutic agents than its counterpart—the European
Medicines Agency (EMA). FDA clocked 170 approvals between 2011 and 2015,
compared to EMA’s 144, according to the analysis.
Although FDA reviewed applications faster, the report shows the agency
approved about the same percentage of drugs as EMA in each therapeutic
area, so FDA was not less critical than EMA.
FDA appeared to outperform EMA in approvals for all therapeutic areas
studied. The U.S. agency approved more drugs than EMA to treat cancer and
hematologic disease, cardiovascular disease, diabetes mellitus and
hyperlipidemia, and infectious diseases.
FDA also approved drugs faster than EMA. It took FDA an average of 306 days
to review drugs, whereas it took the EMA an average of 383 days.
The new analysis also highlights the popularity of FDA’s orphan drug
program. FDA granted more drugs orphan status than EMA and approved orphan
applications at a higher rate than EMA.
GAO: CMS Oversight of Efforts to Reduce Improper Billing Needs
According to a new GAO report, CMS has oversight issues that have led to
billions of dollars in improper payments in the Medicare fee-for-service
program. In 2016, the program made $41.1 billion in improper payments.
To help ensure that payments are made properly, CMS contracts with Medicare
Administrative Contractors (MACs) to educate health care providers. GAO
reviewed the contractors and found issues with CMS’s requirements and
oversight of them. For example, MACs are not required to educate some
providers about proper billing for certain services with high improper
GAO recommended that CMS require MACs to educate these providers and
establish metrics to determine if certain MAC reviews help reduce billing
To see the full report,
If you have any questions, contact the following individuals at
Kennan, Senior Vice President
Charlie Iovino, Vice
Caroline Perrin, Research Assistant
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