nep-hea New Economics Papers
on Health Economics
Issue of 2023‒04‒17
twenty-one papers chosen by
Nicolas R. Ziebarth
Cornell University

  1. Dying or Lying? For-Profit Hospices and End of Life Care By Jonathan Gruber; David H. Howard; Jetson Leder-Luis; Theodore L. Caputi
  2. Longevity, Health and Housing Risks Management in Retirement By Pierre-Carl Michaud; Pascal St. Amour
  3. Emergency Care Centers, Hospital Performance and Population Health By Bhalotra, Sonia; Nunes, Letícia; Rocha, Rudi
  4. The Right to Health and the Health Effects of Denials By Bhalotra, Sonia; Fernández, Manuel
  5. How does Monitoring and Evaluation Affect Racial Health Inequality? Evidence from PMAQ Program in Brazil By Chen, Taoshan
  6. Job Competition in Civil Servant Public Examinations and Sick Leave Behavior By Grace Armijos Bravo; Judit Vall Castelló
  7. Combining Risk Adjustment with Risk Sharing in Health Plan Payment Systems: Private Health Insurance in Australia By Josefa Henriquez; Richard C. van Kleef; Andrew Matthews; Thomas McGuire; Francesco Paolucci
  8. The Long-Term Impact of Paid Parental Leave on Maternal Health and Subjective Well-Being By Katharina Heisig
  9. Prenatal sugar consumption and late-life human capital and health: analyses based on postwar rationing and polygenic indices By van den Berg, Gerard J.; von Hinke, Stephanie; H. Wang, R. Adele
  10. The long-run effects of war on health: Evidence from World War II in France By Olivier Allais; Guy Fagherazzi; Julia Mink
  11. Evaluating the relationship between income, survival and loss of autonomy among older Canadians By Marie Connolly; Akakpo Domefa Konou; Marie-Louise Leroux
  12. Innovative providers’ payment models for promoting value-based health systems: Start small, prove value, and scale up By Luca Lindner; Luca Lorenzoni
  13. Is Income Inequality Linked to Infectious Disease Prevalence? A Hypothesis-Generating Ecological Study Using Tuberculosis By Jay Bhattacharya; Joydeep Bhattacharya; Minkyong Kim
  14. Market Size and Trade in Medical Services By Jonathan I. Dingel; Joshua D. Gottlieb; Maya Lozinski; Pauline Mourot
  15. Enhancing labour productivity by improving nutrition in Kenya: micro-econometric estimates for dynamic CGE model calibration By Ramos, Maria Priscila; Custodio, Estefania; Jiménez, Sofía; Sartori, Martina; Ferrari, Emanuele
  16. Symptom or Culprit? Social Media, Air Pollution, and Violence By Xinming Du
  17. Literature Review on the Effect of Physical and Mental Health on Financial Well-Being By Swensen, Isaac D.; Urban, Carly
  18. Managing Medical Errors in a University Hospital: How to Handle the Internal Learning–External Protection Paradox? By Julien Cusin; Anne Goujon Belghit
  19. Understanding Program Complementarities: Estimating the Dynamic Effects of Head Start with Multiple Alternatives By Chan, M.; Dalla-Zuanna, A.; Liu, K.
  20. Children in Economically Disadvantaged Households Have Lower Early Literacy Skills than their High-Income Peers By Michah W. Rothbart, Colleen Heflin, and Gabriella Alphonso
  21. Environmental costs of the global job market for economists By Alberto Prati; Olivier Chanel; Morgan Raux

  1. By: Jonathan Gruber; David H. Howard; Jetson Leder-Luis; Theodore L. Caputi
    Abstract: The Medicare hospice program is intended to provide palliative care to terminal patients, but patients with long stays in hospice are highly profitable, motivating concerns about overuse among the Alzheimer’s and Dementia (ADRD) population in the rapidly growing for-profit sector. We provide the first causal estimates of the effect of for-profit hospice on patient spending using the entry of for-profit hospices over twenty years. We find hospice has saved money for Medicare by offsetting other expensive care among ADRD patients. As a result, policies limiting hospice use including revenue caps and anti-fraud lawsuits are distortionary and deter cost-saving admissions.
    JEL: H51 I13 K4
    Date: 2023–03
  2. By: Pierre-Carl Michaud; Pascal St. Amour
    Abstract: Annuities, long-term care insurance and reverse mortgages remain unpopular to manage longevity, medical and housing price risks after retirement. We analyze low demand using a life-cycle model structurally estimated with a unique stated-preference survey experiment of Canadian households. Low risk aversion, substitution between housing and consumption and low marginal utility when in poor health explain most of the reduced demand. Bequests motives are found to be a luxury good and play a limited role. The remaining disinterest is explained by information frictions and behavioural status-quo biases. We find evidence of strong spousal co-insurance motives motivating LTCI and of responsiveness to bundling with a near doubling of demand for annuities when reverse mortgages can be used to annuitize, instead of consuming home equity.
    JEL: G51 G53 I13 J14
    Date: 2023–03
  3. By: Bhalotra, Sonia (University of Warwick, CAGE); Nunes, Letícia (Institute of Education and Research (Insper), São Paulo, Brazil); Rocha, Rudi (São Paulo School of Business Administration (FGV EAESP), São Paulo, Brazil)
    Abstract: Hospitals are under increasing pressure as they bear a growing burden of chronic disease while also dealing with emergency cases that do not all require hospital care. Many countries have responded by introducing alternative facilities that provide 24/7 care for basic and medium-complexity cases. Using administrative data, we investigate impacts of the opening of these intermediate facilities (UPA) in the state of Rio de Janeiro in Brazil. We find that an UPA opening in the catchment area of a hospital reduces hospital outpatient procedures and admissions and that this is associated with improved hospital performance. There is a decline in inpatient mortality, particularly mortality from the more complex conditions that hospitals are best equipped to deal with. There is no discernible change in the risk profile of cases going to hospital, and no concurrent policy changes that can account for these findings. In order to capture displacement effects, we investigate city-level population outcomes. We find that two-thirds of the decline in hospital mortality is offset by deaths in UPAs. Looking at individual death causes, we see a net decline in deaths from congestive heart failure.
    Keywords: urgent care centers; hospital performance; displacement effects; health outcomes JEL Classification: I11, I15, I18
    Date: 2023
  4. By: Bhalotra, Sonia (University of Warwick, United Kingdom, CEPR, IZA, IEA, CAGE.); Fernández, Manuel (Universidad de los Andes, Colombia, and IZA)
    Abstract: We investigate supply-side barriers to medical care in Colombia, where citizens have a constitutional right to health, but insurance companies impose restrictions. We use administrative data on judicial claims for health as a proxy for unmet demand. We validate this using the health services utilization register, showing that judicial claims map into large, pervasive decreases in medical consultations, procedures, hospitalizations and emergency care. This manifests in population health outcomes. We identify increases in mortality pervasive across cause, age, sex, and income, with larger increases for cancer and individuals over the age of fifty.
    Keywords: Health care, health insurance, mortality, right-to-health, litigation, accountability, universal-health-coverage, Colombia JEL Classification: G22, I11, I13, I18, K38, K42
    Date: 2023
  5. By: Chen, Taoshan (University of Warwick)
    Abstract: This study provides novel evidence on how monitoring and evaluation affects racial health inequality, with data from the Primary Care Access and Quality (PMAQ) Program in Brazil. By using the heterogeneity-robust estimator from de Chaisemartin and D'Haultfoeuille (2022), this study considers the non-staggered and non-binary characteristics of the treatment. The results show that an increase in monitoring and evaluation intensity can reduce racial health inequality, achieved by improving the health conditions for non-white individuals and deterioration of the health conditions for white individuals. It is suggested for policy makers to increase the allocation of health resources to ensure that while racial health inequality is reduced, both white and non-white individuals can benefit from an improvement in primary health care, rather than narrowing the gap by reducing the quality of care for one group.
    Keywords: Racial Health Inequality ; Monitoring and Evaluation ; Primary Care Access and Quality (PMAQ) Program JEL classifications: I14 ; I18
    Date: 2023
  6. By: Grace Armijos Bravo (Universitat de Barcelona & IEB & ESAI Business School - Universidad Espíritu Santo); Judit Vall Castelló (University of Barcelona, IEB &CRES-UPF)
    Abstract: In several countries the entry system to access public service positions is the traditional public examination procedure. In this setting, candidates have to take passing exams that require a huge load of material to study, and therefore time. Candidates who are working while preparing the public exam may find it difficult to devote enough time to both tasks. Thus, they might experience increased stress/anxiety related to high stakes civil service recruitment testing. In this paper, we investigate the impact of new openings of civil servant positions on sickness absences. Using a unique administrative dataset on the universe of sickness absences and civil servant positions offered in Spain from 2009 to 2015, we find a significant increase in health-related absences several months before the examination date. In particular, this effect is stronger for individuals working in the educational sector as well as for calls offering a large number of positions. This effect is mostly driven by stress related absences. Finally, using data on medical visits (GP and specialist) we find evidence consistent with a deterioration in públic sector workers’ health. Our results are important from a policy perspective as they highlight the existence of important negative consequences of the civil service recruitment process that have been previously overlooked.
    Keywords: Public Examinations, Sick Leave; Negative Externalities, Absenteeism
    JEL: I13 J22 J45
    Date: 2023
  7. By: Josefa Henriquez; Richard C. van Kleef; Andrew Matthews; Thomas McGuire; Francesco Paolucci
    Abstract: Health plan payment systems with community-rated premiums typically include risk adjustment, risk sharing or both to compensate insurers for predictable profits (on young and healthy people) and predictable losses (on the elderly and chronically ill). This paper shows how a payment system based only on risk sharing (like in Australia), is improved by combining risk sharing with risk adjustment. Using Australia’s private health insurance market as a case study, we compare and assess the current risk sharing based payment system against alternative systems which combine risk adjustment and risk sharing. Specifically, we develop outcome measures to compare the models in terms of incentives for risk selection and incentives for cost control. We find that a payment system composed of risk adjustment based on simple risk-adjustor variables, supplemented with outlier risk sharing outperforms the current system based solely on risk sharing. Our results show that as more and better data become available, reliance on risk sharing can be reduced whilst the use of risk adjustment can be expanded. In an additional analysis, we show that changes in the payment system affect the redistribution of claims costs across different levels of coverage. We discuss qualitatively additional measures that can be taken to achieve the desired level of redistribution.
    JEL: I11 I13
    Date: 2023–03
  8. By: Katharina Heisig
    Abstract: This paper studies the long-term impact of a paid parental leave reform in former East Germany in 1986 on maternal physical and mental health and subjective well-being. The reform extended paid leave for first-time mothers by six months to a maximum of twelve months. I use representative survey data from the German Socio-Economic Panel and a difference-in-differences design in a quasi-experimental setting. Results show that the effects of the reform were negligible on maternal long-term physical and mental health and subjective well-being. There is weak, but not robust, evidence for increased satisfaction with household activities, income, and work.
    Keywords: social policy, parental leave, mental health, physical health, subjective well-being
    JEL: I12 J13 J16
    Date: 2023
  9. By: van den Berg, Gerard J. (IFAU - Institute for Evaluation of Labour Market and Education Policy); von Hinke, Stephanie (School of Economics, University of Bristol); H. Wang, R. Adele (School of Economics, University of Bristol.)
    Abstract: Maternal sugar consumption in utero may have a variety of effects on offspring. We exploit the abolishment of the rationing of sweet confectionery in the UK on April 24, 1949, and its subsequent reintroduction some months later, in an era of otherwise uninterrupted rationing of confectionery (1942-1953), sugar (1940-1953) and many other foods, and we consider effects on late-life cardiovascular disease, BMI, height, type-2 diabetes and the intake of sugar, fat and carbohydrates, as well as cognitive outcomes and birth weight. We use individual-level data from the UK Biobank for cohorts born between April 1947–May 1952. We also explore whether one’s genetic “predisposition” to the outcome can moderate the effects of prenatal sugar exposure. We find that prenatal exposure to derationing increases education and reduces BMI and sugar consumption at higher ages, in line with the “developmental origins” explanatory framework, and that the sugar effects are stronger for those who are genetically “predisposed” to sugar consumption.
    Keywords: Nutrition; food consumption; gene-environment interplay; education; developmental origins
    JEL: D45 I12 I15 I18
    Date: 2023–03–17
  10. By: Olivier Allais (ALISS - Alimentation et sciences sociales - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement); Guy Fagherazzi (LIH - Luxembourg Institute of Health); Julia Mink (ALISS - Alimentation et sciences sociales - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement, Sciences Po - Sciences Po)
    Abstract: We investigate the effects of early-life exposure to war on adult health outcomes including cancer, hypertension, angina, infarction, diabetes and obesity. We combine data from the French prospective cohort study E3N on women employed in the French National Education with historical data on World War II. To identify causal effects, we exploit exogenous spatial and temporal variation in war exposure related to the German invasion of France during the Battle of France. The number of French military casualties at the level of the postcode area serves as main measure of exposure. Our results suggest that exposure to the war during the first 5 years of life has significant adverse effects on health in adulthood. A 10 percent increase in the number of deaths per inhabitants in the individual's postcode area of birth increases the probability of suffering from any of the health conditions considered in this study by 0.08 percentage points. This is relative to a mean of 49 percent for the sample as a whole.
    Keywords: Early-life exposure, Developmental origins, World war II, Human capital development
    Date: 2021–05
  11. By: Marie Connolly; Akakpo Domefa Konou; Marie-Louise Leroux
    Abstract: Evaluating the relationship between health at old age and income is crucial for the design of equitable public policies targeted toward the elderly. Using 2016 Canadian survey data on adults aged between 50 and 70, we estimate the relationships between individual income, longevity and dependency at the old age. We use both subjective and objective measures of the probability to survive to age 85, of the probability to have activities of daily living (ADL) limitations, and of the probability of entering a nursing home. We find that income and the (objective and subjective) probability to live to age 85 and over are positively related while income and the (objective and subjective) probability to suffer from ADL limitations are negatively related. We also find that while the objective probability to enter a nursing home is negatively correlated with income, the subjective probability is positively correlated with income. Most of our results are driven by individuals in the highest tercile of the income distribution. Our results are robust to different sensitivity checks.
    Keywords: Long term care, Survival probability, Probability to become dependent, Nursing home, Income.
    JEL: C36 I10 I14 I18 J14
    Date: 2023
  12. By: Luca Lindner; Luca Lorenzoni
    Abstract: Innovative providers’ payment models represent an important policy lever that could be used to promote value-based health systems. By bundling services across the continuum of care or to target acute events or chronic conditions, innovative payment models set financial incentives for providers to increase efficiency in service delivery, improve health outcomes and enhance patient experience with care. This paper offers insights on value-based payment models, a type of innovative payment model implemented in several OECD countries and reviews the publicly available evidence on the impact of those payment models on value. Innovative payment models tend to be exceptional and small-scale compared to activity-based payment models and have been extensively piloted in the United States while implementation and evaluation in other countries is limited. The publicly available empirical evidence points to modest efficiency and quality gains from value-based payment models. Impact on healthcare spending, outcomes and patient experience varies across programmes. Given the significant variation in the key features of value-based payment models and the context-specific issues they address, those models do not offer a one-size-fits-all solution. This paper outlines several intervention points that policy makers need to consider when designing and implementing value-based payment models to maximise their positive outcome.
    Date: 2023–04–03
  13. By: Jay Bhattacharya; Joydeep Bhattacharya; Minkyong Kim
    Abstract: We study the association between infectious disease prevalence and income inequality. We hypothesize that random social mixing in an income-unequal society brings into contact a) susceptible and infected poor and b) the infected-poor and the susceptible-rich, raising infectious disease prevalence. We investigate this association by examining whether countries with elevated levels of income inequality have higher rates of pulmonary Tuberculosis (TB) incidence per capita. We analyzed publicly available country-level panel data for a large cross-section of countries between 1995 and 2013. A “negative control” using anemia (a non-communicable disease, and hence impervious to the hypothesized mechanism) is also applied. We find that elevated levels of income inequality were positively associated with tuberculosis prevalence. All else equal, countries with income-Gini coefficients 10% apart are a statistically significant 4% different in tuberculosis incidence. Income inequality had a null effect on anemia, the negative control. Our cross-country regression results suggest that income inequality may create conditions where TB spreads more easily.
    JEL: I1 I14 O57
    Date: 2023–03
  14. By: Jonathan I. Dingel; Joshua D. Gottlieb; Maya Lozinski; Pauline Mourot
    Abstract: We measure the importance of increasing returns to scale and trade in medical services. Using Medicare claims data, we document that “imported” medical care — services produced by a medical provider in a different region — constitute about one-fifth of US healthcare consumption. Larger regions specialize in producing less common procedures, which are traded more. These patterns reflect economies of scale: larger regions produce higher-quality services because they serve more patients. Because of increasing returns and trade costs, policies to improve access to care face a proximity-concentration tradeoff. Production subsidies and travel subsidies can impose contrasting spillovers on neighboring regions.
    JEL: F12 F14 I11 R12
    Date: 2023–03
  15. By: Ramos, Maria Priscila; Custodio, Estefania; Jiménez, Sofía; Sartori, Martina; Ferrari, Emanuele
    Abstract: Kenya is particularly concerned about the achievement of the Sustainable Development Goal #2 (SDG #2: zero hunger), and its associated consequences for society. Malnutrition in all its forms (stunting, wasting, micronutrient deficiencies and/or overweight/obesity) can compromise human development and economic growth through different pathways. In this context, it is possible to identify at least two pathways through which improving FS&N could enhance labour productivity. Improving the dietary nutrients intake (calories, macro and micronutrients) could allow for better (i) learning capacity and (ii) the reinforcement of health conditions. Besides, education and good health improve labour productivity. Thus, the aim of this paper is to provide insights about the linkages between FS&N indicators and labour productivity for dynamic pathways in a CGE framework, particularly modelling baseline’s drivers about L-productivity and growth. Moreover, the estimates would also allow performing food policy scenarios to get positive impacts over nutrition and health and thus, on economic growth. Our results show that, indeed, daily micronutrients (iron, zinc, calcium, vitamins B2 and A) intakes are significant and positive to explain labour productivity improvement (wage increase), as well as education, while disabilities and/or diseases impact negatively and significantly on labour performance. We also note that in the case of vitamins C and B12 the relation is negative when all the variables are included in the regression but positive when we consider them separately. All in all, results confirm the virtuous cycle between health, nutrition, education and labour productivity.
    Keywords: Food Security and Poverty, Labor and Human Capital
    Date: 2022
  16. By: Xinming Du
    Abstract: This paper provides the first causal evidence that hostile activities online lead to physical violence. Given the recently documented relationship between pollution and social media, I exploit exogenous variation in local air quality as the first step to instrument for online aggression. In an event study setting, I find volatile organic compounds (VOCs) increase by 7% when refineries experience unexpected production outages. Together with higher air pollution, I find more aggressive behaviors both online and offline, as well as worse health outcomes near refineries. A one standard deviation increase in surrounding VOCs leads to 0.16 more hate crimes against Black people and 0.23 more hospital visits per thousand people each day. Second, I consider how emotional contagion spreads through social networks. On days with pollution spikes, surrounding areas see 30% more offensive and racist tweets and 12% more crimes; those geographically distant but socially networked regions also see offensive and racist tweets increase by 3% and more crimes by 4.5%. Nationally, overlooking spillovers would underestimate crime effects of pollution by 24%. My findings highlight the consequences of social media hostility and contribute to the public debate on cyberspace regulation.
    Date: 2023
  17. By: Swensen, Isaac D. (Montana State University); Urban, Carly (Montana State University)
    Abstract: Adverse health conditions have the potential to financially cripple American households. This report reviews the large literature that considers the ways in which health—both physical and mental—impacts household finances. The review largely includes studies with U.S. populations and spans many disciplines: economics, public health, law, medicine, psychology, public policy, and sociology. The overwhelming finding is that deteriorating health, new health conditions, and even health shocks—such as injuries—negatively impact the financial health of households. First, unanticipated out-of-pocket health costs reduce or deplete the household savings, sometimes forcing household members to forego necessary consumption. This reduced consumption could directly harm their health, providing a direct feedback loop into the relationship between health and finances. Second, declining health or new health conditions often force people out of the labor market for an extended period. This reduces household earnings and either forces other household members to work more to compensate for the earnings loss or further harms the household balance sheet. The effects of mental health conditions are often more detrimental than the onset of severe physical health conditions. The detrimental effects of health conditions on household finances are generally largest for those with the fewest protections in place: those with fewer assets, those without insurance coverage, and those with less education. However, the labor market consequences are sometimes largest for the highest earners. Existing policies can blunt the effects of health on finances. Comprehensive health insurance, specifically for the chronically ill, those with high-cost conditions, and those covered under Medicaid, generates the greatest benefits for overall financial health. Paid sick leave and subsidized caregiving limit the effects of work interruptions when someone in the household falls ill. Promising existing policies that do not require federal changes include pausing loan obligations, financial literacy, and pairing healthcare choice with cost information.
    Keywords: health shock, financial well-being, household finances
    JEL: I18 I10 I31 I38
    Date: 2023–03
  18. By: Julien Cusin (IRGO - Institut de Recherche en Gestion des Organisations - UB - Université de Bordeaux - Institut d'Administration des Entreprises (IAE) - Bordeaux); Anne Goujon Belghit (IRGO - Institut de Recherche en Gestion des Organisations - UB - Université de Bordeaux - Institut d'Administration des Entreprises (IAE) - Bordeaux)
    Abstract: Hospitals are looking to strengthen their safety culture by learning internally from medical errors that occur to prevent them from happening again. This implies creating an atmosphere of psychological safety that encourages errors to be reported. Only open communication from teams can help to improve practices. Also, many establishments have implemented no-punishment charters, creating a policy of tolerance of errors. However, a medical error can become a legal issue. The fact that a court of law can use anything hospital staff have said or written after an adverse event has occurred encourages defensive communication to protect oneself from outside stakeholders. To date, the literature on medical errors has not studied how hospitals overcome this contradiction. In this qualitative research, we use paradox theory in the case of a single university hospital to understand how a hospital confronted with medical errors can effectively manage the internal learning–external protection paradox. A deeper study of this specific context also allows us to supplement the literature on organizational paradoxes. We demonstrate how the interactions between different levels of analysis contribute to operationalizing paradox management in a dynamic and characteristic way, on the one hand, and what makes it effective, on the other hand.
    Date: 2022–03–15
  19. By: Chan, M.; Dalla-Zuanna, A.; Liu, K.
    Abstract: We use experimental data from the Head Start Impact Study to examine the effect of sequential participation in childcare programs on cognitive outcomes. Using a sequential threshold model, which accounts for selection beyond initial randomization, we estimate causal returns to program sequences, including joint and cross returns across skill investment programs. We then estimate a dynamic structural model as a juxtaposition and evaluate a counterfactual policy reform which limits individuals to one year of Head Start. Our results support Head Start implementation earlier in life, and support engaging low-ability children with center-based care and high-ability children with some home care.
    Keywords: Head Start, program evaluation, treatment effects, complementarity, child care
    Date: 2023–03–20
  20. By: Michah W. Rothbart, Colleen Heflin, and Gabriella Alphonso (Center for Policy Research, Maxwell School, Syracuse University, 426 Eggers Hall, Syracuse, NY 13244)
    Abstract: Literacy is critical for numerous developmental outcomes and wellbeing among children. Low literacy skills in childhood can also negatively affect individuals in adulthood. Using data from nearly 300, 000 kindergarten students in Virginia (2014-2017), this study finds that children in households that participate in more than one social assistance program (such as Temporary Assistance for Needy Families, the Supplemental Nutrition Assistance Program, and Free or Reduced-Price Lunch) have lower literacy skills when they enter kindergarten than children whose households participate in fewer or no social programs.
    Keywords: Child Health, Literacy, Food Insecurity, Social Welfare Policy
    Date: 2023–03
  21. By: Alberto Prati (UCL - University College of London [London], University of Oxford, CEP - LSE - Centre for Economic Performance - LSE - London School of Economics and Political Science); Olivier Chanel (AMSE - Aix-Marseille Sciences Economiques - EHESS - École des hautes études en sciences sociales - AMU - Aix Marseille Université - ECM - École Centrale de Marseille - CNRS - Centre National de la Recherche Scientifique); Morgan Raux (University of Luxembourg [Luxembourg])
    Abstract: Each year, the international job market for economists involves more than 1, 000 candidates and several hundred recruiters from around the world meeting for short pre-screening interviews at annual congresses in Europe and the United States. Alberto Prati, Olivier Chanel and Morgan Raux argue that it's time to reassess this unsustainable system and estimate the carbon footprint of alternatives.
    Date: 2022–10

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