Greenbayslacker

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Hello SDN, there are a few questions that I would love to get input about in starting a new practice in the NJ/NY metro area. Here is my situation...

I am anesthesia trained and completing a pain fellowship at an Ivy-league pain fellowship. I already have a very-well paying anesthesia & part-time pain job lined up after graduation, however after COVID it seems that it will be primarily anesthesia due to their needs. It is a low-call frequency position so I will have time to pursue my pain ambitions. What I am envisioning is that after 6 months or so of "real world" pain practice and experience, setting up a "part-time" practice, wherein I can see new patients and do procedures on the weekends I am not on call. The pain office would be set up outside of my current non-compete area. During the week days all follow-ups would be telemedicine, unless they need a true physical examination. I can rent a simple medical office for patient visits and do procedures at an ASC. Marketing would ideally be word-of-mouth after having a good patient experience with excellent bedside manner, and online, as in-person marketing with local docs and PCPs would be very difficult. I would control overhead costs by using myself and my wife to do all in-office things ourselves without staff (paperwork, checking patients, appointments, etc), not doing in-office procedures, maximizing telemedicine, and having this alternative income route through anesthesia.

- How do you find an ambulatory surgery center that will allow you to do procedures, what should I look out for when pursuing this agreement?
- Would this model work if I am accepting insurance, or would it only be profitable if I am out-of-network only?
- Can new patient visits be done reasonably through telemedicine?
- Any words of wisdom in general would be greatly appreciated!
 

Ferrismonk

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I am not in your area and haven't started my own practice, so take what I say with a grain of salt. That being said, I'll answer the best I can.

1. Just call them. Many ASCs will love to have you on staff. As a pain physician you can make ASCs a lot of money and you can keep their case load up (important for CON if you have them). Just don't expect a share of the facility fee.
2. Being in-network with insurance companies is likely 100% needed if you wish to grow your practice without face to face marketing. I get patients all the time from other pain groups who no longer take their insurance or directly when a patient calls their insurance company to see who is in network.
3. Telemedicine won't work. Right now it does because of the COVID pandemic, but most insurances either don't normally pay for telmedicine or do so at such a low rate you would likely lose money on your internet bill.
4. Make sure that your non-compete isn't just a distance issue. Many non-competes say you cannot engage in a similar business (anesthesia or pain) while employed without permission from the group/hospital, regardless of the non-compete distance area.
5. FYI, in office procedures pay you more than doing them in an ASC or hospital.
 

Laryngospasm

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New patients visits can not be done through telemedicine. You are going to have a lot of overhead to cover just doing procedures and visits in your off time. How will you have enough time after a year or two to see follow ups, do produces, and new patients in two days? A rule of thumb is the first two to three days of the week go to pay Uncle Sam and overhead. Another question is how fast this model will burn you out. I currently do both and OR anesthesia wears me out. Being there at 545, emergencies etc. Then you are going to spend your time off dealing with needy patients. If you are young you may be able to pull it off for a while but tomorrow is promised to no man and it’s not like this model will let you retire after 5 years. If it would I would say go for it. Also not sure if you are talking about doing asc procedures on the weekend or not but that’s not happening unless you own the asc.
 
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Speaking only to a small part of your questions but I’d say only in very limited circumstances is a telemedicine appointment adequate for new patients. There is no substitute for a real physical exam.
 
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drusso

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Hello SDN, there are a few questions that I would love to get input about in starting a new practice in the NJ/NY metro area. Here is my situation...

I am anesthesia trained and completing a pain fellowship at an Ivy-league pain fellowship. I already have a very-well paying anesthesia & part-time pain job lined up after graduation, however after COVID it seems that it will be primarily anesthesia due to their needs. It is a low-call frequency position so I will have time to pursue my pain ambitions. What I am envisioning is that after 6 months or so of "real world" pain practice and experience, setting up a "part-time" practice, wherein I can see new patients and do procedures on the weekends I am not on call. The pain office would be set up outside of my current non-compete area. During the week days all follow-ups would be telemedicine, unless they need a true physical examination. I can rent a simple medical office for patient visits and do procedures at an ASC. Marketing would ideally be word-of-mouth after having a good patient experience with excellent bedside manner, and online, as in-person marketing with local docs and PCPs would be very difficult. I would control overhead costs by using myself and my wife to do all in-office things ourselves without staff (paperwork, checking patients, appointments, etc), not doing in-office procedures, maximizing telemedicine, and having this alternative income route through anesthesia.

- How do you find an ambulatory surgery center that will allow you to do procedures, what should I look out for when pursuing this agreement?
- Would this model work if I am accepting insurance, or would it only be profitable if I am out-of-network only?
- Can new patient visits be done reasonably through telemedicine?
- Any words of wisdom in general would be greatly appreciated!
You got to get out in front of people. Nothing is more important than face-to-face conversations and building relationships with high volume referral sources. Ask some device reps and others to broker relationships for you and make sure you return the favor by using their stuff. Set aside 2-3 evenings per week to build relationships. Consider joining Rotary, Chamber of Commerce, other community groups, and service organizations to develop networking activities. Find out what gym, golf course, or other recreational activity the spine surgeons who refer out a lot of shots are at and show up there.

Good luck!
 
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Greenbayslacker

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Thank you for the advice everyone!

I think I can control overhead costs pretty well and get it as close to zero as possible, with the only major overhead being renting an exam room two days a week. With that in mind, volume can slowly but steadily increase, without having a need for a huge patient population up front. In-person marketing just isn't an option.

Overall, this practice would be almost like a "hobby" to me, to keep up my pain skills while doing something I enjoy.
 

geauxg8rs

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Overhead close to zero? Man.. you need to teach a course. You could retire in ten years.
Who is paying the malpractice? Isn’t that a cost? Billing? EMR? Are you going to have any staff or are the patients going to just call your cell when they have neuritis, etc?
 
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hyperalgesia

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Thank you for the advice everyone!

I think I can control overhead costs pretty well and get it as close to zero as possible, with the only major overhead being renting an exam room two days a week. With that in mind, volume can slowly but steadily increase, without having a need for a huge patient population up front. In-person marketing just isn't an option.

Overall, this practice would be almost like a "hobby" to me, to keep up my pain skills while doing something I enjoy.
I did pretty much exactly what you are talking about. Even called it a "hobby" lol. Despite having a variable patient load, I never lost money from day 1 due to my overhead and set up. It's hard to make it worthwhile overall though.

You might need to call around for malpractice that allows for part-time work. (I was able to get 1/4 time quote).

For EMR, I wasted a lot of time making my own EMR/billing software with the plan of spinning it off to a new company. Don't do this. I would just use something SIMPLE and CHEAP and absolutely shun all the bells and whistles. You will be well below the Medicare threshold for MACRA so no need to report on metrics or have a "patient portal" or any of that nonsense. Don't buy into the hype, keep it simple.

Ideally. your wife can do the billing.

I would say new visits require phone consult first, to get a history, etc and only schedule "physical exams". This will decrease your office costs.

At some point, I doubt it will be worth it for you and your wife. You won't need the money or the headaches and there will be more rewarding ways to spend your time. Either that, or it could become a full time thing. I enjoyed it for a while - about 7 years.
 
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Agast

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It sounds like part of your zero overhead plan involves your wife's unpaid labor. Is she as excited as you are to spend her weekends doing this?
 
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Greenbayslacker

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It sounds like part of your zero overhead plan involves your wife's unpaid labor. Is she as excited as you are to spend her weekends doing this?
Luckily she is on board for whatever my job and practice bring... lucky to be with someone so supportive and I would have staff to replace those duties as soon as we are able!
 

Greenbayslacker

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I did pretty much exactly what you are talking about. Even called it a "hobby" lol. Despite having a variable patient load, I never lost money from day 1 due to my overhead and set up. It's hard to make it worthwhile overall though.

You might need to call around for malpractice that allows for part-time work. (I was able to get 1/4 time quote).

For EMR, I wasted a lot of time making my own EMR/billing software with the plan of spinning it off to a new company. Don't do this. I would just use something SIMPLE and CHEAP and absolutely shun all the bells and whistles. You will be well below the Medicare threshold for MACRA so no need to report on metrics or have a "patient portal" or any of that nonsense. Don't buy into the hype, keep it simple.

Ideally. your wife can do the billing.

I would say new visits require phone consult first, to get a history, etc and only schedule "physical exams". This will decrease your office costs.

At some point, I doubt it will be worth it for you and your wife. You won't need the money or the headaches and there will be more rewarding ways to spend your time. Either that, or it could become a full time thing. I enjoyed it for a while - about 7 years.
This is encouraging since it’s an almost identical situation, also disappointing to hear about the long term outcome. We’ll see what the market brings after 6 months or so of getting on my feet!
 
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hyperalgesia

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This is encouraging since it’s an almost identical situation, also disappointing to hear about the long term outcome. We’ll see what the market brings after 6 months or so of getting on my feet!
I had another full time job, doing 4, 10 hour shifts/week of pain. I was doing the private practice on Mondays and Saturdays, charting on Sunday, etc.

Over time, my priorities changed. If you're doing part time in 2 places, it might be good. Just don't forget we're all on a clock here. When your number is picked, you don't want to be trying to complete a pre-auth request for Cigna...
 

drusso

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I had another full time job, doing 4, 10 hour shifts/week of pain. I was doing the private practice on Mondays and Saturdays, charting on Sunday, etc.

Over time, my priorities changed. If you're doing part time in 2 places, it might be good. Just don't forget we're all on a clock here. When your number is picked, you don't want to be trying to complete a pre-auth request for Cigna...
I imagine dying at my desk while doing a peer-to-peer with a pediatric endocrinologist about the medical necessity of an SCS for a patient with post-lami pain syndrome...that's why I keep my POLST taped to the back of my chair.
 

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Psych here...
Bare bones EMR that could get the job done; Luminello. Meant for Psych. But it has the basic features to make things easier, and you can turn off certain features if you don't want patients to have access to them like messaging. The built in credit card bill pay feature, and also the third party ApexEDI clearing house is priced well and very affordable. Not MIPS approved with CMS. Probably not the EMR you'll want if you start to scale up, but could be the training wheels to help you figure out what you want when you start to go big.

If you want all the bells and whistles with CMS, messaging, billing, labs, integrated fax, etc, etc, etc EHR Electronic Health Records | EMR Electronic Medical Records | Medical Billing Software | Clearing House | MIPS Registry this is your go to EMR with cheaper pricing compared to Athena, AdvancedMD, practicefusion, etc.

Oh, and it potentially has integration to view Epic based EMR notes, too.
 
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Thank you for the advice everyone!

I think I can control overhead costs pretty well and get it as close to zero as possible, with the only major overhead being renting an exam room two days a week. With that in mind, volume can slowly but steadily increase, without having a need for a huge patient population up front. In-person marketing just isn't an option.

Overall, this practice would be almost like a "hobby" to me, to keep up my pain skills while doing something I enjoy.
Now why in the world would you want to work weekends as well as doing your anesthesia gig?

Life is short and you cannot get that time (which should be spent with family) back. Pick one or the other and be happy.

To do pain properly, it should be "full time".

I have never heard of a practice with zero overhead, unless you are an employee. A full time practice usually requires $600K plus of overhead. Depending on local ACOs, some practices "shop" for the lowest cost provider, which is generally an office setting. In many markets, it makes no difference at all; however, one would assume a trend to seek lower costs will prevail long term.

You may want to check into the Stark laws, as providing free overhead in exchange for doing procedures at a facility is illegal. There was a landmark case in PA in 2009 over that very issue. There are a number of people doing exactly what you are proposing, but all it would take is one disgruntled person to turn you into the feds for cash.
 
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Ligament

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I did pretty much exactly what you are talking about. Even called it a "hobby" lol. Despite having a variable patient load, I never lost money from day 1 due to my overhead and set up. It's hard to make it worthwhile overall though.

You might need to call around for malpractice that allows for part-time work. (I was able to get 1/4 time quote).

For EMR, I wasted a lot of time making my own EMR/billing software with the plan of spinning it off to a new company. Don't do this. I would just use something SIMPLE and CHEAP and absolutely shun all the bells and whistles. You will be well below the Medicare threshold for MACRA so no need to report on metrics or have a "patient portal" or any of that nonsense. Don't buy into the hype, keep it simple.

Ideally. your wife can do the billing.

I would say new visits require phone consult first, to get a history, etc and only schedule "physical exams". This will decrease your office costs.

At some point, I doubt it will be worth it for you and your wife. You won't need the money or the headaches and there will be more rewarding ways to spend your time. Either that, or it could become a full time thing. I enjoyed it for a while - about 7 years.
What did you learn about EMRs and which commercially availalbe EMR do you recommend?
 

hyperalgesia

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What did you learn about EMRs and which commercially availalbe EMR do you recommend?
I know a doc who plugged into our main hospital system Epic for a discounted fee, even though he's totally private. This might be worth considering if available. I have despised Epic but I think if I were able to really sit down and customize it, it might be good.

As you are well aware, all the main commercial EMRs are tailored to guidelines from CMS to achieve their "certification". These guidelines mandate functions that interfere with the job of a physician. Mandatory drug interaction warnings, mandatory "interoperability" with other systems. Those things and others require standardized lists of things that are always changing. Thus require constant updating which never happens so they just don't function properly outside of major systems like Epic.

It's a hard sell to have an EMR with no billing component because the EMR already has all the demographics plugged in, the codes, etc. If you don't integrate EMR and billing, you have to enter everything again. But, just because of all the interference and regulations, I'm sure it's worth separating these systems in some cases.

If I were starting from scratch, I'd look into plugging into a local hospital system. I'd also take a look at stand-alone practice mgmt software.

The system I made was cloud based, written mostly in php and mysql and run off of leased linux/apache servers from Amazon. As I got more and more paranoid about security and durability, I built it bigger and better and, unfortunately more expensive. At the end, I was spending about $400/month just on server space/usage. I guess it doesn't sound like that much.

I thought it was a great system because I built it exactly to what I needed. Just as an example, when you start a note for a patient, your template can be made to include your encounter codes. So, when you sign your note, the encounter is done, with icd and cpts codes already. No searching for codes. If you don't use a template, icd codes and other info from prior note are automatically imported.

I wish I could sell the software but it would be hard for someone to deal with glitches, which are inevitable. I could probably sell it to a medical biller because it does a good job of creating/submitting claims. But then again, most people don't want an "uncertified" EMR. So it will join probably legions of other good things that can't quite find their place in the market lol.
 
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PMR2008

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This is encouraging since it’s an almost identical situation, also disappointing to hear about the long term outcome. We’ll see what the market brings after 6 months or so of getting on my feet!
I started the exact setup 8 years ago. My clinic day is my hobby. Financially I only have to work 4 days a week but I truly enjoy my clinic day. I am PM&R and pain fellowship trained. Did not want to do full time pain but also did not want to lose my skills. Other job is a rehab consultant 4 days a week.
I rent a office which happens to have a gym attached to it along with 3 rooms. I subleased the rest of the offices to a functional med MD, a sports Chiro (basically a PT), a massage therapist and a personal trainer. They basically pay my rent and get a bunch of good referrals from them. I don't take medicare, only in network with 1 PPO. Kept my rates reasonable and service top notch. I have a part time RN. Malpractice is about $4k/year. I use amazing charts for EMR which is about $2500 a year. Billing is outsourced but the RN also helps. I have been doing regen med since 2013. Mostly u/s guided injections and for fluro local ASC was happy to have me. Most referrals are word of mouth and website. I rarely get referrals from local orthos/PCP. But the therapists/Chiro/trainers I have a good relationship keep me plenty busy. I am fortunate to not have prescribed a single narcotic in my clinic in 8 years.
I know this is a very unique situation. But I can tell you it is very doable. You can keep the overhead very low. On a typical day I need to collect $400 to break even.
Go for it.
 

drusso

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I started the exact setup 8 years ago. My clinic day is my hobby. Financially I only have to work 4 days a week but I truly enjoy my clinic day. I am PM&R and pain fellowship trained. Did not want to do full time pain but also did not want to lose my skills. Other job is a rehab consultant 4 days a week.
I rent a office which happens to have a gym attached to it along with 3 rooms. I subleased the rest of the offices to a functional med MD, a sports Chiro (basically a PT), a massage therapist and a personal trainer. They basically pay my rent and get a bunch of good referrals from them. I don't take medicare, only in network with 1 PPO. Kept my rates reasonable and service top notch. I have a part time RN. Malpractice is about $4k/year. I use amazing charts for EMR which is about $2500 a year. Billing is outsourced but the RN also helps. I have been doing regen med since 2013. Mostly u/s guided injections and for fluro local ASC was happy to have me. Most referrals are word of mouth and website. I rarely get referrals from local orthos/PCP. But the therapists/Chiro/trainers I have a good relationship keep me plenty busy. I am fortunate to not have prescribed a single narcotic in my clinic in 8 years.
I know this is a very unique situation. But I can tell you it is very doable. You can keep the overhead very low. On a typical day I need to collect $400 to break even.
Go for it.
Your practice model is the future and you are to be commended for making it happen!
 
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90dayMD

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Your practice model is the future and you are to be commended for making it happen!
I apologize for hijacking this thread. I still have a ways to go in completing fellowship, but looking at jobs online, it seems that pain jobs are very limited? Am I wrong on this? Seems maybe there is a handful of positions here and there.
 

lonelobo

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I apologize for hijacking this thread. I still have a ways to go in completing fellowship, but looking at jobs online, it seems that pain jobs are very limited? Am I wrong on this? Seems maybe there is a handful of positions here and there.
What sites are you looking at ?
 
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90dayMD

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What sites are you looking at ?
I have looked at Indeed, Glassdoor, careerbuilder, gasworks etc. I took a look for example at gaswork a few days ago and there wasn't a single exclusively pain job in my region.
 

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Ok, fair enough. 45 total jobs in the country. Aren't there like 400 plus graduating pain docs every year.
 

hyperalgesia

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I get lists of job openings from recruiters all the time. There are plenty of opportunities, especially in rural areas.
 
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I get lists of job openings from recruiters all the time. There are plenty of opportunities, especially in rural areas.
What about non rural areas? Which recruiters in particular? I get notices from comp health mostly
 

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You definitely hijacked the thread lol. Try practiceline and doximity. Cold calling and word of mouth. Rarely you will see stuff on linkedin. Use a recruiter but be cautious.
 

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You definitely hijacked the thread lol. Try practiceline and doximity. Cold calling and word of mouth. Rarely you will see stuff on linkedin. Use a recruiter but be cautious.
I'm sorry! I apologized in advance though so hopefully you can't be too mad at me :)
 

hyperalgesia

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What about non rural areas? Which recruiters in particular? I get notices from comp health mostly
When non-rural, high highly desired area jobs advertise, you should be very suspicious. These places, and all places, are best contacted directly, not through an ad or a recruiter. Recruiters are called in because they can't fill the position for whatever reason.

I've never personally used a recruiter.


Another site I ran into once and was shocked at the number of postings. No idea about the quality but here it is.

 

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might want to wait a year...

take a job doing your primary specialty (which indubitably has more job openings) and study this forum for tricks on how to set up your own practice.

then, in November or so, decide on whether you want to set up your own practice, or join a group or a hospital based clinic.
cold call pain clinics and hospitals in the area you choose to live, including sending emails to the docs who work at those places. not all hospitals treat their physicians poorly, regardless of what you read from one or two forum members (esp the one with the shark icon... ;) ).
 
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Greenbayslacker

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For what it's worth, plenty of practices in the Northeast where I am were/are still hiring despite the pandemic hitting us hard. They know that business will be booming once things open up in a few weeks. Typically you're looking at 300-350k base + collections, which will usually take 2-3 years to start making. Personally I hated the "eat what you kill" practice model, I felt it lowers both patient care and patient satisfaction. There's immense pressure to pump out patients and procedures, and you are marketing 24/7 to bring in your own cases. I decided to take the $200k pay bump and not have that pressure, and do pain on the side (hence this thread).
 

lonelobo

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Many times busy practices just want to outsource the search so they hire a recruiter.

They can be a good source of information and getting your foot in door at some places, that being said the quality of individual recruiters varies significantly.

You have nothing to lose using them as one resource in a job search as they cost you nothing.
 

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Many times busy practices just want to outsource the search so they hire a recruiter.

They can be a good source of information and getting your foot in door at some places, that being said the quality of individual recruiters varies significantly.

You have nothing to lose using them as one resource in a job search as they cost you nothing.
I've said it before, but not nearly as many times as drusso has talked about SOS, that recruiters will pocket a nice percentage of your first year's salary (often 15-18%) for "finding" you. This is paid to them by the employer. It's not hard to negotiate a higher salary if they don't have to pay that fee. If you are casting a wide net, a recruiter may be a good option. If you have a narrow list of locations, you are far better off making contact directly with the local players (assuming you have at least mediocre social skills).
 
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